Intraarterial Administration of Bone Marrow Mononuclear Cells in Patients With Critical Limb Ischemia

Critical limb ischemia due to peripheral arterial occlusive disease is associated with a severely increased morbidity and mortality. There is no effective pharmacological therapy available. Injection of autologous bone marrow-derived mononuclear cells (BM-MNC) is a promising therapeutic option in patients with critical limb ischemia, but double-blind, randomized trials are lacking. A Randomized-Start, Placebo-Controlled Pilot Trial (PROVASA) was published in Circulation - cardiovascular interventions.In this study Limb salvage and amputation-free survival rates did not differ between the control and study groups. However, cell therapy was associated with significantly improved ulcer healing (ulcer area, 3.2±4.7 cm² to 1.89±3.5 cm²P=0.014] versus placebo, 2.92±3.5 cm²² [P=0.5]) and reduced rest pain (5.2±1.8 to 2.2±1.3 [P=0.009] versus placebo, 4.5±2.4 to 3.9±2.6 [P=0.3]) within 3 months. 

We in India, need to be careful in jumping to conclusions without adequate  supportive evidence in favor of the cell therapies to treat the critical limb ischaemia for the present. If the strong evidence becomes available certainly and eagerly we are waiting to bring that in to our clinical practice.

What is optimum anticoagulation with Heparin in peripheral vascular treatments?

             Beyond the heparin dose ( initially up to 60 U/kg) and the ACT level (250 seconds) , in the multivariate analysis it was found that female sex, creatinine clearance <60 mL/min per 1.73m² age >70 years, preprocedural anemia, history of heart failure, hybrid vascular surgery, rest pain, and below-knee interventions were independent predictors of higher postprocedural bleeding risk. These findings are consistent with those from 2 large retrospective databases of patients undergoing PCI and a registry of 24 045 patients with acute coronary syndromes from the Global Registry of Acute Coronary Events (GRACE).Less aggressive anticoagulation, or use of an alternative anticoagulant strategy such as a direct thrombin inhibitor, may decrease the incidence of bleeding complications in these subgroups of high-risk patients.
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References

1. Moscucci M, Fox KA, Cannon CP et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003; 24: 1815– 1823
2. Shammas NW,Allie D,Hall P: Predictors of in-hospital and 30-day complications of peripheral vascular interventions using bivalirudin as the primary anticoagulant: results from the APPROVE Registry. J Invasive Cardiol. 2005; 17: 356– 359

Surgical site infections in the Hospital patients - Guidelines can prevent them?
American Journal of Surgery - Volume 201, Issue 1 (January 2011)

Surgical site infections (SSIs) occur in more than 500,000 patients annually and result in increased length of hospital stay, readmissions, costs, and mortality in USA. [1] , [2] Up to 60% of SSIs have been estimated to be preventable, [3] , [4] , [5] largely by using recommended evidence-based guidelines such as timely and appropriate administration of antibiotics for prophylaxis and maintenance of perioperative normothermia. [3] , [6] , [7] , [8] A number of hospitals have reported decreased infection rates by improving utilization of these guidelines. [9] , [10] Furthermore, lack of compliance with these guidelines is associated with a significant increase in mortality.[11] Despite the evidence that these measures improve outcome, compliance with these guidelines is suboptimal in many hospitals, as demonstrated by data from large administrative databases and cohort studies. [9] , [12] , [13] , [14] Bratzler et al evaluated a random sample of 34,133 Medicare patients and found that only 56% of patients received antimicrobial therapy within 1 hour before incision and that only 40% had appropriate discontinuation of prophylactic antibiotics after 24 hours.[13] Based on poor compliance with these guidelines and the high morbidity and mortality of postoperative complications, the Surgical Care Improvement Project (SCIP) was developed as a collaborative effort to prevent infectious, thromboembolic, cardiac, and respiratory complications.[15]



1 Kirkland K.B., Briggs J.P., Trivette S.L., et al: The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20. 725-730.1999; Abstract


2 Weinstein R.A.: Nosocomial infection update. Emerg Infect Dis 4. 416-420.1998; Abstract

3 Mangram A.J., Horan T.C., Pearson M.L., et al: Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory CommitteeAm J Infect Control 27. 97-132.1999; Full Text

4 Page C.P., Bohnen J.M., Fletcher J.R., et al: Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical careArch Surg 128. 79-88.1993; Abstract

5 Platt R., Munoz A., Stella J., et al: Antibiotic prophylaxis for cardiovascular surgery. Efficacy with coronary artery bypassAnn Intern Med 101. 770-774.1984; Abstract

6 Chodak G.W., Plaut M.E.: Use of systemic antibiotics for prophylaxis in surgery: a critical review. Arch Surg 112. 326-334.1977; Abstract

7 Horan T.C., Gaynes R.P., Martone W.J., et al: CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 13. 606-608.1992; Citation

8 Kurz A., Sessler D.I., Lenhardt R.: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature GroupN Engl J Med 334. 1209-1215.1996; Abstract

9 Dellinger E.P., Hausmann S.M., Bratzler D.W., et al: Hospitals collaborate to decrease surgical site infections. Am J Surg 190. 9-15.2005; Full Text

10 Hedrick T.L., Heckman J.A., Smith R.L., et al: Efficacy of protocol implementation on incidence of wound infection in colorectal operations. J Am Coll Surg 205. 432-438.2007; Full Text

11 Mahid S.S., Polk , Jr , JrH.C., Lewis J.N., et al: Opportunities for improved performance in surgical specialty practice. Ann Surg 247. 380-388.2008; Abstract

12 Bratzler D.W., Houck P.M.: Antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project. Clin Infect Dis 38. 1706-1715.2004; Abstract

13 Bratzler D.W., Houck P.M., Richards C., et al: Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project. Arch Surg 140. 174-182.2005; Abstract

14 Silver A., Eichorn A., Kral J., et al: Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study GroupAm J Surg 171. 548-552.1996; Abstract

15 Bratzler D.W., Hunt D.R.: The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 43. 322-330.2006; Abstract

Healing of Venous ulcers and cost of therapy


The treatment of venous leg ulcers (VLU) represents 23% of new patient visits and 36% of all patient visits in vascular surgery practice. Depending on the age of the patient cohort, VLU affects between 0.2% and 1% of the population.1 In first world countries, the treatment of VLU may represent a maximum of 3% of health care expenditures.2 Presently, the standard of care for VLU remains compression therapy, in many cases Unna’s boot, but ideally multilayer wraps.3 With this current treatment, healing rates in patients with normal arterial perfusion is reported to be between 63% at 10 weeks retrospectively and 33% at 12 weeks prospectively.[4] and [5] Overall, annual direct costs for the treatment of VLU are in the range of $30,000 per patient per annum, with only 60-80% of them healing at 6 months. Dr O’Donnell has accurately pointed out that “any treatment modality improving VLU healing time or proportion healed would reduce the burden of VLU care.”6


Others have noted that a maximum of 15% of the limbs affected by VLU observed in large volume vascular practices have an ankle–brachial index (ABI) of <0.8.4 Patients with an ABI of <0.8 were noted to take 19 weeks to heal 50% of their ulcers as compared with 9 weeks taken by the normally perfused group. In another study, which evaluated the closure rate of mixed arterial venous ulcers, the closure rate for the standard of care arm at 16 weeks was 46.2% as compared with the 82.6% in the cohort treated with porcine-derived intestinal submucosa (SIS) (Cook Medical Inc., Bloomington IN).7 A 2004 study conducted in the United Kingdom reported that 13.6% of patients presenting with VLU had an ABI of 0.5-0.85 and 2.2% had an ABI of <0.5.8 M.L. Humphreys, A.H. Stewart and M.S. Gohel et al., Management of mixed arterial and venous leg ulcer, Br J Surg 94 (2007), pp. 1104–1107. View Record in Scopus Cited By in Scopus (9)8 Therefore, to assess the effect of intervening percutaneously on the arterial circulation of patients with mixed arterial venous disease who were dependent on compression therapy. This therefore excluded the few patients who had mixed arterial venous disease with easily correctable, superficial-only venous reflux. The hypothesis was that improving or “normalizing” the lower extremity perfusion, as assessed by ABI and pulse volume recordings (PVRs), would normalize the healing trajectory of this hard-to-close patient subset. Few others have applied this protocol selectively but with a large proportion of patients who underwent arguably more morbid open procedures.8

Second - hand smoking and mortality

Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. This exposure was estimated to have caused 379 000 deaths from ischaemic heart disease, 165 000 from lower respiratory infections, 36 900 from asthma, and 21 400 from lung cancer. 603 000 deaths were attributable to second-hand smoke in 2004, which was about 1·0% of worldwide mortality. 47% of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men. DALYs lost because of exposure to second-hand smoke amounted to 10·9 million, which was about 0·7% of total worldwide burden of diseases in DALYs in 2004. 61% of DALYs were in children. The largest disease burdens were from lower respiratory infections in children younger than 5 years (5 939 000), ischaemic heart disease in adults (2 836 000), and asthma in adults (1 246 000) and children (651 000).

The Lancet, Volume 377, Issue 9760, Pages 139 - 146, 8 January 2011

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