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.