Murat Bayazit

Vascular complications related to percutaneous insertion of intraaortic balloon pumps

The hemodynamic effects of intraaortic balloon pumps (IABPs) are well known. The use of IABPs is prone to many complications, including those classified as vascular. These complications are said to be more frequent with percutaneous insertion techniques. These complications and the algorithm for identifying patients who are most likely to suffer vascular complications were evaluated in a retrospective manner in a group of patients that received percutaneous IABPs. The study group consisted of 449 patients. The mean age of these patients was 53.6 +/- 12.8 years (range, 18 to 80 years), and 24.7% were female. The early mortality rate of these patients was 53.2%. The mortality for patients in whom vascular complications developed was significantly higher than that in the patients who did not suffer any vascular complications (65.7% versus 50.8%; p = 0.018). Minor or major vascular complications developed in 17.4% (n = 78) of the patients. There was no statistical difference in the frequency of complications between the patients who received a sheathless IABP and those who received a sheathed IABP. Ischemic complications occurred in 16.6% of the patients who received a sheathless IABP and in 17.6% of the patients with sheathed IABPs (p < 0.05). Diabetic patients (relative risk, 2.5), female patients (relative risk, 1.83), patients with peripheral vascular disease (relative risk, 3.69), and patients undergoing coronary artery bypass operations (relative risk, 2.08) were at increased risk for suffering vascular complications. These risk factors should be evaluated before insertion of an IABP, and routes other than percutaneous femoral insertion are preferred if the patient is IABP dependent.

Routine coronary arteriography before abdominal aortic aneurysm repair

BACKGROUND As cardiac complications constitute the principal cause of early and late morbidity and mortality after the surgical treatment of abdominal aortic aneurysm (AAA), a prospective study was planned to evaluate the effects of revascularization of coronary arteries on survival after AAA repair during early and long-term follow-up periods. PATIENTS AND METHODS A total of 125 patients underwent elective repair of AAA between 1986 and 1994. Coronary arteriography was performed in all cases. All cases with critical left anterior descending artery (LAD) lesions underwent a coronary artery bypass operation either simultaneously or shortly before AAA repair. In addition, percutaneous transluminal coronary angioplasty (PTCA) was performed for symptomatic and critical stenosis of arteries other than the LADs, or if noncritical but symptomatic stenosis of the LADs existed. Early and late follow-up data were obtained for all cases, and late-term cumulative survival rates were calculated. RESULTS Coronary artery lesions were found in 66 (53%) cases. In 24 cases, AAA repairs were performed 2.3 (mean) months after coronary artery bypass grafting (CABG), whereas in 4 cases both procedures were performed simultaneously. PTCA was performed in 4 cases 3 to 4 days prior to the abdominal surgery. Even though the coronary artery lesions were found inoperable in 7 cases, these patients underwent repair of AAA because of rapidly expanding and painful aneurysms. Early mortality rate was 4% (5 cases), in which 3 of these were from the group inoperable for CABG. A mean follow-up of 3.17 years (3 to 87 months) was achieved for all discharged patients. Cumulative survival rates for 6 months and 1, 2, 3, and 6 years were 99%, 99%, 95%, 93%, and 89%, respectively. CONCLUSIONS The results of this study emphasize the importance of coronary artery revascularization for early, and especially for late, survival after AAA repair.

Risk factors for stroke following coronary artery bypass operations.

Abstract  Background: Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8‐year period in our clinic. Methods: Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. Results: Mean age of these patients was 62.3 ± 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty‐seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. Conclusion: Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.

Is Female Gender Really a Risk Factor for Carotid Endarterectomy

BACKGROUND The aim of this study was to assess the effect of gender on mortality and morbidity in carotid endarterectomy (CEA) patients. METHODS Forty-one female and 150 male patients who underwent isolated CEA operations, between 1994 and 2007, were included in this study. To find the role of gender in isolated CEA operations, patients with a previous history of cardiac operations, coronary interventions, and a staged cardiac and/or vascular operation were excluded from the study. RESULTS In the postoperative period, one female patient (2.4%) and 8 male patients (4.9%) had neurological complications (p > 0.05). Hospital mortality rates of female and male groups were 0.0% and 2.4%, respectively (p > 0.05). Perioperative events which cause significant increase in hospital mortality were myocardial ischemia, low cardiac output, and need of intra-aortic balloon pump (p = 0.0001). Late mortality rates of female and male groups were 7.5% and 9.9%, respectively. The actuarial survival rate was 82.2 +/- 11.6% in women and 71.5 +/- 7.5% in men for a mean period of 36.4 +/- 29.1 months (p > 0.05). All the observed mortalities in the long term were cardiac-related or with other causes, no neurological deaths observed in both groups (p > 0.05). According to logistic regression analysis smoking and peripheral arterial disease were found as statistically significant risk factors for late mortality. CONCLUSION Female gender is not a risk factor for stroke or death after CEA. Women should not be excluded from the benefits of CEA and gender should not be a consideration in the decision to perform it.

Inhibition of Myointimal Proliferation by Octreotide in Canine Vein Interposition Grafts

Purpose: The aim of this study was to evaluate the efficacy of octreotide in modulating the progression of intimal hyperplasia in autogenous vein bypass grafts in a canine model. The effect of the drug on the progression of intimal hyperplasia was measured with the Gilman parameter, a measure used extensively as a wound-healing descriptor. Methods: 12 mongrel dogs were randomly and equally divided into two groups. The first group (octreotide group) was administered octreotide 20 µg/kg/day. The control group (group II) received saline solution by subcutaneous injection. Each dog had 8- to 10-cm segments of autogenous jugular vein bypassed to the femoral arteries. Quantitative data on luminel narrowing over time from intimal hyperplasia were compared from calculated Gilman parameters after image analysis of retrieved, histologically processed graft sections. Each vein graft was analyzed by computerized morphometric analysis. Results: The mean Gilman parameter for distal graft segments was 0.47 ± 0.17 mm in the control group and 0.25 ± 0.07 mm in the octreotide group 6 weeks after operation (p < 0.05). Distal graft segments between the control and octreotide groups were statistically significant. In proximal, medial and distal graft segments, the mean Gilman parameters were 0.51 ± 0.16 mm in the control group and 0.37 ± 0.18 mm in the octreotide group, the difference being statistically significant (p < 0.01). Conclusion: Octreotide significantly inhibits myointimal thickening, and these data support the efficacy of octreotide in reducing intimal hyperplasia in arterialized vein grafts during the short postoperative period. Further investigations are required to as certain whether this beneficial effect of octretide persists in the long term.

Short series of upper limb acute arterial occlusions in 4 different etiologies and review of literature

Upper limb acute arterial occlusions are uncommon, and when compared with lower limb occlusions, only a few cases have been reported. Although atrial fibrillation is the most common cause, many conditions may lead to ischemia. In this article, 8 cases of upper limb arterial ischemia due to 4 different etiologies were reported (7 brachial, 1 axillary), and the literature was reviewed.

Carotid Endarterectomy Performed After Carotid Artery Restenosis Following Stent Migration

Right carotid occlusion and left carotid stenosis were determined in a patient who had undergone a cerebrovascular accident. We performed a carotid endarterectomy for the high-risk patient who developed middle cerebral artery occlusion during stenting and a restenosis owing to stent migration.

Is Surgery Justifiable for Treatment of Small Abdominal Aortic Aneurysms

Patients who underwent elective surgery for abdominal aortic aneurysms between January 1990 and December 1996 were evaluated retrospectively. Forty-six patients (group 1) with aneurysms of less than 5 cm in diameter were compared with 121 patients (group 2) with larger aneurysms. There were no differences in age, sex, or associated pathology between the two groups. Hypertension, coronary artery disease, and chronic obstructive lung disease were the most frequently associated conditions. Hospital mortality was not significantly different; 4.3% for group 1 and 2.5% for group 2. At 7 years, the cumulative long-term survival rates for group 1 and group 2 were 97% and 90% respectively (p > 0.05). For any infrarenal aortic aneurysm, indication for surgery should be based on the rate of aneurysm expansion, development of increased aneurysm-related symptoms or complications, and patient anxiety.

Use of axillary artery to maintain cerebral perfusion in a patient requiring reconstruction of the brachiocephalic trunk and coronary arteries: Technical note☆

Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.

Carotid Disease Is a Risk Factor for Stroke in Coronary Bypass Operations

Abstract The purpose of this study was to investigate the risk of perioperative major cere‐brovascular events (MCVEs) in patients undergoing coronary artery bypass grafting (CABG) and to develop preventive therapy. After excluding the patients with marked ascending aortic atheromas and those with combined intracardiac procedures such as valve replacement and aneurysmectomy, 722 consecutive patients who had carotid artery duplex scanning (CADS) and CABG were studied. The results of the study showed the correlation of advanced age, smoking, previous major cerebrovascular event (MCVE), and severe coronary artery disease with high grade carotid artery stenosis of 80–99% (p < 0.05). A total of 13 patients had perioperative MCVE and an analysis of risk factors showed that the MCVE correlated with carotid stenosis of > 60% and reduced cardiac output requiring inotropic support (p < 0.01). Prophylactic carotid endarterectomy (CEA) in patients with 80% to 99% carotid stenosis notably decreased the incidence of MCVE (p < 0.01). and the use of the “pump off” technique instead of standard cardiopulmonary bypass decreased MCVE (p = 0.0561. On the basis of these data, prophylactic carotid endarterectomy is effective in averting perioperative MCVE in subjects with carotid stenosis of 80% to 99%. and for those with 6096 to 7996 carotid stenosis, the pump off technique decreases MCVE.