Aim: Antegrade Selective Cerebral Perfusion (ASCP) with lower body circulatory arrest (LBCA) used in aortic arch surgery can lead to postoperative ischemic organ dysfunctions if it lasts long enough. We aimed to evaluate methods that can provide early detection of spinal cord ischemia during aortic arch surgery. Methods: Thirty consecutive patients were prospectively enrolled and Near infrared spectrometry (NIRS) data obtained from the 5 th and 10 th thoracic vertebral region, S100β protein, lactate blood levels during various operative phases and postoperative neurological outcomes were evaluated. Results: A total of 30 patients underwent elective hemi arch (73.29%) or total arch (23.31%) replacement and with a mean ASCP period of 25.1 ± 19.0 (limits 10-90) minutes. In-hospital mortality was 6.66% (two patients). Paraparesis developed in one patient (3,33%). Thoracic T5 and T10 NIRS values were lowest during the ASCP period (p<0.001) with a good correlation between them (r=0.853, p<0.001). However, a significant difference between the T5 and T10 levels was observed during the same period (55.40 vs 51.07 respectively, p=0.001). A moderately negative correlation between the lactate levels in descending aorta and NIRS values at the T10 level was found during ASCP (r =-0.514, p = 0.004). Conclusion: Thoracic 5 th and 10 th level NIRS monitoring for spinal cord oxygenation were significantly lower during ASCP period compared to the other periods of aortic arch surgery with T10 values being lower than T5 values during the same period indicating a more significant flow disturbance at this level. Measuring lactate levels with thoracic NIRS monitoring seems promising for future studies with larger volumes and longer ASCP periods.

Background.Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used and become the standard treatment option for AAA. The aim of the current study was to evaluate the outcomes and predictors of survival of endovascular treatment of AAA at the short and medium-term. Methods.A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality,complications and need for secondary intervention were collected.Primary endpoint was all-cause mortality.Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival. Results. Median age was 70 years with male predominance(202 patients,91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months(range,1 to 80 months). Survival rates at one, three and five years were 93.5%,81.4% and 62.2% respectively. Freedom from secondary intervention rates were 95.5% at one year,88.7% at three years and 82.1% at five years. Cox proportional hazard models showed that preoperative creatinine levels ≥1.8 mg/dl(hazard ratio (HR) 2.68, 95%CI1.21-6.42, p=0.027), hemoglobin levels <10 gr/dl (HR 3.38 95%CI 1.16-9.90,p=0.026), ejection fraction < 30% (HR 5.67,95%CI1.29-24.86,p=0.021)and AAA diamete≥6.0 cm(HR 2.20,95%CI1.01-4.81,p=0.049)were independently associated with mid-term survival. Conclusion.EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favorable.However, the analyzed factors in this study that predict reduced survival(high preoperative creatinine,ow hemoglobin,low ejection fraction and larger aneurysms) should be judged when planning EVAR.

INTRODUCTION: The aim of this study is to evaluate the effect of acute, iatrogenic right arm ischemia and reperfusion on microcirculation using tissue perfusion markers like central venous oxygen saturation, lactate, the difference between central venous and arterial CO2 pressure, Near-infrared spectroscopy, and biomarkers like sialic acid, malondialdehyde, advanced oxidative protein products in aortic surgery with moderate hypothermia. METHODS: Adult patients undergoing ascending aorta repair with antegrade cerebral perfusion via axillary artery participated in the study. Blood samples were collected from the radial artery, internal juguler vein, right arm cubital vein and left arm cubital vein and analysis were performed at five intraoperative time points. Blood samples for biomarkers were obtained at three intraoperative time points. RESULTS: Right arm venous oxygen saturation are significantly lower than left arm and central venous. Right arm lactate levels are significantly higher than left arm and central venous lactate levels. Somatic right arm near-infrared spectroscopy values are significantly lower than somatic left arm. There are no significant differences for biomarkers throughout the time points. CONCLUSIONS: We have concluded that well-known markers such as central venous oxygen saturation and lactate reflect the results of ischemia-reperfusion faster, and are more valuable than novel biomarkers. Near-infrared spectroscopy is a promising monitor in terms of providing information about tissue oxygenation. However, oxidative stress biomarkers seem to be far from following the results of ischemia-reperfusion damage in an instant or short time, moreover, their costs are high and laboratory studies take time.

Objective.As aneurysm related events and rupture is not eliminated, postoperative lifelong surveillance is mandatory after endovascular aneurysm repair(EVAR).For surveillance colored Doppler ultrasound(CDUS) is a standard method of noninvasive evaluation having the advantages of availability, cost-effectiveness and lack of nephrotoxicity and radiation.We evaluated CDUS for primary surveillance tool after elective EVAR by comparing with computerized tomography. Methods.Between 2018-2020, 84 consecutive post-EVAR patients were evaluated.Firstly, CDUS was performed by two Doppler operators from the Radiology and computed tomographic angiography (CTA) was performed.A reporting protocol was organized for endoleak detection and largest aneurysm diameter. Results.Among 84 patients, there were 11 detected endoleaks(13,1%) with CTA and 7 of them was detected with CDUS (r=0,884,p<0.001).There is an insufficiency in detecting low flow by CDUS.Eliminating this frailty, there was a strong correlation of aneurysm sac diameter measurement between CTA and CDUS (r=0,777,p<0,001).The sensitivity and specificity of CDUS was 63,6% and 100% respectively.The accuracy was 95,2%.Positive and negative predictive values were 100% and 94,8%.Bland-Altman analysis and linear regression analysis showed no proportional bias (mean difference of 1.5±2.2mm,p=0.233). Conclusions.CDUS promises accurate results without missing any potential complication requiring intervention as Type I or III endoleak.Lack of detecting type II endoleaks may be negligible as sac enlargement was the key for reintervention in this situation and CDUS has a remarkably high correlation with CTA in sac diameter measurement. CDUS may be a primary surveillance tool for EVAR and CTA will be reserved in case of aneurysm sac enlargement,detection of an endoleak,inadequate CDUS or in case of unexplained abdominal symptomatology

Coronavirus disease 2019 (COVID-19) is a remarkably challenging health issue that provoked all the health-care providers to contemplate some measures about the situation. All the health-care workers frontline (esp. emergency service, pulmonologists, infection disease specialist and anesthesiologist) have produced recommendations on prevention and taking care of COVID-19 patient (1,2). Whereas, at the second line another important issue is the ongoing healthcare for the continual disease situations.There are two main critical issues on cardiovascular surgery in this pandemic. Firstly, to delay the elective surgeries is essential to sustain the health-care service. Elective case triage is trickier for cardiovascular procedures which are relatively progressive conditions. Definitive decision to defer a procedure should be made regarding firstly to the capacity of health-care system, and then availability of surgical/anesthesia staff, intensive care unit beds, need for isolation beds, ventilators, cardiopulmonary bypass machine, extracorporeal membrane oxygenator, supplies such as sutures, grafts, valves and blood and blood product availability. The patient status should be taken into account to defer or to perform the procedure, as well. Therefore, we developed “Level of Priority” (LoP) statement for cardiovascular procedures (3). Elective cases are defined as LoP I that may be postponed as much as possible. LoP II to IV cases should be reconsidered by individual basis by “Heart Team”. The situations that can be managed by percutaneous coronary intervention, endovascular procedures and etc. may be handled by non-operative manners.The second one is the personal protection equipment and infection measures while dealing with a suspected / confirmed COVID-19 patient. It is obvious that a suspected / confirmed COVID-19 patient ought to be assessed with specific measures for any medical or surgical intervention. Personal protection equipment (PPE) is the most crucial measure during the pandemic. It is recognized that many centers are facing PPE shortages and there are recommendations to re-sterile the masks to be effective for reuse.(4) More measures should be taken into consideration for sterile environment such as surgical procedures. Some added measures such as face shield may be recommended for surgical procedures. The surgical team who scrubbed in, must wear extra equipment such as surgical coat and double gloves. It may be recommended to fix the long-sleeve gloves to the surgical coat by adhesive drapes (3). It is obvious that this kind of working environment with all this equipment is challenging, sometimes irritating and disquieting. One other big problem is the fraught feeling of health-care providers to be diseased or to be contagious for their family. Therefore, health-care providers may need enormous support for burnouts during the pandemic.The other measures such as preparation of the operating room (OR), anesthesiologic management, transportation of patients and disinfection of OR were discussed in the referring article (3).In conclusion, it is important to assess the “Level of Priority” for surgical procedures to support the service of health-care facility. More than that, whole surgical team should be protected by adequate PPE and should take the time to get full protected.