Kutay Tasdemir

The long‐term effects of arteriovenous fistula creation on the development of pulmonary hypertension in hemodialysis patients

The aim of this prospective study was to evaluate long‐term effects of arteriovenous fistula (AVF) on the development of pulmonary arterial hypertension (PAH) and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in the patients with end‐stage renal disease (ESRD). This prospective study was performed in 20 patients with ESRD. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in all patients. After mean 23.50 ± 2.25 months, the second evaluation was performed by echocardiography. Also, the blood flow rate of AVF was measured at the second echocardiographic evaluation. Pulmonary arterial hypertension was defined as a systolic PAP above 35 mmHg at rest. Mean age of 20 patients with ESRD was 55.05 ± 13.64 years; 11 of 20 patients were males. Pulmonary arterial hypertension was detected in 6 (30%) patients before AVF creation and in 4 (20%) patients after AVF creation. Systolic PAP value was meaningfully lower after AVF creation than before AVF creation (29.95 ± 10.26 mmHg vs. 35.35 ± 7.86 mmHg, respectively, P: 0.047). However, there was no significant difference between 2 time periods in terms of presence of PAH (P>0.05). Pulmonary artery pressure did not correlate with blood flow rate of AVF and duration after AVF creation (P>0.05). In hemodialysis patients, a surgically created AVF has no significant effect on the development of PAH within a long‐term period. Similarly, blood flow rate of AVF also did not affect remarkably systolic PAP within the long‐term period.

Popliteal artery branching patterns detected by digital subtraction angiography.

PURPOSE To describe the popliteal and distal branching patterns detected by digital subtraction angiography. MATERIALS AND METHODS The popliteal branching patterns were analyzed in 535 extremities (270 right, 265 left). Of these, 226 limbs were evaluated bilaterally, while 83 were evaluated unilaterally. The branching patterns were classified according to the level of branching and the presence of hypoplasia or aplasia of the distal branches. RESULTS Four hundred and seventy-two (88.1%) limbs had a normal level of popliteal artery branching. Type IA was the most frequently encountered pattern. High division of the popliteal artery was seen in 30 (5.6%) limbs. Type IIA was the most frequently encountered pattern among these limbs. Type IIC was not seen. We encountered a new pattern characterized by high division of the peroneal artery with a trifurcation pattern and an anterior tibial artery with a proximal medial course and a distal lateral course. We called this pattern Type IID. Thirty-three (6.1%) limbs exhibited hypoplasia/aplasia of the distal branches. Type IIIA was the most frequently encountered pattern among these limbs. CONCLUSION Variations that occur in nearly 10% of patients should be understood because they may affect the choice of management strategy.

Prevalence of thromboembolic disease including superior vena cava and brachiocephalic veins

Thrombosis of the brachiocephalic veins or superior vena cava (SVC) is rare. This study was conducted to determine the prevalence and characteristics of thrombosis of brachiocephalic veins and SVC, and its association with symptomatic pulmonary embolism (PE). The prevalence of thrombosis involving the brachiocephalic veins and SVC was evaluated retrospectively at a university hospital during the 3-year period. Patients were identified by hospital records and review of computer-generated lists of of all venograms, contrast-enhanced chest computed tomography, and magnetic resonance angiograms of the upper extremity and SVC. Thrombosis of the brachiocephalic veins and SVC was diagnosed in 33 (0.03%) of 100,942 patients of all ages [(32 of 70,751 adult patients≥ 20 years; 0.04%)]. Twenty-three (70%) patients initially had secondary thrombosis with multiple risk factors: associated with malignancy in 14 (42%) patients, chronic disorders in 13 (39%) patients, central venous lines (CVL) and peripheral venous lines (PVL) in 9 (27%) patients, and thrombophilia in 10 (38%) of 26 patients. Swelling of the arm, head, and neck was present in 32 (97%) patients. Symptomatic PE developed before thrombosis being treated in 12 (36%) patients. All patients except eight (three, thrombolytic; five, thrombectomy) received anticoagulant therapy. Thrombosis of the SVC and brachiocephalic veins is an uncommon but serious complication in patients with malignancy, chronic disorders, CVL, PVL, and thrombophilia. Because it is important clinical problem with frequent PE, the patients with appropriate clinical findings should be diagnosed early with imaging tests and treated with anticoagulant drugs.

Surgical approach to the management of Brucella endocarditis.

OBJECTIVE Brucella endocarditis is a rare complication of Brucella infection; however, it is the major cause of deaths in those infected with this disease. In this study, we aim to discuss the results of seven cases who underwent surgery for Brucella endocarditis in our clinic using the knowledge gathered through the literature. METHODS We reviewed seven patients with Brucella endocarditis, who underwent surgery in our department between October 1990 and April 2007. Brucella endocarditis was diagnosed by physical examination, laboratory findings, serological tests, blood culture, transthoracic and trans-oesophageal echocardiography. All cases underwent surgery after 4-6 weeks of medical therapy. Antimicrobial treatment was maintained for an average of 6 months after surgery. The mean follow-up was 27.4 months. RESULTS The mean age was 30 years (range, 5-47 years). Four of the patients were male. Of the cases, aortic valve replacement (AVR) was performed in three, mitral valve replacement (MVR) was performed in three and combined aortic and mitral valve replacement (AVR+MVR) was performed in one patient. Pericardial tube drainage was done in one patient because of pericardial effusion and cardiac tamponade that developed 13 days after surgery. One (14.3%) of our patients died 15 days after surgery. The others were discharged. CONCLUSIONS We concluded that medical and surgical treatment had to be performed simultaneously for the successful management of Brucella endocarditis, a fatal complication of Brucella infection.

Myxomas Causing Coronary Emboli Resulting in Acute Myocardial Infarction

A 26-year-old female presented with chest pain, numbness in the legs, and electrocardiographic signs of left ventricular aneurysm and recent myocardial infarction. Transesophageal echocardiography detected a mass in each atria. Angiography demonstrated normal coronary arteries, a left ventricular aneurysm, and an apical thrombus. At surgery, myxomas were excised from both atria and the aneurysm was plicated, followed by peripheral embolectomy. The patient made a good recovery.

Does arterio-venous fistula creation affects development of pulmonary hypertension in hemodialysis patients?

Background: Pulmonary arterial hypertension (PAH) is a common complication in hemodialysis (HD) patients and its pathogenesis is not explained clearly. Arterio-venous fistulas (AVFs) creation may contribute to the development of PAH because of increased pulmonary artery blood flow. However, it was not prospectively evaluated that effect of AVF on the development of PAH. Aim: We aimed to evaluate the effects of AVF on PAH and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in HD patients. Patients and Method: The prospective study included 50 patients with end-stage renal disease. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in the patients. After mean 76.14 ± 11.37 days, the second evaluation was performed by echocardiography. Results: Before AVF creation, 17 (34%) out of 50 patients had PAH. The systolic PAP was significantly higher in the patients with PAH compared with patients without PAH (47.82 ± 9.82 mmHg vs. 30.15 ± 5.70 mmHg, respectively, p = 0.001). In the second evaluation, 19 (38%) out of 50 patients had PAH. The systolic PAP values were significantly higher in the patients with PAH compared with patients without PAH (47.63 ± 8.92 mmHg vs. 25.03 ± 7.69 mmHg, P = 0.001, respectively). There was no relationship between the blood flow rate of AVF and PAP. Conclusion: PAH is a common problem in HD patients. AVF has no significant effect on the development of PAH within a short period. Similarly, blood flow rate of AVF also did not affect remarkably the systolic PAP.

Aortic and Coronary Artery Dissection During Percutaneous Coronary Intervention: A Case Report and Review Article

Coronary artery dissection is an uncommon but potentially serious complication in percutaneous coronary interventions. We treated a 53‐year‐old female patient with right coronary spasm, which was misdiagnosed as a coronary lesion. The coronary spasm resolved with nitrate administration, but proximal coronary dissection developed during angiography. It progressed anterograde and led to inferior myocardial infarction and severe hemodynamic instability due to right coronary artery occlusion. Percutaneous intervention failed, and it was determined that coronary dissection progressed retrograde, across the truncus of the aorta. Ascending aortic grafting and coronary bypass surgery were performed. The patient recovered and was discharged after 10 days. Close cardiothoracic observation is mandatory in patient evaluation and management.

Intrathoracic Migration of a Kirschner Wire

Intrathoracic migration of a Kirschner wire is a serious complication and immediate removal of the wire is mandatory. We describe a case of Kirschner wire migration from the left shoulder to the thorax. The wire was successfully retrieved from the intrapleural cavity.

Blunt Thoracic Trauma: Analysis of 1730 Patients

Between 1978 and 1997, 1730 patients with blunt thoracic trauma were treated in our department. There were 450 females and 1280 males. The mean age was 34.3 years ranging from 2 months to 80 years. The most frequent causes of trauma were motor vehicle accidents in 1438 patients and occupational accidents in 232. Injury to multiple intrathoracic structures was noted in 986 (57%) cases. There were associated injuries to the abdomen (13.76%), the head (23.35%), and the skeletal system (22.6%). Eighty-nine percent of the blunt thoracic traumas did not require open thoracotomy but immediate use of lifesaving measures such as closed tube thoracostomy for hemothorax or pneumothorax was necessary in 1543 cases. A laparotomy was carried out in 238 patients. The most common blunt thoracic traumas requiring immediate thoracotomy were massive hemothorax (33 cases), cardiac tamponade (2 cases), and massive tracheobronchial air leak (24 cases). Surgical intervention was necessary in 22 patients with diaphragmatic rupture and in 5 patients with isolated sternal fractures. During the posttraumatic period, adult respiratory distress syndrome occurred in 71 patients, pleural thickening in 29, and pleural empyema in 21 patients. The most common causes of morbidity were atelectasis (10.06%) and pneumonia (5.32%). The mean hospital time for all patients was 15 days and the mortality rate was 5.61%.

A Fibromatosis Case Mimicking Abdominal Aorta Aneurysm

Retroperitoneal fibrosis is a rare fibrosing reactive process that may be confused with mesenteric fibromatosis. Abdominal aorta aneurysm is rare too and mostly develops secondary to Behcets disease, trauma, and infection or connective tissue diseases. Incidence of aneurysms occurring as a result of atherosclerotic changes increases in postmenopausal period. Diagnosis can be established with arteriography, tomography, or magnetic resonance imaging associated with clinical findings. Tumors and cysts should be considered in differential diagnosis. Abdominal ultrasound and contrast-enhanced computerized tomography revealed an infrarenal abdominal aorta aneurysm in a 41-year-old woman, but, on surgery, retroperitoneal fibrosis surrounding the aorta was detected. We present this interesting case because retroperitoneal fibrosis encircling the abdominal aorta can mimic abdominal aorta aneurysm radiologically.