Yigit Goktay

Valiant Thoracic Stent-Graft Deployed With the New Captivia Delivery System: Procedural and 30-Day Results of the Valiant Captivia Registry

Purpose To evaluate procedural and 30-day outcomes of thoracic endovascular aortic repair (TEVAR) employing the Valiant Thoracic Stent Graft with the Captivia Delivery System. Methods Enrollment in the study (www.ClinicalTrials.com identifier NCT01181947) included all eligible patients implanted with the Valiant Captivia System retrospectively and prospectively at 15 sites in Europe and Turkey between October 2009 and June 2010. In the 100 treated patients (81 men; mean age 64.6±12.0 years, range 25–87), indications included descending thoracic aortic aneurysm (TAA, 49.0%) and aortic dissection (42.0%). Results Technical success was 100.0%, with no misaligned deployments or aortic perforations. Mean follow-up was 68.9±34.9 days (range 20–147, median 61). The 30-day rate of all-cause mortality was 4.0% (all 4 cases procedure-related, 3 device-related). Retrograde type A dissection occurred in 2 patients. The only conversion to open surgery was successful in a patient experiencing intraoperative aneurysm rupture. Stroke occurred in 4 (4.0%) patients and paraplegia in 1 (1.0%). Among 66 patients with 30-day imaging studies evaluable for endoleak, 4 (6.1%) had type I and 7 (10.6%) had type II endoleak; there were no types III or IV. Within 30 days, no secondary endovascular procedures were required due to endoleak. One patient with type II endoleak died 3 weeks postimplantation before scheduled embolization. Conclusion In this analysis of procedural and 30-day results, the high technical success and clinical outcome rates showed that the Valiant Thoracic Stent Graft with the new Captivia Delivery System has promising capacity to treat a variety of thoracic aortic conditions in a range of anatomies.

Predictive factors for limb occlusions after endovascular aneurysm repair

OBJECTIVE Greater flexibility and smaller sizes for introducer sheaths in the newest stent grafts increase the feasibility of endovascular aneurysm repair but raise concerns about long-term limb patency. The aim of the study was to determine the incidence of and predictive factors for limb occlusion after use of the Endurant stent graft (Medtronic Inc, Minneapolis, Minn) for abdominal aortic aneurysm. METHODS The Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) prospectively included 1143 patients treated with bifurcated devices who were observed for up to 2 years. Limb occlusions were evidenced by computed tomography, angiography, or ultrasound. To predict stent graft limb occlusion, a two-step model-building technique was applied. We first identified predictors from a total of 47 covariates obtained at baseline and in the periprocedural period. Subsequently, we reduced the set of potential predictors to key factors that are clinically meaningful. To handle large numbers of covariates, we used the Classification And Regression Tree (CART) method. RESULTS Forty-two stent graft limbs occluded in 39 patients (3.4% of the patients). At 2 years, the rate of freedom from stent graft limb occlusion calculated by Kaplan-Meier plot was 97.9% (standard error [SE], 0.33%). Of the 42 occlusions, 13 (31%) were observed within 30 days and 30 (71%) within 6 months. The strongest independent predictors were distal landing zone on the external iliac artery, external iliac artery diameter ≤10 mm, and kinking. High-risk vs low-risk patients were identified according to a decision tree based on the strongest predictors. Freedom from stent graft limb occlusion was 96.1% (SE, 0.64%) in high-risk patients vs 99.6% (SE, 0.19%) in low-risk patients. CONCLUSIONS After Endurant stent grafting, the incidence of limb occlusion was low. Classifying patients as high risk vs low risk according to the algorithm used in this study may help define specific strategies to prevent limb occlusion and improve the overall results of endovascular aneurysm repair using the latest generation of stent grafts.

A comparison of inverted spinal traction and conventional traction in the treatment of lumbar disc herniations

The purpose of this investigation of lumbar disc herniation patients was to compare the effi cacy of the inversion spinal traction and the conventional mechanical spinal traction on several clinical parameters and computed tomography. This investigation consisted of 29 patients with low back pain and sciatica due to lumbar disc herniation. Patients were randomly assigned into two groups: an inversion spinal traction that was applied to 15 patients, and a conventional traction that was applied to 14 patients for ten sessions. The efficacy of the treatments was evaluated based upon clinical parameters before, immediately after, and three months after the treatment. Computed tomographic (CT) investigation was done before and immediately after the treatment. Both methods of traction were found to be clinically effective. Although there was no statistically significant difference between the two groups based upon the clinical parameters, CT fi ndings of the conventional traction group tended to show more improved parameters than the inverted spinal traction group. Reasons for better results of the conventional traction are discussed and the necessity for further investigations on this topic is emphasized.

Outcome and quality of life after endovascular abdominal aortic aneurysm repair in octogenarians

OBJECTIVE This study determined outcome and quality of life (QOL) in octogenarians, compared with patients aged <80 years, 1 year after endovascular aortic aneurysm repair (EVAR). METHODS From March 2009 until April 2011, 1263 patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) registry with an abdominal aortic aneurysm were treated with EVAR using the Endurant endograft (Medtronic Cardiovascular, Santa Rosa, Calif). The patients were grouped according to those aged ≥80 years (290 [22.9%]) and those aged <80 years (973 [77.1%]) at the time of the procedure. QOL was assessed using composite EuroQoL 5-Dimensions Questionnaire (EQ-5D) index scores. Baseline, perioperative, and follow-up data were analyzed at 1 year. RESULTS Octogenarians had poorer anatomic characteristics. The technical success rate was almost 99% for both cohorts, with no deaths. The duration of the implant procedure was significantly longer in the elderly patients (P = .002), with significant differences in overall (P < .001) and postprocedure (P < .001) hospital stays in favor of the younger group. At 1 year, there was a significant difference in all-cause mortality (P = .002) and in the number of major adverse events (P = .003), including secondary rupture (P = .01), to the detriment of octogenarians. There were no significant differences in conversion to open surgery or in overall secondary endovascular procedures. The octogenarians scored lower in their overall health care perception (P < .001) but with no significant difference in the EQ-5D index. Compared with the group aged <80 years, they had still not completely recovered their QOL after 1 year (P = .01). CONCLUSIONS Octogenarians are more difficult to treat by EVAR than younger patients due to poorer anatomic suitability and a higher incidence of complications. Recovery of QOL in octogenarians takes longer (>12 months) than expected.

Ghrelin and adipokines as circulating markers of disease activity in patients with Takayasu arteritis

IntroductionThe current markers of disease activity in Takayasu arteritis (TA) are insufficient for proper assessment. We investigated circulating levels of unacylated and acylated ghrelin, leptin and adiponectin and their relationships with disease activity in patients with TA.MethodsThis study included 31 patients with TA and 32 sex-, age- and body mass index-matched healthy controls. Disease activity was assessed in TA patients using various tools, including Kerrs criteria, disease extent index-Takayasu, physicians global assessment, radiological parameters, and laboratory markers. Plasma unacylated and acylated ghrelin, and serum leptin and adiponectin levels were measured using an enzyme-linked immunosorbent assay.ResultsUnacylated and acylated ghrelin levels were found to be significantly lower in TA patients than that in healthy controls. Patients with active disease had lower unacylated ghrelin levels than those with inactive disease and had lower acylated ghrelin levels than healthy controls. Ghrelin levels were negatively correlated with various parameters of disease activity. The leptin/ghrelin ratio was significantly higher in TA patients than controls. It was positively correlated with disease activity. There was a positive correlation between unacylated and acylated ghrelin and a negative correlation between leptin and ghrelin. There was no statistical difference in adiponectin levels between TA patients and controls. The radiological activity markers were positively correlated with other parameters of disease activity.ConclusionsThis study suggests that plasma unacylated and acylated ghrelin levels may be useful in monitoring disease activity and planning treatment strategies for patients with TA. The serum leptin level and leptin/ghrelin ratio may also be used to help assess the disease activity.

Juvenile linear scleroderma with unique forms of renal involvement

Linear scleroderma is the most common type of juvenile localized scleroderma, which usually involves the limbs. The linear lesions may extend through the dermis, subcutaneous tissue, muscles, and the underlying bone, leading to significant functional and cosmetic deformities. Renal involvement in juvenile localized scleroderma is a rare manifestation. Here we report two cases with juvenile linear scleroderma and unique renal manifestations, including unilateral renal arterial stenosis and immunoglobulin M nephropathy.

The effect of using different embolic agents on survival in transarterial chemoembolization of hepatocellular carcinoma: gelfoam versus polyvinyl alcohol.

PURPOSE We aimed to compare the effect of using different embolic agents such as gelfoam and polyvinyl alcohol (PVA) on survival, tumor response, and complications in transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) patients. MATERIALS AND METHODS We retrospectively reviewed the medical records of 38 inoperable HCC patients who underwent TACE between August 1998 and April 2007. A total of 50 TACE sessions were performed using PVA (n=18) or gelfoam particles (n=20), following the application of 60 mg doxorubicin with 10-20 mL lipiodol emulsion. The PVA and gelfoam groups were compared based on clinical, laboratory and demographic variables. Survival rates were calculated starting from the first TACE session using the Kaplan-Meier analysis. RESULTS There was no significant difference between the survival rates of PVA and gelfoam groups (P = 0.235). Overall survival rates at 12, 24, 36, 48, and 60 months were 55%, 36%, 15%, 7%, and 5%, respectively. Tumor response, age, lipiodol accumulation type, number of HCC foci, complications and serum alpha-fetoprotein level were significant factors for survival in all patients. CONCLUSION Use of gelfoam or PVA as the embolic agent did not have a significant impact on survival. Complete tumor response, intensive lipiodol accumulation in tumor, older age (<60 years), fewer (≤3) HCC foci, low serum alpha-fetoprotein level (≤400 ng/mL) were found to improve cumulative survival significantly.

Relationship between Complications due to Prostate Biopsy and the Scores of Pain and Discomfort

Introduction: Transrectal ultrasound (TRUS)-guided prostate biopsy is routinely performed in the prostate-specific antigen era. In this study, we evaluated morbidity and complications observed in patients undergoing TRUS-guided prostate biopsy following intrarectal lidocaine application and the relation of these complications to pain and discomfort. Patients and Methods: Between January 2000 and August 2002, a total of 128 patients underwent TRUS-guided prostate biopsy. The procedure was carried out following an intrarectal application of 10 cm3 2% lidocaine gel. Immediately after the biopsy, pain and discomfort scores were determined using a 10-point linear visual analog scale. The patients were seen 10 days later and questioned for complications. Results: At least one complication was observed in 107 patients (84%). Most frequent complications were macroscopic hematuria (90%), hematochezia (36%), and hematospermia (13%). The mean pain and discomfort scores of the patients were found to be correlated to each other (p < 0.01). The complication-negative group had significantly lower pain and discomfort scores (p < 0.01). The scores of the patients with hematochezia were significantly higher than the scores of the patients with other complications (p < 0.01). Conclusions: Minor complications like hematuria, hematochezia, and hematospermia are frequently seen in patients undergoing TRUS-guided prostate biopsies. The pain and discomfort scores may be predictors of minor complications, particularly of rectal bleeding.

Doppler US evaluation of renal biopsy complications in children

PURPOSE Percutaneous renal biopsy plays an important role in the diagnosis and management of renal disease in children, but it does carry some complications. As most cases are vascular in origin, Doppler ultrasonography (US) has clear benefits in terms of detecting bleeding and assessing vascular damage. The aim of this study was to investigate the effectiveness of Doppler US in detecting possible complications after percutaneous renal biopsy in pediatric patients. MATERIALS AND METHODS This retrospective study was performed using the data obtained from all pediatric patients who underwent renal biopsy in our institution between 1999 and 2011. RESULTS A total of 175 biopsies were performed in 172 patients (48.3% male, 51.7% female) ranging in age from 1 to 17 years (mean, 8.7 years). Of 175 biopsies, 42 (24.0%) led to complications. Overall, 52 complications (25% major, 75% minor) occurred following 42 biopsies. CONCLUSION Doppler US examination is capable of and helpful in detecting possible vascular complications such as pseudoaneurysm and arteriovenous fistula and improves the management of these patients after biopsy. It is important to recognize the Doppler US appearance of complications associated with percutaneous renal biopsy and to perform close follow-up with Doppler US in the first 24 hours.

A Rare Cause of Renovascular Hypertension: Takayasu Arteritis with Only Renal Artery Involvement

Takayasu arteritis is a chronic inflammatory disease that affects mainly the aorta, main branches of aorta, and pulmonary arteries with unknown etiology. Disease affecting solely the renal arteries is rare. We will present a case that had hypertension, hypokalemia, and metabolic alkalosis where the etiology was type 2 Takayasu arteritis, affecting renal arteries.