Mert Dumantepe

US-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis

PURPOSE We aimed to evaluate the efficacy and feasibility of ultrasonography (US)-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis. MATERIALS AND METHODS A total of 26 patients with deep venous thrombosis were prospectively selected for thrombolysis. Overall, 80.8% of the occlusions were in the lower extremities, and 19.2% were in the upper extremities. US-accelerated catheter-directed thrombolysis was performed using a recombinant human tissue plasminogen activator (alteplase), which was delivered using the EKOS EkoSonic® Endovascular System (EKOS Corporation, Bothell, Washington, USA). Postprocedure venography was repeated after the treatment, which included angioplasty and stenting if stenosis was present. RESULTS Thrombolysis was successful in 92.3% (24/26) of the patients, with complete clot lysis in 14 patients and partial clot lysis in nine patients. The mean symptom duration was 54.9±51 days (range, 6-183 days), and the mean thrombolysis infusion time was 25.3±5.3 hours (range, 16-39 hours). Pulmonary embolism was not observed; however, there were three cases of bleeding at the catheter insertion site. In three patients, the underlying lesions were successfully treated with balloon angioplasty and stent insertion. Two patients developed early recurrent thrombosis due to residual venous obstruction. CONCLUSION US-accelerated thrombolysis was demonstrated to be a safe and efficacious treatment for deep venous thrombosis in this study. The addition of US reduces the total infusion time and increases the incidence of complete lysis with a reduction in bleeding rates. Residual venous obstruction should be treated by angioplasty and stent insertion to prevent early rethrombosis.

Endovenous Laser Ablation of Incompetent Perforating Veins with 1470 nm, 400 μm Radial Fiber

OBJECTIVE To evaluate the efficacy of endovenous laser ablation (EVLA) of incompetent perforating veins (IPVs) with 1470 nm laser with 400 μm radial fiber. BACKGROUND DATA EVLA for perforating veins can be performed with insignificant postprocedural morbidity. This allows treatment to be offered to elderly patients with comorbidities that would preclude anesthesia for surgical treatment or subfascial endoscopic perforator surgery (SEPS). METHODS A total of 24 perforating veins in 16 limbs of 13 patients were treated between July 2010 and December 2011 in our clinic. Follow-up duplex scans were performed at 1 week and 1, 3, 6, and 12 months after the procedure, to determine the treatment outcome. RESULTS Of the 23 treated IPVs, 20 (86.9%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 174 J (range 105-236 J). Four of five ulcers had healed after 8 weeks in clinical-etiology-anatomy-pathophysiology (CEAP) C6 group. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. All components of the Venous Clinical Severity Score (VCSS) demonstrated significant improvements at each postprocedural visit (p<0.001 for all), except for pigmentation and compression, which exhibited variation throughout the follow-up period. CONCLUSIONS Especially in the case of liposclerotic or ulcerated skin in the affected region, EVLA of IPVs with 1470 nm diode laser is highly effective and safe, and appears to be feasible. Additionally, repeat treatment can easily be performed should recurrence of IPVs arise.

Resection of a Right Coronary Artery Aneurysm With Fistula to the Coronary Sinus

We are reporting the successful surgical management of a challenging right coronary artery aneurysm with a giant fistula into the coronary sinus. We performed fistula division, coronary sinus size reduction, and complete resection of the right coronary artery aneurysm with bypass to the posterior descending artery.

Blood Cyst of the Right Ventricle Presenting as Recurrent High Fever and Chills in an Adult

Blood cysts are uncommon primary cardiac tumors, frequently encountered in pediatric patients, but extremely rare when found in adults. Due to the considerable risks of embolization and obstruction of the blood flow, surgical removal is preferred. Herein, we report a case of blood cyst of the right ventricle, presenting as recurrent fever and chills in an adult patient.

Successful treatment of central venous catheter induced superior vena cava syndrome with ultrasound accelerated catheter-directed thrombolysis.

Superior vena cava (SVC) syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology, especially lung cancer and lymphoma. Thrombosis is becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Most patients are unresponsive to anticoagulation alone which appears to be effective only in the mildest cases. However, recent advances in catheter‐based interventions have led to the development of a variety of minimally invasive endovascular strategies to remove venous thrombus and accepted as an important first‐line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. Ultrasound accelerated catheter‐directed thrombolysis (UACDT) has been developed to rapidly and completely resolve the existing thrombus. This technique integrates high frequency, low intensity ultrasound (US) with standard CDT in order to accelerate clot dissolution, reducing treatment time and the incidence of thrombolysis‐related complications. An US wave enhances drug permeation through thrombus by disaggregating the fibrin matrix, exposing additional plasminogen receptor sites to the thrombolytic agent. The US energy affects thrombus in the entire venous segment, increasing the probability of complete thrombus clearing. We report the case of a 56‐year‐old man who presented with a 5 days history of SVC syndrome symptoms who had been receiving chemotherapy for colon cancer through a right subclavian vein port catheter. The patient successfully treated with UACDT with EkoSonic® Mach4e Endovascular device with an overnight infusion.

Normothermia is the key for the treatment of internal thoracic artery spasm.

BACKGROUND Free flow of the internal thoracic artery decreases commonly after harvesting because of spasm. Tissue heat loss is inevitable during surgery. The aim of this study was to compare the internal thoracic artery pedicle rewarming method with topical papaverine applications in different thermal conditions. METHODS Patients (n = 120) were organized in to 6 equally sized groups. The effects of topical papaverine application at room temperature, topical heated papaverine (at 37 degrees C) application, internal thoracic artery pedicle storage in normothermic conditions, pedicle storage in normothermic conditions combined with topical papaverine application, and pedicle storage in normothermic conditions combined with topical heated papaverine application were investigated. In the control group, no treatment was applied and the pedicle was stored in room temperature conditions. We measured internal thoracic artery free flows at 3 stages: at the initiation of harvesting, after total harvesting, and after antispasmodic treatment. Durations of the stages were recorded. At each stage hemodynamic parameters, tissue and core temperatures were also monitored. RESULTS Internal thoracic artery pedicle temperature significantly decreased simultaneously with the free flow after the harvesting procedure. Recovery of the physiologic temperature state, provided by storing the internal thoracic artery pedicle in normothermic conditions, improved the flow and increased the efficiency of topically applied papaverine on the vasospasm of the internal thoracic artery. CONCLUSION Topical application of heated papaverine itself does not warm pedicle tissue, but papaverine efficiency increases when the pedicle is stored in normothermic conditions. Preserving internal thoracic artery pedicles in normothermic conditions can be the preferred treatment for spasms.

Key-lock type mini-sternotomy: an alternative approach for adult cardiac operations.

An alternative technique for minimally invasive aortic valve replacement and atrial septal defect repair is described. After a 5-cm skin incision, a key-lock type sternotomy is made. Excellent exposure of the right atrium and aortic valve was achieved. The configuration of the mini-sternotomy (or the lock) limits the movement of the sternal surfaces (or the key) on the lateral and craniocaudal directions.

Ultrasound-accelerated catheter-directed thrombolysis for the management of postpartum deep venous thrombosis.

Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism, which remains an important cause of maternal morbidity and mortality. Although oral or systemic anticoagulation therapy may minimize thrombus propagation, it remains ineffective in removing thrombus burden and consequently does not prevent post‐thrombotic syndrome. A novel technique, ultrasound accelerated catheter directed thrombolysis (UACDT), has been developed to rapidly and completely resolve thrombus. While pregnancy and the postpartum period are generally considered as contraindications for thrombolysis, we demonstrate in this case study the safety and effectiveness of using UACDT to treat symptomatic, postpartum, iliofemoral deep vein thrombosis after only an overnight infusion.

Are only serum creatinine levels good enough for detecting acute kidney injury

We would like to thank Professor Ghosh et al. [1] for their response to our systematic review [2]. It is well known that in our routine cardiac surgical practice transient low-cardiac output (LCO) state following mitral valve replacement (MVR) can occur. It has often been considered a complication of cardiopulmonary bypass and related to; intolerance to cardioplegic asystolic hypoxic arrest, reperfusion injury, inadequate myocardial protection, or a cardiopulmonary bypass associated systemic inflammatory response. Transient LCO state following mitral valve replacement can also occur for several other reasons: firstly due to an embolic phenomenon, for example, air emboli after inadequate deairing; clot or particulate atheromatic emboli. Secondly, it can be due to metabolic causes such as hypoxia, hypercarbia, or electrolyte abnormalities. Thirdly, it can be related to conduction abnormalities and arrhythmias. Fourthly, it can be due to concomitant mechanical and technical failures, such as abnormal prosthetic valve function. Finally, transient low-cardiac output states can occur because of graft-flow related factors when simultaneous coronary artery bypass grafting is performed [3]. We agree with Professor Ghosh et al. that the association between Takotsubo syndrome and physiological or psychological stress [4] makes it an important differential alongside these recognized causes of low-cardiac output state following cardiac surgery.Particularly aftermitral valve replacement, as the pathognomonic pattern of left-ventricular wall motion abnormality that occurs in Takotsubo syndrome resulting in left-ventricular apical dilation may resemble sphericalization due to loss of mitral annuloventricular continuity [1]. Comparatively high estimates of the incidence of Takotsubo syndrome in patients presenting with acute coronary syndromes [4] suggest that Takotsubo syndrome is more common than previously thought, and may further implicate Takotsubo syndrome in the transient low-cardiac output syndrome that can occur after mitral valve replacement. The importance of Takotsubo syndrome after cardiac surgery needs to be better understood, and clearly further research is needed to quantify the incidenceand risk factors for this syndrome.The important case study in which Takotsubo syndrome is described for the first time after cardiac surgery by Professor Ghosh’s group [5] wasnot included inour reviewof the literature [2] as it has only recently been published and was not available at the time of our literature search. It is important to note however, that the incidence of lowcardiac output syndrome is markedly higher following mitral valve replacement when the mitral subvalvular apparatus are not preserved. Furthermore this effect, unlike Takotsubo syndrome, is often not reversible. This suggests that whilst Takotsubo syndrome may be an important differential when low-cardiac output occurs followingmitral valve replacement, the predominant cause when themitral subvalvular apparatus are not preserved is probably the disruption of annuloventricular continuity and ventricular geometry, resulting in permanent myocardial and valvular dysfunction [2].