A. Kursat Bozkurt

Emergency Endovascular Management of Pulmonary Artery Aneurysms In Behçet’s Disease: Report of Two Cases and a Review of the Literature

his report describes two patients with a known history of Behçet’s disease in whom massive hemoptysis developed from rupture of pulmonary artery aneurysms. The high recurrence rate of complications related to pulmonary artery aneurysms and even the aneurysms themselves due to inadequacy of medical therapy and the disadvantages of surgical treatment make these aneurysms candidates for endovascular management. The pulmonary artery aneurysms reported here were successfully treated with endovascular embolization using n-butyl cyanoacrylate. Pulmonary artery aneurysm embolization in Behçet’s disease has been reviewed in the light of relevant literature.

Attenuation of Ischemia/Reperfusion Injury by N-Acetylcysteine in a Rat Hind Limb Model

BACKGROUND Ischemia/reperfusion is a complex set of events with severe pathologic consequences. Reperfusion initiates both the local and systemic damage in part through rapid oxygen generation. N-acetylcysteine (NAC) is a scavenger of free radical species, inhibits neutrophil accumulation, acts as a vasodilator and also improves microcirculation. In present study, we examined the protective effect of NAC in a rat hind limb ischemia/ reperfusion model. Dimethyl-sulfoxide (DMSO), a well-known antioxidant was also tested for comparison. MATERIALS AND METHODS Ischemia was induced for 4 h by vascular clamping and followed by 1 h of reperfusion. Muscle injury was evaluated in 3 groups as a saline group (control), DMSO group, and NAC group. Plasma levels of creatine kinase, lactate dehydrogenase, thiobarbituric acid reactive substances (TBARS), and blood HCO(3), as well as muscle tissue TBARS, were measured at the end of reperfusion. Muscle tissue samples were taken for histological evaluation. RESULTS DMSO and NAC group showed significant amelioration of plasma CPK (P < 0.05, P < 0.05), plasma TBARS (P < 0.05, P < 0.05), and muscle tissue TBARS (P < 0.05, P < 0.05) compared with the control group. Similarly, neutrophil infiltration in DMSO and NAC groups were significantly less prominent than the control group (P < 0.01, P < 0.01). CONCLUSIONS These results show that NAC improved effectively ischemia reperfusion injury in a rat hind limb model.

Right atrial thrombus mimicking myxoma and bilateral pulmonary artery aneurysms in a patient with Behçet's disease--a case report.

A case of Behçets disease, in which superior vena cava syndrome was the presenting feature is reported. Magnetic resonance imaging and echocardio graphy revealed a mass lesion in the right atrium. This patient developed bilat eral pulmonary artery aneurysms postoperatively and represents one of the bizarre manifestations of Behçets disease.

Surgical treatment of Buerger's disease.

We aimed to evaluate the characteristics of 198 new patients with Buergers disease treated surgically in the last decade. We also compared these results with our former series reported in 1993. The records of patients with Buergers disease who were enrolled in an ongoing investigational protocol between 1991 and 2001 were reviewed. Sympathectomy was carried out in 161 patients and revascularization in 19 patients. The cumulative secondary patency rate was 57.9% for bypass grafts at a mean follow-up of 5.4 years. Clinical outcome following sympathectomy was considered improved in 52.3% of patients, stable in 27.8%, and worse in 19.8%. Seven major and 36 minor amputations were performed, with a limb salvage rate of 95.6%. The aggressiveness of the disease has increased compared with previous series, parallel to the expansion of cigarette consumption. Bypass surgery should be considered for patients with severe ischemia who have target vessels. Sympathectomy still has a role to improve distal flow.

Abdominal aortic aneurysm or aortic occlusive disease: role of trace element imbalance.

The nature of the relationship between atheromatous disease and degenerative aneurysm is yet to be defined. The purpose of this study was to compare tissue Fe, Cu, Zn, and thiobarbituric acid reactive substances (TBARS) levels (as a marker of lipid peroxidation) in the abdominal aorta in relation to the development of aneurysmal and occlusive disease in the infrarenal aorta. This was a prospective clinical study in an institutional referral center, in hospitalized patients. Eighty male patients who underwent surgery for abdominal aortic aneurysm (AAA) or aortic occlusive disease (AOD) were included in the study. Age, risk factors and comorbid conditions were recorded, including diabetes mellitus, hypertension, coronary artery disease, smoking, and chronic obstructive pulmonary disease. Aortic wall biopsies were collected at operation from the anterolateral section of the infrarenal aorta. Tissue Fe, Cu, Zn, and TBARS levels were determined. The mean age of the AAA group was 66.2 (56—75) years and of the AOD group 57.8 (47—72) years (p <0.001). There was a higher prevalence of hypertension in AAA patients compared to AOD patients (62.5%, 35% respectively; p <0.05). The comparison of tissue Zn levels showed no significant difference. Tissue levels of Fe, Cu, and TBARS were found to be higher in the AAA group, compared with the AOD group (p<0.001 for each). These results suggest that higher oxidative stress as a result of higher Fe and Cu levels in the AAA, compared with AOD, may be one of the contributing factors in aneurysmal formation as a result of promoted wall erosion.

Multiple pulmonary artery aneurysms due to infective endocarditis

Bilateral pulmonary artery aneurysms developed in the course of staphylococcal endocarditis in a 6-year-old girl with ventricular septal defect. Consecutive computed tomography scans revealed the progressive enlargement of one of the aneurysms. She underwent an urgent left upper lobectomy because of the impending rupture and a possible life-threatening hemorrhage. The second ipsilateral aneurysm was plicated in order to exclude the aneurysm sac. In the next operation the ventricular septal defect was closed and vegetations located on the tricuspid valve were removed. On follow-up spontaneous thrombotic resolution occurred in the right-sided aneurysms.

Tracheal reconstruction with autogenous composite nasal septal graft.

We describe lateral resection of tracheal tumors and repair of the defect with a composite graft of nasal septal mucosa and cartilage. The preliminary experience with this technique in 3 patients was satisfactory. The procedure can be used for patients who are not candidates for standard resection and end-to-end anastomosis.

The Altered Hemorheologic Parameters in Thromboangiitis Obliterans: A New Insight

The hemorheologic abnormalities were studied in patients suffering from thromboangiitis obliterans (TAO) and compared findings with those of patients suffering from critical limb ischemia because of peripheral atherosclerotic obstructive disease (PAOD) and the healthy subjects. This prospective study included 20 patients with TAO, 20 patients with PAOD, and 20 healthy subjects. Hematocrit, plasma fibrinogen, red blood cell rigidity, and blood and plasma viscosity were determined in all groups. Hematocrit values of the TAO group were significantly higher than those of the PAOD group and the control group (p<0.001 and p<0.001, respectively). BV at a shear rate of 6.00 sec-1 was higher in TAO than the PAOD and control (p<0.01 and p<0.05, respectively). BV at a shear rate of 225 sec-1 was higher in the TAO and PAOD than the control (p<0.001 and p<0.001, respectively) and also PAOD values were higher than the TAO (p<0.05). RBC rigidity was higher in the TAO and PAOD than the control (p<0.001 and p<0.05, respectively) and these values were higher in PAOD than the TAO (p<0.05). These results show the impairment in hemorheologic parameters in TAO may provide a new insight into the treatment of patients with TAO in the active period of the disease.

The Role of Polytetrafluoroethylene Graft Material in Buerger's Disease

The early and long-term results of polytetrafluoroethylene (PTFE) grafts in different anatomical locations were evaluated in 14 patients with Buergers disease (thromboangiitis obliterans). During a 10-year period, 2160 patients with peripheral vascular disease were treated and, in 258, the diagnosis of Buergers disease was made. Fourteen of these 258 patients underwent revascularization with PTFE grafts. In a follow-up period, up to 8 years patency rates were as follows: aorto/ilofemoral bypass 80%, femoropopliteal bypass 40%, femorocrural bypass 50% with a cumulative patency rate of 57.1%, and limb salvage rate of 88.9%. Because of the diverse nature and small number of the operations, the numerical results are not amenable to statistical analysis, but 88.9% limb salvage rate is satisfying in Buergers disease. To the best of our knowledge, this is the first report on the use of PTFE grafts in Buergers disease and it validates limb salvage even below the inguinal ligament.

Epidural anesthesia may attenuate lipid peroxidation during aorto-femoral surgery

PurposeTo determine the effect of epidural anesthesia (EP) on oxygenation of the chronically ischemic limb in patients undergoing aorto-femoral bypass grafting and to assess whether it produces an alteration of lipid peroxidation and antioxidant status following revascularization.MethodsIn this prospective, randomized, single-blinded study 40 ASA II or III patients undergoing elective aorto-femoral bypass grafting were allocated to receive general anesthesia (group GA,n = 20), or epidural + GA (group EP,n = 20) during surgery. Femoral venous blood-gas status, activities of the protecting antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase (GSH-px), glutathione reductase (GSH-rd), glutathione (GSH) and thiobarbituric acid-reactive substances (TBARS) as a marker of lipid peroxidation were determined in blood samples taken from the femoral vein at different intervals before and after revascularization.ResultsBefore the induction of anesthesia in group EP, femoral venous PO2 [mean (standard deviation), 95% confidence interval] increased after achieving an adequate level of blockade by EP extending to the dermatomal level of T6-8 [29.32 (4.6), 26.34–32.30 to 36.29 (4.6), 33.37–39.22 mmHg,P < 0.05]. Femoral venous PO2 was similar in both groups thereafter. In the GA group a significant increase in erythrocyte TBARS was observed immediately after restoration of blood flow when compared with baseline values [221.32 (102), 148.35-294-29 to 337.26 (123) 248.99-425.53 nmol·g−1 hemoglobin,P < 0.01] but not at any other moment. In the EP group TBARS did not increase throughout the study. Within group comparisons revealed no significant differences in GSH, GSH-px, GSH-rd and SOD.ConclusionIn patients with atherosclerotic aorto-iliac occlusive disease EP may possibly attenuate lipid peroxidation following revascularization but has no effect on antioxidant enzyme activities.RésuméObjectifDéterminer l’effet de l’anesthésie péridurale (AP) sur l’oxygénation du membre soumis à l’ischémie chez les patients qui subissent un pontage aorto-fémoral et évaluer si elle produit une altération de la peroxydation lipidique et de l’état antioxydant à la suite de la revascularisation.MéthodeUne étude prospective, randomisée et à simple insu a été menée auprès de 40 patients d’état physique ASA II ou III qui devaient subir un pontage aorto-fémoral sous anesthésie générale (groupe AG, n = 20) ou anesthésie péridurale + AG (groupe AP, n = 20). La gazométrie du sang veineux fémoral, les activités des enzymes protecteurs antioxydants superoxyde dismutase (SOD), glutathion peroxydase (GSH-px), glutathion réductase (GSH-rd), glutathion (GSH) et les substances réactives à l’acide thiobarbiturique (SRATB), comme marqueur de la peroxydation lipidique, ont été mesurés dans les échantillons sanguins prélevés de la veine fémorale à différents intervalles avant et après la revascularisation.RésultatsAvant l’induction de l’AP, la PO2 veineuse fémorale [moyenne (écart type), intervalle de confiance de 95%] s’est élevée après le blocage péridural adéquat s’étendant au niveau du dermatome T6-8 [29,32 (4,6) 26,34-32,30 à 36,29 (4,6) 33,37-39,22 mmHg, P< 0,05]. La PO2 veineuse fémorale a été similaire dans les deux groupes par la suite. Dans le groupe AG, une hausse significative d’érythrocyte SRATB, en comparaison avec les valeurs de base, a été notée immédiatement et seulement après la restauration du débit sanguin [221,32 (102) 148,35-294-29 à 337,26 (123) 248,99-425,53 nmol·g−1 hémoglobine, P < 0,01]. Dans le groupe AP, les SRATB n’ont pas augmenté pendant l’étude. Aucune différence intragroupe significative de GSH, GSH-px, GSH-rd et SOD n’a été notée.ConclusionChez les patients atteints d’occlusion aorto-iliaque, l’AP peut atténuer la peroxydation lipidique à la suite de la revascularisation, mais n’a pas d’effet sur les activités antioxydantes des enzymes.