Long-term patency of autogenous saphenous veins vs. PTFE interposition graft for prosthetic hemodialysis access

OBJECTIVE

Prosthetic vascular access is the other choice when the superficial venous system is inadequate to perform a simple radio-cephalic and brachio-cephalic fistula.

METHODS

This paper reports the outcomes of a prospective cohort study of 54 patients who underwent either saphenous vein (SVI Group, n=29) or PTFE graft (PTFE Group, n=25) interposition surgery for prosthetic hemodialysis access. All patients were evaluated via color Doppler ultrasonography during preoperative course and superficial venous systems of these patients were found inadequate to perform simple radial/brachial artery-cephalic vein anastomosis. Follow-up was performed for every 6-months period. Kaplan-Meier analysis and Log Rank test was used for estimation and comparison of the patency.

RESULTS

In SVI group access failure was observed in 5 of 29 patients (17.2%). In PTFE group, access failure was observed in 13 of the 25 patients (52%). Primary patency rate was 93% in 12th month and 82% in 24th month in SVI group while it was 88% in 12th month and 56% in 24th month in PTFE group. According to the Kaplan-Meier method, mean time of primary patency was significantly higher in SVI group when compared to PTFE group (33.03±1.32 months vs. 28.16±1.91 months, Log Rank chi-square value: 7.01, df:1, p=0.008). Secondary patency rate was 96% in 12th month and 93% in 24th month for SVI group while 96% in 12th month and 84% in 24th month for PTFE group. According to the Kaplan-Meier method, mean time of secondary patency was significantly higher in SVI group when compared to PTFE group (34.27±0.95 months vs. 31.16±1.40 months, Log Rank chi-square value: 7.33, df:1, p=0.007).

CONCLUSION

Autologous saphenous vein can be preferably chosen as a prosthetic hemodialysis access graft due its higher primary and secondary patency, lower complication rate and cost when compared with PTFE grafts.

The intraoperative effect of pentoxifylline on the inflammatory process and leukocytes in cardiac surgery patients undergoing cardiopulmonary bypass

Background: Inflammation plays a pivotal role in the pathogenesis of organ dysfunction after cardiopulmonary bypass (CPB). The aim of this study was to investigate whether pentoxifylline (PTX) has effects on the inflammatory process and leukocytes in cardiac surgery patients undergoing CPB.

Material and methods: A double-blind, prospective, randomized, placebo-controlled study was undertaken to assess the effect of PTX on leukocyte counts, tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and C-reactive protein (CRP) levels in 60 patients undergoing CPB for elective coronary artery bypass grafting. In 30 patients, 200 mg of PTX was added to 500 mL NaCl and perfused for 180 min after induction of anaesthesia and also 100 mg of PTX was added to the warm cardioplegic solution; another 30 patients received saline solution as placebo.

Results: All measurements were performed before PTX infusion (T0), after induction of anaesthesia (T1), 30 min after weaning from CPB (T2), and 6 hours (T3) and 24 hours postoperatively (T4). PTX did not change the percentage of eosinophils, basophils, neutrophils, monocytes, or lymphocytes, or CRP levels. In the control group, however, total leukocyte count and IL-6 level at T3 and T4 period were significantly higher than the study group. The progressive increment in TNF-α level observed at each period was also significantly prominent in the control group.

Conclusion: CPB-related whole body inflammatory response could be partially inhibited by intraoperative PTX administration. This effect of PTX would be helpful in preventing the well-known complications of CPB-induced systemic inflammation.

Thoracic outlet syndrome in an adolescent with bilateral bifid ribs

Reported here is a 13-year-old girl suffering from pain in her right lower neck region and the shoulder for the preceding 2-3 years. She was diagnosed to have right thoracic outlet syndrome due to bifid ribs--caused by the bony fusion of the variant cervical rib. She was operated via supraclavicular approach, whereby the variant cervical rib and the fibrous bands were excised. She was found to be quite improved 1 month after surgery. Thoracic outlet syndrome, a rare disease of childhood, is discussed in the light of the relevant literature.

Aberrant patent ductus arteriosus associated with double brachiocephalic trunk and interrupted left subclavian artery

Although patent ductus arteriosus (PDA) is the most common type of extracardiac shunt, aberrant PDA associated with other cardiac malformations as double brachiocephalic trunk and interrupted left subclavian artery is extremely rare. To the best of our knowledge, the literature contains no other report of a patient who has PDA originated from left subclavian artery associated with ventricular septal defect (VSD), double brachiocephalic trunk and interrupted left subclavian artery.

[Thrombotic, fibrinolytic and proliferative activities of pulmonary vascular bed in secondary pulmonary hypertension]

OBJECTIVE

To determine whether pulmonary vascular bed contributes to the development of in situ thrombosis and vascular remodelling in secondary pulmonary hypertension (SPH) via changes in its local secretory activities.

METHODS

Seventy-one patients with the diagnosis of secondary pulmonary hypertension (38 females, mean age 40.36+/-1.05 years) were included in the study. Selective right and left heart catheterization was performed to each patient for diagnostic purposes. Blood samples obtained from left ventricle (LV) and pulmonary artery (PA) of each patient were analyzed for levels of plasminogen activator inhibitor-1 (PAI-1), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), D-dimer, von Willebrand factor (vWF), protein-C, antithrombin-III, fibrinogen, and plasminogen. Results were compared between LV and PA. Correlation analysis between each parameter and mean pulmonary artery pressure (MPAP) was performed.

RESULTS

Although mean level of VEGF in LV and PA were found to be in normal range, it was significantly higher in LV than in PA (p<0.001). Mean PDGF and D-dimer levels, which remained in normal range were also higher in LV (p<0.001 and p<0.001, respectively) than in PA;.vWF showed similar degree of elevation in both LV and PA. Only one parameter, PAI-1, was found to be significantly higher in PA than in LV (p=0.012). Antithrombin-III, protein C, plasminogen, and fibrinogen levels showed no significant differences between two chambers. They also remained in normal range, except for fibrinogen, which was slightly elevated in both LV and PA. Correlation analysis revealed strong positive correlation between D-dimer level in both LV and PA and MPAP (r=0.775, p<0.001 and r=0.649, p<0.001, respectively).

CONCLUSION

In SPH, pulmonary vascular bed shows increased thrombotic, hypofibrinolytic, and proliferative activities, which are partially related to the severity of illness.

Influence of haematological parameters before coronary angioplasty on subsequent restenosis

OBJECTIVES

Restenosis is the major limitation of coronary interventions occurring in nearly a third of the patients undergoing percutaneous transluminal coronary angioplasty (PTCA) with no single, definite predictor demonstrated in an individual patient. Platelets are known to play an important role in the pathogenesis of subsequent restenosis.

METHODS AND RESULTS

In a prospective study, follow-up coronary angiographies were performed in 102 consecutive patients with stable angina who underwent a successful PTCA for single-vessel coronary artery disease. Demographics, baseline lipid profiles (total cholesterol, HDL- and LDL-cholesterol, triglycerides) and haematological parameters (red cell, white cell and platelet counts, haemoglobin concentration, haematocrite %, mean platelet volume, platelet mass and fibrinogen levels) were compared between patients with and without restenosis. In the restenosis group, mean platelet volume (8.82 +/- 0.78 fl vs. 8.13 +/- 0.64 fl, p < 0.001), white cell count (8673 +/- 322 x 10(3)/microl vs. 7513 +/- 232 x 10(3)/microl, p < 0.01) and fibrinogen level (4.2 +/- 1.4 g/l vs 3.6 +/- 1.1 g/l) were significantly higher. The relative odds for developing angiographically defined restenosis were 2.49 times greater in diabetics (p = 0.11) and 2.54 times greater in men (p = 0.13). It is 1.43 times greater in patients with higher fibrinogen levels (p = 0.16). But, the relative odds for developing restenosis were 10.43 times greater in patients with larger pre-procedural mean platelet volumes (p < 0.01).

CONCLUSIONS

There was a positive correlation between mean platelets volume and loss in luminal diameter between post-angioplasty and follow-up angiographies (r = +2.345, p = 0.01). There was no association between restenosis and haemoglobin, haematocrit, red cell count, white cell count, platelet count, platelet mass and plasma fibrinogen level. The development of restenosis after successful coronary angioplasty may be mainly influenced by the platelet size.

[Single clamp technique in elderly patients undergoing coronary artery surgery]

OBJECTIVE

The results of single clamp and partial clamp techniques were retrospectively compared in elderly patients (>70 years) undergoing coronary artery bypass grafting operation (CABG).

METHODS

A total of 244 elderly patients undergoing CABG between January 1995 and March 2002 in our center were studied. Single-clamp technique was used in 32 cases (Group 1) and partial-clamp technique was used in 212 cases (Group 2). All patients had isolated coronary artery lesions and a primary elective coronary bypass grafting surgery was planned for every case. Preoperative, operative and postoperative variables; age, gender, pre- and post-operative neurological status (stroke, amaurosis fugax, aphasia, hemiplegia, hemiparesis), cerebrovascular diseases, diabetes mellitus, hypertension, number of distal grafts, left ventricular score, durations of aortic cross-clamping and cardiopulmonary bypass (CPB) times, perfusion pressure during CPB, and postoperative cardiac status were recorded. Patients with a history of neurological complications were excluded from the study.

RESULTS

Overall, mean age was 71.9+/-2.18 years. Patients in Group 1 were significantly older as compared to patients in Group 2 (p< 0.01). Average duration of cross-clamping in Group 1 was significantly longer (p<0.001) compared to Group 2, but there were no differences with regard to the total duration of cardiopulmonary bypass (p=0.535). No patients had neurological complications in Group 1, however 22 patients in Group 2 had neurological complications (p<0.05).

CONCLUSION

Although single-clamp technique was associated with a longer cross-clamp time, the duration of CPB was not increased and the incidence of neurological complications was low.

[The efficiency of fast track protocol in elderly patients who underwent coronary artery surgery]

OBJECTIVE

This study is planned to display the efficiency of fast track protocol and its difference from the conventional anesthesia in patients older than 65 years.

METHODS

One hundred patients older than 65 years underwent coronary artery surgery between October 2000-March 2001 in cardiovascular surgery clinic were considered in this study. Fifty patients in whom fast track protocol was applied were included into the study group, group A; fifty patients underwent conventional anesthesia technique were referred to the control group, group B. In both groups demographic characteristics, early hospital mortality, operation time, total drainage, number of transfusions, stay in the intensive care unit and discharge time were recorded.

RESULTS

The mean age was 69.0+/-3.0 years in group A and 70.4+/-3.6 years in group B. Early hospital mortality was 2% in group A, 10% in group B (p>0.05). Intensive care unit stay was 22.01+/-10.12 hours in group A and 60.18+/-32.23 hours in group B (p<0.05). Discharge time was on 5.5+/-1.3 day in group A and on 6.9+/-2.3 day in group B (p<0.05). There were no statistical differences between the two groups in respect to other parameters.

CONCLUSION

Fast track protocol in patients older than 65 years is a suitable technique by using modern cardiac surgery methods. This protocol is successfully used by selecting the suitable patients and following the patients carefully in the postoperative period.

Beneficial effect of BioGlue surgical adhesive in repair of iatrogenic aortic dissection

We report the benefits of using BioGlue surgical adhesive to repair an iatrogenic aortic rupture and dissection that resulted from cannulation of the ascending aorta during open-heart surgery.