Impact of Preoperative Embolization on Carotid Body Tumor Surgery

OBJECTIVES

In this study, investigation of the effect of preoperative carotid body tumor embolization (CBTE) on the amount of bleeding, vascular and neurological complications in carotid body tumors was aimed.

METHODS

50 patients treated for 51 carotid body tumors in 2 clinics, between 2005 and 2020 were evaluated. Polyvinyl alcohol (PVA) embolization of the carotid body tumor was performed in 23 patients before the surgical excision. The results were compared with the remaining 28 patients, whom CBTE was not performed, in terms of neurological complications, requirement of additional vascular interventions, bleeding amount, and length of hospital stay.

RESULTS

Mean bleeding amount was significantly lower in CBTE group (406ml-217ml p<0.05). Median erythrocyte suspension (ES) transfusion was significantly lower in the CBTE group (0.3 units vs. 1.1 units, p<0.05). Neurological deficits developed in a total of 13 patients, 6 of whom were in the CBTE group and 7 in the non-CBTE group, in the early postoperative period (p=0.90). No significant difference was observed between the groups in terms of additional vascular interventions and length of hospital stay (p=0.79 and p=0.61).

CONCLUSIONS

Carotid body tumors are rarely encountered tumors. However, their surgical excision is challenging for surgeons regarding intraoperative and postoperative bleeding. This study demonstrates that preoperative CBTE significantly reduces the amount of bleeding, especially in Shamblin II/III tumors.

The low levels of bone morphogenic protein-4 and its antagonist noggin in type 2 diabetes

OBJECTIVE

Bone morphogenic protein-4 (BMP-4) is a proinflammatory cytokine which is controlled by BMP-4 antagonists. Our aim was to investigate the levels of BMP-4 and its antagonists, noggin and matrix Gla protein (MGP), in prediabetes and diabetes.

DESIGN

One hundred and forty-two type 2 diabetic, 32 prediabetic, and 58 control subjects participated in this cross-sectional study. BMP-4, noggin, and MGP were measured with the ELISA method.

RESULTS

There was a significant difference between the three groups in relation to sex, hypertension, fasting plasma glucose, HbA1c, lipid profiles, and diastolic blood pressure (p < 0.05). BMP-4 levels were significantly lower in the diabetic group compared to the control group (108.5 and 127.5 ng/mL, respectively, p < 0.001 diabetes vs. control). Noggin levels were significantly lower in the diabetic group compared to the prediabetic and control groups (10.5, 11.5, and 12.0 ng/mL, as median, respectively, p < 0.001; diabetes vs. control, p = 0.002; diabetes vs. prediabetes). BMP-4 was associated significantly with noggin in the entire study population (ß coefficient = 0.796, p < 0.001). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve was 0.708 (95% CI 0.551-0.864, p = 0.011) for BMP-4 levels. The optimal cutoff value of BMP-4 for detecting albuminuria was 118.5 ng/mL for which sensitivity was 71.4% and specificity was 66.4%.

CONCLUSIONS

BMP-4 and noggin levels were lower in the diabetic group. High BMP-4 levels were significantly associated with albuminuria. Further studies are warranted to determine the role of BMP-4 in the pathogenic processes underlying albuminuria and hyperglycemia in patients with type 2 diabetes.

Inflammation, Atrial Fibrillation and Cardiac Surgery: Current Medical and Invasive Approaches for the Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is a cardiac dysrhythmia commonly seen in clinical practice especially after cardiac surgery. It is associated with increased morbidity and mortality for the patients. The pathogenesis of AF is not exactly understood yet, but there is growing data about the relationship between AF and inflammation. Cardiac surgery itself is a big source for inflammation. It causes major surgical trauma, ischemia/reperfusion injury, hypothermia, low arterial pressure, and the equipment of cardiopulmonary bypass makes a large foreign surface thus it activates inflammatory response. There is a large number of data about the treatment options of AF and there are also strategies, which are related to reduction of inflammatory activation during cardiopulmonary bypass. In order to review the relationship between cardiac surgery, inflammation, AF and treatment strategies in patients with AF, we conducted a search through Pubmed for articles in English using the keywords: "atrial fibrillation, cardiac surgery, inflammation, medical therapy, surgical therapy, ablation therapy" from January 2012 to present. We also searched separately for each alternative treatment modality on Pubmed. To identify further articles, we also looked into related citations in review articles and commentaries. We searched thoroughly the guidelines published by the European Society of Cardiology (2016), and the American Heart Association/ American College of Cardiology/ Heart Rhythm Surgery (2014). Many studies concluded that inflammation contributes in the occurrence of AF. Inflammatory markers, such as CRP, interleukins and complements have high sensitivity and specificity for prediction of AF whether the patient having cardiac surgery or not. Betablockers, diltiazem and amiodarone are the most commonly used drugs for rate control in AF following surgery. Although there are some new therapeutic approaches to reduce postoperative inflammatory activation, such as the use of vitamins, fatty acids, statins, or technical improvements to cardiopulmonary bypass unit like miniaturized bypass circuits, heparin coating of the circuits, leukocyte filters, or various surgical approaches like off-pump coronary bypass surgery, we still need more effective strategies to reduce both postoperative inflammation and postoperative AF risk after cardiac surgery. Today we use more advanced invasive and surgical treatment strategies for AF although we need far more advanced technics to reduce perioperative inflammatory activation, which actually causes AF.

Dynamic alterations in cerebral, celiac and renal flows resulting from ascending aorta, subclavian artery and femoral artery cannulations of extracorporeal devices

INTRODUCTION

The aim of this study was to assess the relationships among cardiac output, extracorporeal blood flow, cannulation site, right (RCa) and left carotid (LCa), celiac (Ca) and renal artery (Ra) flows during extracorporeal circulation.

METHODS

A mock circulatory circuit was assembled, based on a compliant anatomical aortic model. The ascending aorta, right subclavian and femoral artery cannulations were created and flow was provided by a centrifugal pump (Cp); cardiac output was provided by a roller pump (Rp). Five volume flow rates were tested. The Rp was set at 4 L/min with no Cp flow (R⁴-C⁰) and the basic volume flow rates of the vessels were measured. The flow of the Cp was increased while the Rp flow was decreased for other measurements; R³-C¹, R²-C², R¹-C³ and R⁰-C⁴. Measurements were repeated for all cannulation sites.

RESULTS

The RCa flow rate at R⁴-C⁰ was higher compared to the R³-C¹, R²-C², R¹-C³ and R⁰-C⁴ RCa flows with subclavian cannulation. The RCa flow decreased as the Cp flow increased (p<0.05). The RCa flow with ascending aortic and femoral cannulation was higher compared to subclavian cannulation. Higher flows were obtained with subclavian cannulation in the LCa compared to the others (p<0.05). R⁴-C⁰ Ca and Ra flows were higher compared to other Ca and Ra flows with femoral cannulation. Ca and Ra flows decreased as Cp flow increased. Flows of the Ca and Ra with ascending and subclavian cannulations were not lower compared to the R⁴-C⁰ flow (p<0.05).

CONCLUSION

This study shows that prolonged extracorporeal circulation may develop flow decrease and ischemia in cerebral and abdominal organs with both subclavian and femoral cannulations.

Could the novel 'double-hole' technique be an alternative for the inflow occlusion method?

Background

Inflow occlusion on beating heart and cardiopulmonary bypass techniques have been proposed for the removal of foreign material, such as stents, catheters and mass lesions, from cardiac chambers. However, both techniques are not devoid of disadvantages and complications. In this article, we define an alternative, novel ‘double-hole’ technique, which is based on opening the right atrium without cardiopulmonary bypass .

Methods

Bovine hearts were obtained from a local supermarket. Two purse-string sutures were placed in the right atrium using 2-0 braided, non-absorbable polyester suture material, one close to the auricle, and the other close to the interatrial septum. The guidewire of a haemodialysis catheter was inserted through the superior vena cava into the right atrium and passed all the way through the right ventricle.

Results

We suggest that the double-hole technique may be useful, especially in revision cases with adhesions. Further research should be performed to document the efficacy and safety of this method.

Conclusion

We are aware that further extensive research is necessary to investigate the utility of this novel technique in contemporary cardiovascular surgery. We believe the doublehole technique has the potential to become a safe, practical and effective measure in the future.

Should we change the cannulation site for right subclavian artery cannulation? An experimental study with a newly designed cannula

BACKGROUND:

In this experimental study, we primarily aimed to show the hemodynamic effects and superiority of this newly designed cannula for perfusion compared to standard subclavian cannulation. The new cannula (Figure 1) allows bidirectional axial flow and it directly fits in the brachiocephalic trunk (innominate artery).

METHODS:

We used a cardiopulmonary bypass roller pump, reservoir, 3/8- 1/2- 1/4-inch Y-connectors and tubing set. Lines were set as seen in Figures 2, 3, 4 and 5. The anatomy of the aorta (ascending, arch, branches, descending) was mimicked, using tubing sets with different sizes and the connectors yielding similar angles and configurations. In this experimental vascular system, systemic vascular resistance was created with partial clamping of the common tubing set. The cannulation sites were created in the subclavian artery and the innominate artery. Perfusion was established with the same pump rate and the same occlusion pressures (systemic vascular resistance). The pressure readings were obtained in the right carotid artery, the left carotid artery and the left subclavian artery.

RESULTS:

These experimental models of vasculature allowed us to measure pressures in the carotid system for different cannulation set-ups, using both our newly designed double-outflow cannula, which was introduced via the innominate artery, and the standard arterial cannula, which was introduced via the subclavian artery. Higher pressure recordings were obtained in the carotid system with the new cannula introduced through innominate artery.

CONCLUSION:

Higher cerebral perfusion readings were obtained with our newly designed bidirectional cannula introduced via the innominate artery compared to standard cannulation through the right subclavian artery.

Effect of Adventitial Dissection in Brachiobasilic Arteriovenous Fistulae Opened in Children as Vascular Access for Hemodialysis on Patency and Maturation of Fistulae

Background

Recently, therapy of pediatric patients with chronic renal failure has been carried out using hemodialysis, peritoneal dialysis, or renal transplant. In this study, we prospectively investigated the role of adventitial dissection (performed on brachiobasilic arteriovenous fistulae in the antecubital area) in the patency rate, maturation, and early initiation of dialysis among pediatric cases undergoing chronic hemodialysis.

Methods

Thirty children (7 male and 23 females) were included in this study. They were operated on at the Department of Cardiovascular Surgery of Alsancak State Hospital and Dokuz Eylul University between March 2001 and June 2003. Their mean age was 12.3 ± 2.9 years (range 7-17 years), and their mean weight was 25.5 ± 7.9 kg (range 16-44 kg). Children who underwent only brachiobasilic arteriovenous fistula operation were included. Group 1 (n = 15) consisted of those who underwent adventitial dissection, and group 2 (n = 15) consisted of those not receiving the adventitial dissection procedure.

Results

The procedure was conducted by the same surgeon, and follow-up examinations were done at the Department of Pediatric Nephrology by investigators masked to treatment groups.

Conclusion

There were no significant differences in age, sex, existence of preoperative hypertension, diameter of vein measured preoperatively, and first day of dialysis between the groups. In 29 cases, a palpable thrill was noted at the operation site. Hemodialysis had been initiated after the fourth week, when the fistulae had matured. The mean duration of follow-up was 12.53 ± 8.98 months in group 1 and 11.85 ± 7.55 months in group 2 (p = .880). In group 1, one case developed fistula infection in the second month and one case developed lymphatic drainage. In group 2, one case developed early thrombosis, one case developed hematoma, and one case developed transient ischemia owing to arterial spasm in the ipsilateral limb. One case in each group developed minimal edema in the forearm, which was treated conservatively. The primary patency rate was 93.3% in both groups, whereas the secondary patency rate was 100% in group 1. Adventitial dissection performed on the vein during arteriovenous fistula formation does not result in any additional benefit with respect to fistula maturation, early initiation of dialysis, and patency. Among pediatric patients with chronic renal failure, in cases of inappropriate forearm veins, brachial arteriovenous fistulae performed with a meticulous surgical technique should be the procedure of choice because it is associated with minimal complications and a high patency rate.

Emergency surgical approach to device emboli due to migration of the atrial septal defect occluder

INTRODUCTION

Atrial septal defect (ASD) transcatheter occlusion techniques are now established as the preferred method and have become an alternative to surgery under extracorporeal circulation. In this study, we aimed to present our emergency surgical approach to cases of device embolization due to migration of the atrial septal defect occluder.

MATERIAL AND METHODS

Between June 2009 and June 2011, 6 patients underwent emergency operations due to device emboli secondary to migration of the transcatheter atrial septal defect occluder during the early period. Mean age was 25.5 years (15-45) and 3 of the patients were female (50%). The diagnosis was made via transthoracic echocardiography (TTE) preoperatively.

RESULTS

All of these 6 patients underwent emergency operations. Mean postoperative intensive care unit (ICU) stay was 2.2 days and mean hospital stay was 6 days. No early or late postoperative mortality was seen. Mean postoperative follow-up time was 19.3 months (range: 5-28 months). Early- and late-period TTE examinations showed no residual interatrial shunting. One patient developed a right atrial thrombus in the postoperative 22(nd) month as a complication of long-term follow-up. He was treated with anticoagulant therapy for 6 months with complete resolution at the TTE.

CONCLUSIONS

Transcatheter occlusion of secundum type ASD provides prominent clinical improvement, as well as a regression in dimensions of cardiac chambers. Nevertheless, this technique has drawbacks such as distal migration and residual shunts. Consequently, we think that unfavorable anatomy and device diameter are major issues in device migration. Oversizing also increases the migration risk.

Surgery for false aneurysm developing after type A acute aortic dissection

Aortic false aneurysm is life-threatening with high morbidity and mortality rates. Surgical treatment varies according to the pathologic process, infection status, and site of origin of the aneurysm. We presented a case of false aneurysm of the ascending aorta, developing after type A acute aortic dissection repair. The operation was performed with the use of deep hypothermia and circulatory arrest to avoid massive uncontrollable hemorrhage.

Surgical stimulation of angiogenesis

OBJECTIVE

The results of surgical approaches are unsatisfactory in patients with a distal arterial bed that is ineligible for revascularization. In this retrospective study, we investigated outcomes in patients who underwent surgical interventions that are reported to induce angiogenesis.

METHOD

6 patients diagnosed with thromboangiitis obliterans were included in this study. Of these 6 patients, 2 underwent femoropopliteal bypass surgery using reversed great saphenous vein as a conduit. The other 4 underwent ascending venous arterialization (bypass from the popliteal artery to the great saphenous vein at the level of medial malleolus, using reversed great saphenous vein).

RESULTS

During the early postoperative period, all of the reversed saphenous vein grafts were occluded. The mean postoperative ankle-brachial index increased from 0.33 to 0.83. During the postoperative period, intermittent claudication disappeared in all patients. Angiograms taken during the postoperative period showed evidence of neovascularization when compared to those taken during preoperative evaluation.

CONCLUSION

Wound healing is an inflammatory process that simultaneously activates angiogenesis. We propose that the improved ankle-brachial index values and neovascularization shown in our patients were associated with this inflammatory process.

Risk factors for intraaortic balloon pump use in coronary artery bypass surgery

OBJECTIVES

The study was aimed at investigating the risk factors of using an intraaortic balloon pump (IABP) in coronary artery bypass surgery and presenting the authors' clinical experience of IABP use.

MATERIAL AND METHODS

The study included 1094 patients who underwent coronary artery bypass surgery at the authors' clinic between January 2009 and December 2011. A comparison was made between 17 patients in whom an IABP was used and 1077 patients in whom it was not used.

RESULTS

An intraaortic balloon pump was used in 17 patients (1.55%) out of 1094 patients who underwent isolated coronary artery bypass surgery. The ratio of patients who had had preoperative myocardial infarction within the preceding 30 days, left main coronary artery stenosis of more than 50% and emergency surgery in Group 1 were higher than in Group 2 (p < 0.05). The total cardiopulmonary bypass time of Group 1 was found to be longer than that of Group 2 (p < 0.05). The demand for inotropics after weaning from cardiopulmonary bypass was greater in Group 1 than in Group 2 (p < 0.05). The need for reoperation (because of bleeding) was higher in Group 1 than in Group 2 (p < 0.05). The patients' stay on the intensive care unit was longer in Group 1 than in Group 2 (p < 0.05). Mortality rates were 29.4% in Group 1 and 1.2% in Group 2 (p < 0.05).

CONCLUSIONS

Preoperative myocardial infarction within the preceding 30 days, left main coronary artery stenosis of more than 50%, emergency surgery and long cardiopulmonary bypass time are important risk factors for IABP use in coronary artery bypass surgery.

Coronary surgery in patients with low ejection fraction: mid-term results

BACKGROUND

The aim of this study was to investigate the effect of preoperative low ejection fraction (≤30%) on postoperative morbidity and mortality in patients undergoing isolated on-pump coronary artery bypass grafting. We also investigated the effect of pre- and perioperative factors on survival.

METHODS

Between January 2002 and December 2009, 103 (6.2%) patients with an ejection fraction ≤30% and 1554 (93.8%) with an ejection fraction >30% underwent coronary artery bypass grafting.

RESULTS

In multivariate logistic regression analysis, cardiopulmonary bypass time, operation time, prolonged inotropic support, and intensive care unit stay were independent predictors of mortality in patients with low ejection fraction. Intensive care unit and hospital stays were significantly longer in these patients, and the postoperative mortality rate was significantly higher. Advanced age (≥70 years) influenced mortality during the follow-up of patients with low ejection fraction. Midterm survival was significantly reduced in patients with ejection fraction ≤30%. Smoking, prolonged inotropic support, and prolonged ventilatory support were independent predictors of midterm survival in patients with ejection fraction ≤30%.

CONCLUSION

On-pump coronary artery bypass grafting can be performed in patients with ejection fraction ≤30%, with reasonable mortality and morbidity rates.