Cemal Kocaaslan

Intravascular leiomyomatosis with extension into the pulmonary artery

Intravascular tumors that extend into the pulmonary artery are usually malignant sarcomas. We present images of a patient with an intravascular leiomyoma that extended into the pulmonary artery (PA). A 42-year-old female underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a benign uterine leiomyoma. At the time of surgery, the tumor was noted to involve the left internal iliac vein. A postoperative magnetic resonance imaging scan showed an intravascular mass emerging from the left internal iliac vein and extending into the inferior vena cava, right atrium (RA), and ventricle, and the main and left PA (Figure 1). At the time of surgery, a median sternotomy and midline laparotomy were performed and the left internal, external, and common iliac veins were isolated. The patient was heparinized and cardiopulmonary bypass (CPB) was initiated with cannulas placed in the ascending aorta and RA. The patient was cooled to 16 degrees centigrade and circulatory arrest was instituted. The main PA was opened and the tumor was removed from the main and left PA (Figure 2). The RA was opened as well as the left internal and common iliac veins, and the rest of the tumor was completely removed (Figure 3). During the rewarming period, the PA, RA, and iliac vein incisions were closed. The patient tolerated the procedure well and had an uncomplicated postoperative course. The CPB and circulatory arrest times were 112 and 21min, respectively. The pathology of the mass was consistent with a benign uterine leiomyoma.

Red blood cell distribution width is associated with early failure of arteriovenous fistula for haemodialysis access.

This study aimed to investigate the predictive value of red blood cell distribution width (RDW) for early failure of arteriovenous fistula (AVF) for haemodialysis access. The hospital records of those patients who underwent primary AVF creation procedures for haemodialysis between December 2010 and September 2013 were included for retrospective analysis. Of 313 patients, 195 (62%) were male and 118 (38%) were female. Mean age was 60 (range 17–90) years. Of the 313 AVF procedures performed, 229 (73%) were created at forearm (radial artery–cephalic vein), and 84 (27%) were created upperarm (antecubital, brachiocephalic, or brachiobasilic procedures). Early AVF failure was found in 61 (19%) patients. According to chi-square test, the incidence of early AVF failure was higher in patients with heart failure and peripheral artery disease (P < 0.001). According to Mann–Whitney U test, the RDW (P = 0.001) and C-reactive protein (P = 0.024) values were higher in patients with early AVF. Our data showed that preoperative RDW is a reliable parameter that can be useful in predicting the early failure of AVF.

Outcomes of arteriovenous fistula for hemodialysis in octogenarian population

Introduction Guidelines have been recommending the use of arteriovenous fistula among the hemodialysis population, but no clear conclusion has emerged with regard to the adequate access type in octogenarians. In this paper, the outcomes of arteriovenous fistula in octogenarian cohort were presented for death-censored cumulative patency rate, complications, and patients’ survival rate. Methods A retrospective review of 88 consecutive arteriovenous fistula interventions in 70 octogenarian patients were performed at one referral institution between January 2010 and June 2014. The patients’ records were analyzed and postoperative complications were documented. Death-censored cumulative arteriovenous fistula patency rates were calculated, and Kaplan–Meier method was used to analyze patient survival for 24 months. Findings: Eighty-eight arteriovenous fistula constructions and six salvage procedures were performed in 70 octogenarians. Fifty-four (61.3%) forearm and 34 (38.7%) upper arm fistulas were created. All types of fistulas had 6-, 12-, 18-, and 24-month death-censored cumulative patency rates of 63.6%, 58.3%, 48.8%, and 41.4%, respectively. The primary failure rate was 40.9%. A total of 15 complications were documented as edema, hematoma/bleeding, infection, distal ischemia, and venous aneurysm, all of which had been treated. Patient survival rates for 12 and 24 months were 68.5% and 58.5%, respectively. Discussion and conclusion: This analysis regarding arteriovenous fistula in octogenarian end-stage renal disease patients figured out equal death-censored cumulative patency compared to nonelderly, and two-year survival rate was acceptable. This study strengthens the argument that arteriovenous fistula should be the best proper choice in selected octogenarians; older age only should not be considered as an absolute contraindication for arteriovenous fistula creation in octogenarians; and patient-based approach should be applied.

Ultrasound-Guided Superficialization of an Arteriovenous Fistula by Minimally Invasive Liposuction Technique: Letters to the Editor

Dear Editor, Arteriovenous fistula (AVF) is commonly performed and is the preferred vascular access type for hemodialysis treatment. Fistulas should be located superficially enough to allow repeated safe cannulation. Superficialization of the vein is often necessary in obese patients or those with deep veins. Multiple techniques have been described for superficialization of the fistulas, minimally invasive ultrasound-guided liposuction is one of the promising methods with shorter recovery and theoretically improved patency rates (1). Thus, this technique may be a possible alternative to traditional surgical superficialization procedures. We presented a case of a 68-year-old female patient (obese, BMI: 43.4 kg/m) with a right-sided brachiocephalic AVF created 7 weeks previously and matured properly (6.5 mm diameter and 850 mL/min flow) but cannulation was not achieved due to its deep location. The subcutaneous fat thickness varied from 8 to 12 mm at the upper arm and a minimally invasive ultrasound-guided liposuction technique was planned. The course of the cephalic vein was marked with ultrasound guidance. Under conscious sedation, local tumescent solution was used above the cephalic vein for an 18 × 2 cm area under ultrasound guidance. A stab incision was made 1 cm above the anticubital fossa and the overlying subcutaneous fat was aspirated in radial fashion above the vein with 4and 5-mm Coleman aspiration cannulas (Byron Inc., Tucson, AZ, USA) under continuous ultrasound monitoring (Figs 1–2). The subcutaneous adipose tissue was thinned and visible pulsations were felt by hand after 150 mL of lipoaspirate. A completion ultrasound was performed and no extravasation or injury was noted. The arm wrapped in a slight pressure bandage. The fistula had adequate superficialization at the third week postoperatively and was successfully accessed with two needles. Traditionally, elevation and tunneled transposition technique is the most commonly used formal FIG. 1. A stab incision was made 1 cm above the anticubital fossa. [Colour figure can be viewed at wileyonlinelibrary.com]

Acute pancreatitis after coronary artery bypass surgery treated by plasmapheresis

Acute pancreatitis (AP) is a common disorder and an important cause of morbidity and mortality. There are different causes of AP, including gallstones and excessive alcohol consumption. AP after coronary artery bypass grafting (CABG) surgery is seen less frequently but it is associated with a high mortality rate due to its atypical and misleading symptoms. Supportive treatment, pain management, and treatment of complications are used in the treatment of AP. The treatment of hypertriglyceridemia-induced pancreatitis is plasmapheresis, which is an extracorporeal separation of blood components to assist in the removal of inflammatory mediators. Here we present the case of a 60-year-old male patient who developed severe AP (Ranson Score: 6) without hypertriglyceridemia after CABG. The patient received supportive treatment, but the response to conventional therapy was not predictable. Thus, plasmapheresis was started, and the patient was treated with plasmapheresis successfully. The use of plasmapheresis in patients with this condition is a new treatment modality as far as we know. This case illustrates the efficient and safe use of the plasmapheresis treatment modality in a patient with AP without hypertriglyceridemia.

An Alternative Aortotomy Technique for Aortic Valve Replacement in Porcelain Aorta

Porcelain aorta is extensive calcification of the ascending aorta that can be completely or near completely circumferential. Here we report a case of severe aortic stenosis and left anterior descending coronary osteal stenosis in a patient with a porcelain aorta. In this paper an alternative aortotomy approach; reverse “T” letter aortotomy incision is described for Type IB porcelain aorta. Patient underwent aortic valve replacement in addition coronary bypass grafting via sternotomy. The surgery and the postoperative course were uneventful and she was discharged at 7th day. This aortotomy technique prevents unnecessary and risky manipulations of extensive calcificated porcelain aorta, provides perfect exposure, and can be closed securely via dacron patch after aortic valve surgery. By the help of the described aortotomy technique, AVR can be the preferred choice in patients with porcelain aorta and multiple cardiac comorbidities requiring additional procedures, such as coronary bypass. Key words: Porcelain aorta, Aortic stenosis, Aortotomy.

Recurrent Left Atrial Botyroid Rhabdomyosarcoma

Primary heart tumors are extremely rare and their frequency ranges from approximately 0.01-0.3% in autopsy series. Nearly one quarter of all primary cardiac tumors are malignant tumors such as sarcoma. Rhabdomyosarcoma is the second most common malignant primary tumor of the heart following angiosarcoma.Primary cardiac tumors present with one or more of the symptoms of the classic triad: cardiac symptoms and signs resulting from intracardiac obstruction; signs of systemic embolization; and systemic or constitutional symptoms. The prognosis after surgery is usually excellent in case of benign tumors, but is unfortunately still limited in localized malignant diseases [Butany 2005].In this case report we present a 45-year-old female patient operated three times in 9 years because of left atrial tumor.

A Giant Mediastinal Lipoma: Case Report

ipomas are well-circumscribed mesenchymal tumors that originate from adipose tissue and are reported to represent 1.6%-2.3% of all primary mediastinal tumors. Most mediastinal lipoma are discovered incidentally. Although lipomas are the most common benign neoplasm, occurrence with in the mediastinum is uncommon. In contrast to the frequently multiple subcutaneous lipomas, intrathoracic lipoma is usually a single lesion.

Comparison Primary Failure and Primary Patency Rates of Distal Radiocephalic Arteriovenous Fistulas in Diabetic and Non Diabetic Patients

ABS TRACT Objective: The radiocephalic arteriovenous fistula (avf) at the wrist is the first choice for hemodialysis access. Several authors have reported diabetes mellitus (DM) as an independent risk factor on primary failure and patency of the fistula, also reports stating that DM is only a clinically comorbid factor. We aimed to investigate the effect of DM on primary failure and patency rates of distal radiocephalic avf. Material and Methods: 87 patients (43 diabetic and 44 non diabetic) who underwent distal radiocephalic avf operations between May 2011-January 2013 were reviewed retrospectively. Demographic findings and data about radial artery and cephalic vein were documented. Primary failure and 6 months primary patency of the fistula were also calculated retrospectively. Results: The mean cephalic vein diameters were similar but the mean radial artery diameter (2.34±0.26 mm versus 2.63±0.38 mm, p=0.0002) and the mean radial artery flow (25.05±11.8 ml/min versus 28.9±11.3 ml/min. p=0.0277) of the diabetic group were significantly lower. There were no significant differences on primary failure and primary patency rate for 6 months. Conclusion: Even though the mean radial artery diameter and flow were lower in diabetic group, there are no significant differences at primary failure and patency rates. By so we conclude that DM is not an independent risk factor on primary failure or patency rate of the fistula but may be a comorbid factor. Radiocephalic arteriovenous fistula at the wrist remains our first choice for both diabetic and non-diabetic patients.

Comparison of Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement to Improve Quality of Life in Patients >70 Years of Age with Severe Aortic Stenosis

Objective: Transcatheter aortic valve implantation has recently been used in the treatment of severe aortic valve stenosis, particularly in patients with high mortality and morbidity rates for open surgery. The purpose of this study was to compare quality of life in patients over 70 years of age undergoing surgical or transcatheter aortic valve implantation, before the procedure and in the early post-procedural period. Methods: Seventy-nine patients were included in the study, 38 (48.1%) male and 41 (51.9%) female. Mean age of patients was 74.3±5.2 (70-91) years. The surgical aortic valve replacement group consisted of 51 (64.6%) patients and the transcatheter aortic valve replacement group of 28 (35.4%). Quality of life data before the procedure and at the 3rd month postoperatively in patients aged 70 years and older undergoing surgical or transcatheter aortic valve implantation were assessed using the 36-item Short Form Health Survey form. Results: Positive increases in physical task difficulty (13.2±9.8 vs. 5.1±7.3) (P=0.001), emotional task difficulty (14.4±11.9 vs. 8.5±6.4) (P=0.035), and mental health (0.4±10.4 vs. 9.6±15.1) (P=0.001; P<0.01) scores in patients undergoing transcatheter aortic valve replacement were significantly higher compared to the surgical aortic valve replacement group. No statistically significant difference was determined between the groups in terms of pain, vitality, social function, physical function or general health scores in the preoperative and postoperative periods. Conclusion: The positive increase in quality of life parameters in the transcatheter aortic valve implantation group at the 3rd month postoperatively was significantly higher compared to the surgical aortic valve replacement group.