Mehmet Kurtoglu

Venous Thromboembolism Prophylaxis after Head and Spinal Trauma: Intermittent Pneumatic Compression Devices Versus Low Molecular Weight Heparin

Although there are alternative methods and drugs for preventing venous thromboembolism (VTE), it is not clear which modality is most suitable and efficacious for patients with severe (stable or unstable) head/spinal injures. The aim of this study was to compare intermittent pneumatic compression devices (IPC) with low-molecular-weight heparin (LMWH) for preventing VTE. We prospectively randomized 120 head/spinal traumatized patients for comparison of IPC with LMWH as a prophylaxis modality against VTE. Venous duplex color-flow Doppler sonography of the lower extremities was performed each week of hospitalization and 1 week after discharge. When there was a suspicion of pulmonary embolism (PE), patients were evaluated with spiral computed tomography. Patients were analyzed for demographic features, injury severity scores, associated injuries, type of head/spinal trauma, complications, transfusion, and incidence of deep venous thrombosis (DVT) and PE. Two patients (3.33%) from the IPC group and 4 patients (6.66%) from the LMWH group died, with their deaths due to PE. Nine other patients also succumbed, unrelated to PE. DVT developed in 4 patients (6.66%) in the IPC group and in 3 patients (5%) in the LMWH group. There was no statistically significant difference regarding a reduction in DVT, PE, or mortality between groups (p = 0.04, p > 0.05, p > 0.05, respectively). IPC can be used safely for prophylaxis of VTE in head/spinal trauma patients.

The European experience with vascular injuries

The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.

Traumatic injuries to the subclavian and axillary arteries : A 13-year review

PurposeBy reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma.MethodsWe retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002.ResultsArterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months.ConclusionSuccessful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs.

Purpose: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. Material and Methods: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. Results: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67±0.91 days. Conclusion: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Our early experience with iliofemoral vein stenting in patients with post-thrombotic syndrome.

Introduction: Venous balloon dilation and stent therapy have been proposed as effective treatments for chronic iliofemoral thrombosis. In this study, we report our experience and describe the one-year outcome and efficacy of balloon angioplasty and stenting for the treatment of post-thrombotic syndrome (PTS) in iliofemoral vein segments. Methods: From June 2011 to June 2012, 52 consecutive patients with chronic PTS (59 limbs; 75% women; median age 58 years; range: 23–76 years) referred to our unit for interventional assessment were included in the study. Treatment effects were assessed using Villalta scale, Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Questionnaire (CIVIQ)-20 for PTS, CEAP (clinical, aetiological, anatomical and pathological elements) grading and measurement of leg circumference, before and after intervention. Results: Stenting was successfully accomplished in all patients. Coagulation abnormality was identified in 21 subjects (40.3%). CEAP grades were as follows: C3 in 19 patients, C4 in 24 patients, C5 in one patient and C6 in eight patients. According to Villalta scores, three patients were mild, seven patients were moderate and 42 patients were severe PTS. VCSS, Villalta scale and CIVTQ-20 showed a significant decrease in the severity of PTS signs and symptoms (P < 0.001). The calf and middle thigh circumferences decreased significantly on both sides (P < 0.001). Conclusion: Treatment of iliac venous obstruction with balloon angioplasty and stenting appears to be a minimally invasive and safe therapeutic approach in patients with PTS offering quick symptomatic relief, good patency and minimal morbidity.

The impact of valvular oxidative stress on the development of venous stasis ulcer valvular oxidative stress and venous ulcers.

Background: It is widely believed that venous ulcers result from venous insufficiency related to venous valve damages. To further investigate the pathogenesis of venous ulcers, we compared the influence of oxidative stress in venous valvular tissue on stasis ulcer formation in patients with venous ulcers secondary to superficial venous reflux disease. Methods: Thirty-nine consecutive patients with superficial venous reflux who underwent saphenectomy were included in the study. Patients were divided into 2 groups: with healed venous ulcers (group 1, n = 15) and without ulcers (group 2, n = 24). All patients were preoperatively evaluated with duplex ultrasound scanning and their blood samples were obtained to examine leukocyte count, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) levels. All patients underwent standard above-knee saphenectomy. Extracted saphenous vein segments were from the saphenofemoral junction, the first valve along. The biochemical analysis of the valve tissues included matrix metalloproteinase (MMP)-9, MMP-2, IL-6, TNF-α, superoxide dismutase (SOD), malondialdehyde (MDA), and nitric oxide (NO) studies. Results: There was no significant difference between patients in terms of age, gender, hospital stay, and preoperative blood levels of leukocyte, IL-6, TNF-α, and CRP (P > .05). Biochemical examination of valve tissue showed that the levels of MMP-9, MMP-2, IL-6, TNF-α, SOD, MDA, and NO in patients with healing venous ulcer were higher than those of the second group. Conclusion: A higher oxidative stress in the valvular tissue may contribute to venous stasis ulcer formation.

Traumatic subclavian and axillary vessel injuries

In an analysis of medical records on upper limb vascular trauma over a 9-year period (1989–1997) at Istanbul Faculty of Medicines Surgical and Medical Emergencies Department, it was found that 28 patients required surgery for subclavian or axillary vessel injuries. Of these, 20 cases (71.4%) were the result of penetrating and 8 cases (28.5%) were the result of blunt injury. Eight patients had an associated brachial plexus lesion. Patients were treated by either primary repair (50%), saphenous vein graft interposition (41.6%), or ligation (14.2%). Overall mortality rate was 14% (four cases). No long-term vascular sequela occurred related to the vascular repair techniques. However, the long-term outcome of brachial plexus lesions was poor in four patients. Therefore, the outcome of upper limb injury is not dependent on the vascular injury which can be successfully managed. The long-term consequences are determined by the associated orthopedic, soft tissue, and nerve injuries.

Local thrombolytic therapy in acute mesenteric ischemia.

BackgroundThe aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI).MethodsFrom January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator.ResultsLTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining.ConclusionEarly intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

Iatrogenic major vascular injury during lumbar discectomy: report of three cases.

Iatrogenic vascular injury rarely occurs during lumbar disc surgery and can be fatal if it is not recognized instantly. In this paper we aim to introduce three iatrogenic vascular injuries that occurred during the lumbar disc surgery. The first case was consulted because of the sudden hypotension attack during lumbar disc surgery. The left common iliac artery and bilateral common iliac vein injuries were detected in emergency laparotomy, and repaired primarily. The second case was consulted to our clinic because of the hypotension attack at the first postoperative day. Left common iliac artery and vein injuries were diagnosed by CT angiography. Left common iliac vein was ligated and left common iliac arterial injury was repaired primarily by laparotomy. The third case was referred to our clinic for left lower extremity ischemia. Left common iliac artery injury was diagnosed by simple physical examination. Reconstruction by PTFE graft interposition was performed. The first patient died due to disseminated intravascular coagulation at the early postoperative period. Pulmonary embolus developed in the iliac vein ligated patient but was well treated by anticoagulant therapy. The last patient was discharged without any problem. Two of the patients are well on long-term follow-up.

Long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep vein thrombosis in the TROMBOTEK trial

OBJECTIVE The present study was designed to evaluate the long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep venous thrombosis (DVT). METHODS A total of 246 patients, comprising 128 men (mean age, 54.28±16.48 years) and 118 women (mean age, 50.11±16.47 years) with symptomatic lower extremity DVT, were included in this open-label, single-arm, multicenter, phase IV clinical trial conducted at 14 centers in Turkey. All patients were administered subcutaneous enoxaparin (1.5 mg/kg, once-daily) until international normalized ratio (INR) levels reached to 2 to 3, followed by oral warfarin (5 mg/d) for at least 3 months and elastic compression stockings (30-40 mm Hg). Clinical signs (leg circumference), symptoms (edema, pain, tenderness), recanalization rates upon duplex ultrasound examination, laboratory findings (D-dimer and INR levels), and postthrombotic syndrome status with CEAP classification were the efficacy parameters evaluated every 3 months during 18 months of follow-up. Safety end points included minor and major bleeding as well as serious adverse events. RESULTS Ambulatory treatment with enoxaparin plus warfarin significantly reduced physical symptoms, including tenderness, edema, pain (P<.001), and the circumference of the affected leg (P<.001). The leg circumference difference in almost all patients was <1.5 cm at the end of 18 months (P<.001). Recanalization rates for occluded iliofemoral vein were 76.1% at 3 months and 86.5% at 18 months (P<.001). An early and significant decrease obtained in D-dimer levels on day 10 continued to decline significantly until month 6 and remained unchanged afterwards (P<.001). Of four patients diagnosed with major bleeding during oral anticoagulant use, three recovered with conservative treatment (reduction in hemoglobin levels in 2 developed at visit 2 [day 10] and intracranial bleeding in 1 developed at visit 3 [day 30]), and one patient required a hysterectomy after menorrhagia developed at visit 7 (month 18). Two of the 65 (9.9%) adverse events documented were serious adverse events, but none of the serious adverse events leading to death were related to the study medications. CONCLUSION Ambulatory treatment with enoxaparin plus warfarin seems to be effective in symptomatic healing and in clinical improvement by reducing thrombus formation and organization at all levels of lower extremity venous system with DVT, without a significant major bleeding risk. Therefore, the results of our conventional conservative treatment are in line with 1A level evidence reported in the recent American College of Chest Physicians guideline.