Mete Hidiroglu

Comparison of original EuroSCORE, EuroSCORE II and STS risk models in a Turkish cardiac surgical cohort

OBJECTIVES The aim of this study was to compare additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II and the Society of Thoracic Surgeons (STS) models in calculating mortality risk in a Turkish cardiac surgical population. METHODS The current patient population consisted of 428 patients who underwent isolated coronary artery bypass grafting (CABG) between 2004 and 2012, extracted from the TurkoSCORE database. Observed and predicted mortalities were compared for the additive/logistic EuroSCORE, EuroSCORE II and STS risk calculator. The area under the receiver operating characteristics curve (AUC) values were calculated for these models to compare predictive power. RESULTS The mean patient age was 74.5 ± 3.9 years at the time of surgery, and 35.0% were female. For the entire cohort, actual hospital mortality was 7.9% (n = 34; 95% confidence interval [CI] 5.4-10.5). However, the additive EuroSCORE-predicted mortality was 6.4% (P = 0.23 vs observed; 95% CI 6.2-6.6), logistic EuroSCORE-predicted mortality was 7.9% (P = 0.98 vs observed; 95% CI 7.3-8.6), EuroSCORE II- predicted mortality was 1.7% (P = 0.00 vs observed; 95% CI 1.6-1.8) and STS predicted mortality was 5.8% (P = 0.10 vs observed; 95% CI 5.4-6.2). The mean predictive performance of the analysed models for the entire cohort was fair, with 0.7 (95% CI 0.60-0.79). AUC values for additive EuroSCORE, logistic EuroSCORE, EuroSCORE II and STS risk calculator were 0.70 (95% CI 0.60-0.79), 0.70 (95% CI 0.59-0.80), 0.72 (95% CI 0.62-0.81) and 0.62 (95% CI 0.51-0.73), respectively. CONCLUSIONS EuroSCORE II significantly underestimated mortality risk for Turkish cardiac patients, whereas additive and logistic EuroSCORE and STS risk calculators were well calibrated.

Covered Stent-Graft Treatment of a Postoperative Common Carotid Artery Pseudoaneurysm

Background Extracranial carotid artery pseudoaneurysms are rare cases resulting from trauma, mycotic infection, head and neck carcinomas or complications related to their treatment. Trauma is the most common cause of carotid artery pseudoaneurysms. They can also present after surgery, most commonly following endarterectomy, which is a rare cause with an estimated incidence of 0.3–0.6%. Case Report A 26-year-old male patient was admitted with swelling in his left neck after left carotid endarterectomy. Angiography confirmed pseudoaneursym in the left carotid bulb and it was treated successfully with two heparin-bonded covered stent grafts. Conclusions Endovascular treatment of carotid pseudoaneurysms with covered stent-grafts is a safe and efficient method providing definitive arterial reconstruction. But series with longer follow-up periods are needed to evaluate patient compatibility to lifelong antiplatelet theraphy.

Single-Centre Experience with Perioperative Use of Intraaortic Balloon Pump in Cardiac Surgery

BACKGROUND Intraaortic balloon pump (IABP) is frequently used in cardiac surgery in order to prevent or treat low cardiac output syndrome. Although being widely used and forming the first line therapy in these haemodynamically unstable patients despite maximal medication, optimal timing for IABP insertion is still discussed. This retrospective study evaluates hospital outcomes of patients receiving IABP at preoperative, intraoperative and postoperative periods during cardiac surgery. MATERIALS AND METHODS Between 2006 and 2012, 2196 patients underwent open cardiac surgery in our centre. IABP was used in 121 (5.4%) patients. Nine patients had preoperative IABP insertion, 76 patients (62.8%) had intraoperative insertion to ease weaning from cardiopulmonary bypass, and 36 patients (29.8%) had postoperative insertion in the intensive care unit mainly due to refractory haemodynamic instability. Hospital outcomes of these 121 patients were analysed retrospectively. RESULTS The majority of the patients were male (men 89, 73.6% and women 32, 26.4%; mean age was 65.9±11.5 years). Among the cohort 87 (71.9%) underwent isolated coronary artery bypass surgery (CABG) and the rest (34 patients, 28.1%) were operated for valve disease with/without CABG or for CABG with carotid endarterectomy, left ventricular aneurysm repair, post myocardial infarction ventricular septal defect or pathologies involving ascending aorta. The overall hospital mortality of the whole cohort was 27.3%. Mortality rates according to IABP timing were 33.3%, 19.7% and 41.7% for pre, intra and postoperative insertion, respectively. Logistic regression analysis identified female gender, low ejection fraction (<30%), complex surgery and postoperative insertion as risk factors for mortality. CONCLUSION IABP insertion timing in cardiac surgery is crucial and many reports advocate early insertion since patient outcomes are poor for late insertions. This single centre study also confirms that the least favourable results are among patients with postoperative IABP insertion.

Sequential radial artery for coronary artery bypass grafting: Five-year follow-up and evaluation with multi-detector row computed tomography

This study was undertaken to compare early postoperative results, programmed multi-detector row computed tomography coronary angiographic patency and midterm results of revascularization by sequential radial artery grafting with those of single radial artery grafting during a five-year period. Patients were grouped as those with sequential radial artery grafts (Group A, n = 27) and single radial artery grafts (Group B, n = 26). Multi-detector row computed tomography coronary angiography was scheduled at 1 and 5 years postoperatively. Each distal anastomosis was accepted as nonfunctional if a radial artery graft was occluded proximally or there was a critical stenosis. One sequential radial artery graft and two single radial artery grafts failed in the 1-year period (p>0.05). In the 5-year period, three radial artery grafts failed in each group (p>0.05). In Group A, there was no mortality in the five-year period, but in Group B, one patient died four years after the operation due to cardiac problems (p>0.05). In addition to one death in Group B, there were three percutaneous interventions and two myocardial infarctions among the 26 patients during the five-year follow-up. In group A, among 27 patients, there were 4 percutaneous interventions and one myocardial infarction (p>0.05). Although the sample size is relatively small to be conclusive, these data suggest that sequential radial artery grafting may be considered as a method of choice for maximizing arterial graft survival and patency. Noninvasive control of sequential and single radial artery grafts with multi-detector row computed tomography is feasible with no discomfort for the patient and excellent visualization of grafts.

Saccular Pseudoaneurysm Originating From Fusiform Abdominal Aortic Aneurysm

We read with great interest the case report by Cariati et al. [1] about an acute symptomatic type IV thoracoabdominal aortic aneurysm with supra-anastomotic aneurysm formation involving the renal and visceral arteries and including a pseudoaneurysmatic sac localized in the left psoas muscle. The authors performed endovascular treatment using a two-by-two chimney-and-periscope technique. This case is unique because it presents the first case of two-by-two chimney-and-periscope treatment of symptomatic type IV thoracoabdominal aortic aneurysm and the third case of ‘‘total visceral and renal artery endo-branching’’ as the authors termed. We assume that the huge pseudoaneursymatic sac formation from fusiform aortic aneurysm, as shown in Fig. 1 in the article, is another point to be underscored in this patient [1]. A saccular pseudoaneurysm with a maximumdiameter of 8 cm arising from the proximal anastomosis of a previously inserted aorto-biiliac surgical prosthetic graft was presented [1]. The most frequently encountered type of abdominal aortic aneurysm is fusiform, whereas saccular aneurysm is comparatively rare [2]. A saccular pseudoaneurysm originating from a fusiform aneurysm, as in the authors’ case, is an extremely rare pathology. We aim to discuss this uncommon pathology, that is, saccular pseudoaneurysm originating from fusiform AAA, and include two additional cases of our own experience. Our first patient was a 66-year-old man with back and abdominal pain. He was admitted to the emergency department. His complaints had been continuing occasionally for [1 year. Laboratory parameters were in the normal range. Unenhanced computed tomography (CT) scan, which was obtained to exclude urinary calculus, showed an infrarenal AAA with a maximum diameter of 95 mm and a suspicious mass localized adjacent to the right side of the AAA and anterior to the right psoas muscle at the level of the third and fourth lumbar vertebrae (Fig. 1A). Subsequently achieved contrast-enhanced CT scan, including arterial and venous phases, showed that the suspicious mass represented a pseudoaneurysmatic sac with a maximum diameter of 40 mm (Fig. 1B). The aneurysm was treated with aorto-bifemoral stent-graft using an endovascular approach with the patient under general anaesthesia. Follow-up 5 months after the procedure was uneventful. Our second patient was an 83-year-old man with abdominal pain. He underwent magnetic resonance imaging (MRI) evaluation to exclude biliary and pancreatic pathologies. MRI showed an infrarenal AAA with a maximum diameter of 52 mm and a pseudoaneurysmatic sac localized in the left psoas muscle at the level of the third lumbar vertebra arising from the AAA with a maximum diameter of 44 mm (Fig. 2A). Subsequently, CT angiography was obtained for endovascular planning of the AAA treatment by our endovascular team. The aneurysm was treated with endovascular aortic repair with the patient M. Canyigit (&) G. Annac Department of Radiology, Ankara Ataturk Training and Research Hospital, Bilkent, 06810 Ankara, Turkey e-mail: mcanyigit@yahoo.com

Treatment of acute thoracic aortic syndromes using endovascular techniques.

PURPOSE Acute thoracic aortic syndrome (ATAS) is a novel term to define emergency aortic conditions with common clinical features and challenges. Traditional management of ATAS includes surgical replacement of the aorta and is correlated with high perioperative mortality and morbidity. We aimed to evaluate our experience and outcomes in patients presenting with ATAS, managed by endovascular techniques. METHODS This cohort consisted of 31 consecutive patients (24 males; mean age, 57.5±13.81 years; range, 19-84 years) with acute thoracic aortic pathologies who underwent endovascular repair between January 2011 and January 2015. The study was designed as a retrospective analysis of prospectively maintained data. RESULTS Complicated acute type-B aortic dissection was the most common pathology (35.5%). All aortic stent-grafts (n=37) and dissection stents (n=9) were implanted with 100% procedural success. The overall in-hospital mortality was 9.7%. The mean follow-up duration of patients who were alive at 30 days was 25.9±11.49 months (3-53 months). So far, there have been no late deaths after 30 days. CONCLUSION In the high-risk setting of ATAS, endovascular procedures come forward as novel therapeutic strategies with promising results. Endovascular repair of ATAS can be considered as a first-line treatment alternative under emergency conditions with encouraging results, particularly when conventional surgical repair cannot be implemented due to prohibitive comorbidities.

Treatment of Deep Venous Thrombosis with Percutaneous Ultrasonographic Thrombolysis Catheter

Deep venous thrombosis is a common pathology frequently managed conservatively with anticoagulant therapy alone. Unfortunately,conservative treatment may fail to achieve enough venous flow through recanalization within the thrombus. We present a 38 year old young woman with deep venous thrombosis treated with intravenous catheter mediated thrombolysis with ultrasonographic waves and had a good outcome. Catheter-directed trombolysis and pharmaco-mechanical procedures seem to be effective alternative treatment strategies to resolve symptoms in a shorter period than conventional anticoagulant theraphy. We aimed to emphasize the evolving management of deep venous thrombosis.