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
--------------------------------------------

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

------------------------------------------------------------------------------------------------

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

--------------------------------------------------------------------------------------------

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
----------------------------------------------------------------------------

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.

-------------------------------------------------------------------------------------------------

Crush injury to shoulder / arm from Tractor wheel
-------------------------------------------

Crush injuries are usually difficult to treat when they are around the shoulder girdle and pelvic girdle. Recently a middle aged gentleman was referred to us after giving initial treatment in a local govt hospital. On examination the shoulder, upper limb was crushed, edematous, tense and infected. Clavicle and Corocoid process fracture was noted. There was occlusion of the 2nd and 3rd part of the subclavian artery. Devitalized skin (necrotic skin) around the shoulder and arm was infected. A large collection was noted in the axilla and sub pectoral region. There was significant induration around the clavicle fracture (12 days) and it was looking like phlegmon.

what should be done in such cases?

what is the expected outcome?

By
Pinjala R K

--------------------------------------------------------------------------------------------------

Training in vascular surgery and a career in vascular surgery
----------------------------------------------------------------------------------------------

Peripheral vascular problems are now getting the attention after significant improvement in the cardiac care. There are few vascular surgeons and vascular surgical centers in the country. We will be requiring more number of trained doctors for taking care of the people with vascular problems. The National board of examinations has introduced 3 years course in vascular surgery in 3 centers in India. MCI is also going to start the MCh in vascular surgery in more centers soon. Nurses, technicians and other paramedical staff are needed to complete the vascular surgical services to the patients. At the same the needs of the people with arterial disorders is different from those with venous problems. Majority of the patients are now looking for the day care services and minimally invasive procedures. The hospitals have to gear up to face this challenge by providing new facilities focused around the day care for the vascular (arterial / venous) surgical patients. We hope that there is going to be bright future for those who are opting for the career in vascular surgery.

By
Pinjala RK
-----------------------------------------------------------------------------------------------

What condition is this?

This patient was undergoing cardiac surgery for Atrial septal defect cardiothoracic OT. Then the Cardiac surgeon and anesthetist called for help from the vascular surgeon. The right upper limb was found to be swollen and ischemic on examination by vascular surgeon.

A small procedure was done. What could it be?

What can happen to the limb if unattended?

By
Pinjala R K

VAICON 2009 (23, 24, 25 Jan'09)

Dear friends,

It is my pleasure to invite you to attend the VAICON 2009 in Jan 2009 on 23,24,25th at Hyderabad, Fortune Manohar Hotel. Venous disease is common and we all see clinical problems related to the venous disease often in our patients. These patients with venous disease present with varicose veins, swollen legs, painful legs, recurrent ulcerations and pigmentation around the ankles. we would like to discuss these clinical problems and share our views and experiences in the coming meeting about the current methods of treating venous disease. Doctors from India, Europe, Australia and America are going to participate in this meeting and present their perspectives.we would like to meet you and welcome you. Please make it possible to attend the actively participate in this meeting and make it a successful meeting.
(Photo: A happy person after treatment at NIMS for Bilateral leg venous ulcer ( 10 yrs).

with regards

Pinjala R K
on behalf of the Organizing committee.
Call 9490295027 for more details.

Dr LRC Reddy and Dr Devendersingh are the conference coordinators.

Development of Tissues with structural abilities on biodegradable scaffolds!
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
In recent past stem cell therapy is recognized as an important tool in the regenerative medicine. The different types of cells with functional abilities can be produced from the stem cells but the development of tissues and organizing them as functional units is not that simple. We need different types of scaffolds for the cells to grow and produce the tissues with structural functional abilities. Probably this will be helpful in closing the congenital defect in the heart, A V- Fistulas and other types of medical problems.
Development of different types of bio-degradable scaffold to allow the cells to arrange themselves in to the tissues with structural and functional abilities. We hope this new developement published in the On line edition of the Nature materials is going to quoted for very long time in the future with further advancement of science in the regenerative medicine.
By
Pinjala R K

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

What is new in Thromboprophylaxis?
Cost-Effectiveness of Thromboprophylaxis with two different low molecular weigh heparins? Enoxaparin vs Fondaparinux!
presented in CHEST 2008, the annual meeting of the American College of Chest Physicians.

Enoxaparin discharges had a mean total direct medical cost of $9,755 compared with $12,683 for fondaparinux discharges, for a difference of $2,928 per patient, Dr. Merli reported. After adjusting for patient and hospital characteristics, the costs associated with enoxaparin were $6,479 compared with $6,658 with fondaparinux, for a difference of $179.The cost of anticoagulant therapy was also lower for enoxaparin discharges than for fondaparinux discharges, at $130 and $163, respectively."The total adjusted medical cost savings per patient was $442 with enoxaparin compared with fondaparinux," Dr. Merli stated. "This is a significant savings, considering the number of patients treated each year for VTE prophylaxis."
"The annual cost of VTE prophylaxis is around $1.5 billion." in USA says Dr Merli.

It would be too primitive to talk about the annual cost of VTE prophylaxis in a big country like India or China based on the ACCP guide lines.In the ENDORSE study we noted that 50% of the hospitalized ( Acute care) would be requiring some form thromboprophylaxis. One can imagine that type calculations would be mind boggling for the indian pharmaceutical industry. In our country many are still of the opinion that very few can chemical thromboprophylaxis and in some situations the doctors are still hesitant to consider the chemical thromboprophylaxis. Injection Heparin ( UFH) is still used by majority when they think it is necessary due to the cost of the low molecular weight heparins. In India LMWH is produced by one or two companies but they are not able to compete with the international brands in many angles. The awareness for the Venous thromboembolism increased in the last 10 years but there is lot more to be done by the Indian doctors and medical companies in this direction.

Pinjala R K. Nov'08