Sadettin Karacagil

Incidence of Deep Venous Thrombosis in Patients Undergoing Obesity Surgery

The aim of this study was to investigate prospectively the incidence of deep venous thrombosis (DVT) after surgery for morbid obesity. The series comprised 116 consecutive patients undergoing Roux-en-Y gastric bypass. The median age and body mass index were 35 years (range 19–59 years) and 42 kg/m2 (range 32–68 kg/m2), respectively. The patients were examined with duplex ultrasonography pre- and postoperatively. No patient had any symptoms or signs of DVT postoperatively, and ultrasonography showed no signs of thrombosis in iliac, femoral, and popliteal veins in any of the patients. Two patients (1.7%) had a thrombus in the peroneal vein of one leg. Repeated ultrasonographic investigation after 1 week showed complete resolution of both. One patient with a previously unknown activated protein C resistance had an angiographically confirmed minor pulmonary embolus. The incidence of venous thromboembolism after obesity surgery seems to be low, and obesity as a risk factor for thromboembolic disease might have been overestimated in the past.

The use of below-knee percutaneous transluminal angioplasty in arterial occlusive disease causing chronic critical limb ischemia.

PurposeTo determine the efficacy, safety and long-term results of crural artery percutaneous transluminal angioplasty (PTA) in limbs with chronic critical limb ischemia (CLI).MethodsPatients undergoing crural artery PTA due to CLI were followed at regular clinic visits with ankle brachial pressure index (ABPI) measurements. PTA of the crural arteries was attempted either alone (n=39) or in combination with PTA of the superficial and/or popliteal artery (n=55) in 86 limbs (82 patients and 94 procedures) presenting with CLI. The ages of patients ranged from 37 to 94 years (mean 72 years). The indications for PTA were rest pain in 10 and ulcer/gangrene in 84 limbs.ResultsA technically successful PTA with at least one crural level was achieved in 88% of cases (n=83). Cumulative primary clinical success rates at 6, 12, 24, and 36 months were 55%, 51%, 36%, and 36%, respectively. Cumulative secondary clinical success and limb salvage rates at 36 months were 44% and 72%, respectively.ConclusionPTA of the crural arteries might be considered the primary choice of treatment in patients with CLI and distal lesions with localized stenosis or segmental short occlusions.

Value of duplex scanning in evaluation of crural and foot arteries in limbs with severe lower limb ischaemia : a prospective comparison with angiography

OBJECTIVES To compare Duplex scanning with angiography for evaluation of crural and pedal arteries in limbs with lower limb ischaemia. DESIGN The findings obtained during Duplex scanning and angiography were prospectively compared in a blinded manner. SETTING Departments of Surgery, Diagnostic Radiology and Clinical Physiology, University Hospital. MATERIALS Duplex scanning and selective angiography of femoropopliteal, crural and foot arteries were performed in 40 limbs (38 patients, 480 segments) with intermittent claudication (n = 6), rest pain (n = 13) and ulcer/gangrene (n = 19). Each arterial segment were graded into four categories: normal, < or = 50% diameter reduction, > 50% diameter reduction and occlusion. Pedal arteries were evaluated as patency or occlusion of dorsal pedal artery and plantar arch. CHIEF OUTCOME MEASURES Accuracy (AC), sensitivity (SE), specificity (SP), positive predictive (PPV), negative predictive (NPV) and kappa values. MAIN RESULTS The Duplex scanning of the tibioperoneal trunk, crural and pedal arteries had an accuracy of 80% (kappa = 0.6). The SE, SP, PPV and NPV values were 83%, 77%, 79% and 81%, respectively. The SP was relatively low for the peroneal artery (58%) compared to the others. CONCLUSIONS The results demonstrate the feasibility and reliability of Duplex scanning in detecting crural and pedal artery lesions in lower limbs with severe ischaemia.

Comparative analysis of patency, limb salvage and survival in diabetic and non-diabetic patients undergoing infrainguinal bypass surgery

In 92 diabetic and 175 non‐diabetic patients undergoing 336 femoropopliteal or femorodistal bypass procedures, 1‐ and 3‐year cumulative life‐table patency, limb salvage, and survival rates were comparatively analysed. The peroperative mortality rate was significantly higher in diabetic patients (5% compared to 1.4%, p < 0.001). The cumulative graft patency rates were 61% at 12 months and 46% at 36 months in diabetic patients compared to 64 and 52% in non‐diabetic patients. Significantly better patency rates were observed in limbs with good runoff compared to limbs with poor runoff in both groups. The limb salvage rates at 3 years were 70% in diabetic patients and 62% in non‐diabetic patients. The survival rate at 3 years was significantly lower in diabetic patients, 62% compared to 86% in non‐diabetic patients. Diabetic patients with poor runoff demonstrated a significantly lower survival rate after 36 months compared to diabetic patients with good runoff (48% and 74%, respectively). The results of this study demonstrate that the early and intermediate patency and limb salvage rates are similar in diabetic and non‐diabetic patients. On the other hand the survival rate in diabetic patients, especially in those with poor distal runoff, is significantly lower than non‐diabetic patients.

Carotid Artery Endarterectomy Solely Based on Duplex Scan Findings

The purpose of this study was to review experience with carotid artery surgery based on findings obtained solely from duplex scanning with special regard to unexpected findings during surgery and the early outcome. From January 1993 through December 1999, 271 consecutive patients underwent 287 carotid endarterectomies (CEAs), 229 (80%) of which were performed solely based on duplex scan findings. During the study period 5,932 carotid artery duplex scans were performed in 4,466 patients. Of 589 patients with internal carotid artery (ICA) stenosis? 70%, 246 underwent CEA compared to 25 of 156 with 50-69% ICA stenosis. The indications for CEA were transient ischemic attack (TIA) in 88 (30.7%), amaurosis fugax in 60 (20.9%), previous stroke in 91 (31.7%) and asymptomatic disease in 48 (16.7%) cases. There were no statistically significant differences between the groups operated on with and without preoperative angiography with respect to the indications for surgery, associated risk factors, or the degree of stenosis on the contralateral side. In patients undergoing surgery without angiography, there were no unexpected findings that influenced the performance of surgery, in all except 1. There were no significant differences in perioperative morbidity and mortality in patients undergoing surgery with and without conventional angiography. The combined mortality and major stroke rates were 3.4% and 2.2%, respectively. It is concluded that CEA can safely be performed without preoperative angiography in cases with conclusive duplex scan findings.

Endovascular approach to treating secondary arterioureteral fistula

Two patients with the rare entity of arterio-ureteral fistula are presented. Both highlight the predisposing factors of radiation, major surgery in the region, history of vascular surgery and presence of double-J-stent. Both patients presented with the clinical sign of intermittent gross hematuria. Both patients were successfully treated by endovascular intervention using graft covered stent.

The Role of Duplex Scanning in the Selection of Patients with Critical Lower-Limb Ischemia for Infrainguinal Percutaneous Transluminal Angioplasty

AbstractPurpose: To investigate the role of duplex scanning in the selection of patients with critical lower-limb ischemia (CLI) for infrainguinal percutaneous transluminal angioplasty (PTA). Methods: One hundred and sixty-two limbs with CLI (150 patients) that underwent duplex scanning within 3 months prior to conventional diagnostic angiography (n = 88) or infrainguinal PTA (n = 74) were retrospectively studied. The findings obtained from duplex scanning and angiography were analyzed in a masked fashion by two different investigators. Results: The accuracy, sensitivity, specificity, and negative and positive predictive values of duplex scanning in the selection of patients for infrainguinal PTA were 86%, 84%, 89%, 86%, and 87% respectively. Forty-two procedures (57%) were performed at multiple arterial segments. The accuracy of duplex scanning in the selection of femoropopliteal and crural lesions for PTA was over 85%. However, the sensitivity of duplex scanning in the selection of popliteal and crural lesions for PTA was 49% and 38% respectively, compared with 80% for superior femoral artery lesions. In 39% of patients who were correctly selected for PTA, duplex scanning misdiagnosed one of the multiple lesions treated by PTA. Conclusion: Duplex scanning can safely be used for the selection of patients for infrainguinal PTA. The sensitivity of duplex scanning in the selection of lesions for PTA was less satisfactory in the popliteal and crural arteries compared with the femoropopliteal arteries.

Continuous monitoring of intrathecal pO2, pCO2 and pH during surgical replacement of type II thoracoabdominal aortic aneurysm

Continuous monitoring of intrathecal pO2, pCO2 and pH during surgical replacement of type II thoracoabdominal aortic aneurysm

Renal Artery Stenosis Evaluated with 3D-Gd-Magnetic Resonance Angiography Using Transstenotic Pressure Gradient as the Standard of Reference. A Multireader Study

Purpose: To evaluate 3D-Gd-magnetic resonance angiography (MRA) in detecting hemodynamically significant renal artery stenosis (RAS). Material and Methods: Thirty patients evaluated for atherosclerotic RAS by MRA and digital subtraction angiography (DSA) were retrospectively included. Standard of reference for hemodynamically significant RAS was a transstenotic gradient of 15 mmHg. DSA visualized 60 main renal arteries and 9 accessory arteries. Pressure gradient measurement (PGM) was available from 61 arteries. Three radiologists evaluated all examinations independently in a blinded fashion. Results: RAS was present in 26 arteries. On MRA, each reader identified 4 of 9 accessory renal arteries, a detection rate of 44%. The three readers correctly classified 22/25/22 of the 26 vessels with a significant gradient as ⩾60% RAS and 31/25/32 of the 35 with no significant gradient as <60% RAS on MRA. Interobserver agreement was substantial. MRA image quality was adequate for RAS evaluations in all patients. ROC curves indicated that MRA is an adequate method for evaluating RAS. When screening for RAS, a 50% diameter reduction cut-off is better than 60%. RAS with 40–80% diameter reductions accounted for 65% of discrepancies. Conclusion: MRA is an adequate method for evaluating RAS limited mainly by poor detection rate for accessory renal arteries.

Composite polytetrafluroethylene/vein bypass grafts: conventional distal vein segment or vein cuff?

OBJECTIVES To determine the current status of PTFE vein composite grafts, we reviewed our experience with 205 composite reconstructions and compared the results of conventional distal vein segment to that of distal vein cuff. DESIGN Retrospective review. SETTING Department of Surgery, University Hospital. PATIENTS AND METHODS The series included 85 women and 102 men with a median age of 70. The indications for surgery were claudication in 30, rest pain in 71 and ulcer/gangrene in 103. The site of the distal anastomosis was the popliteal artery in 111 and crural artery in 94. The graft consisted of a proximal PTFE graft anastomosed to a distal segment of reversed saphenous vein in 169 or to a modified distal Miller cuff in 36 operations after 1992. RESULTS Cumulative life table primary patency rates for the whole series at 12, 24 and 36 months were 39%, 32% and 25% respectively. Limbs with good run-off demonstrated significantly better patency rates compared to limbs with poor run-off (55% and 17% at 12 months, 35% and 11% at 36 months, p = 0.04). The patency rate of femorocrural grafts with poor run-off was only 4% at 12 months. The overall limb salvage rates at 12 and 36 months were 63% and 55%, respectively. Similar results were obtained in limbs with distal reversed vein segment and distal vein cuff. CONCLUSION The results of this study suggest that for infrainguinal bypass grafting where the saphenous vein is unavailable, a composite PTFE-vein graft might be an acceptable alternative in limbs with good run-off. Although not a randomised study, the results using a distal reversed vein segment of a cuff were similar.