Turkiye Klinikleri Cardiovascular Sciences

.: ORIGINAL RESEARCH
Effect of Previous Stent Implantation in Elective Coronary Artery Bypass Grafting Operation; Multivariate Analysis of 1,259 Patients: Retrospective Clinical Trial
Geçirilmiş Stent İmplantasyonunun Elektif Koroner Arter Baypas Greft Operasyonundaki Etkisi; 1.259 Hastanın Multivaryant Analizi: Retrospektif Klinik Çalışma
Mehmet Erdem TOKERa , Muharrem DAĞLIb , Cüneyt ARKANc , Ömer Faruk AKARDEREa
aDepartment of Cardiovascular Surgery, University of Health Sciences Koşuyolu Heart Training and Research Hospital, İstanbul, Türkiye
bClinic of Cardiovascular Surgery, Gebze Fatih State Hospital, İzmit, Türkiye
cClinic of Cardiovascular Surgery, Tunceli State Hospital, Tunceli, Türkiye
Turkiye Klinikleri J Cardiovasc Sci. 2023;35(2):31-7
doi: 10.5336/cardiosci.2022-95172
Article Language: EN
Full Text
ABSTRACT
 Objective: This study aims to investigate the effect of previous stent implantation on early mortality in patients undergoing elective coronary artery bypass grafting (CABG). Material and Methods: A total of 1,259 patients who underwent elective isolated CABG between January 2015 and December 2016 were included. There were 970 patients in the CABG without stent group and 289 patients in the CABG with stent group. Preoperative, intraoperative, and postoperative data of both groups were compared. Predictors of early mortality in CABG were examined using the logistic regression analysis. Results: Early mortality rates after surgery between the groups were similar (CABG without stent group vs. CABG with stent group; 2.9% vs. 3.1%, p=0.998). The length of intensive care unit stay, the use of intraaortic balloon pump, tracheotomy, new dialysis, revision and the use of extracorporeal membrane oxygenator were also comparable between the groups (p>0.05). The mean number of grafts was significantly lower in the CABG with stent group than the CABG without stent group (2.62±0.91 vs. 2.87±0.9; p<0.001 respectively). Multivariate analysis revealed that an ejection fraction of ≤40% [odds ratio (OR): 3.8; 95% confidence interval (CI): 1.9-7.7; p<0.001], preoperative renal failure (OR: 3.7; 95% CI: 1.5-8.8; p=0.003), and advanced age (OR: 1.07; 95% CI: 1.03-1.1; p<0.001) were independent predictors of early mortality. Previous stent implantation has not been found out as a risk factor for early mortality (OR: 1.08; 95% CI: 0.5-2.3; p=0.998). Conclusion: Previous stent implantation was not found to be a factor affecting early mortality in patients undergoing elective CABG operations.

Keywords: Coronary artery bypass; cardiopulmonary bypass; extracorporeal membrane oxygenation; percutaneous transluminal coronary angioplasty; stents
ÖZET
 Amaç: Bu çalışmada, koroner arter baypas greftleme (KABG) yapılan hastalarda geçirilmiş stent implantasyonunun erken dönem mortaliteye olan etkisi araştırıldı. Gereç ve Yöntemler: Ocak 2015- Aralık 2016 yılları arasında elektif izole KABG yapılan toplam 1.259 hasta çalışmaya dâhil edildi. KABG stentsiz grupta 970 hasta yer alırken, KABG stentli grupta 289 hasta vardı. Her iki grup ameliyat öncesi, ameliyat sırası ve ameliyat sonrası özellikler açısından karşılaştırıldı. Lojistik regresyon analizi ile KABG'de erken dönem mortaliteyi etkileyen faktörler araştırıldı. Bulgular: Ameliyat sonrası erken mortalite oranları her iki grupta benzerdi (KABG stentsiz gruba oranla KABG stentli grup; %2,9'a karşı %3,1, p=0,998). Yoğun bakım ünitesinde kalış süresi, intraaortik balon pompası kullanım oranı, trakeostomi, yeni diyaliz, reviyon ve ekstrakorporeal sirkülasyon kullanım oranları her iki grupta karşılaştırılabilir düzeydeydi (p>0,05). Ortalama greft sayısı, KABG stentli grupta, KABG stentsiz gruba göre anlamlı düzeyde daha düşüktü (2,62±0,91'e karşı 2,87±0,9; p<0,001). Çok değişkenli analizde ≤%40 ejeksiyon fraksiyon [göreceli olasılıklar oranı (odds ratio ''OR''): 3,8; %95 güven aralığı (confidence interval ''CI''): 1,9-7,7; p<0,001], ameliyat öncesi böbrek yetersizliği (OR: 3,7; %95 CI: 1,5-8,8; p=0,003) ve ileri yaş (OR: 1,07; %95 CI: 1,03-1,1; p<0,001) erken dönem mortaliteyi etkileyen bağımsız öngördürücüler olarak bulundu. Geçirilmiş stent implantasyonu, erken mortaliteyi etkileyen bir risk faktörü olarak saptanmadı (OR: 1,08; %95 CI: 0,5-2,3; p=0,998). Sonuç: Elektif koroner arter baypas operasyonu yapılan hastalarda, geçirilmiş stent implantasyonu erken mortaliteyi etkileyen bir faktör olarak bulunmamıştır.

Anahtar Kelimeler: Koroner arter baypas; kardiyopulmoner baypas; yapay dolaşım membran oksijenasyonu; perkütan translüminal koroner anjiyoplasti; stentler
REFERENCES:
  1. O'Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al; Society of thoracic surgeons quality measurement task force. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2--isolated valve surgery. Ann Thorac Surg. 2009;88(1 Suppl):S23-42. [Crossref]  [PubMed] 
  2. ElBardissi AW, Aranki SF, Sheng S, O'Brien SM, Greenberg CC, Gammie JS. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg. 2012;143(2):273-81. [Crossref]  [PubMed] 
  3. Kötting J, Beckmann A, Döbler K, Schäfer E, Veit C, Welz A, et al. German CABG score: a specific risk model for patients undergoing isolated coronary artery bypass grafting. Thorac Cardiovasc Surg. 2014;62(4):276-87. [Crossref]  [PubMed] 
  4. Kindo M, Hoang Minh T, Perrier S, Bentz J, Mommerot A, Billaud P, et al. Trends in isolated coronary artery bypass grafting over the last decade. Interact Cardiovasc Thorac Surg. 2017;24(1):71-6. [Crossref]  [PubMed] 
  5. Movahed MR, Ramaraj R, Jamal MM, Hashemzadeh M. Nationwide trends in the utilization of multivessel percutaneous coronary intervention (MVPCI) in the United States across different gender and ethnicities. J Interv Cardiol. 2009;22(3):247-51. [Crossref]  [PubMed] 
  6. Hakamada K, Sakaguchi G, Marui A, Arai Y, Nagasawa A, Tsumaru S, et al. Effect of multiple prior percutaneous coronary interventions on outcomes after coronary artery bypass grafting. Circ J. 2021;85(6):850-6. [Crossref]  [PubMed] 
  7. Lisboa LA, Mejia OA, Dallan LA, Moreira LF, Puig LB, Jatene FB, et al. Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting. Arq Bras Cardiol. 2012;99(1):586-95. English, Portuguese. [Crossref]  [PubMed] 
  8. Thielmann M, Leyh R, Massoudy P, Neuhäuser M, Aleksic I, Kamler M, et al. Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery. Circulation. 2006;114(1 Suppl):I441-7. [Crossref]  [PubMed] 
  9. Tran HA, Barnett SD, Hunt SL, Chon A, Ad N. The effect of previous coronary artery stenting on short- and intermediate-term outcome after surgical revascularization in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2009;138(2):316-23. [Crossref]  [PubMed] 
  10. Thielmann M, Neuhäuser M, Knipp S, Kottenberg-Assenmacher E, Marr A, Pizanis N, et al. Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple-vessel disease undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2007;134(2):470-6. [Crossref]  [PubMed] 
  11. Nakazawa G, Otsuka F, Nakano M, Vorpahl M, Yazdani SK, Ladich E, et al. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol. 2011;57(11):1314-22. [Crossref]  [PubMed]  [PMC] 
  12. Yoneda S, Abe S, Kanaya T, Oda K, Nishino S, Kageyama M, et al. Late-phase inflammatory response as a feature of in-stent restenosis after drug-eluting stent implantation. Coron Artery Dis. 2013;24(5):368-73. [Crossref]  [PubMed] 
  13. Mitsutake Y, Ueno T, Yokoyama S, Sasaki K, Sugi Y, Toyama Y, et al. Coronary endothelial dysfunction distal to stent of first-generation drug-eluting stents. JACC Cardiovasc Interv. 2012;5(9):966-73. [Crossref]  [PubMed] 
  14. Yap CH, Yan BP, Akowuah E, Dinh DT, Smith JA, Shardey GC, et al. Does prior percutaneous coronary intervention adversely affect early and mid-term survival after coronary artery surgery? JACC Cardiovasc Interv. 2009;2(8):758-64. [Crossref]  [PubMed] 
  15. Ueki C, Miyata H, Motomura N, Sakaguchi G, Akimoto T, Takamoto S. Previous percutaneous coronary intervention does not increase adverse events after coronary artery bypass surgery. Ann Thorac Surg. 2017;104(1):56-61. [Crossref]  [PubMed] 
  16. Massoudy P, Thielmann M, Lehmann N, Marr A, Kleikamp G, Maleszka A, et al. Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: a multicenter analysis. J Thorac Cardiovasc Surg. 2009;137(4):840-5. [Crossref]  [PubMed] 
  17. Stevens LM, Khairy P, Agnihotri AK. Coronary artery bypass grafting after recent or remote percutaneous coronary intervention in the Commonwealth of Massachusetts. Circ Cardiovasc Interv. 2010;3(5):460-7. [Crossref]  [PubMed] 
  18. Mariscalco G, Rosato S, Serraino GF, Maselli D, Dalén M, Airaksinen JKE, et al. Prior percutaneous coronary intervention and mortality in patients undergoing surgical myocardial revascularization: results from the E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) with a systematic review and meta-analysis. Circ Cardiovasc Interv. 2018;11(2):e005650. [Crossref]  [PubMed] 
  19. Luthra S, Leiva Juárez MM, Senanayake E, Luckraz H, Billing JS, Cotton J, et al. Percutaneous intervention before coronary artery bypass surgery does not unfavorably impact survival: a single-center propensity-matched analysis. Ann Thorac Surg. 2016;102(6):1911-8. [Crossref]  [PubMed] 
  20. Biancari F, Dalén M, Ruggieri VG, Demal T, Gatti G, Onorati F, et al. Prognostic impact of multiple prior percutaneous coronary interventions in patients undergoing coronary artery bypass grafting. J Am Heart Assoc. 2018;7(20):e010089. [Crossref]  [PubMed]  [PMC] 
  21. Bugajski P, Greberski K, Kuzemczak M, Kalawski R, Jarząbek R, Siminiak T. Impact of previous percutaneous coronary interventions on the course and clinical outcomes of coronary artery bypass grafting. Kardiol Pol. 2018;76(6):953-9. [Crossref]  [PubMed] 
  22. Toker ME, Arkan C, Akardere ÖF. Right coronary endarterectomy with stent removal before right coronary artery bypass during coronary artery bypass grafting surgery. Koşuyolu Heart J. 2021;24(1):63. [Crossref] 
  23. Grieshaber P, Oswald I, Albert M, Reents W, Zacher M, Roth P, et al. Risk of perioperative coronary stent stenosis or occlusion in patients with previous percutaneous coronary intervention undergoing coronary artery bypass grafting surgery. Eur J Cardiothorac Surg. 2020;57(6):1122-9. [Crossref]  [PubMed] 
  24. Mannacio V, Di Tommaso L, De Amicis V, Lucchetti V, Pepino P, Musumeci F, et al. Previous percutaneous coronary interventions increase mortality and morbidity after coronary surgery. Ann Thorac Surg. 2012;93(6):1956-62. [Crossref]  [PubMed] 
  25. Nauffal V, Schwann TA, Yammine MB, El-Hage-Sleiman AK, El Zein MH, Kabour A, et al. Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease. J Thorac Cardiovasc Surg. 2015;149(5):1302-9. [Crossref]  [PubMed]  [PMC] 

.: Up To Date

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com