Gökhan Erol

Adding Doppler ultrasonography to the follow-up of patients with vasospastic disorder improves objectivity.

Background Assessing therapeutic efficacy and patient satisfaction objectively and quantitatively has always been a problem in patients with vasospastic disorders. We aimed to present the additive value of ultrasonographic assessment of peripheral arteries secondary to cold stimulation, as a test for treatment efficacy during follow-up. Material/Methods Arterial blood flow rates were measured from radial artery with Doppler USG in patients who presented to our department with vasospastic disorders. Ultrasonography was performed at the following intervals; before cold stimulation and at 5th, 10th, 15th, 20th minutes of cold stimulation. Patients were controlled by repeat cold stimulation test and Doppler US at the 2nd month of the treatment. Results were analyzed with SPSS for Mac 20.0 package program. Results We enrolled 46 patients in the study. All patients were male and mean age was 22.3±2.17 years. Most common symptoms were cyanosis and coldness. There were statistically significant differences between pre-treatment and post-treatment arterial blood flow rates at each measurement time point (p<0.001) except initial measurement (p>0.05). On post-treatment values, there were 10.04±0.78 cm/s increase in 5th minute, 6.25±1.39 cm/s in 10th minute, 6.43±2.13 cm/s in 15th minute, and 6.38±1.86 cm/s in 20th minute measurements. All increases at the 5 time points were statistically meaningful when compared to their pre-treatment corresponding time points (p<0.001). Conclusions Doppler flowmetry added to standard cold stimulation test for evaluating the patients with vasospastic disorders provides better and more objective results when compared to the patient-oriented subjective scoring systems.

Acute arterial thrombosis following chemotherapy in a patient with a gastric carcinoma : case report - online article

The pathogenesis of in situ thrombosis in cancer patients is not well known. Possible factors include endothelial damage, decreasing levels of anticoagulant factors and increasing levels of pro-coagulants. In the literature, the incidence of arterial thrombosis in cancer patients is reported to be 3.8%; 5-fluorouracil is mentioned as a rare causative agent, whereas cisplatin is thought to be the most common agent responsible for in situ thrombosis. In this report we present a 43-year-old male patient with bilateral popliteal artery embolism after 5-fluorouracil/cisplatin/taxotare combination chemotheraphy for gastric carcinoma. He had no additional risk factors such as smoking or any persistent organic arterial disease. He had sinus cardiac rhythm on electrocardiography and there were no abnormalities on echocardiography that could have been source of emboli. Surgical thrombectomy was performed with effective anticoagulation. After the operation, our medical oncologist discontinued 5-fluorouracil. At follow up, there was no evidence of thrombosis, with normal vascular flow rate.

How Can Follow-Up of Patients with Raynaud Phenomenon be Optimized?

Background Raynaud phenomenon (RP) is common worldwide and presents diagnostic and therapeutic difficulties. We aimed to share our experience with optimizing of patient follow-up by using the cold-stimulation test (CST). Material/Methods Data of 81 patients admitted with RP symptomatology were collected. Demographic data and symptoms were recorded. A scale was used for determining the severity of disease at pre-treatment and post-treatment. CST was performed to all patients at pre-treatment and post-treatment for assessment of treatment efficiency in follow-up. Results were analyzed with the SPSS for Mac 20.0 program. Results All the patients were male. Mean age was 22.3±2.14 (19–29). Mean duration of symptoms from onset to present was 4.59±2.85 years. There were statistically significant differences between pre-treatment and post-treatment hand temperatures measured by CST (p<0.001). However, there were no statistically significant differences between pre-treatment and post-treatment severity scores of patients (p=0.135). Conclusions To quantitatively determine the treatment efficacy, CST may be used instead of asking simple questions of patients.

Acute on Chronic Renal Failure has Worse Postoperative Outcomes than End-Stage Renal Disease Following Cardiac Surgery

Background: Renal failure is a systemic disorder and has destructive effects among all organs including cardiovascular system. The development of postoperative acute kidney injury has been recognized as one of the strongest risk factor for mortality in patients undergoing cardiac surgery.

Key points of reducing neurologic complications in frozen elephant trunk technique.

We have read the interesting article entitled “Surgical treatment of complex aneurysms and thoracic aortic dissections with the Frozen Elephant Trunk technique” carefully[1]. The authors report their initial experience with this technique in 21 patients. First of all we appreciated the authors for this nice study. We would like to add some critics about this study. There were some neurologic complications such as stroke (in one patient) and paraplegia (in two patients) in the study. Did the authors make any assessment about neurologic complications and their protection strategies? This is a very important point that should be detailed in paper. The exact mechanism of spinal cord injury in frozen elephant trunk interventions is not fully understood. Stent graft length, thromboembolism, and spinal cord ischemia time during total circulatory arrest are considered responsible factors[2]. Cerebrospinal fluid drainage is recommended for spinal cord protection strategy in current guideline (Class I, level of evidence B)[3]. Proximal aortic pressure maintenance and distal aortic perfusion are some of the other recommendations (Class IIa, level of evidence B). From this point, did the authors use any of suggested protection method? On the other hand, neurologic complications can also be associated with distal length of endovascular prosthesis. In literature, 130 mm stent length is recommended for preventing paraplegia[2]. What was the distal length of prosthesis in these patients? Did authors make any assessment about distal position of stent in patients with neurologic complications? The authors performed surgery in conventional operating room, without the use of scopes or guidewire. How can authors identify the true lumen? Wasn’t it a risk? Can mentioned neurologic complications as well as renal failure be associated with possible selection of incorrect lumen? Why didn’t authors use guidewire? Has the dissection also included both femoral arteries? Hybrid operating room doesn’t exist in many centers, however, guidewire may be used to identify true lumen. In our center, we also don’t have hybrid operating room, but we routinely use guidewire from intact femoral artery through descending thoracic aorta in retrograde way. Therefore we are able to see the true lumen directly. In conclusion, we consider that, this single stage technique is so useful especially in complex aortic pathologies. Learning curve is a reality of these novel strategies of course, but morbidity rates can be decreased with appropriate surgical strategies and known guideline recommendations.

Platelet indices may be correlated with severity of vasospastic disorders.

Background Vasospastic disorders are common worldwide. In daily practice, routine blood samples are used for several investigations. In this study we aimed to determine the possible correlations between lymphocyte count, platelet indices, and the severity of vasospastic disorders. Material/Methods Data of 102 patients admitted to our department with vasospastic disorder symptomatology were retrospectively collected. Demographic data, symptoms, and blood test results were recorded. Patients were divided into 2 groups according to their rewarming time, which is determined by the cold stimulation test. Group 1 consisted of patients with rewarming time below 20 min and Group 2 consisted of patients with rewarming time above 21 min. Demographic data and blood test results were compared between groups. Results were analyzed with the SPSS for Mac 20.0 package program. Results There was no statistically significant difference between the groups in demographic variables and symptomatology. In Group 2, mean platelet volume (MPV) and platelet distribution width (PDW) were higher than in Group 1, which was statistically significant (8.87±0.74 vs. 8.38±0.78, p=0.001 and 15.91±1.92 vs. 14.7±1.99, p=0.002, respectively). Similar to MPV and PDW, lymphocyte count was also higher in Group 2 than in Group 1 (2.28±0.65 vs. 1.90±0.68, p=0.002). Conclusions Diagnosis and grading the severity of VD is challenging, but it can be supported by the presence of increased PDW, MPV, and lymphocyte count.

Lower Extremity Post-Traumatic Lymphedema Secondary to Accidental Injection of a Veterinary Drug: Case Report

134 Lymphedema is significant disorder that can be defined as abnormal accumulation of the interstitial fluid in the intracellular space. It is closely related to lymphatic and venous pathologies. Although it is more common in females, it can affect both genders.1 This disorder can be classified into two forms, according to its etiologies. If there is not another underlying disorder, it is called as primary lymphedema, and if there is an underlying cause, it is called as secondary form.1,2

Huge Intravascular Tumor Extending to the Heart: Leiomyomatosis

Intravenous leiomyomatosis (IVL) is a rare neoplasm characterized by histologically benign-looking smooth muscle cell tumor mass, which is growing within the intrauterine and extrauterine venous system. In this report we aimed to present an unusual case of IVL, which is originating from iliac vein and extended throughout to right cardiac chambers. A 49-year-old female patient, who was treated with warfarin sodium due to right iliac vein thrombosis, was admitted to our department with intermittent dyspnea, palpitation, and dizziness. Physical examination was almost normal except bilateral pretibial edema. On magnetic resonance venography, there was an intravenous mass, which is originated from right internal iliac vein and extended into the inferior vena cava. Transthoracic echocardiography and transesophageal echocardiography revealed a huge mass extending from the inferior vena cava through the right atrium, with obvious venous occlusion. Thoracic, abdominal, and pelvic MR showed an intravascular mass, which is concordant with leiomyomatosis. Surgery was performed through median sternotomy. A huge mass with 25-cm length and 186-gr weight was excised through right atrial oblique incision, on beating heart with cardiopulmonary bypass. Histopathologic assessment was compatible with IVL. Exact strategy for the surgical treatment of IVL is still controversial. We used one-stage approach, with complete resection of a huge IVL extending from right atrium to right iliac vein. In such cases, high recurrence rate is a significant problem; therefore it should be kept in mind.

Effects of topical hypothermia on postoperative inflammatory markers in patients undergoing coronary artery bypass surgery : cardiovascular topic

Summary Background We aimed to examine the effects of topical hypothermia on inflammatory markers in patients undergoing coronary artery bypass surgery. Methods Fifty patients undergoing isolated coronary artery bypass surgery were included the study. They were randomised to two groups. Mild hypothermic cardiopulmonary bypass (28–32°C) was performed on both groups using standardised anaesthesiology and surgical techniques. Furthermore, topical cooling with 4°C saline was performed on patients in group I. We recorded peri-operative and intra-operative results of blood samples, pre-operative and postoperative outcomes of electrocardiography and echocardiography, diaphragm levels on X-ray, and the necessity of positive inotropic medication and intra-aortic balloon pump (IABP). Results Time-dependent changes in blood samples were compared between the two groups. The changes on complement 3 (C3) and TNF-α levels were more significant in group I than group II (p < 0.05 and p < 0.001, respectively). Spontaneous restoration rate of sinus rhythm was higher in group II than group I (80 vs 32%, p < 0.01). Atrial fibrillation was seen in six patients in group I and one patient in group II (p < 0.05). IABP was performed on four patients (16%) in group I (p < 0.05). Diaphragmatic paralysis was seen in seven patients in group I but not in group II (p < 0.01). Partial pericardiotomy rates were compared within the groups but there was no statistically significant difference (p > 0.05). One patient in group I died on the 18th postoperative day, but operative mortality rate was not statistically significant between the two groups (p > 0.05). Conclusions Topical hypothermia had a negative impact on inflammatory markers and postoperative morbidities.

Kommerell's Diverticulum with Aberrant Left Subclavian Artery: Original Image

A 21-year-old male who had symptoms such as chest pain, dyspnea and dysphagia, presented to our department due to worsening of his symptoms. There were no signs of ischemia on electrocardiography or abnormal findings on echocardiography. Three dimensional computerized tomography scans performed, and Kommerell’s Diverticulum with aberrant left subclavian artery was found (Figure 1-3). Despite his dyspnea and dysphagia symptoms, there was no significant esophageal or tracheal compression on computerized tomography due to diverticula, and surgical treatment was not preferred.