Radial artery harvesting technique for use in coronary bypass surgery

Universitatea de Medicină și Farmacie ”Gr. T. Popa” Iași, România Institutul de Boli Cardiovasculare „Prof. Gr. George I.M. Georgescu”, Iași, RomâniaThe radial artery (RA) was introduced in coronary artery bypass grafting (CABG) as an alternative to the use of the great saphenous vein at the beginning of the 1970s (Carpentier, 1973). The authors describe the anatomical characteristisc of the radial artery, the main procedures used in harvesting the vessel, underlying the most risky anatomical area that should be avoided during the surgical procedures. Compared with the internal mammary artery (IMA), the radial artery is characterized by an increased prevalence of intimal alterations of fibrointimal hyperplasia or atherosclerosis type. Rigurous knowledge of brachi-antebrahial anatomical structures and gentle manipulation of the RA prevents CABG complications such as arterial spasm, injury to the endothelium, dysesthesia, ischemia, and compartment syndrome. The strategy of the graft procedure (graft type, method of harvesting) depends on the clinico-anamnestic specificities of the case, on the surgeon's choice and his surgical expertise.Artera radială (AR) a fost introdusă în chirurgia cardiacă la începutul anilor 1970 ca alternativă a utilizării venelor în chirurgia de bypass aorto-coronarian (BAC) (Carpentier, 1973). Autorii descriu caracteristicile anatomice ale AR și metoda de recoltare chirurgicală insistând asupra zonelor anatomice riscante care trebuie abordate cu atenție pe parcursul intervenției. Datorită introducerii în practica medicală a blocanţilor de calciu, a perfecţionării tehnicilor de recoltare şi preparare a AR, a crescut durata patenţei graftului arterial, AR redevenind graft de elecţie în chirurgia arterelor coronare. Comparativ cu artera mamară internă (AMI), AR este caracterizată de o prevalență crescută a leziunilor intimale de tip hiperplazie fibrointimală sau ateroscleroză. Cunoaşterea morfologiei și anatomiei topografice a structurilor brahiantibrahiale precum și manevrarea delicată a AR previne apariţia complicațiilor secundare bypass-ului de tipul spasmului arterial, lezarea endarterei, disesteziilor, ischemiei, sindromului de compartiment. Tehnica BAC (alegerea tipului de graft, metoda de recoltare) depinde de particularitățile clinoc-anamnestice ale cazului, opțiunea și experiența chirurgului

Managementul terapeutic hibrid al patologiei arcului aortic

Institutul de Boli Cardiovasculare „Prof. Dr. George I.M. Georgescu”, Universitatea de Medicină și Farmacie „Grigore T. Popa” Iași, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Patologia arcului aortic include afecțiuni precum dilatație anevrismală, disecție sau ruptură traumatică. Tratamentul chirurgical convențional a reprezentat mult timp „standardul de aur” pentru aceste afecțiuni și constituie cel mai complex tip de intervenție chirurgicală pe artera aortă, asociat cu neîndeplinirea criteriilor de includere în 20-40% din cazuri și rate ridicate de mortalitate postoperatorie (5-15%). Patologia arcului aortic implică dificultăți tehnice deosebite datorită tortuozității vasului cu angulații majore, originii trunchiurilor supra-aortice, aterosclerozei de obicei severe la acest nivel, proximității cuspelor aortice și necesității protecției cerebrale. Introducerea metodelor endovasculare în arsenalul terapeutic al chirurgiei cardiovasculare a schimbat radical managementul afecțiunilor arcului aortic în sensul unei excluderi a segmentului afectat exclusiv pe cale endovasculară sau a tratamentului hibrid care presupune asociere debranching-ului și reimplantării prin chirurgie convențională a colateralelor emergente din arcul aortic cu excluderea endovasculară a segmentului afectat. Material și metode: În lucrarea de față, autorii prezintă experiența Institutului de Boli Cardiovasculare „Prof. Dr. George I.M. Georgescu” (IBCV) din Iași în abordul endovascular și hibrid al patologiei arcului aortic din punct de vedere al evaluării preoperatorii, algoritmului decizional, managementului circulator și strategiei operatorii în funcție de segmentul afectat. Rezultate: Pentru exemplificare sunt prezentate 4 cazuri reprezentative, un pacient cu ruptură traumatică a istmului aortic, un pacient cu fistulă aorto-esofagiană și 2 pacienți cu anevrism de arc aortic tratați la IBCV Iași. În ultimele 2 cazuri, tratamentul endovascular a fot combinat cu debranching-ul arcului aortic, reimplantare a colateralelor emergente din arc într-un graft de Dacron suturat la aorta ascendentă și transpoziția artera carotidă comună stângă – artera subclaviculară stângă cu rezultate favorabile pe termen lung. Concluzii: Excluderea pe cale endovasculară a segmentului afectat reduce gradul de complexitate și caracterul agresiv al intervenției chirurgicale ceea ce permite tratarea inclusiv a pacienților care prezintă contraindicații pentru intervenția chirurgicală convențională. O colaborare eficientă între cardiologii intervenționiști, chirurgii cardiovasculari, anesteziști și imagiști este esențială pentru optimizarea abordului terapeutic și succesul intervenției

Takayasu Arteritis: new trends in surgical approach – case presentation

Takayasu arteritis (TA) is defined as a rare chronic granulomatous panarteritis that classically involves segments of large arteries such as the aortic arch. The aim of this report is to present our recent experience in diagnosis and treatment of TA and to provide aspects of surgical strategy for inflammatory aneurysms caused by TA. We present the case of a 36-year-old Caucasian female admitted to our clinic with low effort dyspnea, fatigability, palpitations, sweats, malaise and light-headedness. The medical history revealed a history of treated tuberculosis, anemia, arterial hypertension, chronic inflammatory syndrome, aortic insufficiency, and anterior mitral valve prolapse. Echocardiography revealed grade III-IV aortic regurgitation, grade I-II mitral regurgitation, a dilated ascending aorta and mild systolic dysfunction. CT angiography revealed an aneurysmal dilatation of the ascending aorta. Surgical treatment was mandatory, and intraoperative, the surgeon noted a diffuse thickening of the aortic wall and suspected TA, further confirmed by histopathological examination. The tricuspid aortic valve was excised and a composite graft with a biological valve and an aortic conduit were implanted on patient’s request. Postoperative course was uneventful and the patient was discharged from the hospital on the 10th postoperative day, and directed towards Rheumatology Clinic for medical treatment. A multidisciplinary approach to the diagnosis and management of TA patients is essential to a satisfactory outcome

Artera radială sau vena safenă în revascularizarea miocardică? Actualități, limite, controverse, perspective

Institutul de Boli Cardiovasculare „Prof. Dr. George I.M. Georgescu”, Universitatea de Medicină și Farmacie „Grigore T. Popa” Iași, Universitatea de Medicină și Farmacie Târgu Mureș, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Bypass-ul aorto-coronarian (BAC) reprezintă tehnica de revascularizare de elecție la pacienții cu leziuni coronariene ce interesează trunchiul arterei coronare stângi sau mai mult de 3 artere coronare. Artera mamară internă constituie graftul gold standard, controverse existând în privința alegerii celui de al 2-lea sau al 3-lea graft. Ultima ediție a Ghidului de Revascularizare Miocardică elaborat de Societatea Europeană de Cardiologie în 2018, prezintă drept indicație de clasă IB utilizarea arterei radiale în detrimentul venei safene interne drept graft adițional după artera mamară internă în cazul pacienților cu stenoze coronariene severe. Materiale și metode: Studiul de față prezintă perspectiva Institutului de Boli Cardiovasculare „Prof. Dr. George I.M. Georgescu” din Iași asupra selecției, recoltării, tehnicii operatorii și prognosticului grafturilor de arteră radială și venă safenă internă cu analiza beneficiului clinic obiectiv în funcție de tipul de graft. În cadrul cercetării au fost analizați 1021 pacienți cu BAC realizat în perioada 2000-2018 utilizând cel puțin o arteră radială și care au supraviețuit perioadei postoperatorii. Vârsta medie a pacienților analizați a fost de 61,30±9,22 ani, iar 182 pacienți (17,83%) au fost de sex feminin. Bypass-ul a fost efectuat utilizând exclusiv grafturi arteriale în 698 cazuri, grafturi de venă safenă (BAC mixt) fiind folosite în 323 cazuri. În total au fost efectuate 1236 anastomoze distale utilizând grafturi de arteră radială și 411 folosind grafturi de venă safenă internă. Rezultate: Permeabilitatea grafturilor la peste 10 ani din momentul intervenției inițiale a fost evaluată în 136 cazuri prin angiografie computer tomografică și a fost constatată o permeabilitate mai mare pentru grafturile de arteră radială (77,05%) comparativ cu cele de venă safenă internă (72,97%) în special pentru teritoriul drept. Supraviețuirea pe termen lung a pacienților a fost de asemenea superioară în cazul revascularizării total arteriale utilizând grafturi de arteră mamară internă și arteră radială (72,31%) comparativ cu BAC mixt utilizând și grafturi de venă safenă (64,14%). Concluzii: Spre deosebire de vena safenă internă mai permisivă la fluxul competitiv, artera radială s-a dovedit mai susceptibilă la vasoconstricție și ocluzie în cazul anastomozării la vase fără stenoză critică. In concluzie, graftul de arteră radială este asociat cu un prognostic favorabil atunci când este utilizat drept al 2-lea sau al 3-lea graft asociat cu una sau ambele artere mamare interne în special pentru a revasculariza artere cu stenoze proximale severe, peste 90%. Studii adiționale sunt necesare pentru identificarea configurațiilor de grafturi cu cel mai mare beneficiu din punct de vedere clinic

Magnetic Resonance Imaging in Assessing Chemotherapy-Induced Peripheral Neuropathy: Systematic Review

Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of many anticancer drugs that may cause various symptoms altering the quality of life. We conducted a systematic review to evaluate the peripheral and central nervous system changes associated with CIPN and detected by magnetic resonance imaging (MRI). Medical literature databases (PubMed, Scopus, Thomson Reuters - Web of Science and Embase) were searched for original studies reporting the use of MRI in the evaluation of CIPN. A total of 31 studies were identified and 9 were eligible for analysis. Results indicate few changes of the peripheral nervous system, most CIPN-associated nervous alterations involving pain processing areas and circuits inside the central nervous system. Distinct patterns of pain processing, changes in cerebral perfusion and gray matter density together with chronic activation of somatosensory areas have been observed in patients with CIPN compared to healthy subjects or cancer patients who did not develop CIPN. Identification of vulnerable brain areas and circuits may indicate future targets for novel therapies directed to prevent or treat CIPN. A preexisting vulnerability suggested by a unique pattern of brain activation following nociceptive stimulation prior to chemotherapy could help identify high-risk individuals, candidates to close monitoring and preventive strategies.</p

An unusual presentation of atrioventricular nodal reentrant tachycardia

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most frequent supraventricular tachycardia, commonly manifesting as autolimited paroxysmal episodes of rapid regular palpitations that exceed 150 beats per minute (bpm), dizziness and pounding neck sensation. Case presentation: We present a case of a male patient, 70 years old, with ischemic heart disease and slow-fast AVNRT treated with radiofrequency catheter ablation (RFCA) in March 2019, with regular 6-months follow-ups. He was readmitted in our department in November 2020 for rest dyspnea and incessant fluttering sensation in the neck, without palpitations. The event electrocardiogram (ECG) was initially interpreted by general cardiologist as accelerated junctional rhythm, 75 bpm. Due to the persistence of symptoms and ECG findings, a differential diagnosis between reentry and focal automaticity was imposed. The response to vagal maneuvers and Holter ECG monitoring characteristics provided valuable information. We suspected recurrent slow ventricular rate typical AVNRT, which was confirmed by electrophysiological study and we successfully performed the RFCA of the slow intranodal pathway. Conclusion: AV nodal reentry tachycardia may have an unusual presentation, occurring in elder male patients with structural heart disease. Antiarrhythmic drugs can promote reentry in this kind of patients. In cases of slow ventricular rate, vagal maneuvers and Holter ECG monitoring can help with the differential diagnosis. The arrhythmia can be successfully treated with RFCA with special caution regarding the risk of AV block

The Impact of the Early COVID-19 Pandemic on ST-Segment Elevation Myocardial Infarction Presentation and Outcomes—A Systematic Review and Meta-Analysis

Background: The influence of the early COVID-19 pandemic on non-COVID-19 emergencies is uncertain. We conducted a systematic review and a meta-analysis to evaluate the impact of the first months of the COVID-19 pandemic on the presentation, management, and prognosis of patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: We searched the PubMed, Scopus, and Embase databases from January to August 2020. A meta-analysis of studies comparing the profile, STEMI severity at presentation, reperfusion delay, and in-hospital mortality for patients presenting before and during the early COVID-19 pandemic was conducted. Fifteen cross-sectional observational studies including 20,528 STEMI patients from the pre-COVID period and 2190 patients diagnosed and treated during the first months of the COVID-19 pandemic met the inclusion criteria. Results: Patients presenting with STEMI during the pandemic were younger and had a higher comorbidity burden. The time interval between symptoms and first medical contact increased from 93.22 ± 137.37 min to 142 ± 281.60 min (p p = 0.293). The pooled odds ratio (OR) for low left ventricular ejection fraction at presentation during the pandemic was 2.24 (95% confidence interval (CI) 1.54–3.26) and for a presentation delay >24 h was 2.9 (95% CI 1.54–5.45) relative to before the pandemic. In-hospital mortality did not increase significantly during the outbreak (p = 0.97). Conclusion: During the first months of the COVID-19 pandemic, patients presenting with STEMI were addressed later in the course of the disease with more severe left ventricular impairment. In-hospital emergency circuits and care functioned properly with no increase in door-to-balloon time and early mortality

Trends in Coronary Artery Anomalies Detection by Coronary Computed Tomography Angiography (CCTA): A Real-Life Comparative Study before and during the COVID-19 Pandemic

Background: In the wake of the coronavirus disease 19 (COVID-19) pandemic, affecting healthcare systems globally, urgent research is needed to understand its potential repercussions on the diagnosis and management of cardiovascular disorders. This emphasises the importance of detecting coronary artery anomalies (CAAs), rare conditions that can range from benign to potentially life-threatening manifestations. We aimed to retrospectively assess the impact of the COVID-19 pandemic on the detection of various coronary anomalies using Coronary Computed Tomography Angiography (CCTA) within a regional tertiary cardiology unit in north-eastern Romania, focusing on perceived occurrence in the population under study, types, and related demographic and clinical factors. Methods: We analysed CCTA scans and investigated the trends in CAA detection among cardiology patients over a decade. We compared pre-COVID-19 and pandemic-era data to assess the impact of healthcare utilisation, patient behaviour, and diagnostic approaches on anomaly detection. Results: Our analysis revealed a higher detection rate of CAAs during the pandemic (3.9% versus 2.2%), possibly highlighting differences in patient clinical profile and addressability changes presentation compared to the previous period. Origination and course anomalies, often linked to severe symptoms, were significantly higher pre-COVID-19 (64.1% versus 51.3%). Conversely, intrinsic CAAs, typically asymptomatic or manifesting later in life, notably increased during the pandemic (49.0% versus 61.4%; p = 0.020). Conclusions: Our study underscores a significant rise in CAA detection during the COVID-19 era, potentially linked to changes in cardiovascular and respiratory clinical patterns, with advanced imaging modalities like CCTA offering accuracy in identification

Postmortem Diagnosis of Ketoacidosis by Determining Beta-Hydroxybutyrate Levels in Three Types of Body Fluids by Two Different Methods

Background: Postmortem assessment of endogenous ketoacidosis is primarily focused on the determination of 3-beta-hydroxybutyrate (BHB). The aim of our study was to identify the most adequate body fluid and postmortem quantification method for assessing ketoacidosis status immediately prior to death. Material and method: We performed a prospective study on 53 cases of sudden death or in-hospital death that were considered forensic cases and could present a state of ketoacidosis prior to death, the autopsies being performed at a post-mortem interval of 24&ndash;72 h. BHB analysis was performed by Multi-Functional Monitoring System XPER Technology analyzer (method A&mdash;portable analyzer) for peripheral blood, and by BHB Assay MAK041 Kit (method B) for vitreous humor (VH) and cerebrospinal fluid (CSF). Results: We identified 11 ketoacidosis cases using method A and 9 ketoacidosis cases using method B. All nine cases of ketoacidosis identified using the MAK041 kit were confirmed with the portable analyzer. For the 2 cases of ketoacidosis identified only with the portable analyzer, the values obtained by method B were at the diagnostic limit. BHB concentrations determined in VH and CSF by method B were statistically significantly correlated with each other and with peripheral blood BHB concentration. Conclusion: BHB, a marker of ketoacidosis, should be determined post-mortem whenever a metabolic imbalance is suspected irrespective of known risk factors or obvious morphological substrate to help establish the thanatogenic mechanism. BHB quantification can easily be performed using a handheld automatic analyzer and a sample of peripheral blood as BHB levels in various body fluids correlate with each other

Quantification of Salivary Nitric Oxide in Patients with Fixed Orthodontic Treatment

Nitric oxide (NO) is considered a regulator of bone response to mechanical stress that mediates adaptive bone formation, the pathological effects of lipopolysaccharides (LPS), tumour necrosis factor (TNF), interleukin 1 (IL-1) and other cytokines; regulates leukocytes and epithelial cell adhesion; inhibits T cell proliferation; and enhances natural killer (NK) cell activity, as well as other immune-related processes. The aim of the current study was to test the potential use of salivary NO as a biomarker of bone response that is specific and sensitive to local changes, following the application of different types of dental appliances. Material and methods: Salivary NO was determined in 30 patients divided into three groups with 10 participants each: control (C), fixed metal braces group (M), and aligners group (A). Salivary NO was determined four times in each group (before the procedure, at 2 weeks, 30 days, and 60 days after the procedure) using ELISA and rapid semi-quantitative assay with Nitric Oxide Saliva Test Strips (Berkeley, CA, USA). The mean results were compared with the ANOVA test, and the Pearson correlation index was calculated. The results show a significant increase in salivary NO levels by both methods only in the metal braces group, which is suggestive of oxidative damage, increased invasiveness, and bone response to metal braces. In conclusion, our study showed that metal brackets lead to a significant temporary increase in oral oxidative stress as an adaptive reaction to the presence of foreign bodies in the oral cavity. The subsequent concentration decrease at 60 days suggests a normalization of the body&rsquo;s response to foreign bodies