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   Table of Contents - Current issue
April-June 2019
Volume 6 | Issue 2
Page Nos. 61-141

Online since Thursday, June 6, 2019

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Wither “clinical evaluation” p. 61
Kalkunte R Suresh
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Paradigm shift in mentoring Highly accessed article p. 63
Edwin Stephen
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Limb salvage using microvascular reconstructions for secondary regional vascular insufficiency in the neuro ischemic diabetic foot; is it making impact? Highly accessed article p. 65
Thalaivirithan Margabandu Balakrishnan, Illayakumar Pramasivam, Krishnakumar Thirunavukarasu, Jaganmohan Janardhanan, Sritharan Narayanan
Introduction: Secondary regional vascular insufficiency (RVI) is a pathophysiological state that occurs most commonly following the successfully involved perforosome-directed distal revascularization (IPDDR). This IPDDR renders bounding pulse in the vicinity of diabetic foot ulcer, which shows no signs of early granulation (the sign of healing potential) for variable time. This is the main cause for delaying the definitive reconstruction in the successfully revascularized diabetic foot. Aim: The aim of this study is to evaluate the effectiveness of microvascular and nonmicrovascular reconstructions (NMVRs) in the treatment of secondary RVI of the neuroischemic diabetic foot following successful IPDDR. Endpoints assessed in this study were as follows: (1) Time taken to render a stable and shoe able foot or foot residuum following successful revascularization of the neuroischemic diabetic foot. (2) Time interval between IPDDR and definitive reconstruction in both groups. (3) Rate of complications including recurrence of foot ulcers and failures of reconstruction in each group. Patients and Methods: From 2014 to 2017, 128 neuroischemic diabetic foot patients (a multicenter study) after successful IPDDR for their critical limb ischemia subsequently underwent various types of reconstructions. All had a variable period of secondary RVI following successful revascularization. A retrospective study was conducted by dividing them into two groups – MVR group with 69 patients and NMVR group with 59 patients. The interval between the IPDDR and definitive reconstructions in each group was called the “latent period.” All were followed up for an average period of 30 months. The standard postoperative care and offloading techniques were followed in both groups. Results: The average time taken for obtaining shoeable and stable foot or its residuum in the MVR group was 55.5 days and NMVR group was 76.5 days. By statistical analysis, the MVR group had lesser latency period (P = 0.042), lesser ulcer recurrences (P = 0.044), and lesser flap and reconstruction failures leading to amputation (P = 0.0345). Conclusion: The MVR by bringing tissue from above or at the level of hip area produces sound and early healing of secondary RVI with higher limb salvage rate following the successful revascularization of neuroischemic diabetic foot.
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Preoperative factors predicting the outcomes of arteriovenous fistula surgery Highly accessed article p. 74
Vedamurthy Reddy Pogula, Mallikarjuna Reddy Nalubolu, Ranadheer Byram, Harikrishna Maddiboina, Sudeep Bodduluri, AP Pavan, P Banuteja Reddy, Jayaraju Juturu
Purpose: The aim is to study the preoperative factors predicting the outcome of arteriovenous fistulas (AVF) in chronic kidney disease (CKD) patients. Successful AVF formation is vital to the success of hemodialysis treatment. The factors leading to failure of AVF maturation are still ill defined and there is a limited ability to predict surgical vascular outcomes. In part, this is due to the heterogeneity of end-stage renal disease populations. Methods: A prospective observational study was under taken on CKD patients requiring vascular access surgery for a period of 2 years were from November 2015 to October 2017. Informed consent was obtained. Demographic, clinical factors, comorbidities including age, gender, site, laterality, smoking, diabetes, hypertension, coronary artery disease and peripheral vascular disease, vessel caliber, type of anastomosis, flow across vein, and anastomosis were noted. The patient's vessel status recorded preoperatively by a Doppler ultrasound. Postoperative assessment of AVF was performed with Doppler 4 weeks after surgery. Data were analyzed to assess the risk factors predicting AVF outcomes. Results: A total of 330 cases of AV fistula were enrolled in the study. Of these 330 cases, they were categorized and evaluated separately according to the site of fistula creation. 180 underwent radio-cephalic fistulas, 100 brachio-cephalic and 50 had brachio-basilic fistulas. All the fistulas were separately categorized and evaluated for the factors predicting their outcome. Conclusions: In this study, the outflow vein diameter, arterial diameter and flow rate in the vein and across the anastomosis were the predominant factor determining the success of the proximal and distal arm fistulas.
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Ulnar basilic arterio venous fistula: An useful alternative access for hemodialysis p. 79
Sekar Natarajan
Objective: Native arteriovenous fistula done at the distal most site has been promoted as the vascular access of choice. Radiocephalic fistula at wrist or snuffbox is widely used but ulnar basilic fistula is seldom performed. The aim of this study is to analyse the usefulness of ulnar basilic fistula as a hemodialysis access. Method: Retrospective analysis of 52 ulnar basilic fistula done in 51 patients over 20 years (2007-2017) with a follow up of one year was done. Results: Fifty two ulnar basilic fistulae were established in 51 patients. Three patients developed early thrombosis and in one of them another ulnar fistula could be established in the same limb. Three others thrombosed within the next 4 months. Six fistulas failed to mature and could not be used for dialysis. Fortyone out of 52 remained patent at the end of one year (78.8 %).There was no distal ischaemia in any of them. Majority of the failures occurred in women. Conclusion: Ulnar basilic fistula is an useful alternative when radiocephalic fistula is not possible or has already failed. It has high long term patency, has minimal complications and has the advantage of retaining the proximal sites for fistula in case of failure.
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Ultrasound-assisted angioplasty for failing arteriovenous access p. 82
Shahzad Sarosh Bulsara, Vinit Paliwal, Govind Prasad, NR Manjubharath, Ashutosh Aher, Ashish Airen, Tapish Sahu, Virender Sheorain, Tarun Grover, Rajiv Parakh
Introduction: Arteriovenous (AV) access maturity and patency is critical for patients on hemodialysis. Maintaining a functioning AV access for these patients is of paramount importance. Salvage of failing AV accesses has been traditionally done mainly with angiographic techniques requiring significant amounts of contrast agent and radiation exposure. Ultrasound-guided angioplasty has been described, but its utility needs to be further studied. Methods: Group 1: 42 patients undergoing ultrasound-assisted angioplasty (UAA) for AV access salvage were assessed prospectively for 9 months (October 2016 to June 2017). Group 2: Retrospective data of 47 patients who underwent angioplasty for failing AV access without ultrasound assistance, over 9 months was collected (January to September 2016). This group was matched with Group 1 in terms of age, sex, type of AV access, and cause of AV access dysfunction. Results: There was a statistically significant decrease in the average number of angiographic runs (2.5 vs. 7.9) and fluoroscopy time in minutes (3.8 vs. 13.1) recorded during UAA (P < 0.01). The average quantity of contrast agent used in milliliters (17.6 vs. 49.8) was also significantly less when ultrasound assistance was used (P < 0.01). Conclusion: UAA for failing AV access reduces the radiation exposure and the amount of contrast agent used in these patients who require multiple of these sessions and need dialysis to get the contrast agent out of their circulation. This technique is feasible and reliable; hence should be used more frequently and effectively. Our model of UAA for AV access salvage allows all cases including complex cases to be performed with the added advantage of reduced radiation exposure and contrast agent; serving as a boon to these already distressed patients. Immediate complication management and adjunctive open procedures also become possible because of the hybrid operating room setup with fluoroscopy facility.
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Vascular access related complications with ipsilateral upper limb oedema in hemodialysis p. 89
RD Nagaraj, Sarala Settipalli, P Sandeep, AY Lakshmi, V Sivakumar
Background: Central vein-related obstruction is a growing problem in maintenance hemodialysis (MHD). Prior to central vein temporary access, failure to implement “fistula first policy” is an important contributor for this problem. It interferes with the outcomes in dialysis adding to mechanical vascular perturbations, resulting in limb, facial, and chest wall edema. Keeping them in view, we undertook this study on MHD patients, presented with central vein-related vascular access problems and ipsilateral upper limb edema, with the aim to investigate the vascular anatomical obstructive lesions causing the clinical syndrome and their management. Materials and Methods: This cross-sectional study included 25 patients of end-stage renal disease on MHD who manifested with vascular access dysfunction, presented with ipsilateral upper limb edema, and were the study subjects. All patients were evaluated with thorough clinical, laboratory, and computed tomographic (CT) angiography (CTAngio) studies to address the issues. Results: All patients had ipsilateral upper limb edema and 36% of them had in addition facial edema. Fifty percent had difficult cannulation with raising venous pressure during HD sessions and difficulty in securing hemostasis at the end of dialysis. CTAngio revealed central vein stenosis in 48%, peripheral stenosis in 20%, and combined central and peripheral stenosis in 32% patients. Cephalic arch involvement was noted in 16% patients. Depending on the patients preference, dialysis switched over to peritoneal dialysis in 24%, new vascular access was created in 20%, and balloon angioplasty in 16% during management. Conclusions: This study describes the central venous-related problems in MHD patients. We reiterate the importance of three early warning signs: high venous pressure, difficulty to achieve hemostasis at the end of dialysis, and ipsilateral limb, face, chest wall edema as the presage signs to suspect and exclude the underlying central vein obstructions. A continuum of management is discussed.
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Role of brachial artery ligation as an emergency procedure in bleeding arteriovenous access p. 99
AR Chandrashekhar, Luv Luthra, Sanjay C Desai, B Rajendra Prasad
Introduction: Bleeding from a ruptured or infected arteriovenous (AV) access is a life-threatening situation leading to increased mortality in chronic kidney disease (CKD) patients. All these patients need emergent and expeditious management. The procedures described for bleeding complications in AV access are associated with high morbidity and mortality. In some cases, there is a need for a major surgery or bypass. Aim: The aim was to evaluate the safety and efficacy of brachial artery ligation (BAL) in bleeding AV access. Materials and Methods: This was a single-center retrospective analysis of 106 patients who underwent BAL for bleeding AV access (AV graft [AVG]/brachiocephalic [BC] AV fistula [AVF]) from January 2007 to 2017. Results: During this study period, BAL was done in a total of 106 patients, out of which 51 patients underwent AVG explantation with BA ligation and 55 with ligation in BC fistulas. There were 73 males and 33 females with a mean age of 45 years (11–90). The primary etiology was hypertension (66%), diabetes (23.58%), and other causes (10.3%). Twenty patients presented with acute bleeding due to graft erosion and 31 patients had purulent discharge from puncture site with sepsis. Infection was involving anastomosis in all patients. Out of 55 patients who underwent AVF, 5 patients had infection at puncture site 3–4 cm near the anastomosis. Fifty patients had infected pseudoaneurysms at the anastomotic site that developed within 1 week of the creation of fistula. All patients were evaluated and assessed for signs of ischemia in the postoperative period till the time of discharge. Conclusion: BAL is a safe alternative in patients with access site bleeding as it reduces not only the operative time but also the morbidity and mortality associated with CKD patients. Ligation of the brachial artery at the elbow can be used as a primary approach in complicated vascular access.
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Pseudoaneurysm of peripheral arteries: Our experience in a community-based hospital p. 102
Lokesh Shekher Jaiswal, Narendra Pandit, Jagat Narayan Prasad, Shailesh Adhikary
Introduction: Pseudoaneurysms are false aneurysm where disruption in the arterial wall forms a localized pulsatile hematoma connecting the artery. The common causes are intravenous drug abuse (IVDA), iatrogenic (vascular interventions and surgery), trauma, and infections. Aims: The aim of this study was to analyze the etiology, management, and outcome of patients with pseudoaneurysms of peripheral arteries. Materials and Methods: This is a retrospective analysis of prospectively maintained database of 32 patients with peripheral artery pseudoaneurysms over 45 months at a community-based hospital of Eastern Nepal. Results: The most common site involved was femoral artery (56.3%) followed by brachial (15.6%), radial (6.3%), anterior tibial (6.3%), and others (15.5%). The common etiologies were iatrogenic (46.9%), IVDA (31.3%), trauma (18.7%), and infection (3.1%). Operative intervention was performed in 29 (90.6%) patients as follows: ligation of artery and debridement (46.9%), primary repair (28.1%), and venous graft bypass (15.6%). Three patients (9.4%) with noninfected iatrogenic pseudoaneurysms of <3 cm were managed conservatively. Infected pseudoaneurysms were seen in 14 (43.7%) patients. Staphylococcus aureus was the most common isolate in the culture. There was no reoperation, amputation, or any in-hospital mortality. At follow-up, one patient developed leg claudication pain following a femoral artery ligation and one of the five patients developed a graft thrombosis after an autologous reversed saphenous vein bypass graft without any sequelae. Conclusion: Although repair with distal revascularization is an ideal approach, debridement and simple ligation of pseudoaneurysms is a safer alternative especially in IV drug abusers.
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Risk assessment of varicose veins among the traffic police of Kathmandu Metropolitan City, Nepal p. 107
Robin Man Karmacharya, Laxmi Prajapati, Sangeeta Rai
Introduction: Varicose veins are swollen, tortuous, and sometimes painful veins that are filled with an abnormal collection of blood. Varicose veins are known to be common among professionals such as teachers, traffic police, nurses, shopkeepers, and bus conductors, who have to stand for a long time daily. Other risk factors include age, obesity, pregnancy, smoking, and family history. If left untreated, it can lead to several complications such as ulcers, bleeding, and thromboembolism. Objective: The objective was to assess the risk of varicose veins among traffic police officers of Kathmandu Metropolitan City. Methods: An analytical cross-sectional study was conducted. Data were collected by interview technique and observation method which consisted of self-constructed semi-structured questionnaire for sociodemographic data, descriptive rating scales for symptoms, and observational checklist for signs of varicose veins. Nonprobability convenient sampling technique was used. Results: Out of 200 respondents, 24 (12%) were at risk of varicose veins, out of which 22 were male and the rest were female. Conclusion: The results of the study suggest that overall risk of varicose vein is 12%, with males accounting for 12.3% and females for 9.5%. In the study, the risk of varicose veins is statistically significantly associated with the family history of varicose vein and smoking.
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Development of cardiac risk assessment model for vascular surgery patients based on single-center experience p. 110
Vivek Kumar Singh, Sudhir Rai, Vembu Anand
Introduction: Existing methodologies and risk stratification indices from western countries for predicting perioperative cardiac complications in vascular surgery patient lack sufficient predictive value and therefore cannot be recommended for risk stratification. There are no Indian studies for preoperative cardiac risk scores for patients who undergo vascular and endovascular procedures. The aim of this study is: (a) to test the usefulness of Detsky's cardiac index in an independent series of patients who underwent peripheral arterial vascular procedures and (b) to develop cardiac risk assessment model. Materials and Methods: We studied 103 patients at single-center who underwent cardiac risk stratification before undergoing vascular interventions. It was a prospective cohort study for 2 years. The Detsky's cardiac risk index was calculated for each patient to predict perioperative cardiac risk in patients undergoing vascular interventions. Sensitivity, specificity, positive and negative predictive values were calculated. To determine the accuracy of stratification for Detsky's index, the area under the receiver-operating characteristic curves was also calculated. Results: Eighteen patients (17.4%) had cardiac complications. The Detsky's index was found to be a satisfactory predictor of postoperative cardiac events (P < 0.001). There were a total of 10 mortalities (9.7%) with the Detsky's model, having positive predictive value of 73.3% and specificity of 94.1%. Discussion: The overall sensitivity, specificity, positive predictive value, negative predictive value of the Detsky's risk index in the prediction of cardiac events was 31.4%, 94.1%, 73.3%, 72.7% respectively. In our study, the area under ROC for Detsky class was 0.76 versus 0.75 and superior to C statistic. One important inference from the study was that 77.6% patients were smoker in the study group which emphasize direct relation of peripheral vascular disease with smoking. Conclusion: The study concluded that patients with good surgical risk and profile undergoing minor vascular procedures can be operated without further testing. For other patients, the next step would be to incorporate the Detsky index. A Detsky score of 20 or more is comparable to a major clinical predictor in the ACC/AHA15 scheme.
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Study of risk factors affecting the limb salvage in patients with lower extremity arterial trauma p. 115
Mukesh Kumar Garg, Varinder Singh Bedi, Ajay Yadav, Sandeep Agarwal, Ambarish Satwik, Apurva Srivastava
Background: Vascular injury in extremity is a complication of both blunt and penetrating trauma. In Indian scenario, patients generally present late to the tertiary care center with mangled extremity for treatment. The aim of the study is to assess the risk factors affecting the outcome in the management of patients with lower extremity arterial trauma. Materials and Methods: A single-center, observational study was conducted at Sir Ganga Ram Hospital, New Delhi, from January 2013 to June 2017. Sixty patients of lower extremity arterial trauma who underwent revascularization were included and followed up for 6 months. All the risk factors (mode/mechanism of injury, time since injury, compartment syndrome, mangled extremity severity score [MESS], etc.,) and limb salvage were assessed at 6 months. Statistical analysis was performed using Chi-square test and Fisher's exact test. Results: Majority of the patients presented late (6–24 h) of injury and had high mean MESS (7.85). The most common mechanism of injury was blunt trauma (83.3%), and popliteal artery (72%) was the most commonly injured artery. Limb salvage was achieved in 75% of the patients. Time since injury and MESS score affected the limb salvage significantly. On multivariate analysis, MESS score was the single independent factor which affected the limb salvage (95% confidence interval, 0.231–0.769, P = 0.005). Conclusions: MESS is the most important predictors for limb salvage. Multidisciplinary team approach with timely diagnosis and immediate repair is the key to the ultimate goal of functional limb salvage.
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Venous angioplasty with stenting for obstructive iliac vein lesions: A case series p. 121
M Bathavatchalam, S Sasikumar, Jayakrishnan Ramakrishnan
Background: Deep-vein reflux has been a major cause for chronic venous insufficiency (CVI). Secondary reflux due to obstructive lesions has been treated with conservative methods. The advent of dedicated venous stent and intravascular ultrasound has renewed interest in the correction of obstructive component in CVI pathophysiology. We have followed a protocol-based approach for identifying the patients who would probably be benefitted with iliac vein stenting. Materials and Methods: Of the 156 patients who have presented to our institution over a 3-year period (2015–2018) with chronic venous insufficiency, based on the inclusion criteria, 31 patients were included with a probable diagnosis of deep-vein reflux due to obstructive iliac vein lesion. All these patients were subjected to duplex study initially and all had deep-vein reflux. Twenty-three patients had presented with superficial vein reflux. Magnetic resonance (MR) venogram was performed in all patients prior to proceeding with digital subtraction venography. Iliac vein stenting was performed in seven patients using wall stent. All patients had lesion on the left side with lesion ranging from 4 to 12 cm. Results: Seven patients who had iliac stenting had significant improvement in symptoms. Three patients had superficial venous ablative procedure done after 3 months combined with foam sclerotherapy. There were no procedure-related complications. Six-month follow-up study revealed one recurrent ulceration with bleeding superficial varices. Stent patency at 1-month follow-up was 100%. Symptomatic relief was achieved in all patients. Conclusion: Iliac vein stenting is effective in controlling CVI symptoms in selected patients. Those patients with potentially correctable lesions were identified with the application of duplex criteria for initial screening. Clinical examination and duplex criteria had equivalent predictive value compared to MR study. Symptom relief was achieved in all patients after iliac stenting. Those presenting with recurrence had adjunctive procedures with optimal results.
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A tribute to the inventor of arteriovenous fistula for hemodialysis: James E Cimino p. 127
Devender Singh, C Harita
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Anastomotic pseudoaneurysm of brachioradial artery p. 129
S Roshan Rodney, Vivek Anand, M Vishnu, Sumanth Raj, Hemant Chaudhari, C P S Sravan, Vaibhav Lende, Hudgi Vishal, K Siva Krishna, B Nishan
Brachioradial (BR) artery also known as “radial artery of high origin” is the most common anatomical variation in the upper extremity arterial system. However, the clinical significance of this variation is rarely recognized in daily practice. This article reports the case of a 40-year-old male patient who presented with anastomotic pseudoaneurysm of an arteriovenous fistula, which had been created between the BR artery and median cubital vein in the antecubital fossa. The patient underwent aneurysm excision with repair of BR artery. Postoperative period was uneventful.
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A case report of lipedema with acute bilateral lower limb ischemia p. 132
Shivakumar Mutnal, Pradeep Rangappa, Ipe Jacob, Krishna Chaitanya, Karthik Rao
Lipedema is a poorly recognized disorder of subcutaneous adipose tissue that commonly presents as lower limb enlargement due to large deposits of subcutaneous fat and is seen mainly in women. It requires to be differentiated from lymphedema and venous insufficiency that may present similarly. Early recognition is important as the condition carries the risk of venous and arterial thrombosis and associated complications such as pain and ischemia.
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Complete aortic thrombosis in a ruptured mycotic aneurysm due to infection with Burkholderia pseudomallei p. 135
Darpa Narayan Hazra, Indrani Sen, Amit Mahajan, Sunil Agarwal
Complete thrombosis of the aorta in patients with abdominal aneurysms is extremely rare. The risk factors, natural history, and rupture risk are not well known. We report a case of a complete aortic thrombosis in a ruptured infrarenal mycotic aneurysm caused due to infection with Burkholderia pseudomallei.
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Buruli ulcer: Rare presentation of a chronic nonhealing ulcer in India p. 138
Ajith John George, Vimalin Samuel, Vasanth Mark Samuel, Pranay Gaikwad
Buruli ulcer is a rare disabling skin infection caused by Mycobacterium ulcerans. It is essential to consider Buruli ulcer as one of the possible differential diagnoses for a chronic nonhealing ulcer and treat the wounds with antitubercular therapy for at least 2 months before grafting. A young male from Nigeria, which is endemic for Buruli ulcer, presented with a long-standing ulcer with undermined edges. Various differential diagnoses were ruled out, such as venous stasis ulcer, cutaneous leishmaniasis, squamous cell carcinoma, and others. A biopsy and culture was suggestive of an atypical mycobacterial species. Early diagnosis of ulcers of infective etiology is imperative to prevent functional disability. Early debridement and initiation of antitubercular therapy is essential.
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Erratum: Evaluation of radiofrequency ablation for primary varicose veins: A preliminary study p. 141

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