Post thrombotic syndrome after thrombolytic therapy- Do we have enough support for considering thrombolytic therapy?

Deep venous thrombosis (DVT) of the lower limbs can lead to post-thrombotic syndrome. There is a strong correlation between post-thrombotic syndrome and the extent of the thrombotic process. The progress of distal DVTs is benign with a high rate of recanalization and low rate of venous reflux. Persistence of chronic occlusion and venous reflux is common in extensive DVTs. The proximal DVT (upto 96%) may progress with reflux and/or venous obstruction. Venous segments with evidence of reflux after DVT recanalization were those presenting a spontaneous fibrinolysis up to 7 times longer than the observed in competent segments, suggesting that thrombus removal time is also an important factor in vein valve preservation. The use of locally infused fibrinolytic agents presents the possibility of direct intervention for immediate thrombus removal.Theoretically, this specific feature of thrombolysis should lead to immediate improvement of clinical results in extensive cases of DVT, as well as to preservation of valvular competence and venous wall morphology as has been described by experimental studies. So, we can think in favor of Thrombolytic therapy in extensive proximal DVT cases.

References:

1. Masuda EM, Kessler DM, Kistner RL, Eklof B, Sato DT. The natural history of calf vein thrombosis: lysis of thrombi and development of reflux. J Vasc Surg. 1998;28:67-74. [ Links ]
2. McLafferty RB, Moneta GL, Passman MA, Brant BM, Taylor LM Jr, Porter JM. Late clinical and hemodynamic sequelae of isolated calf vein thrombosis. J Vasc Surg. 1998;27:50-7. [ Links ]
3. O'Shaughnessy AM, FitzGerald DE. The patterns and distribution of residual abnormalities between the individual proximal venous segments after an acute deep vein thrombosis. J Vasc Surg. 2001;33:379-84. [ Links ]
4. Lindner DJ, Edwards JM, Phinney ES, Taylor LM Jr, Porter JM. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J Vasc Surg. 1986;5:436-42. [ Links ]
5. Haenen JH, Janssen MC, van Langen H, van Asten WN, Wollersheim H, Heystraten FM, et al. Duplex ultrasound in the hemodynamic evaluation of the late sequelae of deep venous thrombosis. J Vasc Surg. 1998;3:472-8. [ Links ]
6. Meissner MH, Manzo RA, Bergelin RO, Markel A, Strandness DE Jr. Deep venous insufficiency: The relationship between lysis and subsequent reflux. J Vasc Surg. 1993;18:596-608. [ Links ]
7. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999;211:39-49. [ Links ]
8. Emanuelli G, Segramora V, Frigerio C. Selected strategies in venous thromboembolism: local thrombolytic treatment and caval filters. Haematologica. 1995;80 (2 Suppl):84-6. [ Links ]
9. Molina JE, Hunter DW, Yedlicka JW. Thrombolytic therapy for iliofemoral venous thrombosis. Vasc Surg. 1992;26:630-7. [ Links ]
10. Verhaeghe R, Stockx L, Lacroix H, Vermylen J, Baert AL. Catheter directed lysis of iliofemoral vein thrombosis with use of rt-PA. Eur Radiol. 1997;7:996-1001. [ Links ]
11. Palombo D, Porta C, Brustia P, Peinetti F, Udini M, Antico A, et al. La thrombolyse loco-régionale dans la thrombose veineuse profonde. Phlebologie. 1993;46:293-302. [ Links ]
12. Burkart DJ, Borsa JJ, Anthony JP, Thurlo SR. Thrombolysis of occluded peripheral arteries and veins with tenecteplase: a pilot study. J Vasc Interv Radiol. 2002;13:1099-102. [ Links ]
13. Sugimoto K, Hofmann LV, Razavi MK, Kee ST, Sze DY, Dake MD, et al. The safety, efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter-directed thrombolysis of arterial and venous occlusions. J Vasc Surg. 2003;37:512-7. [ Links ]
14. Shortell CK, Queiroz R, Johansson M, Waldman D, Illig KA, Ouriel K, et al. Safety and efficacy of limited-dose tissue plasminogen activator in acute vascular occlusion. J Vasc Surg. 2001;34:854-9. [ Links ]
15. Rhodes JM, Cho S-J, Gloviczki P, Mozes G, Rolle R, Miller VM. Thrombolysis for experimental deep venous thrombosis maintains valvular competence and vasoreactivity. J Vasc Surg. 2000;31:1193-205.

High-sensitivity cardiac troponin assay in predicting mortality?

Recent studies have shown that the high-sensitivity cardiac troponin assay can substantially improve early diagnosis of acute myocardial infarction and allow risk stratification of patients with stable congestive heart failure and acute coronary syndromes. An important recent study involving patients with stable coronary artery disease enrolled in the Prevention of Events with Angiotensin Converting Enzyme Inhibition Trial showed that elevated cardiac troponin T levels, measured with a high-sensitivity troponin assay, were significantly associated with the increased incidence of cardiovascular death. However, exclusion criteria consequent on the primary study design on angiotensin-converting enzyme inhibition produced a selected population that, among others, did not include patients who had a recent or planned revascularization procedure.

References:
1. Keller T., Zeller T., Peetz D., et al: Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 361. 868-877.2009;
2 Reichlin T., Hochholzer W., Bassetti S., et al: Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 361. 858-867.2009;

Effects of smoking and smoking cessation on lipids and lipoproteins: Outcomes from a randomized clinical trial
American Heart Journal - Volume 161, Issue 1 (January 2011)
In this study, despite weight gain, smoking cessation improved HDL-C, total HDL, and large HDL particles, especially in women. Smoking cessation did not affect LDL or LDL size. Increases in HDL may mediate part of the reduced cardiovascular disease risk observed after smoking cessation.

Each year, smoking contributes to >443,000 smoking-related deaths in the United States and few millions in the rest of the world; and nearly 20% of all coronary heart disease deaths can be attributed to smoking. Although the strong relationship between smoking and cardiovascular disease (CVD) has been well-documented, the mechanisms by which smoking increases CVD risk appear to be multifactorial and incompletely understood. Clinical trials, suggest that cigarette smoking is associated with a more atherogenic lipid profile characterized by higher total cholesterol and triglycerides (TG) with lower levels of high-density lipoprotein cholesterol (HDL-C).

References:
1 Center for Disease Control and Prevention : Smoking-attributable mortality, years of potential life lost, and productivity losses—United States. 2002-2004. [accessed 2009 Apr 8]Morb Mortal Wkly Rep 57. 1226-1228.2008;
2 American Heart Association : Heart disease and stroke statistics—2009 update. American Heart AssociationDallas (Tex)2009.
3 Doll R., Peto R., Boreham J., et al: Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 328. 1519.2004;
4 Freund K.M., Belanger A.J., D'Agostino R.B., et al: The health risks of smoking. The Framingham Study: 34 years of follow-up. Ann Epidemiol 3. 417-424.1993;
5 Ambrose J.A., Barua R.S.: The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol 43. 1731-1737.2004;
6 Gossett L.K., Johnson H.M., Piper M.E., et al: Smoking intensity and lipoprotein abnormalities in active smokers. J Clin Lipidol 3. 372-378.2009;

Novel and new oral antithrombotic drugs for prevention of VTE

Patients undergoing surgery receive anticoagulation for perioperative thromboprophylaxis or ischemic cardiovascular disease. Because anticoagulants may also potentiate bleeding, clinicians need to understand the implications of anticoagulation in perioperative and postoperative patient management. Many newer anticoagulants that are now available or are in clinical development do not require routine coagulation monitoring, have more predictable dose responses, and have fewer interactions with other drugs and food. The most advanced oral anticoagulants in clinical development are the direct factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran etexilate. These agents have been evaluated in the postoperative setting in patients undergoing total hip- or knee-replacement surgery with promising results, and it remains to be seen whether these results will translate into other surgical settings. The impact of the new agents will be influenced by the balance between efficacy and safety, improved convenience, and potential cost-effectiveness benefits.

Injury to the Axillo-Brachial artery in a violent act (Axe)
Vascular injuries are commonly seen in road side accidents. Few cases of vascular injuries are treated at NIMS are due to domestic violence at home with sharp, heavy and blunt objects. Usually axillary artery is well protected and so it is rarely injured. Today we repaired axillary artery in young man after axe-injury. Vein graft was needed to bridge the gap. This patient was initially treated with ligation of the injured axillary artery by the local doctors who later referred him to our center for the definitive repair. There was also injury to the median nerve which required plastic surgical repair. Post operatively doppler signals are normal.

Reference
Aust N Z J Surg. 1995 May;65(5):327-30.
Penetrating injuries of the axillary artery.

Degiannis E, Levy RD, Potokar T, Saadia R.
Department of Surgery, Baragwanath Hospital, University of Witwatersrand Medical School, Johannesburg, Republic of South Africa.
Abstract

This is a retrospective study of 32 patients with penetrating injury of the axillary artery. There was an overall mortality of 6% entirely accounted for by associated injuries. Pre-operative angiography was used in 12 of these patients either to confirm the presence of an injury or to define its location. Twelve patients underwent lateral arteriorrhaphy or an end-to-end anastomosis and 19 patients had an interposition graft. No immediate problems were experienced with polytetrafluoroethylene grafts compared with autogenous vein grafts. There were 14 patients with a concomitant venous injury; 13 were repaired and only transient arm oedema was experienced. Eleven patients had a brachial plexus injury and, of these, nine underwent a secondary nerve repair with a poor outcome. Axillary artery injury has a good prognosis with a morbidity related mainly to associated nerve injury and a mortality accounted for by injuries to other body systems.

Happy new year 2011

During the last year 2010, we have seen changing concepts in medicine. The management of diabetes, Hypertension, Hyperlipidaemia improved and results of vascular therapies significantly improved by the addition of statins to all therapies. Thrombolytic therapies have not taken any progress in peripheral vascular surgery, though the catheter directed thrombolysis in the iliofemoral venous thrombosis got the attention in few centres with cath lab facilities. There has been better acceptance for the low molecular weight heparins and the market is flooded with number of LMWH brands and too much of noice in the market. Oral anticoagulation has not changed much but there are hopes about the oral antithrombotic drugs such as Apixaban, Riveroxaban which are going to come in to the market soon. Vascular surgical education is still going slowly in the country and very centers are giving the training for surgeons interested to learn. Endovascular aneurysm repair has shown rapid strides in the western countries but in India it is going very slowly due to the high cost of the prosthesis and also due to lack of adequate skills to do the procedure. Vascular Trauma due to road side accidents continued to be most common vascular emergency in our hospital after the orthopedic trauma.There are three DNB trainees in the department and two of them are going to complete examinations soon. On average 50 patients are attending and seeking the consultations in the vascular surgery out patient clinic every day at NIMS hospital. Carotid body tumors, cervical ribs, carotid disease, vascular malformations are treated as before and their numbers remained the same. The number of patients attending the out patient clinic with Venous problems, varicose veins, Deep vein thrombosis and diabetic foot increased this year. Similarly more number of patients are presenting with cellulitis with resistant bacterial infections which are MRSA and ESBL+ve. They are requiring dual antibiotic therapies and Inj daptomycin has shown very good results in some patients who failed to respond to Tiecoplanin. We have shown interest to consider the cell therapies for neovascularization in advanced ischemia patients but we are still waiting and organizing for the cell therapies by forming a team with the physicians. A workshop was done in which varicose veins were treated by the Radiofrequency ablation device and the early results were satisfactory in those patients. We presented papers in the Asian vascular society (July'10)in Japan and received awards for two of our papers. We participated and presented papers in the VAICON Bangalore, VSICON Chennai.
We welcome the new year 2011 and hope that there will be significant changes in the patient care and we will develop the more cost effective therapies in vascular surgery with improved quality of life.

with best wishes,
Pinjala R K

This is the MRAngiogram of the a patient with Bilateral lower limb Claudication. He is diabetic, underwent Coronary bypass grafting 16 years back in USA. Ankle pulses are not palpable. He is living alone and unable to walk few yards. But he is able to slowly climb the stairs according to him. MRA showed occlusion of the superficial femoral artery on both the sides. Echo cardiogram showed 30% ejection fraction, Moderate mitral regurgitation and pulmonary hypertension. We discussed about the possibility of interventions and medical therapies in improving his leg condition. The risk of investigations and interventions seems to be higher in this gentleman that too without the family members near him. He was advised to continue medical therapies and attend the out patient clinic for monthly follow up and consideration of interventions or bypass in the due course of time. Do you recommend angioplasty of the SFA from popliteal route in this case! Please suggest your opinion and points in favour of your suggestion.

e-Cigarette
The electronic cigarette was invented by a Chinese medicine practitioner Hon Lik in China in 2003 and introduced to the market the next year. The company he worked for, Golden Dragon Holdings, later changed its name to Ruyan (meaning "to resemble smoking") and started selling abroad.

The electronic cigarette, e-cigarette or personal vaporizer, is a battery operated device that provides inhaled doses of nicotine or non-nicotine vaporized solution. It is an alternative to smoked tobacco products, such as cigarettes, cigars, or pipes. In addition to purported nicotine delivery, this vapor also provides a flavor and physical sensation similar to that of inhaled tobacco smoke, while no smoke or combustion is actually involved in its operation. Manufacturers promote electronic cigarettes as a safer alternative to smoking cigarettes by claiming that most of the harmful material produced by the combustion of tobacco in traditional cigarettes is not present in the atomized liquid of electronic cigarettes. Despite claims that electronic cigarettes are safer, manufactures include warning labels with their products.

Schwannoma in the parapharyngeal space ( Glossopharyngeal Nerve)

Tumors near the carotid bifurcation are usually diagnosed as carotid body tumors. This patient was also initially diagnosed as a case of carotid body tumor but after the surgery, the biopsy report came as Schwannoma and it was connected with the Glossopharngeal nerve. The Vagus nerve and carotid arteries are separated from the tumor but Glossopharyngeal nerve could not be separated from the tumor and the tumor was removed with nerve. The photograph is showing the relationship between the deep seated tumor and carotid artery bifurcation. The tumor was removed without sacrificing the carotid artery branches.

Deep vein thrombosis in patients undergoing brain tumor surgeries

A Neurosurgeon will be operating on a large brain tumor successfully and in the post operative period some of his patients will be developing life threatening venous thrombosis and pulmonary embolism. This is the CT image of a patient showing a large brain tumor. It was successfully removed by neurosurgeon and after discharge from the hospital, patient developed massive swelling of the lower limb and brought to the vascular surgeon. She received anti-coagulation therapy and the swelling subsided and thrombus was found to be re canalized during the follow up. Thrombo-prophylaxis (mechanical / chemical) may be helpful in these patients to prevent life threatening complications after a successful surgery.

A large aneurysm of the aorta at the level of the occluded renal arteries in a poor patient who is getting dialysis in a Govt general hospital through special health scheme (ARSR).

It is difficult and a Challenge to manage a large abdominal aortic aneurysm very close to (involving) the superior mesentric artery (SMA) in a patient who is getting hemodilaysis through a neck jugular line in the Govt hospital without significant morbidity and mortality. The CT scan is showing (see fig) a large aneurysm >10cm and intra vascular thrombus, and the patient has pre-rupture symptoms. The Govt scheme (ARSR) is supporting such treatments providing financial help up to Rs 1.25 Lakhs. The total care of such patients along with dialysis may be costing more than that and private hospitals will not be willing to take up such cases. The Govt hospitals are not in a position to take up such cases. It is very unlikely that centers will be coming forward to take these challenging operations without adequate financial planning.

vascular ( blood vessels)

http://www.jbppni.com/content/pdf/1749-7221-3-9.pdfvascular ( blood vessels)

http://www.jbppni.com/content/3/1/9vascular ( blood vessels)

Blunt injury to the Axilla resulting in vascular (axillary artery) injury, Brachial plexus injury, fracture of the head of the humerus (epiphysis).

Early detection and repair of the axillary artery is helpful when ever axillary artery injury is suspected, as this is going to give an opportunity to release compression of the Brachial plexus, early repair of the Brachial plexus. Recently we repaired the axillary artery in a girl with axillary vein as a suitable great saphenous (matching) vein is not available. Post operative recovery is uneventful.


Reference:
Vasc Endovascular Surg. 2004 Mar-Apr;38(2):175-84.
Axillary artery injury from humeral neck fracture: a rare but disabling traumatic event.
Yagubyan M, Panneton JM.
Mayo Clinic, Division of Vascular Surgery, Rochester, MN 55905, USA.
Axillary artery injury from blunt trauma to the shoulder is uncommon. Fracture of the neck of the humerus is a rare cause of injury to the axillary artery. Four cases of axillary artery thrombosis from humeral neck fracture are reported. Each of the first 2 patients presented with a pulseless and acutely ischemic limb after a trivial fall. A repair of the axillary artery with saphenous vein interposition graft was performed in the first patient. The extremity was salvaged, but a residual radial and ulnar neurologic deficit persisted. The second patient presented with a pulseless insensate upper extremity accompanied by motor loss. He underwent primary axillary artery repair. Still early in his postoperative course, he has had global brachial plexopathy and is undergoing intensive physical therapy. The third patient had a delayed presentation of brachial plexopathy and sympathetic reflex dystrophy. Arterial reconstruction was not required owing to excellent collateralization. The fourth patient presented with a cool pulseless extremity. His recovery is nearly complete after bypass of the axillary artery with a reversed saphenous vein graft.

In addition, a review of the literature revealed 24 cases of axillary artery injury associated with humeral neck fracture. The mean age was 66.6 years. The most common mechanism of injury was a fall (79%). Thirteen patients (46%) presented with a neurologic deficit. Acute ischemia was present in 68%. Physical examination predicted the arterial injury in all but 1 patient. The injured axillary artery was repaired in 26 cases. Revascularization by an interposition graft was the most common procedure. All grafts and reanastomoses were patent and led to limb salvage. Of 9 primary repairs, 3 amputations were performed. Although limb salvage rate was 89%, a good functional outcome was obtained in only half of the patients. A high index of suspicion is required for early diagnosis of axillary artery injury. Despite excellent results of vascular reconstruction, the outcome remains determined by the excessive neurologic morbidity. Recognition of the associated brachial plexus injury is essential to improve the functional outcome of this unusual arterial injury.

Is there a place for the synthetic grafts for bypass in the Buerger's disease?

Diabetic foot care -
A team of doctors and technicians (Nurses, foot ware specialists, counselors) can help the patients and improve the limb salvage. In the workshop conducted at NIMS, it was shown that corns in the foot should be carefully excised without bleeding (special technique demonstrated on the skin of oranges). Similarly it was discussed and demonstrated that the evaluation of the neuropathy and foot ware can prevent ulceration and facilitate trophic wound healing at the pressure points.

Deep vein thrombosis awareness Month - March 2010
Venous thrombosis is known to affect the leg and progress to threaten the life by pushing the clots up in to the lungs from legs (propagation). There are many risk factors for the venous thrombosis. Hospitalization for the acute problems and getting strict bed rest for more than 3days is a major risk factor. In the ENDORSE, a multinational study - it was observed that every alternate patient in the acute care hospital bed is at risk of venous thrombosis. It is advised that some kind of the evidence based Thrombo-prophylactic measure is essential in these patients. It is important to note that the overall management of the patients without prophylaxis would be much more expensive than giving them the Thrombo-prophylaxis. It is recommended that every hospital should develop its own prevention guidelines and advocate the measures to reduce the risk of venous thrombosis and its complications through consensus meetings including all clinical departments. The cost management is crucial in the coming years, let it be hospitals in the western countries or eastern countries, we should save the people and cut the expenditure.
Pinjala R K'2010

Right Subclavian artery aneurysm with distal occlusion - repaired with vein graft

Occlusion of the vein graft used in the repair of the subclavian aneurysm lead to replacing it with the synthetic graft. After 3 months the synthetic graft was infected. Then it was removed and a rim of synthetic graft was left behind to avoid the compromise of the cerebral circulation. But after few days patient came back with bleeding through a sinus. Then carotido -carotid bypass (extra anatomical) was done and brachio-cephalic artery was ligated. Post operative recovery was uneventful. conclusion: A staged removal of synthetic graft may help us to reduce the morbidity and gives time to plan extra anatomic graft with minimal septic complications. This patient with the staged operations performed post operatively better and there were no further complications.

Pulsatile mass in the right submandibular region reported as Aneurysm in MRI


13 month old baby was admitted with pain, right facial palsy, pulsatile mass in the right submandibular region. M R Angiogram was done in the peripheral hospital and it was reported as aneurysm from a branch of the external carotid artery. There was blood discharge from the right ear and baby was not allowing to clean it. So, it was thought that the aneurysm ruptured in to the ear. This patient was given a course of antibiotics and Spiral CT angiogram was done. It did show the communication with the aneurysm and the swelling slowly started regression with antibiotics.Pulsations in the mass disappeared. Patient was discharged with antibiotics and advised to atttend the ENT clinic for the future management of septic complications.

Neurofibroma of saphenous nerve mimicking thrombophlebitis

Young man (25 yrs) complained of persistent pain on the medial side of the lower part of the left thigh. A cord like structure with 3 small nodular thickenings was palpable parallel to the course of the great saphenous vein. Initially in a he was treated as case of superficial thrombophlebitis of the great saphenous vein in private clinic near his home. But when the pain persisted even after receiving local therapies and Injection Heparin (LMWH) he is referred to the vascular surgery unit in our hospital. Duplex scan of the thigh reported it as thrombophlebitis of a vein parallel to the great saphenous vein. We continued Injection Heparin and suspected thrombophilia. The pain persisted and on further detailed examination of swelling we noted nodular swellings over a cord like structure. He did not give history of risk factors for thrombophlebitis. We considered biopsy of the cord with nodules to confirm a diagnosis. The excised cord with nodular structure was sent to histological examination. It was confirmed as “Neurofibroma” of the saphenous nerve. Post operatively the pain subsided dramatically and patient was discharged with an advice to attend the follow-up clinic. Diagnosis of small tumors of peripheral nerve at this site can be mistaken as a case of thrombophlebitis and there may be undue delay in diagnosis as we do not perform biopsy for thrombophlebitis in routine clinical practice. Unusual pain, nodular feeling of the swelling in this case helped us to consider early biopsy and excision of the tumor.

Excision of infected PTFE graft from the neck.

Subclavian artery aneurysm is rare. Young man (20yrs) developed right subclavian artery aneurysm after blunt injury. Aneurysm was repaired with saphenous vein but thrombosed. So, it was replaced by PTFE graft. After 3 months PTFE graft also occluded.

A sinus discharging pus formed exposing the graft. Infected PTFE graft was excised. A rim of graft was left proximally to avoid injury. Early excision of infected synthetic grafts with or with out another bypass can avoid further complications.

Aneurysm with aortic stenosis just distal to the origin of the left subclavian artery in thoraic aorta.

Patients will be waiting for long time with symptoms before they come to the major hospitals with large aneurysms of this size due to various reasons. In addition to the socio-economic reasons they also fear that the operations are not safe in the hospitals. When are grown to this size as there is no alternative they come to hospitals in prerupture syndrome. The results in such patients with prerupture or rupture of the thoracic aneurysms the results are critical supporting their fears. We need to develop a aneurysm central registry to help these patients with the initiative of the government. The national surgical and medical associations can be given this responsibility by the government or medical council of India.

Radial artery Aneurysm in a young man working in bar

Glass bottle or glass piece injuries to the forearm can easily injure the radial artery which is superficial and close to the bone. The local pressure can stop the bleeding and it may result in thrombosis of the radial artery without any problems. But in some it can recanalize and later present as pseudoaneurysm ( 2-3 months) as in this case. It will be tender to touch and starts expanding after that. In this patient the ulnar artery is palpable and it is providing the major blood supply to the palm. Simple excision of the aneurysm and repair of the radial artery is required. Some times one may argue that ligation of the radial artery proximal and distal to the aneurysm may be sufficient to releive the symptoms.

Are we still seeing Buerger's disease (TAO)?

we used to see more patients with gangrenous tips due to excessive smoking in young people 15 years back. Then slowly the number of such patients attending our clinic slowly decreased. But in the recent past again we are finding more of them coming to our clinics. It is probably due to the Aarogyasri scheme which is providing them financial support to come to the big hospitals for special care. The disease presentation in the hospitals is dependent on many aspects and one may get misguided if the disease presentation is not understood. Buerger's disease still persists in our low socioeconomic group of people.

Synthetic graft for replacing the diseased common femoral artery and superficial femoral artery in the groion with implantation of the profunda femoris artery.

Young smokers usually present to the vascular clinics from the rural areas with disease below the knee and above the knee. Such patients may need repair of the thigh blood vessels with poor distal runoff below the knee. One would be heistantly usin the synthetic grafts in them as there is no other alternative to the diseased veins (graft). In such cases we feel it is very important to make sure the profundafemoris branch is revascularised (with or without endarterectomy) by reimplanting it in to the synthetic graft. This will probably help also in improving the patency of the synthetic graft. This video was taken after completion of the operation where the profunda is attached to the graft ( hidden) in graft bed.

Pinjal R K '09

Carotid body Tumor in a father and daughter

Carotid body tumors are uncommonly seen in the clinical practice. Many times, when they are small in size they are mistaken as the lymphnodes in the neck. Some times people consider biopsies suspecting tuberculosis or other patholgies. attempted. Carotid body tumors are also seen in the families, like in this photo a father and daughter are seen with tumors.

World No Tobacco Day - May 31st 2009
100 million people lives are at risk due to the use of tobacco.
In India, 25ooo are killed by bad effects of tobacco. It is important that fact is recognized and people should act. The govt has taken a stand by banning smoking in the public places. But public should take interest and avoid the death due to the side effects of smoking. 70% of the tobacco users in India are smoking bidis. we need to educate the commo man now to avoid the tobacco and there should be special monitoring programs for the tobacco control actions by the government like we have for Tuberculosis, HIV and Malaria. This is very important to avoid the cancers, cardiovascular problems in the society.
Pinjala R K

Large Abdominal Aortic Aneurysm

In many hospitals, large aortic aneurysms are diagnosed after an initial ultrasound examination which is later confirmed on CT scanning

Excision of Thrombosed
Varicose Veins
Thrombosis of the varicose veins may induce local inflammatory symptoms with bulging and pain. Local pigmentation over the thrombosed veins is also common. Medical therapies, compression bandages may relieve the symptoms during course of 2-3 weeks. There is a possibility that the same thrombosis may also recur again in some patients after recanalization. Surgical excision of the thrombosed varicose veins along with neighboring varicose veins with reflux will facilitate early recovery without any major risk of pulmonary embolism. It would be necessary to consider Thrombo-prophylaxis with LMWH in the peri-operative period.

Leiomyosarcoma from vein wall

Tumors from the vessel walls are rare. Leiomyosarcoma from the Iliac vein wall can present as mass, deep vein thrombosis. Complete excision is the best possible treatment for them. Reconstruction of the resected is to be considered if possible. Usually these grafts may get thrombosed after some time without any problems due to the development of collateral veins. Prognosis is poor if there are metastasis to the liver and lung. Their 5 yr survival is reported to 32%. Till now less than 100 cases of leiomyosarcoma were reported from extremity veins.

Two Post graduates from Dept of Vascular surgery, Chennai General Hospital - visiting (Fellowship) Nizam's Institute of Medical Sciences, Hyderabad, AP, India

We are pleased to invite the postgraduates in vascular surgery from Chennai general hospital to visit our department. There are very few centres training vascular surgeons in our country. Nizam's Institute of Medical Sciences has been imparting training to the vascular surgeons for the past 20 years. The department of vascular surgery is adequately supported by all the other sub-specialities. The common man is able to get specialized vascular surgical services. The young surgeons are able to get an opportunity to see different presentations of vascular disease and classical and special treatments provided to these patients. All those doctors who were trained in this department are now independently practicing vascular surgery in differrent parts of India.

Superior venacaval Syndrome - Is prognosis really worse in these patients? Why?

The prognosis is dependent the etiology of the obstruction and rate of progression of the underlying disease. More than 75% the SVC syndrome cases are associated with some form of malignancy and so the prognosis is perceived as poor. If SVC obstruction is secondary to benign condition then the prognosis is better.

Pinjala RK

VAICON 2009 at Hyderabad

In this 2nd Annual conference of the Venous Association of India 225 delegates participated the conference. Pre-Conference CME was organized for Doctors, Nurses and Physiotherapists on 23rd January at NIMS, Learning center for 200 participants. The Nurses and Nursing students organized exhibition on various types of Venous disorders and all of them participated with lot of enthusiasm. The senior delegates who went round to see the charts exhibited by the nurses, heard their presentations and deeply appreciated their talent and hard work.

The conference on 24th , 25th of January at Hotel FORTUNE SELECT MANOHAR was attended by participants from different parts of India and abroad. All the participants appreciated the scientific content of the conference, arrangements and hospitality extended by the organizing committee and made it a successful conference.
The new executive committee was formed for the Venous Association of India. New members were inducted in to the excutive committee.

The venue for the "VAICON 2010" is going to be Bangalore and will be organized by Dr. Vasudeva Rao from Manipal Hospital.

An Invitation was extended to all participants to become the members of the Venous Association of India and participate in all the events organized by venous association of India.

(More details on the scientific presentations will be posted later)

Prof Pinjala Ramakrishna, MS,FRCSEd
VENOUS ASSOCIATION OF INDIA
26th Jan 2009

9th Jan 2009

VAICON 2009 - Hyderbad on 24,25th Jan2009 and the CME on 23rd at NIMS learning center.

We are inviting all the post graduates, nurses with special interest in the venous disorders to participate in the CME to learn more about the venous disorders. Varicose veins, DVT, Venous ulcers are still common problems in our hospitals. They are better understood and better cared in the past few years. This is helping our patients to get better relief and prevent recurrences of the venous problems with adequate therapies and preventive measures. -- Pinjala R K

Dysphagia in association with Thoracoabdominal aneurysm of the Aorta

Thoracoabdominal aneuryms (TAAA)which are close to esophagus may produce extrinsic compression of esophagus. It will be seen as a smooth bulge during the
during the endoscopy. Manometric studies were found to be abnormal in these patients. In this endoscopic photograph (see the attached image) the mucosal swelling and ulceration is seen near the site of extrinsic compression. Endoscopic ultrasonography has shown gas bubbles in the wall of the esophagus. Patient was able to swallow liquids only. Such types of comression of esophagus was managed some times by medical meaures in elderly woman (>84 years) successfully. But it would need attention and intervention to releive the compression in the youger and middle aged people. We have recently managed another patient with absolute dysphagia associated with TAAA. He required Total parenteral nutrition before the Endovascular repair of the TAAA. His ability to swallow improved after the Endorepair with Endograft due to the relief of pressure over the esophagus by the TAAA.
By
Pinjala R K

Affect of the “Tibial-arterial disease” on the outcomes in leg vascular disease patients

The lower limb arterial system is divided in to 3 segments for better understanding of the disease and also for planning various therapeutic options. Aorto-iliac, Femoro-popliteal and Tibio-peroneal diseases are three zones. However the quantity of the disease is not measured accurately for the routine clinical purposes. Therefore comparing the out comes of procedures performed on patients with different degrees of functionally active and mechanical disease. The failure rates of infra popliteal revascularization are high across all the countries irrespective of their methods of revascularization.The determining factors seem to be diabetes and history of prior tissue loss or gangrenous changes.In the routine clinical practice it is important to grade the tibial vessel disease which is often missed. In the post operative period one tries to look for the Doppler signals and palpable pulses which may be or may not be good enough for the relief of symptoms over a long period of time.

In a recent paper published -Multivariable analysis demonstrated tobacco use, renal disease, diabetes, and tissue loss are all predictors of patency loss, while only diabetes and tissue loss were associated with greater limb loss. There was no difference in patency rates irrespective of location of Trans Atlantic Inter-Societal Consensus (TASC) classification, vessel treated (femoral vs tibial), or degree of stenosis (occluded vs stenotic). Also, multiple vessels treated in the same patients had no affect on patency. The mean ankle brachial index (ABI) pre-op was 0.57 +/- 0.19, and this increased to 0.81 +/- 0.21 (P < .001) at 30 days post-op. CONCLUSION: Lower extremity atherectomy procedures with the SilverHawk device are safe and effective means in improving symptoms. However, there is decreased durability and significant patency and limb loss over time. Diabetes, renal disease, tobacco use, and tissue loss are all associated with inferior outcomes.

Reference:

Sarac TP et al, J Vasc Surg. 2008 Oct; 48(4):885-90

Midterm outcome predictors for lower extremity atherectomy procedures. Sarc TP et al
Department of Vascular Surgery, The Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.

Atherectomy in the lower limb arteries
Is there a future for this procedure in getting better limb salvage ?

Laparoscopic Vascular injuries at the level of Iliac artery (Pelvis) can be life threatening due to pelvic and retroperitoneal bleeding.

In the recent past 3 patients with iliac artery injury were referred from the peripheral hospitals for management. In these there has been difficulty in sending to the concerned specialist centers very late due to logistics. In all the three patients an attempt was made by the general surgeons to control the bleeding but it also resulted in systemic problems and distal limb ischemia (Acute). In one patient there was iliac vein thrombosis in addtion to the arterial injury. One patients required femoro-femoral corss over graft ( tubectomy patient) , 2nd patient required direct repair of the iliac artery ( plus appendicectomy) and 3rd patient required Aortofemoral bypass (+Tuberculous adhesiolysis). In all the three patients the limb was salvaged.

Large Venous Malformations in the Neck -

Are they curable with the available therapies?

Open surgeries, endovascular therapies and other plastic surgical procedures?

Large Venous malformations in the Head neck region are associated with complex hemodynamics and anatomy. Imaging these lesions adequately is difficult and planning interventions in multiple stages may be expensive and tiring to the family and providers. In addition the procedures are associated with hidden complications. Probably one would like to hear about the possibility of genetic therapies for such large lesions with intra thoracic ramifications and communications with other large veins in the head and neck region.

Vascular Malformations in the thigh and lower extremities
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Vascular malformations would require detailed evaluation and planning to remove of them. It is possible through multiple approaches such as endovascular, operative vascular and plastic surgical reconstructions after excisions.
It involves repeated, investigations and multiple visits to the hospital, blood transfusions. Surigcal excision after a previous failed attempt is much more difficult due to the adhesions and neovascularization. This is the photograph of such patient with a large thigh AVM with aneurysmal component of the AV communication. The cost of management in such cases will be always more than what is expected by a common man. Adequate planning for the finances and explaining the patients about the risks including the limb loss is essential part of the treatment.

Pinjala R K

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Non-healing Ischemic Ulcer on the Dorsum of Foot

Fig: Non healing ulcer

This type of ulcers are difficult to manage and fail to heal with the usual measures such as local wound care and improvement of micro circulation (drugs). This patient (58 yrs) had Femoro-popliteal bypass in the past (10 yrs back) and that was blocked in the due course of time with development of tibial vessel disease. He received Injection Heparin, PGE-1 infusion, antiplatelet drugs and statins. It failed to heal and rest pain persisted ( 2 years). The tibial vessels were not suitable for any type of distal bypass. The heal of the foot is healthy and so are the toes as seen the photograph.

1. What further treatment can be offered in this patient for healing of ulcer and relief of pain?
2. Would like to consider any type of amputations?
3. Any special Endovascular therapies?

By Pinjala R K

Chronic wounds and facilitating their healing with Growth factors-

EGF, PDGF in non healing ulcers.

Growth factors such as EGF ( Epidermal growth factor), PDGF ( platelet derived growth factor) have been found to be useful in improving the wound healing. These are available in gel forms to applied after controlling the wound infections. Arterial ischemia, neuropathy, venous insufficiency are common in those non healing ulcer to different degrees. Correction is possible in some patients but in few the correction of them is partial or may not be possible. In such cases, we need to consider the growth factors such as these to facilitate and enhance the healing rates. Probably these growth healing help in shifting wounds from one stage to the other that is from inflammatory to the proliferative and from there to the maturation phase when the native wound growth factors fail to do so, due to the underlying pathophysiological changes. In India, these two growth factors are available in the market for use and are also affordable.

by

Pinjala R K

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Behcet's disease:

This is Brachial artery angiogram showing - total occlusion of the radial artery close to its origin. The ulnar is showing short segment of stenosis. The median interosseous artery is reformed and coursing down wards in the middle of forearm.

During surgery, the brachial artery and its bifurcation were found to be be engulfed by inflammatory tissues with excessive adhesions and edema. The tissues are fragile and the veins are dilated and thickened. The arterial wall is also fragile, thickened along with multiple dilated venules over its wall. The thinned walled collateral (neovascularization) vessels in the arterial walll are easily bruising. It is suggestive of a chronic process affecting (in elbow region) affecting brachial, radial and ulnar arteries and bifurcation. The brachial and ulnar artery were felt after the dissection and isolation of areteries with release of tight adhesive inflammatory tissues around them.

There was strong clinical suspicion of Behcet's syndrome based on the findings in this patient. He was given steroid in the peri-operative period and his clinical condition significantly improved. Through multiple incisions in the forearm and plam fasciotomies were done to release intra compartmental pressure.

Pinjala R K
15th Nov 2008

Sent from BlackBerry® on Airtel

VEIN GRAFTs+ SYNTHETIC GRAFTs = Composite graft
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Non availability of the long saphenous vein grafts for the long segment Femoro-popliteal bypass in the legs with distal anastomosis below the knee is common. The great saphenous vein is many times not suitable for the bypass surgery as its size is less than 4 mm in diameter in all its length and there can be branching of great saphenous vein. We do not have Indian data on the suitability of vein grafts for Femoro-popliteal bypass. We do not want to place the synthetic grafts across the knee joints due to the fear early thrombosis. Composite grafts ( half synthetic grafts and half vein grafts) are probably best suited for the Femoro-distal bypass in such cases.

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