Mustafa Aldag

Intravascular leiomyomatosis with extension into the pulmonary artery

Intravascular tumors that extend into the pulmonary artery are usually malignant sarcomas. We present images of a patient with an intravascular leiomyoma that extended into the pulmonary artery (PA). A 42-year-old female underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a benign uterine leiomyoma. At the time of surgery, the tumor was noted to involve the left internal iliac vein. A postoperative magnetic resonance imaging scan showed an intravascular mass emerging from the left internal iliac vein and extending into the inferior vena cava, right atrium (RA), and ventricle, and the main and left PA (Figure 1). At the time of surgery, a median sternotomy and midline laparotomy were performed and the left internal, external, and common iliac veins were isolated. The patient was heparinized and cardiopulmonary bypass (CPB) was initiated with cannulas placed in the ascending aorta and RA. The patient was cooled to 16 degrees centigrade and circulatory arrest was instituted. The main PA was opened and the tumor was removed from the main and left PA (Figure 2). The RA was opened as well as the left internal and common iliac veins, and the rest of the tumor was completely removed (Figure 3). During the rewarming period, the PA, RA, and iliac vein incisions were closed. The patient tolerated the procedure well and had an uncomplicated postoperative course. The CPB and circulatory arrest times were 112 and 21min, respectively. The pathology of the mass was consistent with a benign uterine leiomyoma.

Effect of nutritional status on mortality in patients undergoing coronary artery bypass grafting

OBJECTIVES The prognostic effects of poor nutritional status and cardiac cachexia on coronary artery disease (CAD) are not clearly understood. A well-accepted nutritional status parameter, the prognostic nutritional index (PNI), which was first demonstrated to be valuable in patients with cancer and those undergoing gastrointestinal surgery, was introduced to patients requiring coronary artery bypass grafting (CABG). The aim of the present study was to evaluate the prognostic value of PNI in patients with CAD undergoing CABG. METHODS We evaluated the in-hospital and long-term (3-y) prognostic effect of PNI on 644 patients with CAD undergoing CABG. Baseline characteristics and outcomes were compared among the patients by PNI and categorized accordingly: Q1, Q2, Q3, and Q4. RESULTS Patients with lower PNI had significantly higher in-hospital and long-term mortality. Patients with lower PNI levels (Q1) had higher in-hospital mortality and had 12 times higher mortality rates than those with higher PNI levels (Q4). The higher PNI group had the lower rates and was used as the reference. Long-term mortality was higher in patients with lower PNI (Q1)-4.9 times higher than in the higher PNI group (Q4). In-hospital and long-term mortality rates were similar in the non-lower PNI groups (Q2-4). CONCLUSION The present study demonstrated that PNI, calculated based on serum albumin level and lymphocyte count, is an independent prognostic factor for mortality in patients undergoing CABG.

Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes

Objective The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Outcomes of arteriovenous fistula for hemodialysis in octogenarian population

Introduction Guidelines have been recommending the use of arteriovenous fistula among the hemodialysis population, but no clear conclusion has emerged with regard to the adequate access type in octogenarians. In this paper, the outcomes of arteriovenous fistula in octogenarian cohort were presented for death-censored cumulative patency rate, complications, and patients’ survival rate. Methods A retrospective review of 88 consecutive arteriovenous fistula interventions in 70 octogenarian patients were performed at one referral institution between January 2010 and June 2014. The patients’ records were analyzed and postoperative complications were documented. Death-censored cumulative arteriovenous fistula patency rates were calculated, and Kaplan–Meier method was used to analyze patient survival for 24 months. Findings: Eighty-eight arteriovenous fistula constructions and six salvage procedures were performed in 70 octogenarians. Fifty-four (61.3%) forearm and 34 (38.7%) upper arm fistulas were created. All types of fistulas had 6-, 12-, 18-, and 24-month death-censored cumulative patency rates of 63.6%, 58.3%, 48.8%, and 41.4%, respectively. The primary failure rate was 40.9%. A total of 15 complications were documented as edema, hematoma/bleeding, infection, distal ischemia, and venous aneurysm, all of which had been treated. Patient survival rates for 12 and 24 months were 68.5% and 58.5%, respectively. Discussion and conclusion: This analysis regarding arteriovenous fistula in octogenarian end-stage renal disease patients figured out equal death-censored cumulative patency compared to nonelderly, and two-year survival rate was acceptable. This study strengthens the argument that arteriovenous fistula should be the best proper choice in selected octogenarians; older age only should not be considered as an absolute contraindication for arteriovenous fistula creation in octogenarians; and patient-based approach should be applied.

Ultrasound-Guided Superficialization of an Arteriovenous Fistula by Minimally Invasive Liposuction Technique: Letters to the Editor

Dear Editor, Arteriovenous fistula (AVF) is commonly performed and is the preferred vascular access type for hemodialysis treatment. Fistulas should be located superficially enough to allow repeated safe cannulation. Superficialization of the vein is often necessary in obese patients or those with deep veins. Multiple techniques have been described for superficialization of the fistulas, minimally invasive ultrasound-guided liposuction is one of the promising methods with shorter recovery and theoretically improved patency rates (1). Thus, this technique may be a possible alternative to traditional surgical superficialization procedures. We presented a case of a 68-year-old female patient (obese, BMI: 43.4 kg/m) with a right-sided brachiocephalic AVF created 7 weeks previously and matured properly (6.5 mm diameter and 850 mL/min flow) but cannulation was not achieved due to its deep location. The subcutaneous fat thickness varied from 8 to 12 mm at the upper arm and a minimally invasive ultrasound-guided liposuction technique was planned. The course of the cephalic vein was marked with ultrasound guidance. Under conscious sedation, local tumescent solution was used above the cephalic vein for an 18 × 2 cm area under ultrasound guidance. A stab incision was made 1 cm above the anticubital fossa and the overlying subcutaneous fat was aspirated in radial fashion above the vein with 4and 5-mm Coleman aspiration cannulas (Byron Inc., Tucson, AZ, USA) under continuous ultrasound monitoring (Figs 1–2). The subcutaneous adipose tissue was thinned and visible pulsations were felt by hand after 150 mL of lipoaspirate. A completion ultrasound was performed and no extravasation or injury was noted. The arm wrapped in a slight pressure bandage. The fistula had adequate superficialization at the third week postoperatively and was successfully accessed with two needles. Traditionally, elevation and tunneled transposition technique is the most commonly used formal FIG. 1. A stab incision was made 1 cm above the anticubital fossa. [Colour figure can be viewed at wileyonlinelibrary.com]

Acute pancreatitis after coronary artery bypass surgery treated by plasmapheresis

Acute pancreatitis (AP) is a common disorder and an important cause of morbidity and mortality. There are different causes of AP, including gallstones and excessive alcohol consumption. AP after coronary artery bypass grafting (CABG) surgery is seen less frequently but it is associated with a high mortality rate due to its atypical and misleading symptoms. Supportive treatment, pain management, and treatment of complications are used in the treatment of AP. The treatment of hypertriglyceridemia-induced pancreatitis is plasmapheresis, which is an extracorporeal separation of blood components to assist in the removal of inflammatory mediators. Here we present the case of a 60-year-old male patient who developed severe AP (Ranson Score: 6) without hypertriglyceridemia after CABG. The patient received supportive treatment, but the response to conventional therapy was not predictable. Thus, plasmapheresis was started, and the patient was treated with plasmapheresis successfully. The use of plasmapheresis in patients with this condition is a new treatment modality as far as we know. This case illustrates the efficient and safe use of the plasmapheresis treatment modality in a patient with AP without hypertriglyceridemia.

Miller–Fisher syndrome after coronary artery bypass surgery

Miller-Fisher syndrome (MFS) is an uncommon neurological disorder that is considered a variant of the Guillain-Barre syndrome (GBS). It is clinically defined by a triad of symptoms, namely ataxia, areflexia and ophthalmoplegia. These acute inflammatory polyradiculopathic syndromes can be triggered by viral infections, major surgery, pregnancy or vaccination. While the overall incidence of GBS is 1.2-2.3 per 100 000 per year, MFS is a relatively rare disorder. Only six cases of GBS after cardiac surgery have been reported, and to our knowledge, we describe the first case of MFS after coronary artery bypass surgery. Although cardiac surgery with cardiopulmonary bypass may increase the incidence of MFS and GBS, the pathological mechanism is unclear. Cardiac surgery may be a trigger for the immune-mediated response and may cause devastating complications. It is also important to be alert to de novo autoimmune and unexpected neurological disorders such as MFS after coronary bypass surgery.Summary Miller–Fisher syndrome (MFS) is an uncommon neurological disorder that is considered a variant of the Guillain–Barre syndrome (GBS). It is clinically defined by a triad of symptoms, namely ataxia, areflexia and ophthalmoplegia. These acute inflammatory polyradiculopathic syndromes can be triggered by viral infections, major surgery, pregnancy or vaccination. While the overall incidence of GBS is 1.2–2.3 per 100 000 per year, MFS is a relatively rare disorder. Only six cases of GBS after cardiac surgery have been reported, and to our knowledge, we describe the first case of MFS after coronary artery bypass surgery. Although cardiac surgery with cardiopulmonary bypass may increase the incidence of MFS and GBS, the pathological mechanism is unclear. Cardiac surgery may be a trigger for the immune-mediated response and may cause devastating complications. It is also important to be alert to de novo autoimmune and unexpected neurological disorders such as MFS after coronary bypass surgery.

An Alternative Aortotomy Technique for Aortic Valve Replacement in Porcelain Aorta

Porcelain aorta is extensive calcification of the ascending aorta that can be completely or near completely circumferential. Here we report a case of severe aortic stenosis and left anterior descending coronary osteal stenosis in a patient with a porcelain aorta. In this paper an alternative aortotomy approach; reverse “T” letter aortotomy incision is described for Type IB porcelain aorta. Patient underwent aortic valve replacement in addition coronary bypass grafting via sternotomy. The surgery and the postoperative course were uneventful and she was discharged at 7th day. This aortotomy technique prevents unnecessary and risky manipulations of extensive calcificated porcelain aorta, provides perfect exposure, and can be closed securely via dacron patch after aortic valve surgery. By the help of the described aortotomy technique, AVR can be the preferred choice in patients with porcelain aorta and multiple cardiac comorbidities requiring additional procedures, such as coronary bypass. Key words: Porcelain aorta, Aortic stenosis, Aortotomy.