The effects of tranexamic acid and 6% hydroxyethyl starch (HES) solution (130/0.4) on postoperative bleeding in coronary artery bypass graft (CABG) surgery.

BACKGROUND: The addition of 6% hydroxyethyl starch (HES) into Ringer lactate priming solution may have adverse effects on hemostasis in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) with or without the use of tranexamic acid. METHODS: In a prospective, randomized clinical trial, 132 patients were assigned to receive 20 ml/kg of Ringer priming solution with or without tranexamic acid (TA) (Group RS-TA, n=34 and Group RS-noTA, n=32) or 10 ml/kg of 6% HES plus 10 ml/kg of RS priming solution with or without intravenous tranexamic acid (Group HES-TA, n=35 and Group HES-noTA, n=31). Estimated blood loss, chest tube drainage, amount of blood products, hemoglobin, hematocrit, platelet and coagulation parameters were examined before and 24 hour after surgery. RESULTS: For Group HES with tranexamic acid, when compared to other groups, estimated blood loss, postoperative 24 hour drainage loss and blood product transfusions were less (P=0.023; P=0.003; P=0.001; respectively) and hemoglobin, hematocrit values at 12 and 24 hours after surgery increased in comparison to other groups (P=0.041, P=0.034, P=0.004, P=0.001; respectively). Platelet concentrations were similar between groups (P>0.05). CONCLUSIONS: In CABG, the administration of tranexamic acid in HES 130/0.4 prime solution study group decreased estimated blood loss and chest tube drainage in comparison to patients receving Ringer prime solution with or without tranexamic acid postoperatively however, no effects on renal functions or postoperative complications were shown.

Is it necessary to use an intraluminal shunt in symptomatic patients with contralateral carotid artery stenosis?

BACKGROUND: We aimed to investigate our results of carotid endarterectomy operations in symptomatic patients operated by using an intraluminal shunt and without use of an intraluminal shunt in patients with contralateral carotid artery stenosis. METHODS: We reviewed the results of 144 carotid endarterectomy operations in patients with contralateral carotid artery stenosis from January 2007 to December 2012. These patients were allocated in 2 groups. Group 1 (n = 70) consisted of the patients operated by using an intraluminal shunt and Group 2 (n = 74) consisted of the patients operated without use of an intraluminal shunt. Postoperative neurologic complications were recorded. RESULTS: Temporary neurologic impairment developed in 3 (4.3%) patients postoperatively in group 1 and in 2 (2.7%) patients postoperatively in group 2. This difference was not statistically significant between groups (p = 0.675). None of the patients returned to operation theatre due to excessive bleeding postoperatively. The stroke/death rate was 0.7% in the study group. CONCLUSIONS: We conclude that carotid endarterectomy in symptomatic patients with contralateral occlusion can be performed safely without the systematic use of a shunt. However, it is not possible to define exact indications for use of a shunt as we have no information on the reason why some surgeons used a shunt.

Surgical management of iatrogenic femoral artery pseudoaneurysms: A 10-year experience.

BACKGROUND: Vascular complications of cardiac catheterization have increased in line with increasing number of percutaneous interventions. Open repair is the standard method of treatment for true and false aneurysms of femoral artery. We report results of patients operated due to femoral artery pseudoaneurysm after cardiac catheterization. METHODS: Data from 12,261 patients who underwent percutaneous intervention for cardiac catheterization between January 2003 and January 2013 were evaluated. Diagnosis of pseudoaneurysm was established mainly by doppler ultrasonography in patients with complaints of pain and hematoma at the intervention site. Pseudoaneurysms less than 2 cm in diameter were treated non-operatively and were followed up by regular ultrasonographic examination at the outpatient clinic. Pseudoaneurysms with a diameter of 2 cm or more underwent primary repair. All patients were followed up for one year. RESULTS: We detected 55 (0.44%) patients with femoral artery pseudoaneurysm and 42 of them were operated. The mean age was 60.7 ± 6.3 years. Thirty nine (94.5%) patients underwent elective surgery, three (5.5%) patients were operated on under emergency conditions. Operation was performed under local anesthesia in 32 patients, under local anesthesia and sedation in eight patients, and under general anesthesia in three patients. Location of the pseudoaneurysm was the superficial femoral artery in 29 (69%), the common femoral artery in nine (21.4%), and the deep femoral artery in four (9.6%) patients. No limb loss occurred, no patient died and no recurrence was detected during the follow up. CONCLUSIONS: Performing vascular reconstruction before the rupture of pseudoaneurysm is important in terms of morbidity and mortality. We concluded that surgical repair in pseudoaneurysms larger than 20 mm is safe and essential.

Community-acquired left-sided Pseudomonas aeruginosa endocarditis in a patient without intravenous drug use.

We present a case of community-acquired left-sided Pseudomonas aeruginosa endocarditis in a person without intravenous drug use. The patient presented with facial numbness and did not have any predisposing condition for endocarditis. He was treated successfully with valvular surgery, along with combination antibiotics.

Pseudoaneurysm of brachiocephalic artery caused by blunt chest trauma.

Traumatic aneurysms of the brachiocephalic artery may cause mostly nonspecific symptoms, which may lead to a misdiagnosis with serious complications. This report describes a 27-year-old woman with a traumatic aneurysm of the brachiocephalic artery,suffering from lung symptoms. Brachiocephalic aneurysm and bronchiectasis were diagnosed by chest CT scan. A bypass from the ascending aorta to the distal brachiocephalic artery with a prosthetic graft and aneurysmectomy were performed without the use of cardiopulmonary bypass. The patient had an uneventful recovery.

Late manifestation of a pseudoaneurysm in the descending thoracic aorta.

Rupture of the descending aorta following deceleration trauma is a catastrophic event because it has a high mortality. Prompt surgical treatment is generally considered to be mandatory. However, a few injured patients may leave the hospital with an undiagnosed aortic rupture which may give rise to a chronic pseudoaneurysm. In this report, a 28-year-old man is presented in whom a pseudoaneurysm of the descending thoracic aortic was diagnosed six months after a car accident.

Brachial plexus injury during open heart surgery--controlled prospective study.

BACKGROUND: Postoperative brachial plexus injury is often reported because the brachial plexus is stretched by sternotomy and the use of sternal retractors during open heart surgery. In many studies, brachial plexus injuries have been demonstrated by postoperative electrophysiological studies in susceptible patients. In this study, we estimated the incidence, severity, and type of brachial plexus injuries by routine preoperative and postoperative electrophysiological studies of patients undergoing open heart surgery. METHODS: Patients undergoing coronary artery bypass grafting (CABG) surgery (Group 1), heart valve surgery (Group 2), or peripheral vascular surgery (Group 3) were included in the investigation. Electrophysiological studies of both upper extremities were performed five days before and three weeks after the operation. RESULTS: Peripheral nerve problems were found preoperatively in 23 of the 112 patients (21 %). These problems persisted, but similar findings were obtained postoperatively from the left upper extremities of six of the 42 CABG (14 %) and two of the 24 heart valve (8 %) patients who had had normal preoperative evaluations. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables. CONCLUSIONS: There are no reports in the literature of routine preoperative and postoperative electrophysiological studies in large patient groups to evaluate brachial plexus injury during open heart surgery. It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period.

The importance of aprotinin and pentoxifylline in preventing leukocyte sequestration and lung injury caused by protamine at the end of cardiopulmonary bypass surgery.

BACKGROUND: Protamine has adverse effects on pulmonary gas exchange during the postoperative period. The objective of this study was to investigate the importance of aprotinin and pentoxifylline in preventing the leukocyte sequestration and lung injury caused by protamine administered after the termination of cardiopulmonary bypass (CPB). METHODS: Participants (n = 39) were allocated into three groups at the termination of CPB: Group 1, (control group, n = 16); Group 2 (aprotinin group, n = 12), who received protamine + aprotinin (15,000 IU/kg); and Group 3 (Pentoxifylline group, n = 11), who received protamine + pentoxifylline (10 mg/kg). Leukocyte counts in pulmonary and radial arteries were determined after the termination of CPB and before any drug was given (t1), and 5 minutes (t2), 2 hours (t3), 6 hours (t4) and 12 hours (t5) after the administration of protamine. Alveolar-arterial O2 gradient (A-aO2) and dynamic pulmonary compliance were measured at t1, t2 and t3. RESULTS: In the control group, an increase in pulmonary leukocyte sequestration was observed 5 minutes and 2 hours after protamine administration, after which this difference disappeared. No significant degree of pulmonary sequestration was detected in any measurements after protamine was administered in the aprotinin and pentoxifylline (PTX) groups. Dynamic lung compliance was 50.1, 45.2 and 47.2 ml/cm H2O in the control group, 49.2, 61.1 and 56.3 ml/cm H2O in the aprotinin group, and 49.5, 54.5 and 50.4 ml/cm H2O in the PTX group. The A-aO2 gradient was 212.2, 263.3 and 254.3 mm Hg in the control group, 209.4, 257.1 and 217.3 mm Hg in the aprotinin group, and 211.3, 260.8 and 219.2 mm Hg in the PTX group. CONCLUSION: Aprotinin and PTX treatments have favourable effects on lung function by reducing protamine-induced leukocyte sequestration into lungs at the end of CPB.

Arterial and venous reconstruction for free tissue transfer in diabetic ischemic foot ulcers.

OBJECTIVE: To review our experience with temporary arteriovenous (AV) fistula followed by free tissue transfer in the treatment of diabetic foot ulcers associated with peripheral arterial occlusion. PATIENTS AND METHOD: From July 1997 to July 2002, 15 lower extremities were operated in 14 patients. An AV loop with its apex below the medial malleolus was created between popliteal artery and saphenous system. Three weeks later, the loop was divided to provide an artery and a vein end. Foot defect was covered with latissimus dorsi muscle flap followed by split thickness skin grafting. RESULTS: Fistulas were patent in 12 extremities. Free tissue transfer was performed in 13 extremities. Two free flaps failed. After patent temporary arteriovenous fistula, free tissue transfer was successful in 11 of 12 extremities. One patient was amputated below knee due to ongoing infection despite successful free tissue transfer. Early mortality rate was 7%. Limb salvage was achieved in 11 of 13 extremities that staged operation was performed. Overall extremity loss was four of 15 lower extremities in 14 patients. Overall mortality was 21% for mean 20 follow-up period. CONCLUSION: Temporary AV fistula and free flap may provide stable wound coverage and high rate of limb salvage in treatment of diabetic foot ulcers with large tissue loss.

The effects of intracoronary administration of vitamin E on myocardial ischemia-reperfusion injury during coronary artery surgery.

BACKGROUND: Vitamin E has a strong antioxidant capacity, and has been used in several ischemia-reperfusion studies. The aim of this study was to investigate the effects of water-soluble vitamin E (alpha-tocopherol) on myocardial protection during coronary artery surgery. METHODS: Water soluble vitamin E (100 mg) in tepid saline (n = 14) or tepid saline alone (n = 16) was administered into the coronary arteries at the end of aortic cross-clamping. Cardiac troponin-I (cTn-I), MB-isoenzyme of creatine kinase (CK-MB), myoglobin, blood gas, and lactate levels in systemic and coronary sinus blood and hemodynamic variables were assessed during and after the operation. RESULTS: Eight hours after reperfusion, cTn-I levels increased to 3.06 +/- 1.8 ng/ml and 6.97 +/- 3.9 ng/ml in the vitamin E group and control group, respectively (p = 0.01). Coronary sinus lactate concentration was 2.68 +/- 0.5 mmol/l in the vitamin E group and 4.01 +/- 1.5 mmol/l in the control group 60 minutes after reperfusion (p = 0.027). CONCLUSIONS: Administration of vitamin E into the coronary arteries before removal of the aortic cross-clamp can reduce myocardial cell injury and protect the myocardium from ischemia-reperfusion injury.

The effects of cardiopulmonary bypass on androgen hormones in coronary artery bypass surgery.

The effects of testosterone on coronary vasomotor regulation have been described by several recent reports. Here we investigated changes in serum androgen levels during and after cardiopulmonary bypass (CPB) in patients who had undergone coronary artery bypass surgery. Serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate (DHEA sulphate) levels were evaluated in 38 male coronary artery bypass surgery patients using a chemical immunoassay technique. All hormone levels were corrected to account for haemodilution. Serum-free testosterone level decreased significantly during weaning from CPB (from 15.7 +/- 4.2 nmol/l to 6.2 +/- 2.8 nmol/l), and an even greater decrease was observed in the first post-operative day (5.4 +/- 3.1 nmol/l). On the seventh post-operative day, free testosterone levels reached a normal value (11.8 +/- 5.5 nmol/l), although they were still significantly lower compared with the pre-operative value. There were slight alterations in serum DHEA sulphate levels, although the only significant decrease occurred from the first to the seventh day post-operation (from 4.7 +/- 2.2 mumol/l to 3.7 +/- 1.8 mumol/l, respectively). Serum luteinizing hormone levels were decreased during weaning from CPB (from 4.8 +/- 2.1 mIU/ml to 3.9 +/- 1.8 mIU/ml), but increased rapidly to the pre-operative value (5.5 +/- 2.5 mIU/ml) at the first post-operative day. These results show that CPB affects serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate levels. The free testosterone level decreases significantly both during and after CPB surgery.

[A case of hydatid cyst in the pancreatic head causing obstructive jaundice]. / Obstruktif sariliga neden olan pankreas basinda kist hidatik vakasi.

The patient (male; age = 69) was referred to the Department of 1st Surgery upon suspicion of obstructive jaundice. He was admitted to the Department of Internal Medicine with back pain, loss of appetite, and jaundice and some laboratory tests were performed. He has no history of alcohol use. During his physical examination, pain was noted in the upper right quadrant and the gall bladder was palpable and hydropic. A 22 mm. cystic structure with smooth contours was detected in the abdominal CT scan. An exploratory laparatomy was planned. During the perioperative cyst aspiration, the laminar membrane of hydatic cyst led to the probable diagnosis of hydatic cyst. Cholecystectomy, choledochoduodenostomy, partial cystectomy and capitonnage was performed. The patient was started on 800 mg/day albendazole during postoperative period and then was discharged.

The prevalence of hereditary thrombophilia in the Trakya region of Turkey.

The prevalences of deficiencies in antithrombin III (AT III), protein C (PC), protein S (PS) and in the activated protein C (APC) resistance in the thrombotic population of the Trakya region, Turkey were investigated. 37 patients with venous thrombosis (VT) and 17 patients with arterial thrombosis (ArT) were included in this study. The mean ages of the patients with VT and ArT were 46 years (range 20-70) and 38 years (range 32-40), respectively. The activity of AT III was measured by commercially available immuno-turbidimetric assay. The activities of PC and PS were determined by coagulometric assay. The APC resistance was measured using a modified APTT-based clotting assay. Among the VT patients, there were 2 cases (5.4%) with AT III, 5 (13.51%) with PC deficiency, 5 (13.51%) with PS deficiency and 2 (5.4%) with APC resistance. In the ArT patient group, there was 1 patient (5.88%) with AT III, 3 (17.64%) with PC deficiency, 1 (5.88%) with PS deficiency and no APC resistant patients, while there was one (2.08%) with PC deficiency and one (2.08%) with APC resistance in the control group (49 persons, mean age 41 years). The relative risk of thrombosis (odds ratio) was 1.7 in the deficiency of PC and 5.6 in the deficiency of PS. The data presented suggests that the prevalences of AT III, PC and PS deficiencies causing thrombophilia in the Trakya region of Turkey are higher than in other reported studies while the APC resistance is lower than in others. Further studies including more patients would be required to clarify these discrepancies.