Awareness of diabetic neuropathy in diabetics

Diabetic foot society of India 2012 lecture by Pinjala

DFSICON2012 7sept

Infected PTFE graft

Supra Renal Abdominal Aortic Aneurysms

Aortic aneurysms of the abdominal aorta are often seen in very sick patients in our clinics in public hospitals  Many times they are not suitable for the operations due to systemic problems. Endorepairs are expensive and they are not done in many public hospitals run by the governments. These are the images of the patient with symptomatic supra renal AAA involving the visceral branches. The aortic patch with all these branches was anastomosed to another graft from the main stem.  The aneurysm cavity shows the erosion of the vertebral bodies. The inter vertebral discs between the eroded vertebral bodies are seen in cavity. This is due to the late presentation of the patients which is common in people who are not able to get the interventions at an early stage. 

Endorepair of Aortic aneurysms, is it a failure?

Superglue and varicose veins

Carotid Endarterectomy

In India, carotid artery intervnetions are less often performed than coronary artery interventions. There are many reasons for the same. Carotid endarterectomy is also less often performed. In the elderly people there is tendency to consider angioplasty and stenting for carotid stenosis. But the studies are saying that the carotid endarterectomy is safer in the older people than the stenting. In a study published EJVES  it was shown that Carotid Endarterectomy was safer in the short-term than stenting, because of an increased risk of stroke associated with stenting in patients over the age of 70 years. Stenting should be avoided in older patients, but may be as safe as endarterectomy in younger patients.Determination of the efficacy and ultimate balance between the two procedures requiresfurther data on long-term stroke recurrence.

Eur J Vasc Endovasc Surg (2011) 41, 153e158

Happy new year 2013 to you. from Pinjala R K

Every year is new and we all look for betterment the next year. Change is inevitable and we all know that. But we want it to be our advantage. Well, some times yes but other times it is not. We need to ask for the strength to cope with the negatives and look the next year.

Clinical Medicine and medical education are rapidly changing with the progression of the internet science. We are going to see many more changes in this year 2013 with the introduction of the web2 or web 3, 4. Learner centric approach seems to be more appropriate and soon the typical class room teaching is going to take a back seat in all the medical colleges.  

Superior Mesenteric Artery Thrombosis

 Acute mesenteric ischemia is a rare. It is characterized by a high mortality rate. This may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thrombo-endarterectomy, although some prefer an endovascular approach.
A second-look laparotomy could be required to evaluate viable intestinal handles. we support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.

Femoro-femoral Cross over Graft in leg ischemia

Femoro-femoral cross over graft in leg ischemia

Patients develop critical limb ischemia due to multi segmental disease or one or two segmental steno-occlusive lesions. We are now considering Endovascular therapies (angioplasty and stenting) or hybrid procedures for revascualarization of the lower limbs. Long segmental occlusions, failed iliac stenting patients ( occlusion) are occassionally considered for femoro-femoral bypass which is very useful in them. There is always a concern about the chances of infection if there is an ulcer in the foot or toes with infected groin lymphatics. The need for this operation is certainly decreased over period of time.

Happy new year 2013

Professor Pinjala Ramakrishna, MS.,FRCSEd.,FICS
Head of the department of Vascular surgery
Nizams's Institute of Medical Sciences
Hyderabad - AP, India 
Tel No 0091 40 3317115

Drug Eluting stents and disadvantages- can we overcome these?

Drug Eluting Stents for coronary arteries

The use of metal Drug Eluting Stents (DES) presents some potential drawbacks. These include a predisposition to late stent thrombosis, prevention of late vessel adaptive or expansive remodeling, hindrance of surgical re-vascularization, and impairment of imaging with multi slice CT. That means we need some thing better than this in future. Are we there yet? However, it has been hypothesized that stents placed in many atherosclerotic arteries may require only about 3–6 months of mechanical integrity for scaffolding. Bioabsorbable or biodegradable stents that provide mechanical support during vascular wall repair and then harmlessly erode after the vascular wall has stabilized may eliminate some of the potential chronic risks of permanent stents and may mitigate the complexity of repeat stenting at the same site in the event of restenosis.

Smart phone based Ultrasound device

Smart phone based ultrasound for bed side use

We  would like to get the diagnosis  in patients as early as possible with the use of small gadget. We would like to get all the information needed to take a decision or start a treatment. 

In the beginning stethoscope and knee hammer were useful to examine the patients with cardiovascular and neurological problems. In recent past after the emergence of CT and MRI scans they basic tools have fallen out of fashion. We are looking for new devices which are simpler but provide more crucial information on the bed side to change the medications or start new treatment. 

CME - Management of Varicose Veins and Venous Insufficiency

Varicose veins in both legs - marking on left side

Varicose veins are common as the age advances. Chronic venous disease presents with a spectrum of signs and symptoms, including cosmetic spider veins, asymptomatic varicosities, large painful varicose veins, edema, hyperpigmentation and lipodermatosclerosis of skin, and ulceration. But there is no definitive stepwise progression from spider veins to ulcers and, in fact, severe skin complications of varicose veins are not seen in some with extensive varicose veins.

1. Precipitating factor for varicose veins include 

A. nulligravida pregnancy status. 

B. normotension.  

C. prolonged standing. 

D. autosomal-recessive genotype with complete penetrance.

2. Symptoms of chronic venous insufficiency 

A. include swelling, restlessness, limb heaviness and fatigue, aching/throbbing sensation, burning, tingling, direct tenderness, itch, and nocturnal leg cramps. 

B. are usually worse at the beginning of the day. 

C. decrease during the menstrual cycle and in cold weather. 

D. are not relieved by elevation.

3. In varicose veins patients, what can compression stockings do?

A. control pain and edema.  

B. help patients lose weight. 

C. are most practical for patients who are elderly, are obese, or have skin damage. 

D. slow the progression of venous insufficiency.

4.  When there are cosmetic spider angiomas (≤3 mm) any of one these therapies - sclerotherapy, thermocoagulation, or cutaneous laser therapy will 

A. seldom necessitates more than 1 treatment. 

B. leads to complete resolution of varicosities in most patients.  

C. induces endothelial damage leading to venous thrombosis and fibrosis.  

D. All of the above

5. When high volumes of dilute local anesthetic is injected into a treatment area of VVs, it  is called 

A. truncal reflux.  

B. transilluminated powered phlebectomy.  

C. tumescent anesthesia. 

D. micronized purified flavonoid fraction. 

---

 Answers

C,A,A,C,C

Govt funded Health Insurance schemes

Age, BMI determine the severity of chronic venous disease?

Age, body mass index and severity of primary chronic venous disease.

Chronic venous disease

The severity of CVI is linked with the age and BMI of the individuals. A study confirmed the relationship between age, CEAP clinical class and extent of the venous reflux severity of CVD. Older age means an increased number of insufficient venous segments and increased risk of the clinical progression of CVD from varicose veins to chronic venous insufficiency (C(3)-C(6), trophic skin changes and venous ulcers). The results in this study support the BMI, in term of frequency of venous reflux, as a risk factor in the whole group of patients but only in women but not in men. Multiple linear regression showed BMI together with age as significant predictors of clinical grade of CVD according to the CEAP classification. As regards the influence of BMI on clinical severity/grade of CVD, the results of our study support BMI as an important risk factor.  Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011 Dec;155(4):367-71. doi: 10.5507/bp.2011.054.

http://www.ncbi.nlm.nih.gov/pubmed/22336650

Obesity and Venous thrombosis

Obesity is a world wide problem. It is now common to see obese diabetic or obese person with venous disorders. It would be a good habit to measure the BMI of patients in the clinics and give them necessary precautionary advices when they are getting admitted to the hospitals for various therapies.

Carotid interventions in severe CKD patients

carotid artery disease and outcomes in CKD

Carotid artery stenotic disease is treated by endarterectomy and angioplasty/ stenting. The trials have shown that the incidence of MI is more after surgical endarterectomy in patients in the first few months.

Biochemical MI seems to be high after endarterectomy. In renal failure patients contrast injection may be a concern and surgery may be safer than the angioplasty and stenting. In a recent study this fact has been observed. Arch Surg. 2011;146(10):1135-1141. Published online June 20, 2011.

Clinical Image of the week

Fig: Femoro-popliteal angiogram of lower limb

Clinical information- This is the lower limb angiogram of the leg of a patient who is complaining of a pulsatile swelling on the back of the knee.

What is your diagnosis based on the findings in angiogram?

Answer:

Popliteal artery aneurysm with occlusion of distal popliteal artery

Comments:

Repair of popliteal artery aneurysm with revascularization of the tibial arteries.