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Objective: Endovenous laser treatment (EVLA) is fast gaining acceptance as an alternative to open surgery for the treatment of saphenous vein incompetence. The method of action of these techniques is based on heat, making tumescence anaesthesia necessity. Heat-induced complications may occur with inadequate application of tumescent anaesthesia. Our hypothesis was, local cooling effect of tumescent anaesthesia on tunica adventitia might be kept undamaged from disruption due to the thermal injury. Methods: We experimented with two popular laser wavelengths (980 and 1470 nm) and with two different thermal media (+4 and +24°C) in vitro for perforation. Twenty different 12 cm length vein pieces were numbered randomly to set up four groups of the experiment. Endovenous laser procedures were applied in same manner in a unique design test tube with same energy density per pieces on same duration (10W/second) (linear endovenous energy density 60 J/cm). Procedure video was recorded for macroscopic perforations. All postprocedure vein segments were examined microscopically. Results: Activities of both wavelengths were much better in cold medium (P < 0.05). Cold tumescent anaesthesia reduces the bleeding complication rate. But the performance of 1470 nm laser was better than that of 980 nm in cold environment (P = 0.0136). Conclusions: It can be commented that reducing the ambient temperature is more beneficial than modifying the laser wavelength on perforation rates. Therefore we suppose tumescent anaesthesia temperature is effective on perforation independently from the wavelengths or type of the laser fibre. [ABSTRACT FROM AUTHOR]

Objective: This retrospective, multicentre study aimed to assess the prognostic value of a proposed classification system for chronic venous obstruction (CVO) patients undergoing successful interventional procedures., Methods: This study analysed data from 13 vascular centres, including 1 033 patients with CVO treated between 2015 - 2019. The patients were classified into five category types: 1 - non-thrombotic iliac vein lesion; 2 - CVO of iliac segment; 3 - CVO of iliofemoral segment above common femoral vein confluence; 4 - CVO of iliofemoral segment extending into the femoral vein (FV) or deep femoral vein (DFV); and 5 - CVO of iliofemoral segment involving both DFV and FV. Stent deployment, complications, and follow ups were evaluated. Uni- and multivariable analyses were performed to identify predictors of primary patency loss., Results: The mean age of the patients was 44.0 ± 14.7 years, with 59.9% being women. A median of two stents was used for unilateral cases and five stents for bilateral cases. At twelve months follow up, primary patency rates for types 1 - 5 were 94.9%, 90.3%, 80.8%, 60.6%, and 39.4%, respectively. These rates were strongly correlated with the extent of CVO and showed significant differences between each type. Univariable analysis identified predictors of primary patency loss as the type of CVO, history of deep vein thrombosis, and the total number of stents. In the multivariable analysis, the significant independent predictors of primary patency loss were the type of CVO and the total number of stents., Conclusion: The proposed anatomical classification of iliofemoral CVO will help to predict intervention outcomes and facilitate comparison of stent outcomes in future studies. However, further evaluation and validation in prospective studies are needed to confirm the utility of this classification., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Data on availability, affordability, and accessibility is key for the planning of global strategies to reduce the burden of venous thromboembolism (VTE)., Objectives: A survey was conducted for the 10th anniversary of World Thrombosis Day to assess the availability of VTE therapies worldwide and challenges in uniform implementation., Methods: We gathered information on the approval status, availability, utilization, occurrence of shortages, and spread of medical and interventional therapies for VTE. Furthermore, we collected information by accessing or contacting national or continental medicines agencies, manufacturers or distributors, and online drug repositories., Results: We obtained data from a total of 69 countries: 33 countries in Europe, 19 in Asia, 7 in the Americas, 9 in Africa, and 1 in Oceania. Unfractionated heparin, low-molecular-weight heparin, and vitamin K antagonists were available in almost all countries, but shortages were recorded in 13%, 19%, and 15% of them, respectively. Direct oral anticoagulants were available in approximately three-quarters of the surveyed countries. At least one parenteral medication for heparin-induced thrombocytopenia was available in 57% of countries and a shortage was reported in 9% of these. Shortage of thrombolytics was recorded in 50% of countries. Overall, at least one type of catheter-directed therapy system was approved for use in 77% of countries and available in 23% of surveyed institutions. Our findings revealed notable geographic disparities in the worldwide availability of VTE therapies, the access to which appeared to be limited by economic and geopolitical factors., Conclusion: We anticipate that this comprehensive information will play a pivotal role in highlighting the shortcomings of VTE therapies and the lack of homogeneous availability globally., Competing Interests: Declaration of competing interests C.A. received honoraria for lectures and participation in advisory boards from Bayer, BMS/Pfizer, Daiichi Sankyo, and Sanofi. L.A.C. research institution has received honoraria from Bayer, BMS-Pfizer Alliance, The Academy for Continued Advancement in Healthcare Education, Amag Pharmaceutical, LEO Pharma, Sanofi, Valeo Pharma, and Servier. L.A.C. holds a Tier 2 research Chair in Thrombosis and Anticoagulation Safety from the University of Ottawa. S.B. received institutional grants from Sanofi, Concept Medical, Bayer, Medtronic, Boston Scientific, Bard, Novartis, and Daiichi Sankyo and honoraria for advisory boards or lectures from Boston Scientific, Penumbra, Viatris, Bayer, Sanofi. S.A.M., R.M.F., G.C.M., E.V.D.P., M.D., M.C.G.E., L.H., P.S., C.M.S., and M.T.S. report no conflicts of interest., (Copyright © 2023 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Background: The optimal treatment of high-risk pulmonary embolism (PE) with cardiac arrest is still controversial although various treatment approaches have been developed and improved. Here, we present a serie of patients with high-risk PE showing hemodynamic collapse, who were successfully treated with extracorporeal membrane oxygenation (ECMO) as an adjunct to EKOS™ acoustic pulse thrombolysis (APT)., Methods: From April 2016 to June 2020, 29 patients with high-risk PE with cardiac arrest were retrospectively included. The mean age was 55.3 ± 9.2 years. A total of 12 (41.3%) patients were female. All patients had cardiac arrest, either as an initial presentation or in-hospital after presentation. All patients exhibited acute symptoms, computed tomography evidence of large thrombus burden, and severe right ventricular dysfunction. Primary outcome was all-cause 30-day mortality., Results: Twenty-two patients survived to hospital discharge, with a mean intensive care unit stay of 9.9 ± 1.6 days (range: 7-22 days) and mean length of hospital stay of 23.7 ± 8.5 days (range: 11-44 days). Six patients died from refractory shock. Ninety-day mortality was 24.1% (7/29). The Mean ECMO duration was 3.5 ± 1.1 days and the mean RV/LV ratio decreased from 1.31 ± 0.17 to 0.92 ± 0.11 in patients who survived to discharge. The mean tissue plasminogen activator dose for survivor patients was 20.5 ± 1.6 mg., Conclusion: Patients with high-risk pulmonary embolism who suffer a cardiac arrest have high morbidity and mortality. APT complemented by ECMO could be a successful treatment option for the patients who have high-risk PE with circulatory collapse., (© 2022 Wiley Periodicals LLC.)

Introduction: Venous thromboembolism (VTE) is a leading cause of cardiovascular morbidity and mortality. The majority of VTE events are hospital-associated. In 2008, the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) multinational cross-sectional study reported that only approximately 40% of medical patients at risk of VTE received adequate thromboprophylaxis., Methods: In our systematic review and meta-analysis, we aimed at providing updated figures concerning the use of thromboprophylaxis globally. We focused on: (a) the frequency of patients with an indication to thromboprophylaxis according with individual models; (b) the use of adequate thromboprophylaxis; and (c) reported contraindications to thromboprophylaxis. Observational nonrandomized studies or surveys focusing on medically ill patients were considered eligible., Results: After screening, we included 27 studies from 20 countries for a total of 137 288 patients. Overall, 50.5% (95% confidence interval [CI]: 41.9-59.1, I 2 99%) of patients had an indication to thromboprophylaxis: of these, 54.5% (95% CI: 46.2-62.6, I 2 99%) received adequate thromboprophylaxis. The use of adequate thromboprophylaxis was 66.8% in Europe (95% CI: 50.7-81.1, I 2 98%), 44.9% in Africa (95% CI: 31.8-58.4, I 2 96%), 37.6% in Asia (95% CI: 25.7-50.3, I 2 97%), 58.3% in South America (95% CI: 31.1-83.1, I 2 99%), and 68.6% in North America (95% CI: 64.9-72.6, I 2 96%). No major differences in adequate thromboprophylaxis use were found across risk assessment models. Bleeding, thrombocytopenia, and renal/hepatic failure were the most frequently reported contraindications to thromboprophylaxis., Conclusions: The use of anticoagulants for VTE prevention has been proven effective and safe, but thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients around the globe with marked geographical differences., (© 2021 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals LLC on behalf of International Society on Thrombosis and Haemostasis.)

Objective: To examine the efficacy and durability of an interwoven self-expanding nitinol stent for the treatment of superficial femoral and popliteal arteries., Method: Consecutive patients with severely diseased superficial femoral and popliteal arteries who received SUPERA® stents were retrospectively identified.The patients were followed for 12 months by Doppler ultrasound examinations, stent roentgenograms, and estimation of Rutherford-Becker class and ankle-brachial index., Results: From July 2012 to May 2014, 42 limbs in 36 patients (mean age, 61.5 ± 7.5 years; 75% male) were treated with angioplasty and primary stenting. Total occlusions were present in 14 limbs, and 63.8% had either moderate or severe calcification. The mean (±SD) lesion length was 105 mm (±28). Primary patency was 91.4% at 6 months and 85.7% at 12 months. The ankle brachial index increased from 0.57 ± 0.19 preoperative to 0.91 ± 0.12 postoperative. There was no procedural or device-related morbidity or mortality after revascularization and only one major amputation was observed on follow-up., Conclusions: Our experience shows that, Supera stents are safe and effective in our cohort of patients, with acceptable patency rates. There were no stent fractures so far even with stenting of the femoropopliteal segments. Stent design provides a viable option for high-grade obstructive disease in the femoropopliteal artery.

Introduction: Pulmonary embolism (PE) has not been accounted for as a cause of death contributing to cause-specific mortality in global reports., Methods: We analyzed global PE-related mortality by focusing on the latest year available for each member state in the World Health Organization (WHO) mortality database, which provides age-sex-specific aggregated mortality data transmitted by national authorities for each underlying cause of death. PE-related deaths were defined by International Classification of Diseases, Tenth Revision codes for acute PE or nonfatal manifestations of venous thromboembolism (VTE). The 2001 WHO standard population served for standardization., Results: We obtained data from 123 countries covering a total population of 2 602 561 422. Overall, 50 (40.6%) were European, 39 (31.7%) American, 13 (10.6%) Eastern Mediterranean, 13 (10.6%) Western Pacific, 3 (2.4%) Southeast Asian, and 2 (1.6%) African. Of 116 countries classifiable according to population income, 57 (49.1%) were high income, 42 (36.2%) upper-middle income, 14 (12.1%) lower-middle income, and 3 (2.6%) low income. A total of 18 726 382 deaths were recorded, of which 86 930 (0.46%) were attributed to PE. PE-related mortality rate increased with age in most countries. The reporting of PE-related deaths was heterogeneous, with an age-standardized mortality rate ranging from 0 to 24 deaths per 100 000 population-years. Income status only partially explained this heterogeneity., Conclusions: Reporting of PE-related mortality in official national vital registration was characterized by extreme heterogeneity across countries. These findings mandate enhanced efforts toward systematic and uniform coverage of PE-related mortality and provides a case for full recognition of PE and VTE as a primary cause of death., (© 2021 The Authors. Research and Practice in Thrombosis and Haemostasis published by Wiley Periodicals LLC on behalf of International Society on Thrombosis and Haemostasis (ISTH).)

Background: Chronic post-thrombotic occlusion of the iliofemoral veins causes significant morbidity, which can be alleviated if venous drainage is restored. We report our technique of surgical endophlebectomy and patchplasty of the common femoral vein (CFV) in conjunction with iliac vein stenting to restore venous flow from the infrainguinal venous system to the vena cava., Methods: There were 157 patients who underwent CFV endophlebectomy combined with iliocaval recanalization. Questionnaires were completed both preoperatively and postoperatively to allow comparison. These included the Clinical, Etiology, Anatomy, and Pathophysiology clinical classification; the Venous Clinical Severity Score; the Villalta scale; the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms; and the 36-Item Short Form Health Survey quality of life questionnaire., Results: Mean follow-up duration was 14.4 ± 2.9 months (range, 10-29 months). The mean preoperative Venous Clinical Severity Score was 15.3 ± 2.2, and this fell to 6.1 ± 1.8 after treatment (P < .001). The mean preoperative Villalta score dropped from 12.7 ± 2.6 to 6.3 ± 1.4 (P < .001). The quality of life and symptom severity scores were improved after 3 months by 17.2 points for quality of life (P < .001) and 20.5 points for symptom severity (P < .001). Primary patency was 81% (124/153) and secondary patency was 89.5% (137/153) at 12 months. Wound complications related to groin incision and lymphatic fistulas were observed in 22.8% (35/153) and 28.7% (44/153), respectively., Conclusions: The hybrid operation of CFV endophlebectomy in conjunction with iliac vein recanalization should be considered a safe and effective treatment option in patients with severe post-thrombotic syndrome and iliofemoral veno-occlusive disease., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In this study, we present our clinical experience and midterm results with the robotic-assisted concomitant procedures during mitral valve operations., Methods: Between March 2010 and February 2018, a total of 34 patients (8 males, 26 females; mean age 58.3 years; range, 34 to 78 years) who underwent robotic-assisted concomitant procedures during mitral valve surgery were retrospectively analyzed. Demographic characteristics of the patients, comorbidities, medical, and surgical histories, operative and laboratory results, electrocardiographic findings, postoperative intensive care unit and ward outcomes, and cardiac follow-up data were recorded. Atrial fibrillation-related medication use, stroke, or other thromboembolic events, and electrocardiographic reports in patients who underwent cryoablation were reviewed at three and 12 months after the operation., Results: A total of 76 robotic-assisted concomitant procedures were performed during mitral valve repair (n=11) or replacement (n=23) in 34 patients. These procedures were cryoablation (n=29), tricuspid valve repair (n=6), tricuspid valve replacement (n=2), left atrial appendage ligation (n=32), atrial septal defect and patent foramen ovale closure (n=5), and left atrial thrombectomy (n=2). The mean preoperative EuroSCORE values were 5.1±2.5. The mean duration of cardiopulmonary bypass and cross-clamp was 156±69.4 min and 101±42 min, respectively. Normal sinus rhythm was restored in 85% of the patients (24/28) after cryoablation and two patients (5.8%) had permanent pacemaker within a year during follow-up. There was one (2.9%) mortality in the early postoperative period due to hemorrhage related to the posterior left ventricular wall rupture. No blood product was used in 82.4% of the patients. One patient had a transient cerebral event and symptoms regressed completely within two months., Conclusion: Technological improvements and growing experience can decrease the suspects related to prolonged operational duration during robotic-assisted cardiac surgery. Concomitant procedures in addition to mitral valve operations can be performed with low complication rates in centers with experience of robotic surgery., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2019, Turkish Society of Cardiovascular Surgery.)

Objective To evaluate the clinical safety and effectiveness of percutaneous rheolytic thrombectomy in patients with acute lower extremity deep venous thrombosis. Method Sixty-eight consecutive patients with acute massive lower extremity deep venous thrombosis were included in this retrospective study. A percutaneous rheolytic thrombectomy device (Angiojet ® Rheolytic thrombectomy catheter, Boston Scientific, Marlborough, MA, USA) was used in all patients in an angiography suite through ipsilateral popliteal vein access. Thrombus clearance and complications were evaluated. Furthermore, patients underwent a clinical evaluation according to a modified Villalta scale for the investigation of post thrombotic syndrome in follow-up. The Venous Clinical Severity Score, Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Sym questionnaires were completed preoperatively and readministered postoperatively. Results Overall thrombus clearance (complete recanalization was achieved in 58 patients (85.2%) and partial recanalization was achieved in 7 patients (10.2%) confirmed through venographic assessment was achieved in 95.5% of the patient population. The mean Venous Clinical Severity Score preoperatively was 13.1 ± 2.2 and decreased to 4.0 ± 1.3 postoperatively (P < 0.01). The Villalta scale dropped from 12.9 ± 2.8 to 5.5 ± 1.4 postoperatively (P < 0.001). Overall quality of life and symptoms improved as assessed by Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Sym (P < 0.01 and 0.02, respectively). Only three minor bleedings were seen but none of the patients suffered from major bleeding, symptomatic pulmonary embolism, death, or other procedure related complications. Fifty-nine out of 65 patients (90.7%) who were treated successfully with rheolytic thrombectomy remained patent at 12 months according to DUS and five patients (7.3%) developed a mild post thrombotic syndrome. Conclusion Rheolytic thrombectomy with or without stenting is superior to anticoagulant therapy alone in terms of both ensuring venous patency and improving clinical symptoms. This technique is a safe, effective and easily performed method of endovascular treatment with a low rate of major treatment complications and shows promising clinical mid-term results.

Objective: The aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with chronic total occlusions of superficial femoral artery (SFA)., Method: From July 2012 to May 2014, a total of 28 patients (20 men, mean age 61.2 ± 11.5 years) with total occlusion of the SFA and good distal runoff were treated with percutaneous atherectomy, balloon angioplasty, and stenting (mean length 165.3 ± 57.5 mm, range 72-336 mm). All patients had severe claudication or critical limb ischemia, and most of the lesions were TransAtlantic Inter-Society Consensus classification type D (n = 21)., Results: Technical success was achieved in all cases. In majority (26, 92.8%) of the patients, endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. During a mean follow-up of 12.9 ± 2.5 months, claudication, severity, rest pain, and toe ulcers improved significantly. Ankle-brachial index changed from 0.54 ± 0.11 to 0.91 ± 0.2 at 1 year after intervention ( P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 92.8%, and 85.7%, respectively. One pseudoaneurysm and 1 arteriovenous fistula were found in the popliteal region on duplex examinations. There were 2 in-stent restenosis and 3 occlusions during the 12-month follow-up. These occlusions were treated with reendovascular procedures. Our secondary patency rate was 96.4%. No stent fracture was observed., Conclusion: The retrograde popliteal artery approach under duplex guidance can be considered as safe, efficient, and the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and mid-term results.

Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.

Objective: To determine the prevalence of abdominal aortic aneurysm (AAA) in patients with chronic obstructive pulmonary disease (COPD) and to assess the characteristics of these patients., Materials and Methods: Stable COPD patients (age, >40 years) were included in the study between January 2014 and June 2014. Patients with acute exacerbations and a previous lung resection were excluded. Data regarding demographic characteristics were recorded. The modified Medical Research Council (mMRC) dyspnea scale was used to assess the severity of breathlessness. The COPD Assessment Test (CAT) was performed. Abdominal aortic diameter was measured using abdominal ultrasonography (AUS), and AAA was diagnosed as an aortic diameter of ≥30 mm at the renal artery level., Results: In total, 82 patients were examined. AAA was detected in five (6.1%) patients. Diabetes mellitus, hypertension, and coronary artery disease were present in four patients with AAA. The average mMRC score was 3.2±0.4, and the mean CAT score was 18.4±6.0. Aneurysmal diameter was >50 mm in four patients and 37 mm in one patient. Statistically significant differences were found between patient with AAA and those without AAA with respect to the mean abdominal aortic diameters at the renal artery and iliac artery levels (p=0.012 and 0.002, respectively)., Conclusion: Our findings suggest that AAA is associated with COPD, with a prevalence rate of 6.1%. AAA is usually asymptomatic until a clinical status of rupture, which is associated with a higher mortality risk. Early diagnosis of AAA is lifesaving. In COPD patients, AAA might be easily determined using AUS, which is a noninvasive and relatively cheap procedure., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Background: Pulmonary embolism (PE) associated with hemodynamic instability has exceedingly high mortality. We describe our experience using percutaneous mechanical thrombectomy (PMT) in patients with massive PE (MPE) and submassive PE (SPE)., Methods: Thirty-six patients (16 males and 20 females; mean age, 51.4 ± 6.6 years) with massive and submassive PE were treated with PMT. All patients exhibited acute symptoms and computed tomography evidence of large thrombus burden and evidence of right ventricular (RV) dysfunction and/or failure. An Aspirex® percutaneous aspiration device was used in all patients. Clinical outcomes, hemodynamic recovery, RV and pulmonary artery pressures (PAP), blood gas changes, thrombus clearance, and complications were evaluated., Results: Treatment of 36 patients resulted in complete thrombus clearance (≥ 90%) in 83.3% of the patients (n = 30) and near-complete (50% to 90%) clearance in 13.8%. Measurements before and after treatment showed a decrease in mean PAP (53 ± 5.8 mmHg versus 25.6 ± 6.3 mmHg in MPE group [p < 0.01] and 46 ± 7.7 versus 22 ± 3.6 in SPE group [p < 0.01]). One patient died from refractory shock. No cardiovascular deaths or recurrent PE were documented during clinical follow-up but one patient demonstrated evidence of mild cor pulmonale., Conclusions: This study demonstrates safety and effectiveness of percutaneous mechanical aspiration thrombectomy in patients with massive and submassive PE with a large thrombus burden., (© 2015 Wiley Periodicals, Inc.)

Objective: The aim of this study was to explore the clinical effects of intralesional administration of an epidermal growth factor (EGF) up to complete wound closure., Methods: Seventeen diabetic patients with full-thickness lower extremity ulcers of more than 4 weeks of evolution were enrolled in the study. Mean ulcer size was 15.5 +/- 7.5 cm(2). Intralesional injections of 75 µg of Heberprot-P three times per week for 5-8 weeks were given up to complete wound healing., Results: Full granulation response was achieved in all patients in 32.4 +/- 6.6 days. Complete wound closure was obtained in 16 (94.1%) cases in 53.1 +/- 4.7 days. The most frequent adverse events were burning sensation, tremors, chills and pain at the site of administration. After 1-year follow-up, only one patient relapsed., Conclusions: Intralesional EGF administration up to complete closure can be safe, effective and suitable to improve healing of chronic diabetic foot ulcer (DFU).

Objective: The aim of this study was to compare the pain perception and side effects during and after endovenous laser ablation with a 1470 nm diode laser using cold or room temperature tumescence anesthesia., Methods: One hundred and one patients were randomly assigned in two groups. Group A received room temperature (+24℃) and Group B received cold (+4℃) tumescence fluid, which was used for local anesthesia in the track of great saphenous vein. A visual analog score was recorded immediately after the procedure. Patients were asked to register pain scores and the amount of pain medication consumed during the week., Results: There was no significant difference concerning gender, age, Clinical Etiological Anatomical Pathological Classification, body mass index, or diameter of the treated vein. In Group A, the mean linear endovenous energy density was 59.5 J/cm and in Group B, it was 60.4 J/cm. The average visual analog score after the endovenous laser ablation procedure in Group A was 5 and in Group B was 2. Third day after the procedure, the average visual analog score in Group A was 3 and in Group B was 1. Patients in Group B needed significantly less analgesics compared with patients in Group A (p<0.05). The most frequent side effects in both groups were ecchymosis, induration, and minor paraesthesia, all of which were more common in Group A (p < 0.001)., Conclusions: To date, most published endovenous laser ablation series describe the use of room temperature tumescence fluid infiltration of the perivenous stroma for tumescent analgesia and protection against thermal injury to the nearby structures. We describe an alternative technique using cold tumescence fluid infiltration, which is equally effective as, but safer than, room temperature tumescence fluid infiltration, and which yields better visual analog scores., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Pulmonary embolism (PE) associated with haemodynamic instability has exceedingly high mortality. We describe our experience using percutaneous mechanical thrombectomy (PMT) in patients with massive PE and right ventricle dysfunction., Methods: Sixteen patients (11 males and five females; mean age, 55.7 ± 8.3 years) with massive PE were treated with PMT. A percutaneous Aspiration Device (8 French Aspirex® aspiration thrombectomy catheter, Straub Medical, Switzerland) was used in all patients. Clinical outcomes, right ventricle and pulmonary artery pressures (PAP), thrombus clearance and complications were evaluated., Results: Treatment of 16 patients resulted in complete thrombus clearance (≥ 90%), in 87.5% of the patients and near-complete (50%-90%) clearance in 6.3%. Measurements before and after treatment showed a decrease in PAP (73 ± 11 mm Hg to 34 ± 8 mm Hg, P<.001). The RV/LV ratio decreased from 1.32 ± 0.15 to 0.84 ± 0.13 at follow-up (P<.001). One patient died from refractory shock. No cardiovascular deaths or recurrent PE were documented during clinical follow-up but one patient demonstrated evidence of mild cor pulmonale., Conclusions: This study demonstrates safety and effectiveness of percutaneous mechanical aspiration thrombectomy in patients with massive PE with a large thrombus burden., (Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolysis (UACDT) in the treatment of patients with massive and submassive pulmonary embolism (PE)., Method: Twenty-two patients (13 males and nine females; age range, 38 to 71 years; mean age, 53.7 years) with massive or submassive PE were treated with UACDT with the EKOS EkoSonic® system. All patients exhibited acute symptoms, computed tomography (CT) evidence of large thrombus burden, and evidence of right ventricular (RV) dysfunction and/or failure. Clinical outcomes and complications, RV pressures, and thrombus clearance were evaluated., Results: Treatment of 22 patients resulted in complete thrombus clearance (≥90%) in 77.2% of the patients, and near-complete (50% to 90%) clearance in 22.8%. The median tissue plasminogen activator (tPA) dose for all patients in our study was 21.0 mg (range 16 to 35 mg) and the median infusion time was 20.5 hours (range 12 to 28 hours). Measurements before and after treatment showed a decrease in pulmonary artery pressure (67 ± 14 to 34 ± 11 mmHg [systolic], p < 0.001). The RV/LV ratio decreased from 1.29 ± 0.17 to 0.92 ± 0.11 at follow-up (p < 0.001). Modified Miller score was significantly reduced (from 28 ± 4 to 13 ± 5, p < 0.001) in 21 of 22 (95%) patients who survived to discharge. There were only two minor access site bleeding complications, neither requiring transfusion., Conclusion: This study demonstrates safety and effectiveness of UACDT in patients with acute PE with a large thrombus burden., (© 2014 Wiley Periodicals, Inc.)

Pregnancy and the postpartum period are generally considered as contraindications for thrombolysis. We evaluate in this report the safety and effectiveness of using ultrasound-accelerated catheter-directed thrombolysis (UACDT) in treating three symptomatic postpartum deep vein thrombosis (DVT). UACDT was performed using a recombinant human tissue plasminogen activator (alteplase) which was delivered using the EKOS EkoSonic® system. Postprocedure venography was repeated after treatment which include stenting if stenosis was present. The treatment was successful in all three cases of iliofemoral DVT and symptom relief was achieved in all cases. Minor bleeding at the catheter insertion site in one patient was observed but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. UACDT is a safe and effective treatment for restoration of the venous flow in patients with postpartum iliofemoral DVT. Residual venous obstruction should be treated by angioplasty and stent insertion to avoid early re-thrombosis.

Superior vena cava (SVC) syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology, especially lung cancer and lymphoma. Thrombosis is becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Most patients are unresponsive to anticoagulation alone which appears to be effective only in the mildest cases. However, recent advances in catheter-based interventions have led to the development of a variety of minimally invasive endovascular strategies to remove venous thrombus and accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. Ultrasound accelerated catheter-directed thrombolysis (UACDT) has been developed to rapidly and completely resolve the existing thrombus. This technique integrates high frequency, low intensity ultrasound (US) with standard CDT in order to accelerate clot dissolution, reducing treatment time and the incidence of thrombolysis-related complications. An US wave enhances drug permeation through thrombus by disaggregating the fibrin matrix, exposing additional plasminogen receptor sites to the thrombolytic agent. The US energy affects thrombus in the entire venous segment, increasing the probability of complete thrombus clearing. We report the case of a 56-year-old man who presented with a 5 days history of SVC syndrome symptoms who had been receiving chemotherapy for colon cancer through a right subclavian vein port catheter. The patient successfully treated with UACDT with EkoSonic(®) Mach4e Endovascular device with an overnight infusion. © 2013 Wiley Periodicals, Inc., (Copyright © 2013 Wiley Periodicals, Inc.)

Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism, which remains an important cause of maternal morbidity and mortality. Although oral or systemic anticoagulation therapy may minimize thrombus propagation, it remains ineffective in removing thrombus burden and consequently does not prevent post-thrombotic syndrome. A novel technique, ultrasound accelerated catheter directed thrombolysis (UACDT), has been developed to rapidly and completely resolve thrombus. While pregnancy and the postpartum period are generally considered as contraindications for thrombolysis, we demonstrate in this case study the safety and effectiveness of using UACDT to treat symptomatic, postpartum, iliofemoral deep vein thrombosis after only an overnight infusion., (© 2013 The Authors. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.)

Purpose: We aimed to evaluate the efficacy and feasibility of ultrasonography (US)-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis., Materials and Methods: A total of 26 patients with deep venous thrombosis were prospectively selected for thrombolysis. Overall, 80.8% of the occlusions were in the lower extremities, and 19.2% were in the upper extremities. US-accelerated catheter-directed thrombolysis was performed using a recombinant human tissue plasminogen activator (alteplase), which was delivered using the EKOS EkoSonic® Endovascular System (EKOS Corporation, Bothell, Washington, USA). Postprocedure venography was repeated after the treatment, which included angioplasty and stenting if stenosis was present., Results: Thrombolysis was successful in 92.3% (24/26) of the patients, with complete clot lysis in 14 patients and partial clot lysis in nine patients. The mean symptom duration was 54.9±51 days (range, 6-183 days), and the mean thrombolysis infusion time was 25.3±5.3 hours (range, 16-39 hours). Pulmonary embolism was not observed; however, there were three cases of bleeding at the catheter insertion site. In three patients, the underlying lesions were successfully treated with balloon angioplasty and stent insertion. Two patients developed early recurrent thrombosis due to residual venous obstruction., Conclusion: US-accelerated thrombolysis was demonstrated to be a safe and efficacious treatment for deep venous thrombosis in this study. The addition of US reduces the total infusion time and increases the incidence of complete lysis with a reduction in bleeding rates. Residual venous obstruction should be treated by angioplasty and stent insertion to prevent early rethrombosis.

An alternative technique for minimally invasive aortic valve replacement and atrial septal defect repair is described. After a 5-cm skin incision, a key-lock type sternotomy is made. Excellent exposure of the right atrium and aortic valve was achieved. The configuration of the mini-sternotomy (or the lock) limits the movement of the sternal surfaces (or the key) on the lateral and craniocaudal directions.

Objective: To evaluate the efficacy of endovenous laser ablation (EVLA) of incompetent perforating veins (IPVs) with 1470 nm laser with 400 μm radial fiber., Background Data: EVLA for perforating veins can be performed with insignificant postprocedural morbidity. This allows treatment to be offered to elderly patients with comorbidities that would preclude anesthesia for surgical treatment or subfascial endoscopic perforator surgery (SEPS)., Methods: A total of 24 perforating veins in 16 limbs of 13 patients were treated between July 2010 and December 2011 in our clinic. Follow-up duplex scans were performed at 1 week and 1, 3, 6, and 12 months after the procedure, to determine the treatment outcome., Results: Of the 23 treated IPVs, 20 (86.9%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 174 J (range 105-236 J). Four of five ulcers had healed after 8 weeks in clinical-etiology-anatomy-pathophysiology (CEAP) C6 group. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. All components of the Venous Clinical Severity Score (VCSS) demonstrated significant improvements at each postprocedural visit (p<0.001 for all), except for pigmentation and compression, which exhibited variation throughout the follow-up period., Conclusions: Especially in the case of liposclerotic or ulcerated skin in the affected region, EVLA of IPVs with 1470 nm diode laser is highly effective and safe, and appears to be feasible. Additionally, repeat treatment can easily be performed should recurrence of IPVs arise.

Objective: Use of the radial artery (RA) as a conduit in coronary artery bypass grafting (CABG) has become increasingly popular in recent years. The aim of this prospective randomized study is to determine how the endothelial wall and blood flow of RA are differently affected with the usages of ultrasonic scalpel and conventional electrocautery in addition to effects of hypothermia and storage solutions. Histopathologic study was achieved by electron microscope to evaluate endothelium of the grafts., Methods: Between 2008 and 2009, 182 patients with coronary artery diseases were operated for coronary artery revascularization. The radial arteries were harvested for 40 of these patients and divided into two groups depending on the use of the ultrasonic cautery (UC) (n=20) and the high-frequency electrocautery (EC) (n=20). Patients were divided into two subgroups according to the storage media of the graft. RA was preserved in situ at room temperature (Group 1) and normothermic organ bath (NOB) (Group 2). Harvesting time, use of hemostatic clips, frequency of spasm, in situ free flow, temperature and endothelial damage were compared between the two groups. Statistical analysis was performed using one-way ANOVA, Friedman and unpaired t tests., Results: In all groups, blood flows were significantly decreased as parallel to the local temperatures. Second and third phase flows were similar in group EC1 and UC1 (p>0.05). Free flow was increased in group UC+NOB when comparing with only EC group (60.4±9.83 ml/min and 40.8±7.50 ml/min, p<0.001), whereas the graft preparing time "t2" was shorter in group EC than UC (10.9±2.42 min and 15.2±1.31 min, p<0.01). Nonetheless scoring of the groups in terms of endothelial cell structure and mitochondrial morphological changes did not show any significant difference., Conclusion: If endothelial integrity of the RA can be preserved along with the application of systemic temperature (NOB), regardless of harvesting technique, it provides better flow rates.

Infective endocarditis is a diagnostic and therapeutic challenge that ultimately requires surgical intervention in 20% of all cases. Surgical treatment of active infective endocarditis requires not only hemodynamic repair, but also special emphasis on the eradiation of the infectious focus to prevent recurrence. This goal can be achieved by the combination of aggressive debridement of infective tissue and appropriate and adequate antibiotic treatment. We report a case of Streptococcus viridans induced aortic valve perforation related to aortic valve and root endocarditis, which was successfully treated with aortic root replacement using stentless bioprosthesis. This bioprosthesis thus seems to be a valuable option for active endocarditis, provides excellent hemodynamics with low gradients. Acceptable operative risk can be achieved by full root stentless valve replacement in physically active patients such as divers.

Blood cysts are uncommon primary cardiac tumors, frequently encountered in pediatric patients, but extremely rare when found in adults. Due to the considerable risks of embolization and obstruction of the blood flow, surgical removal is preferred. Herein, we report a case of blood cyst of the right ventricle, presenting as recurrent fever and chills in an adult patient.

We are reporting the successful surgical management of a challenging right coronary artery aneurysm with a giant fistula into the coronary sinus. We performed fistula division, coronary sinus size reduction, and complete resection of the right coronary artery aneurysm with bypass to the posterior descending artery.

Objective: Radial artery pedicle tissue cooling during harvesting is one of the major causes of vasospasm. We aimed to compare the effects of the pedicle rewarming method, normothermic organ bath, and one of the most preferred topical antispasmodic agents, verapamil-nitroglycerin solution alone or in combination on the blood flow of radial artery., Methods: Consecutively randomized patients (n=80) undergoing coronary bypass were organized as four equal-sized groups. Effects of normothermic organ bath and topically performed verapamil-nitroglycerin solution alone or in combination on the blood flow of radial artery were investigated. In the control group no antispasmodic treatment was performed. Free flows were measured at three stages: as initial flow after minimal distal harvesting, post-harvesting flow after total harvesting, and post-treatment flow following a waiting period after the application of the antispasmodic protocol. At each stage, pedicle and esophageal temperatures were also recorded., Results: Radial artery pedicle temperatures decreased significantly during harvesting in all groups (p<0.001). Normothermic organ bath, topical verapamil-nitroglycerin solution treatment, and their combination increased flow significantly (p<0.001, from 40.3+/-10.48 ml/min to 64.3+/-18.8 ml/min, from 38.9+/-13.91 ml/min to 62.75+/-15.23 ml/min, from 41.4+/-11.19 ml/min to 75.4+/-15.32 ml/min, respectively). The differences between the initial and post-treatment flows were not significant in the combined procedure group (p>0.05), whereas the initial levels were not reached in the post-treatment flows (p<0.05) in the normothermic organ bath and verapamil-nitroglycerin groups., Conclusions: Hypothermia plays an important role in radial artery vasospasm. Normothermic organ bath and verapamil-nitroglycerin solution alone or in combination relieve spasm of radial artery.

Background: Free flow of the internal thoracic artery decreases commonly after harvesting because of spasm. Tissue heat loss is inevitable during surgery. The aim of this study was to compare the internal thoracic artery pedicle rewarming method with topical papaverine applications in different thermal conditions., Methods: Patients (n = 120) were organized in to 6 equally sized groups. The effects of topical papaverine application at room temperature, topical heated papaverine (at 37 degrees C) application, internal thoracic artery pedicle storage in normothermic conditions, pedicle storage in normothermic conditions combined with topical papaverine application, and pedicle storage in normothermic conditions combined with topical heated papaverine application were investigated. In the control group, no treatment was applied and the pedicle was stored in room temperature conditions. We measured internal thoracic artery free flows at 3 stages: at the initiation of harvesting, after total harvesting, and after antispasmodic treatment. Durations of the stages were recorded. At each stage hemodynamic parameters, tissue and core temperatures were also monitored., Results: Internal thoracic artery pedicle temperature significantly decreased simultaneously with the free flow after the harvesting procedure. Recovery of the physiologic temperature state, provided by storing the internal thoracic artery pedicle in normothermic conditions, improved the flow and increased the efficiency of topically applied papaverine on the vasospasm of the internal thoracic artery., Conclusion: Topical application of heated papaverine itself does not warm pedicle tissue, but papaverine efficiency increases when the pedicle is stored in normothermic conditions. Preserving internal thoracic artery pedicles in normothermic conditions can be the preferred treatment for spasms.