Vein grafts are often used for bypassing the occluded arterial segments in diabetic people and those who are habituated to smoking. Thrombosis of the vein grafts occur in some patients though the veins look healthy from out side and it is often considered to be a technical problem and revision of the vein grafting is often done especially in peripheral vascular surgical patients. Hyperglycemia is known to effect the endothelial functions and endothelial derived relaxation is abnormal in the diabetic people to varying degrees depending on the exposure of the patient to the glycemic variability in the previous times. Now there seems to evidence to support that BMP-4 is probably responsible for this impaired EDR ( endothelium derived relaxations) which is not linked to cyclooxygenase-2 pathway.   

Can we develop specific ischemia resist muscle fibers in chronic stable ischemia people?

The answer to this question can solve some of the problems faced by lower limb ischemia patients who are not suitable for interventional therapies or after failure of all the existing therapies?

This year slogan on world health day is control your blood pressure. We are aware of the importance of controlling high blood pressure in people attending our outpatient clinics. This is chosen with an aim to prevent the morbidity and mortality associated with the hypertension related cardiovascular outcomes.
The governments should take notice of the importance of implementation of the blood pressure control programs and support them to see that blood pressure of the people at large is kept under control health education and also providing basic medicinal supplies to the people. Ideally it would be helpful to train more paramedical people record the blood pressure and register hypertensive patients e-register so, that necessary supports can reach them to prevent complications.
In our world 9 million death are attributed to the hypertension related complications. That means they are potentially preventable with active implementation of the antihypertensive programs.
from  Pinjala R K,  7th April 2013

AV grafting for Vascular Access

Newer Anticoagulants

Vascular lesions and Oral cavity bacteria

Buerger's disease progression after 60 years of age?

Buerger's disease vessel with thrombus in lumen

Buerger's disease is often seen in people who started  smoking tobacco early in their lives.   
Can we arrest this disease progression?

 It is known that people develop atherosclerosis if they had been smoking for a long time with classical plaque formation. We can expect them to develop the major cardiovascular events prematurely. It is in this aspect it would be interesting to know if these phenomena (MACE) are more common in the Buerger's disease patients during the follow up! There are very few papers published on long term survival and  the natural course of the disease. Takashi Ohta etal followed 110 patients for a mean follow up period of 10.6 years. Natural course of life and limb is favorable in many patients with TAO. The part of the disease which causes the necrotic lesions seems to be arrested in patients after 60 years of age. Early treatment and abstaining from smoking can certainly help in modifying the disease progression significantly.  Here, in our unit, Injection Prostaglandin E-1 infusion therapy ( 500 mcg  in 3 days/ once in a month injections ) over 6 months brought lot of relief to these patients and arrested the progress of the disease avoided the major amputations.

J Vasc Surg 2004;39:176-180   

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.