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Aorta-right atrial tunnel is a rarely seen congenital anomaly with an unknown etiopathology. Due to its life-threatening complications, it must be treated either surgically or by transcatheterization technique as soon as possible. Planning the treatment strategy considering the relation between the aorta-right atrial tunnel and coronary arteries is of utmost importance. Herein, we report a young case of a right coronary artery ostium originating from the proximal part of aorta-right atrial tunnel and her successful treatment with a new surgical technique using a pericardial patch.

Amaç: Bu çalışma ile 1-12 aylık bebeklerde sık karşılan ağrı durumları ve annelerin bebeklerinin ağrı durumlarına yönelik geleneksel uygulamalarının belirlenmesi amaçlanmıştır. Gereçler ve Yöntem: Kesitsel tipte olan bu araştırmaya bir devlet hastanesinin çocuk polikliniğine herhangi bir nedenle başvuran 140 anne alınmıştır. Veriler araştırmacılar tarafından literatüre temellendirilerek hazırlanan soru formu ile toplanmıştır. Çalışma sonucunda elde edilen veriler SPSS 22.0 programında ve tanımlayıcı istatistikler (yüzde, frekans ve ortalama) kullanılarak değerlendirilmiştir. Bulgular: Annelerin yaş ortalaması 28.40±5.67 ve %28.6’sı lise mezunudur. Bebeklerin yaş ortalaması 6.99±3.31 ay ve %52.1’i erkektir. Bebeklerin %81.4’ünün ağrı yaşadığı, en sık karşılaşılan ağrının %67.1 ile karın ağrısı olduğu belirlenmiştir. Bebeklerinin ağrı durumunda annelerin %71.4’ü doktora gitmenin yanı sıra, %74.3’ü ağrıyı azaltmaya yönelik geleneksel bir uygulamaya başvurduğunu belirtmiştir. Bebeklerinin karın ağrısında anneler en sık karına masaj yapma (%84.5), aşı ağrısında ağrı kesici ilaç verme (%88.2), diş ağrısında ağrı kesici ilaç verme, boğaz ağrısında antibiyotik verme (%63.6), göz ağrısında göze anne sütü damlatma (%41.7) uygulamasına başvurdukları belirlenmiştir. Anneler evde kullandıkları tüm bu uygulamaların ağrıyı azaltmada etkisinin yüksek olduğunu belirtmişlerdir. Sonuç: Annelerin bebeklerinin ağrı deneyiminde evde birçok geleneksel uygulamaya başvurdukları belirlenmiştir. Ailelerin akut ağrı yönetimi ile ilgili bilgilendirilmesi, kültürel yaklaşım, yanlış bilgi ve uygulamalara yönelmesini engellemektedir. Ailelerin bu konuda desteklenmesi önemlidir.

Background A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG. Methods Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n = 3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan–Meier survival analyses of the study group and propensity score–matched control group. Results The mean age of the 3137 patients was 60 ± 9 years, and 28% (n = 885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P = .01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P = .01) showed strong multivariate associations with postoperative NE. Median CHA 2 DS 2- VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively ( P = .01). The overall mean follow-up was 4.6 ± 3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups ( P = .02). Conclusions Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.

An operation on the beating heart was planned for a 60-year-old woman who applied to our clinic with aortic stenosis, three vessel coronary artery disease and poor left ventricular function. There are reports about beating heart valve surgery perfomed alone or combined with coronary artery bypass operations using continuous retrograde coronary sinus isothermic blood perfusion in patients with poor ventricle. We performed a coronary revascularization process for three-vessel disease on the pump beating heart and aortic valve replacement under cross-clamp using continuous retrograde coronary sinus isothermic blood perfusion in the same session. She was discharged on the sixth postoperative day after an uneventful recovery. She is well and active 24 months after the operation. Valve replacement using the retrograde coronary sinus isothermic blood perfusion technique due to its protective effect on the already borderline myocardial functions in patients with poor ventricles is a useful and clinically successful method.

Introduction: Cardiac reoperations are ever increasing as invasive cardiology develops and average patient age and life expectancies increase. Patients with increased life expectancies and life qualities become symptomatic after a time due to graft insufficiencies and stenoses because atherosclerosis is inherently a continuous process. This causes an increase in referrals for reoperative procedures. Reoperations are necessary in failing prosthetic cardiac valves, in the presence of a significant paravalvular leak and for degenerated bioprostheses. It became a necessity to evaluate results of reoperations as a result of an increase in the number of such patients. In this study we evaluated the rates of morbidity, mortality and complications in our patients who underwent cardiac reoperations with respect to the results of the early period and the question whether reoperations by themselves are risk factors for morbidity and mortality or not was tried to be answered. Materials and Methods: Forty seven cardiac reoperations have been performed in our institution between January 2007 and May 2010. The patients’ demographic, operative and postoperative data were retrospectively evaluated using dossier and digitally recorded information including operation records and control forms.Results: We only observed two early mortalities (4.3%) in our study group. One patient had a combined renal, pulmonary and neurological complication that resulted in his moratlity. Two patients had gastrointestinal hemorrhage one of whom died. Total complication rate was found as 4.3%. Conclusion: Cardiac reoperations can be performed with low mortality and complication rates when indicated. Mortalities are caused by comorbidities. Until recently reoperations were accepted as a risk factor by themselves. In the current time cardiac reoperations by themselves are beginning to be no longer risk factors for mortality.

C-reactive protein (CRP) is a standard and widely used acute phase reactant. It is a prototypic marker of inflammation and an adverse event indicator. Elevated CRP levels have been found to be correlated with higher risk for potential adverse cardiac events in patients with acute myocardial infarction, stable and unstable coronary artery disease. However the relationship between presence of left ventricular thrombus (LVT) and levels of CRP have not been investigated in the patients undergoing left ventricular restorative operations. In order to investigate the correlation and seek out the ability of the predictive value of CRP levels in patients with left ventricular aneurysm (LVA), we studied operational and biochemical findings of our patients with LVA, who underwent coronary revascularization operations. We found that CRP levels do not predict presence of LVT. Key words: C-Reactive Protein; Left Ventricular Aneurysm; Left Ventricular Restoration; Coronary Revascularization., C-reaktif protein (CRP) yaygın kullanılan ve standart bir akut faz reaktanıdır. Yüksek CRP değerlerinin akut miyokard enfarktüsü, stabil ve anstabil koroner arter hastalığında ileride oluşabilecek olumsuz (advers) kardiyak olaylarda ilişkili olduğu gösterilmiştir. Ancak sol ventrikül onarımları yapılan hastalarda sol ventrikül trombüsü (SVT) ve CRP değerleri arasında bir ilişkinin varlığı araştırılmamıştır. Biz böyle bir korelasyonun var olup olmadığını ve sol ventrikül anevrizması (SVA) olan hastalardan alınan CRP değerlerinin trombüs varlığı konusundaki prediktif değerlerini araştırmak için SVA olup koroner revaskülarizasyon ameliyatına giden hastalarımızın cerrahi ve biyokimyasal verilerini gözden geçirdik. CRP değerlerinin SVT varlığı üzerinde önceden belirleyici (prediktif) değerinin olmadığını tespit ettik. Anahtar kelimeler: C-Reaktif Protein; Sol Ventrikül Anevrizması; Sol Ventrikül Onarımı; Koroner Revaskülarizasyon.

Objective To retrospectively evaluate technical success and long-term outcome of endovascular treatment in patients with iliofemoral deep vein thrombosis (DVT) due to iliac vein compression syndrome (IVCS). Materials and methods Between March 2003 and September 2006, 36 consecutive patients (26 women [72%], 10 men, mean age 50 ± 18 years) with acute or chronic iliofemoral deep vein thrombosis due to iliac vein compression syndrome were evaluated for outcome of endovascular treatment. Stent patency was estimated by using the Kaplan–Meier method. Results Technical success was achieved in 34 of 36 patients (94%). Six patients with acute or subacute thrombosis had chronic occlusion of the left common iliac vein. Rethrombosis of the stents was observed in four patients. Primary and secondary patency rates were 85 and 94% at 1 year, and 80 and 82% at 4 years. Resolution of symptoms was achieved in 17 of 20 patients (85%) with acute and subacute DVT, and 4 of 16 patients (25%) with chronic DVT. Major complication was seen in one patient (3%). Conclusion Intimal changes in the left common iliac vein are mostly chronic in nature even in patients with acute DVT secondary to IVCS. Endovascular treatment with stent placement has a high technical success rate and good long-term patency in the treatment of acute and chronic DVT due to IVCS. Symptomatic improvement seems to be better in patients with acute than chronic DVT due to IVCS.

This study determined whether prolonged QRS duration (QRSd;or =120 ms) is an independent predictor of low cardiac output syndrome (LCOS) in patients with low left ventricular (LV) ejection fraction (EF) who underwent isolated coronary artery bypass grafting (CABG). Abnormal LV systolic function places patients at greater risk for developing LCOS after isolated CABG. In patients with this form of ventricular function impairment, prolonged QRSd is associated with adverse hemodynamic effects. Clinical, operative, and outcome data from 190 consecutive patients with LVEF50% who underwent isolated CABG (mean 62 +/- 9 years of age) were retrospectively analyzed. For all patients, preoperative QRSd was determined. LCOS was the primary outcome investigated. Fifty-seven patients (30%) developed LCOS. Compared with the subgroup without LCOS, the subgroup with this syndrome had significantly larger proportions of patients with LVEF30% and prolonged QRSd. In addition, the group that developed LCOS had a longer mean QRSd (117 +/- 25 vs 102 +/- 17 ms, respectively, p = 0.00003) and a significantly higher frequency of adverse postoperative outcomes. Hospital stay was significantly longer in the subgroup with LCOS than in the subgroup without. Multivariate logistic regression analysis identified prolonged QRSd as the most significant predictor of LCOS. LVEF30%, diuretic therapy, and preoperative risk score (European System for Cardiac Operative Risk Evaluation) were also identified as independent predictors of LCOS. In conclusion, in patients with impaired LV systolic function, prolonged QRSd is a highly significant predictor of LCOS development after isolated CABG.

Sinus valsalva aneurysm is a rare condition. Most aneurysms usually originate from the right or non-coronary sinus. A few series were reported about the sinus valsalva aneurysm describing its origin, diagnostic tools and prognosis. We describe a case of a sinus valsalva aneurysm originating from the left coronary sinus that ruptured into the right atrium, diagnosed with echocardiography and cardiac computed tomography, confirmed by angiography and operational findings.

The aim of the study was to evaluate the effect that coronary artery bypass grafting (CABG) and aneurysmectomy in the same session have on QT dispersion (QTd) in moderate or severe left ventricular dysfunction.Forty-four patients underwent QT interval analyses before and 1 month after aneurysmectomy and CABG. QT interval and QTd were corrected for heart rate using the square root formula of Bazett (QTCB), the cubic root formula of Fridericia (QTCF), and the linear formula of Sagie et al (QT CS ).The mean pre- and postsurgery QTd results were 65.29 +/- 29.25 and 51.76 +/- 18.49 milliseconds, respectively; the corresponding findings for QT CF were 68.06 +/- 31.26 and 55.16 +/- 24.56 milliseconds; and the corresponding findings for QT CS were 66.53 +/- 32.22 and 51.10 +/- 18.29 milliseconds. With these 3 methods, the postoperative findings were significantly lower than the preoperative findings ( P.05 for all). In contrast, the opposite was true with the QT CB method (preoperative 71.1 +/- 65.80 vs postoperative 76.43 +/- 7.96 milliseconds, P.05).The study showed that based on the methods of Fridericia (QT CF ) and Sagie et al (QT CS ), QT intervals are significantly decreased after CABG and aneurysmectomy.

A 24-year-old woman with uncontrollable high blood pressure for 3 months had significant stenosis of the left renal artery caused by fibromuscular dysplasia (FMD). The lesion was resistant to percutaneous transluminal angioplasty at 18 atm with a semicompliant balloon. Angioplasy with a 6 x 10 mm cutting balloon (CB) caused rupture of the artery. Low-pressure balloon inflation decreased but did not stop the leak. An attempt to place a stent-graft (Jostent; Jomed, Rangendingen, Germany) failed, and a bare, 6-mm balloon-expandable stent (Express SD; Boston Scientific, MN) was deployed to seal the leak, which had decreased considerably after long-duration balloon inflation. The bleeding continued, and the patient underwent emergent surgical revascularization of the renal artery with successful placement of a 6-mm polytetrafluoroethylene bypass graft. CBs should be used very carefully in the treatment of renal artery stenosis, particularly in patients with FMD.

Pericardial fluid reflect the composition of cardiac interstitium in myocardial ischemia. This study investigated the value of the pericardial and serum myoglobin (MG) measurements for the diagnosis of perioperative myocardial infarction (MI) after coronary artery bypass grafting (CABG). Postoperative arterial and pericardial blood samples were taken in 64 subjects undergoing elective CABG allocated to two groups according to the 12-lead electrocardiogram (ECG) abnormalities observed during the first postoperative 24 h. Group 1 =normal and nonspesific ECG abnormalities, and Group 2 =perioperative Q-wave MI. The occurrence of perioperative MI was associated with a dramatic increase in both serum and pericardial cardiac troponin I (CTnI) and MG concentrations. Pericardial concentrations were higher than serum concentrations during the first postoperative 24 h in all subject. However, pericardial/serum CTnI ratio in subjects in Group 2 was not statistically different from Group 1 at the time of admission to the intensive care unit (ICU) and did not significantly change at time intervals. On the other hand, more than two-fold increase in the pericardial/serum MG ratio was determined for all patients who experienced perioperative Q-wave MI with the lowest value as 2.75, whereas only 1 of 59 patients in group 1 had the ratio higher than 2 with the highest value as 2.15 at the time of admission to the ICU. In conclusion, determination of pericardial/serum MG ratio may be a useful tool for the early diagnosis of the perioperative MI after CABG. © 2004 Elsevier Ltd. All rights reserved.

A 50-year-old man, presented with sudden onset of right leg coldness, numbness and pain for 1.5 months. It was found that the right superficial femoral artery was thrombosed, which ended at the mid-thigh level and a continued as the popliteal artery in magnetic resonance angiography. Persistence of the sciatic artery is extremely rare vascular anomaly. It is prone to undergo early atherosclerotic changes, occlusive embolism, and aneurysm formation. In this article we report a patient with acute artery occlusion developed in popliteal and crural arteries in a patient with persistent sciatic artery which was successfully treated through surgical and endovascular intervention., Elli yaşında erkek hasta, 1.5 aydır sağ bacakta ani başlayan soğukluk, hissizlik ve ağrı şikayetiyle başvurdu. Manyetik rezonans anjijyografide sağ süperfisyel femoral arterin orta uyluk seviyesinde sonlanarak popliteal arter olarak devam ettiği ve tromboze olduğu saptandı. Persistan siyatik arter çok nadir görülen vasküler bir anomalidir. Erken aterosklerotik değişiklikler, emboli ve anevrizma oluşumunda yatkınlığa neden olur. Biz bu çalışmada, popliteal ve krural arterlerinde akut arteriyel oklüzyon gelişen persistan siyatik arterli bir hastada, cerrahi ve endovasküler girişim ile başarılı bir şekilde tedavisini sunduk.

Primary tumors of the heart is rarely seen and atrial myxoma is the most common primary tumor of the heart. In this article, we present a 21-year-old male case with the history of atrial septal defect closure in another clinic who developed de novo right atrial myxoma nine months after surgery.

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We retrospectively compared the results of conventional coronary artery bypass grafting (CABG) performed on patients who showed no preoperative evidence of serious atherosclerosis of the ascending aorta with the results of the aortic no-touch technique (using coronary artery–saphenous vein composite grafts) on CABG patients who did show such evidence. From 2003 through 2012, 3,152 consecutive patients underwent isolated primary CABG at our hospital. We chose 360 for the current study. The study group (n=120) comprised patients who had undergone operation via the aortic no-touch technique. Propensity-score-matching (1:2) was used to select the control group of 240 patients who had undergone conventional CABG. Early and late survival rates, reintervention-free survival rates, and freedom from cardiac death were compared. Early and late mortality rates were similar in the study and control groups (P=0.19 vs P=0.29, respectively), as were cardiac-related death (2.5% vs 2.1%, respectively; P=0.53) and overall death (8.3% vs 7.9%, respectively; P=0.51). Overall survival rates were 91.7% vs 92.1% and freedom-from-cardiac-death rates were 97.4% vs 97.5% (P=0.71 vs P=0.78, respectively; mean follow-up period, 5.27 ± 2.51 yr). Reintervention-free survival rates were also similar (96.7% vs 98.8%, respectively; P=0.2). As a result of the similar rates of early and late survival, reintervention-free survival, and freedom from cardiac death, we conclude that the aortic no-touch technique with composite grafts might be a reasonable option in patients who have atherosclerotic ascending aorta that cannot be clamped.

To compare the efficacy of aprotinin and methylprednisolone in reducing cardiopulmonary bypass (CPB)-induced cytokine release, to evaluate the effect of myocardial cytokine release on systemic cytokine levels, and to determine the influence of cytokine release on perioperative and postoperative hemodynamics.Prospective, randomized clinical trial.University teaching hospital and clinics.Thirty patients undergoing elective coronary artery bypass graft surgery.Patients were randomly allocated into groups treated with aprotinin (n = 10) or methylprednisolone (n = 10) or into an untreated control group (n = 10). Aprotinin-treated patients received aprotinin as a high-dose regimen (6 x 10(6) KIU), and methylprednisolone-treated patients received methylprednisolone (30 mg/kg intravenously) before CPB.Patients were analyzed for hemodynamic changes and alveolar-arterial PO2 difference (AaDO2) until the first postoperative day. Plasma levels of proinflammatory cytokines (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, IL-6, and IL-8) were measured in peripheral arterial blood immediately before the induction of anesthesia, 5 minutes before CPB, 3 minutes after the start of CPB, 2 minutes after the release of the aortic cross-clamp, 1 hour after CPB, 6 hours after CPB, and 24 hours after CPB; and in coronary sinus blood immediately before CPB and 2 minutes after the release of the aortic cross-clamp. The hemodynamic parameters did not differ among the groups throughout the study. After CPB, AaDO2 significantly increased (p0.05) in all groups. A significant decrease in AaDO2 was observed in aprotinin-treated patients at 24 hours after CPB compared with the other groups (p0.05). TNF-alpha level from peripheral arterial blood significantly increased in control patients 1 hour after CPB (p0.01) and did not significantly increase in methylprednisolone-treated patients throughout the study. In all groups, IL-6 levels increased after the release of the aortic cross-clamp and reached peak values 6 hours after CPB. At 6 hours after CPB, the increase in IL-6 levels in methylprednisolone-treated patients was significantly less compared with levels measured in control patients and aprotinin-treated patients (p0.001). In control patients, IL-8 levels significantly increased 2 minutes after the release of the aortic cross-clamp (p0.05), and peak values were observed 1 hour after CPB (p0.01). IL-8 levels in control patients were significantly higher compared with patients treated with aprotinin and patients treated with methylprednisolone 1 hour after CPB (p0.05).This study showed that methylprednisolone suppresses TNF-alpha, IL-6, and IL-8 release; however, aprotinin attenuates IL-8 release alone. Methylprednisolone does not produce any additional positive hemodynamic and pulmonary effects. An improved postoperative AaDO2 was observed with the use of aprotinin.

Cardiac papillary fibroelastoma (CPF) is a pathologically benign cardiac tumor. This tumor usually arises from cardiac valves, and it is the most common cardiac valvular tumor. This usually single and pedunculated tumor should be surgically treated when the mass is mobile and the patient has experienced a prior stroke, even if the stroke has manifested as a transient ischemic attack. Surgical treatment is definitive, and no recurrences have been reported in the literature. We describe a patient who had a diagnosis of CPF while undergoing investigation for a cryptogenic stroke.

Tricuspid valve regurgitation is a rare complication of blunt thoracic trauma. In addition to the uniqueness of this condition, the diagnosis can be overlooked because of other effects related to the trauma. The literature contains approximately 100 cases of trauma-induced tricuspid regurgitation. Traumatic tricuspid valve regurgitation can be diagnosed in the early or late periods after trauma. Patients who are diagnosed early usually have severe symptoms of tricuspid regurgitation or signs of accompanying cardiac trauma. These cases require immediate surgery. Patients who are diagnosed later usually have isolated chronic tricuspid regurgitation. In most cases, this is well tolerated and the patient typically experiences few or no symptoms in the early posttrauma period. Chronic cases feature progressive dilation of the right ventricle and tricuspid annulus, and right ventricle dysfunction eventually develops. In this article, we document the combination of surgical techniques that was used to repair tricuspid valve regurgitation in a patient who was diagnosed 4 years after blunt thoracic trauma.

In patients with aneurysms of the thoracic aorta, the risks of cerebral embolism and malperfusion are increased if retrograde aortic perfusion via the femoral artery is used during repair. We describe a surgical technique used for 6 aneurysms of the thoracic descending aorta that were operated on via thoracotomy with cannulation of the ascending aorta and deep hypothermic circulatory arrest.

A 63-year-old man with severe coronary artery disease and occlusion of aortic arch branches presented with dizziness, syncope and unstable angina. He underwent a combined surgical procedure of aorto-bicarotid bypass and off-pump myocardial revascularization. The operation was successful and he had no complications during 11 months of follow-up.

We describe the successful treatment of a patient with iatrogenic acute aortic dissection including cerebral malperfusion as a complication of coronary artery surgery. After beginning cardiopulmonary bypass, a retrograde ascending aortic dissection associated with cerebral malperfusion was recognized. Systemic circulation was immediately arrested at 31 degrees C. After aortotomy, hypothermic selective antegrade cerebral perfusion was established. Replacement of the ascending aorta with coronary artery bypass grafting was performed without neurologic complications.

Hemangioma of the heart is an extremely rare benign cardiac tumor. A 61-year-old woman presented with a huge hemangioma on the right ventricle. The tumor was completely surrounding the right coronary artery. Under cardiopulmonary bypass, the right coronary artery was transected from the aortic sinus and the supplying arteries of the tumor were divided. The tumor was successfully resected, and the right coronary artery was reanastomosed to the aortic sinus.

Popliteal artery aneurysms (PAAs) can be treated successfully by surgical and endovascular methods; however, the best treatment strategy for a ruptured PAA has yet to be established. We assessed the clinical results of using saphenous vein interposition to treat ruptured PAAs in our hospital. The subjects of this study were seven men (average age 59 years, range 43–71 years), who underwent emergency surgery for a ruptured PAA at our hospital between January 2007 and November 2012. The patients were assessed after 1, 6, and 12 months, postoperatively. All included patients underwent saphenous vein graft interposition via a medial approach. No complications or graft thromboses were encountered in the immediate postoperative period. The patients were discharged after an average of 4 days postoperatively (range 3–5 days). The patients were followed up for an average of 32 months (range 2–60 months). The medium-term graft patency was 100 %. No patients suffered early or medium-term limb loss and there was no mortality. Based on our positive results, saphenous vein graft interposition should be considered as the first choice of surgical treatment for a ruptured PAA.

Objective Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal. Methods We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography. Results The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina. Conclusions Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

PURPOSE: We aimed to describe the long-term outcome of endovascular treatment of iliofemoral deep vein thrombosis in the postpartum period. MATERIALS AND METHODS: Between 2002 and 2010, 18 consecutive female patients with acute or subacute iliofemoral deep vein thrombosis in the postpartum period who had endovascular treatment were retrospectively evaluated. Treatment consisted of manual aspiration thrombectomy with or without catheter-directed thrombolysis. Stents were placed in the iliac veins, if deemed necessary. Clot removal was graded as complete (>95%), partial (50%-95%), and poor (

PURPOSE The purpose of this study was to evaluate the outcomes of ultrasound-guided femoral artery access for total percutaneous endovascular repair of abdominal and thoracic aortic aneurysms. MATERIALS AND METHODS Total percutaneous aneurysm repair of the abdominal and thoracic aorta was performed in 52 consecutive patients (46 males, 6 females; mean age, 64.6±16 years; age range, 24-93 years) in a total of 85 access arteries. Of the aortic aneurysms repaired, 33 were abdominal, and 19 were thoracic. Ultrasound- guided puncture of the access artery was performed in all patients. The access artery was closed with a Prostar XL device at the end of the procedure. RESULTS The outer diameter of the vascular sheaths or the stent graft system ranged from 14 F to 27 F. All but one patient achieved successful closure of the arterial puncture with the closure device. One patient required surgical cutdown because of device failure. Two patients required long-duration manual compression. Technical success was achieved in 49 patients (94%). Forty-five patients (87%) were discharged on the first postoperative day. There were no complications of the access arteries one day or one month postoperatively, as determined by ultrasonography and computed tomography examinations, respectively. The mean diameters of the access arteries prior to and one month after the procedure were unchanged, as demonstrated by computed tomography. CONCLUSION Ultrasound-guided puncture of the common femoral artery for percutaneous closure of the access site has a high technical success rate and a very low complication rate. The addition of ultrasound guidance decreases the difficulty of the procedure and helps to avoid some of its complications.

Purpose To evaluate the immediate and long-term outcomes of percutaneous manual aspiration thrombectomy with provisional stent placement in treating acute and subacute iliofemoral deep venous thrombosis (DVT). Materials and methods One hundred and thirty-nine consecutive patients (75 women; mean age, 51 years) with acute (n=110) or subacute (n=29) iliofemoral DVT underwent endovascular treatment (total of 148 limbs). All patients were treated with percutaneous manual aspiration thrombectomy by using large-bore guiding catheters with adjunctive catheter-directed thrombolysis and stent placement, if needed. Venography was used to grade thrombus removal. Results Thrombus removal was less than 50% in five limbs (3.4%), between 50% and 95% in 45 limbs (30.4%), and more than 95% in 98 limbs (66.2%). At least one stent was placed in 99 limbs. Recurrent thrombosis occurred in 27 patients, mostly during the first few months after the procedure. Rethromboses were more frequent among postpartum patients. One patient had a major pulmonary embolism. No major hemorrhage or procedure-related deaths occurred. Conclusion Manual aspiration thrombectomy is a safe, rapid, and effective treatment option for acute and subacute iliofemoral DVT. Hence, catheter-directed thrombolysis may not be required in a majority of patients.

PURPOSE: To report the immediate and midterm results of manual aspiration thrombectomy as the first thrombus removal method in the treatment of acute or early chronic arterial thromboembolism in the lower extremity. MATERIALS AND METHODS: Retrospective review of 40 limbs in 37 nonconsecutive patients between March 2006 and March 2008 (21 female [57%], 16 male; mean age, 67 +/- 10 years; age range, 42-84 years) who had percutaneous aspiration thrombectomy for lower limb arterial thromboembolism. Twenty-nine legs had acute ( < 14 days) and 11 legs had early chronic (15-60 days) thromboembolism. Clinical categories of limb ischemia were stage I in 12 limbs, stage IIa in 17 limbs, and stage IIb in 11 limbs. RESULTS: Technical success was achieved in 35 limbs (88%). Complete thrombus removal was achieved in 26 of 29 limbs (90%) with acute occlusions and 4 of 11 limbs (36%) with early chronic occlusions (P < 0.05, chi(2) test). Amputation-free survival rate was 100% at one month, 93% at one year, and 93% at two years with Kaplan-Meier survival analysis. Freedom from symptoms of claudication or critical limb ischemia was achieved in 31 of 39 limbs (80%) at one month and 25 of 35 limbs (71%) at one year. There were three major complications and ten minor complications. CONCLUSION: Percutaneous aspiration thrombectomy is a rapid and effective way of removing thrombus in thromboembolic occlusions of the limb arteries below the inguinal ligament. It can be used in patients with acute limb ischemia (Rutherford clinical category IIb).

A 7-year-old girl presented to the hospital with dyspnea, fatigue, and anorexia. Her family also reported significant weight loss. One year earlier, she had undergone an unsuccessful balloon aortic valvuloplasty. During the previous 3 months, she had undergone extensive empiric antibiotic treatment. Despite this treatment, her general status worsened, and she was transferred to our institution. On physical examination, the patient was pale. Her temperature was 36.7 C, and there was a harsh ejection systolic mummer and a quiet aortic diastolic murmur. Results of standard blood laboratory analyses showed a white blood cell count of 10 550 /mm, a hemoglobin level of 7.85 g/dL, a C-reactive protein level of 42 mg/dL, and a sedimentation level 23 mm/hour. Transthoracic echocardiography showed a large vegetation in the aortic valve, abscess formations in the aortic root, and an aortic stenosis and mild aortic regurgitation. The results of blood cultures were negative. At surgery, a large mycotic aneurysm (3 9 2.5 cm) was found on the ascending aorta (Fig. 1). The mycotic aneurysm of the ascending aorta and aortic valve was surgically removed (Figs. 2, 3). Paraaortic abscess formations also were shown. One annular abscess was found under the noncoronary cusp, the other one was found under the right coronary cusp. After debridement and irrigation of the abscess formations, both cavities were covered with fresh autologous pericardium. The aortic incision extended approximately 20 mm across the fibrous origin of the mitral ring, downward into the aortic leaflet of the mitral valve. The narrow aortic annulus was enlarged with a large piece of glutaraldehyde-treated autologous pericardium. After the enlargement, a 21 hydrodynamic plus mechanical valve (St. Jude Medical, Inc., St Paul, MN) was implanted in the aortic annulus. The pericardium also was used to cover the defect left from the removed aneurysm of the ascending aorta (Fig. 4). Results of intraoperative multiple cultures of the aneurysm, aortic valve, and root abscess formation were negative. Because of a persistent complete A-V block, a permanent pacemaker was implanted 21 days after surgery.

Postoperative ileus is a major gastrointestinal complication of abdominal aortic surgery leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs. In this study, we evaluated the effect of epidurally administered neostigmine on postoperative ileus after abdominal aortic surgery.We enrolled 45 patients who were scheduled for elective abdominal aortic surgery at our institution. All patients received identical general and epidural anesthesia. Before the induction of general anesthesia, an epidural catheter was placed at the T7-T8 intervertebral space, and 20 mL bupivacaine (0.5%) was injected over 15 min. Patients were randomized into two groups. Patients received a 5 mL bolus of neostigmine (1 microg/kg) diluted with normal saline (Group 1) or a 5 mL bolus of normal saline (Group 2) via an epidural catheter at the end of surgery and 8 h postoperatively. Times of bowel sounds were recorded postoperatively in the intensive care unit. Times of daily passage of flatus and defecation also were recorded.Times to the first bowel sounds and the first flatus were significantly shorter in Group 1 than they were in Group 2 (11.6 +/- 11.2 h vs 22.6 +/- 12.8 h and 21.8 +/- 15.6 h vs 36.6 +/- 19.1 h, respectively, P0.05). The times to first defecation were similar in both groups (P0.05). Nausea was more frequent in patients in Group 2 than in Group 1 (P0.05). The incidence of postoperative complications was similar between the groups (P0.05).Thoracic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of postoperative ileus after abdominal aortic surgery.

The aim of the study was to determine carotid artery intima-media thickness (IMT) in patients with rheumatic mitral stenosis (RMS). Between January 2001 and December 2003, 112 consecutive patients who had been diagnosed with RMS were screened. Patients with known cerebrovascular disease, coronary artery disease, diabetes, hypertension, left ventricular hypertrophy, hyperlipidemia, abnormal laboratory results, smoking, or age over 50 years were excluded. Forty-eight patients (43 women, 5 men, mean age 39.7 ±8.3 years) with RMS without risk factors were enrolled in the study. Age- and sex-matched healthy individuals (n = 48; 43 women, 5 men, mean age 39.6 ±8.6 years) with normal echocardiographic findings constituted the control group. Carotid IMT was determined by using a high-resolution ultrasound system equipped with a 7-MHz imaging probe (Acuson 128 XP CI) with a computer measurement software. The mean common carotid artery IMT thicknesses both in the right (0.604 ±0.112 mm vs 0.521 ±0.072 mm) and in the left side (0.581 ±0.097 mm vs 0.516 ±0.065 mm) were significantly higher in patients with RMS than in the control group (p < 0.001). Backward stepwise logistic regression analysis identified RMS as independent predictors of increased IMT (OR, 17.25 (CI, 3.99 to 76.28), p

Objective: In combined carotid-coronary artery surgery, it is important to determine patients’ neurologic status after carotid endarterectomy (CEA). An initial stroke could be exacerbated by cardiopulmonary bypass required for coronary artery bypass graft (CABG) surgery. Various monitoring methods (eg, electroencephalogram) have been used to reduce neurologic deficits during CEA under general anesthesia. However, none of the methods of determining neurologic status of patients are ideal during the time between the end of CEA and the beginning of CABG surgery. In this study, patient’s neurologic status was assessed after CEA with a wake-up test to identify stroke before CABG surgery. Design: A prospective nonrandomized case series. Setting: Single institution, university hospital. Participants: Forty-four patients with carotid artery stenosis and coronary artery disease underwent combined carotid-coronary artery surgery. Interventions: After CEA, propofol and remifentanil anesthesia was discontinued, the wake-up test was performed, and then anesthesia was reinstituted for CABG surgery. Measurements and Results: A total of 48 wake-up tests were performed in 43 patients. Two wake-up tests were performed in each of the 5 patients who underwent bilateral CEA. Postoperative stroke were seen in 2 patients. In the first patient, despite a normal wake-up test, the stroke occurred in the cerebral hemisphere contralateral to the CEA, and the patient recovered within 12 days. In the second patient, there was a positive wake-up test after CEA, and he recovered within 3 days. One patient died postoperatively because of ventricular failure. Conclusions: Although this is a case series, the authors believe that performing a neurologic examination using a wake-up test may make a contribution and increases the safety of combined surgical procedures in patients with coronary and carotid artery disease.

Large aneurysms of the ascending aorta occasionally cause severe hemodynamic disturbance by compression. We describe the case of an 18-yr-old man who presented with dyspnea and developed hemodynamic collapse during computed tomography scanning. Computed tomography during resuscitation revealed that the aneurysm was compressing both the right pulmonary artery and the left bronchus. Emergency surgery was performed, but the patient died because of generalized cerebral infarction.

Acute aortic dissection that involves the ostium of the right coronary artery is a rare occurrence, but treatment by composite graft replacement of the aortic root is a technically difficult procedure, usually involving implantation of an aortic button. We describe 2 patients with ostium of the right coronary artery severely damaged by acute aortic dissection. In both cases we used a technique that mobilized the right coronary artery sufficiently so that it could be implanted without including an aortic button.

In patients with acute bacterial endocarditis and annular abscess formation, cardiac valve replacement is associated with high perioperative mortality and morbidity. We present two patients who had had infective endocarditis and annular abscess formation in the mural leaflet region. Before replacing the mitral valve, we covered the atrium and annulus with a flap of evaginated left atrial appendix.

T A E HE REPORTED RATES of pericardial effusion after cardiac surgery are as high as 64%.1 However, it is rare for his to lead to life-threatening conditions such as cardiac arrest. t is very difficult to maintain cardiac output during cardiopulonary resuscitation (CPR) in the setting of pericardial effuion. In such cases, declining perfusion pressure primarily esults in neurologic complications, specifically anoxic brain amage, cerebrovascular accident, and/or seizures. It is uncomon to see paraplegia alone (ie, without accompanying cerebral omplications) after CPR.2 However, other predisposing facors such as diabetes, hypertension, and atherosclerotic disease f the lower extremities may contribute to an increased incience of spinal cord ischemic injury in this setting. The authors resent a rare case in which acute paraplegia developed after rolonged cardiac arrest secondary to pericardial effusion.

A 44-year-old woman was admitted to the emergency service with dyspnea, chest pain, and vomiting. Cardiac tamponade due to right ventricular penetration of a Kirschner wire was detected as a late complication of wire placement in the sternoclavicular joint. Clinicians should be aware of wire migration with cardiac penetration as a late complication of Kirschner wire placed in any part of the body.

Background Abdominal aortic aneurysm formation is among the arterial complications of Behcet's disease. Weakness and fragility of aortic walls leads to the development of arterial complications like pseudoaneurysms. Case Presentation A case of huge saccular abdominal aortic aneurysm in a young Behcet patient who was successfully treated with endovascular stent graft placement is reported, diagnostic and interventional procedures are discussed, and mid-term follow-up results are presented. Conclusions Endovascular treatment of abdominal aortic aneurysm complications of young Behcet patients who are not suitable for open surgery and need intervention could be an alternative treatment modality even without performing preprocedural angiography.