Turkiye Klinikleri Cardiovascular Sciences

.: ORIGINAL RESEARCH
Aort Koarktasyonunda Balon Anjiyoplasti Sonuçlarını Etkileyen Faktörlerin Belirlenmesi
Determination of Factors Affecting the Results of Balloon Angioplasty in Coarctation of Aorta
Özlem SARISOYa, Canan AYABAKANa, Niyazi Kürşad TOKELb
aÇocuk Kardiyoloji BD, Başkent Üniversitesi İstanbul Sağlık Uygulama ve Araştırma Merkezi Hastanesi, İstanbul, TÜRKİYE
bÇocuk Kardiyoloji BD, Başkent Üniversitesi Tıp Fakültesi, Ankara, TÜRKİYE
Turkiye Klinikleri J Cardiovasc Sci. 2019;31(2):100-8
doi: 10.5336/cardiosci.2018-63455
Article Language: TR
Full Text
ÖZET
 Amaç: Aort koarktasyonunda balon anjiyoplastinin başarısını, sonuçlarını, rekoarktasyon sıklığını ve bunu etkileyen faktörleri saptamaktır. Gereç ve Yöntemler: Nisan 2007-Mayıs 2012 tarihleri arasında koarktasyon tanısıyla balon anjiyoplasti yapılan 53 hastanın verileri retrospektif olarak değerlendirildi. Bulgular: Ortalama yaş 14,7±35,5 (0,1-198) ay, ağırlık 7,8±8,9 kg; 23 (%43)'ü kız, 30 (%57)'u erkek hasta idi. Yaş grupları balon öncesi ve sonrası arkus ve istmus z değerleri açısından karşılaştırıldı. Balon öncesi ve sonrası, 0-3 ay (grup 1) ile 12 ay üzeri grupta arkus Z-skorları ve istmus Z-skorları, ayrıca 4-12 ay (grup 2) ile 12 ay üzeri (grup 3) grupta yine arkus aorta ve istmus Z-skorları açısından fark anlamlı bulundu. Balon öncesi sistolik basınç gradientinin ortalama 35,8±18,2 mmHg'dan, 13,8±10 mmHg'a gerilediği, koarktasyon çapının 3,3±1,9 mm'den 4,9±2,6 mm'ye arttığı görüldü. Anjiyoplasti öncesinde çıkan aorta, istmus, distal aortik arkus ve abdominal aorta çaplarının, anjiyoplasti sonrasında anlamlı olarak arttığı belirlendi. İşlem başarısı tüm hastalarda %81; 0-3 ayda %79, 4-12 ayda %77, 12 ay üzerinde ise %92 olarak bulundu. Yaş ile rekoarktasyon arasında anlamlı ilişki belirlendi. Balon öncesi istmus çapı, çıkan aorta çapının %50'si ve altında olanlarda rekoarktasyon sıklığının anlamlı düzeyde yüksek olduğu belirlendi. Komplikasyon oranı %19 olarak saptandı. Sonuç: Balon anjiyoplasti, koarktasyon tedavisinde cerrahiye alternatif ve güvenli bir tedavi yöntemidir. Balon öncesi ve sonrasında distal transvers arkus çapı ve Z-skoru, istmus çapı ve Z-skoru, koarktasyon bölgesinin çapı rekoarktasyon ile ilişkili önemli ölçümlerdir. Yaş ve ciddi istmus hipoplazisi, rekoarktasyon için anlamlı risk faktörleridir.

Anahtar Kelimeler: Aort koarktasyonu; arkus hipoplazisi; balon anjiyoplasti; istmus hipoplazisi; rekoarktasyon
ABSTRACT
 Objective: The aim of this study is to determine the factors affecting the success rate, outcome and rate of recoarctation in patients treated with balloon angioplasty for coarctation. Material and Methods: Ballon angioplasty was performed on 53 patients for coarctation of aorta between April 2007 and May 2012. The medical files of the patients were evaluated retrospectively. Results: The mean age of the patients was 14.7±35.5 months, mean weight was 7.8±8.9 kilograms. 30 were males (57%), while 23 were females (43%). The patients were classified into age groups (group 1: 0-3 months, group 2: 4-12 months, and group 3: >12 months). Arcus aorta and isthmus measurements, and their Z-scores were compared between the age groups. Between groups 1 and 3, the Z-scores of arcus and isthmus differed significantly both before and after angioplasty. Similarly the arcus and isthmus Z-scores differed significantly between groups 2 and 3. Mean systolic pressure gradient across the coarctation reduced from 35.8±18.2 to 13.8±10 mmHg. Also, the mean diameter of the coarctation segment increased from 3.3±1.9 mm to 4.9±2.6 mm. The diameters for ascending aorta, isthmus, distal aortic arch and abdominal aorta increased significantly after angioplasty as well. The overall success rate of the procedure was 81%, which increased with patient's age (79% for 0-3 months, 77% for 4-12 months, and 92% for >12 months). Younger age was significantly related with recoarctation. The frequency of recoarctation was significantly higher in patients with isthmus diameters less than or equal to 50% of ascending aorta prior to angioplasty. The rate of recoarctation for all patients was 19%. Conclusion: Balloon angioplasty is a safe alternative to surgery for aortic coarctation. Diameters and Z-scores of distal transverse arch and isthmus; and diameters of the coarctation segment both before and after ballon angioplasty may be important predictors for recoarctation. Recoarctation is anticipated more in younger age and isthmus hypoplasia.

Keywords: Coarctation of aorta; hypoplasia of arch; ballon angioplasty; isthmus hypoplasia; recoarctation
REFERENCES:
  1. Sen S, Garg S, Rao SG, Kulkarni S. Native aortic coarctation in neonates and infants: immediate and midterm outcomes with balloon angioplasty and surgery. Ann Pediatr Cardiol. 2018;11(3):261-6. [Crossref] [PubMed] [PMC]
  2. IJsselhof R, Liu H, Pigula F, Gauvreau K, Mayer J, Nido P, et al. Rates of interventions in isolated coarctation repair in neonates versus infants: does age matter? Ann Thorac Surg. 2019;107(1):180-6. [Crossref] [PubMed]
  3. Dilawar M, El Said HG, El Sisi A, Ahmad Z. Safety and efficacy of low-profile balloons in native coarctation and recoarctation balloon angioplasty for infants. Pediatr Cardiol. 2009;30(4):404-8. [Crossref] [PubMed]
  4. Kaine SF, Smith EO, Mott AR, Mullins CE, Geva T. Quantitative echocardiographic analysis of the aortic arch predicts outcome of balloon angioplasty of native coarctation of the aorta. Circulation. 1996;94(5):1056-62. [Crossref] [PubMed]
  5. Ovaert C, McCrindle BW, Nykanen D, MacDonald C, Freedom RM, Benson L. Balloon angioplasty of native coarctation: clinical outcomes and predictors of success. J Am Coll Cardiol. 2000;35(4):988-96. [Crossref]
  6. Tynan M, Finley JP, Fontes V, Hess J, Kan J. Balloon angioplasty for the treatment of native coarctation: results of valvuloplasty and angioplasty of congenital anomalies registry. Am J Cardiol. 1990;65(11):790-2. [Crossref]
  7. Hellenbrand WE, Allen HD, Glinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of valvuloplasty and angioplasty of congenital anomalies registry. Am J Cardiol. 1990;65(11):793-7. [Crossref]
  8. Doshi AR, Chikkabyrappa S. Coarctation of aorta in children. Cureus. 2018;10(12):e3690. [Crossref]
  9. Lee CL, Lin JF, Hsich KS, Lin CC, Huang TC. Balloon angioplasty of native coarctation and comparison of patients younger and older than 3 months. Circ J. 2007;71(11):1781-4. [Crossref] [PubMed]
  10. Liang CD, Su WJ, Chung HT, Hwang MS, Huang CF, Lin YJ, et al. Balloon angioplasty for native coarctation of the aorta in neonates and infants with congestive heart failure. Pediatr Neonatol. 2009;50(4):152-7. [Crossref]
  11. Redington AN, Booth P, Shore DF, Rigby ML. Primary balloon dilatation of coarctation of the aorta in neonates. Br Heart J. 1990;64(4):277-81. [Crossref] [PubMed] [PMC]
  12. Walhout RJ, Lekkerkerker JC, Oron GH, Bennink GBWE, Meijboom EJ. Comparison of surgical repair with balloon anjioplasty for native coarctation in patients from 3 months to 16 years of age. European Journal of CardioThoracic Surgery. 2004;25(5):722-7. [Crossref] [PubMed]
  13. Yetman AT, Nykanen D, McCrindle BW, Sunnegardh J, Adatia I, Freedom RM, et al. Balloon angioplasty of recurrent coarctation: a 12-year review. J Am Coll Cardiol. 1997;30(3):811-6. [Crossref]
  14. Morrow WR, Vick GW 3rd, Nihill MR, Rokey R, Johnston DL, Hedrick TD, et al. Balloon dilation of unoperated coarctation of the aorta: shortand intermediate-term results. J Am Coll Cardiol. 1988;11(1):133-8. [Crossref]
  15. Fletcher SE, Nihill MR, Grifka R, O?Laughlin MP, Mullins CE. Ballon anjioplasty of native coarctation of the aorta: midterm follow-up and prognostic factors. J Am Coll Cardiol. 1995;25(3):730-4. [Crossref]
  16. Rao PS, Thapar MK, Kutaylı F, Carey P. Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation. J Am Coll Cardiol. 1989;13(1):109-15. [Crossref]
  17. Wong D, Benson LN, Van Arsdell GS, Karamlou T, McCrindle BW. Balloon angioplasty is preferred to surgery for aortic coarctation. Cardiol Young. 2008;18(1):79-88. [Crossref] [PubMed]
  18. Rao PS. Transcatheter interventions in critically ill neonates and infants with aortic coarctation. Ann Pediatr Cardiol. 2009;2(2):116-9. [Crossref] [PubMed] [PMC]
  19. Francis E, Gayathri S, Vaidyanathan B, Kannan BRJ, Kumar RK. Emergency balloon dilation or stenting of critical coarctation of aorta in newborns and infants: an effective interim palliation. Ann Pediatr Card. 2009;2(2):111-5.[Crossref] [PubMed] [PMC]
  20. Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aortic coarctation. Ann Thorac Surg. 1991;52(3):621-31. [Crossref]
  21. Rao PS, Chopra PS, Koscik R, Smith PA, Wilson AD. Surgical versus balloon therapy for aortic coarctation in ınfants < or = 3 months old. J Am Coll Cardiol. 1994;23(6):1479-83. [Crossref]
  22. Rao PS. Should balloon angioplasty be used instead of surgery for native aortic coarctation? Br Heart J. 1995;74(6):578-9. [Crossref] [PubMed] [PMC]
  23. Rao PS, Galal O, Smith PA, Wilson AD. Fiveto nine-year follow up results of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol. 1996;27(2): 462-70. [Crossref]
  24. Rao PS, Jureidini SB, Balfour IC, Singh GK, Chen SC. Severe aortic coarctation in infants less than 3 months: successful palliation by balloon angioplasty. J Invasive Cardiol. 2003;15(4):202-8.
  25. Park Y, Lucas VW, Sklansky MS, Kashani IA, Rothman A. Balloon angioplasty of native aortic coarctation in infants 3 months of age and younger. Am Heart J. 1997;134(5 Pt 1):917-23. [Crossref]
  26. Dijkema EJ, Sieswerda GT, Takken T, Leiner T, Schoof PH, Haas F, et al. Longterm results of balloon angioplasty for native coarctation of the aorta in childhood in comparison with surgery. Eur J Cardiothorac Surg. 2018;53(1): 262-8. [Crossref] [PubMed]
  27. Ylinen MK, Tyni VE, Pihkala JI, Salminen JT, Sairanen H, Sarkola T. Procedural risk factors, incidence and timing of reintervention after treatment for native coarctation of the aorta in children: a populationbased study. Eur J Cardiothorac Surg. 2018. doi: 10.1093/ejcts/ezy252. [Crossref] [PubMed]
  28. Hijazi ZM, Fahey JT, Kleinman CS, Hellenbrand WE. Balloon anjioplasty for recurrent coarctation of aorta. Immediate and long-term results. Circulation. 1991;84(3):1150-6.[Crossref] [PubMed]

.: Up To Date

.: Process List

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