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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 6 | Issue 3
Page Nos. 147-222

Online since Thursday, August 29, 2019

Accessed 3,832 times.

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LEAD ARTICLE  

Global vascular guidelines on the management of chronic limb-threatening ischemia: A brief purview Highly accessed article p. 147
Kalkunte R Suresh
DOI:10.4103/ijves.ijves_50_19  
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EDITORIAL Top

How informed are you about informed consent? p. 158
Edwin Stephen
DOI:10.4103/ijves.ijves_48_19  
The past decade has seen a rise in the awareness of patients, and their attendants have about their disease, options for treatment and their legal rights, thanks to easy access to the Internet, however accurate it may be. Surgeons need to be aware of the need to consent, which is now termed as “prior informed consent” as it is required by law to be taken prior to any examination or intervention. This article is meant to give the reader a quick overview about informed consent.
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INVITED COMMENTARY Top

Introduction to translational research in vascular surgery/medicine Highly accessed article p. 162
Thushan Dhananja Gooneratne, Gnaneswar Atturu
DOI:10.4103/ijves.ijves_30_19  
Translational research is the process of applying the knowledge gained from basic research to clinical practice. Over the past three decades, translational research has transformed from a simple bi-directional flow from basic science to clinical care to a multifaceted, translational research spectrum that has the patient as the centerpiece. Globally, the vascular diseases spectrum has also been continuously changing with the aging population, change in lifestyle, and diabetic epidemic. This review aims to introduce new and exciting translation research concepts in the field of vascular surgery and medicine in general that could transform the management of patients with vascular diseases. An overview of contemporary translational research in the management of atherosclerosis, aneurysmal disease, and peripheral arterial disease is also highlighted.
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ORIGINAL ARTICLES Top

Clinical profile of abdominal aortic aneurysms undergoing open surgical repair: A single-center experience p. 171
PT Afshan, Shivanesan Pitchai, Sreekumar Ramachandran, Prakash Goura, Harishankar Ramachandran
DOI:10.4103/ijves.ijves_96_18  
Introduction: An abdominal aortic aneurysm (AAA) is defined as an aortic diameter at 1.5 times the normal diameter at the level of the renal arteries, which is approximately 2 cm. Existing data of clinical profile of AAA are mainly based on screening studies in the Western population. Materials and Methods: This is a retrospective observational study which included 165 patients who underwent conventional open repair for elective AAAs in a single center from January 2008 to August 2016. Results: The mean age of the patient cohort was 64.9 years with majority (92.7%) of them being a male cohort (male: female, 12.75:1). The mean size of the aneurysm was 6.8 cm. Ninety-six percent of the patients were hypertensive, 86% were smokers, 4.2% of patients had chronic obstructive pulmonary disease, and 16% of patients had preoperative renal dysfunction. Fifty-four percent of the patients had significant coronary artery disease (CAD), of which 19% underwent coronary intervention. Eighty-two percent of patients had infrarenal and 18% had juxtarenal AAA. Thirty-three percent of the patients who underwent open repair had concomitant common iliac artery aneurysm/ectasia. Conclusion: Clinical profile of AAA in this study shows a significantly high preponderance for males, hypertensive patients, and smokers, which have already been established as significant risk factors. Moreover, majority of the patients had significant CAD detected by routine preoperative cardiac evaluation which shows the significant coexistence between AAA and CAD in our population. Apart from coronary angiogram, evaluating patients with dobutamine stress echocardiography for inducible ischemia will act as a guide to detecting patients who are likely to benefit from revascularization and who are at increased risk of periprocedural cardiac events.
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From compression to injections: Prostaglandins paving a new direction for venous leg ulcer treatment Highly accessed article p. 176
Rajendra Prasad Basavanthappa, Ashwini Naveen Gangadharan, Sanjay C Desai, AR Chandrashekar
DOI:10.4103/ijves.ijves_12_19  
Objective: Venous ulcers play a major burden on the patient and health-care system in terms of morbidity and medical expenditure. The objective of the study was to evaluate the efficacy of prostaglandin E1 (PGE1) administered via intravenous infusion in the healing time of venous leg ulcer and to evaluate the safety of prostaglandin intravenous infusion. Materials and Methods: This was a prospective observational study at a single tertiary care center. Patients who had proven venous ulcers of the legs which are not healing for more than 3 months with conventional therapy were included. About 500 μg PGE1 was given in equally divided doses over 5 days as intravenous infusion along with regular compression therapy. Ulcers were followed up every 3 weeks for 18 weeks and measurement of ulcer area done. Results: A total of 47 patients with 50 ulcers were included in the study with a mean age of 55.9 years. About 50% of ulcers healed 9 weeks after PGE1 administration and 92% healed after 18 weeks of treatment. The estimated healing time of 25%, 50%, and 75% of the patients treated with PGE1 was 40, 63, and 86 days, respectively, which was statistically significant compared to the previous studies with compression therapy alone. The only factor to independently affect healing time was found to be the initial ulcer size. There were no major adversities with PGE1 administration, 2 patients developed minor symptoms, in the form of hypotension and tachycardia, which were managed with stoppage of infusion for short duration. Conclusion: The study shows the effectiveness of PGE1 in reducing the healing time of VLUs, thereby allowing patients for lesser hospitalization and quicker return to work and life producing improvement in the quality of life. The adverse effects were also very minor with PGE1 treatment, overall, acceptable and were well tolerated by the patients.
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HISTORICAL VIGNETTE Top

Prof. Emerick Szilagyi: An empiricist vascular surgeon p. 182
Srujal Shah
DOI:10.4103/ijves.ijves_51_19  
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CASE REPORTS Top

Treatment of infected aortic aneurysms: Case reports and review of the literature p. 184
Pranay Pawar, Jithin Jagan, Radhakrishnan Raju, MK Ayyappan, Kapil Mathur
DOI:10.4103/ijves.ijves_1_19  
Management of infected aortic aneurysms remains one of the most challenging clinical problems for the vascular surgeon, as they are rare and difficult to treat. Curative treatment is achieved by removal of all infected native tissue followed by a vascular reconstruction. Endovascular repair can also be used as a “bridge therapy” to reduce the mortality in these patients.
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Distalization of left subclavian artery for cerebral revascularization during hybrid repair of complex and contained rupture of aortic arch aneurysm p. 187
Harishankar Ramachandran Nair, Shivanesan Pitchai, Vineeth Kumar, Unnikrishnan Madathipat
DOI:10.4103/ijves.ijves_5_19  
A ruptured aortic arch aneurysm is imminently fatal unless expeditiously intervened. Hybrid thoracic endovascular aneurysm repair has revolutionized the therapeutic paradigm, in a complex clinical setting, in particular, compared to demanding and particularly riskier open reconstruction with its attendant cardiac and neurological sequelae. Herein, we describe a 52-year-old male who presented with a ruptured aortic arch aneurysm and concomitant innominate artery aneurysm with occluded left common carotid artery (CCA). Computed tomography (CT) aortogram visualized large retrosternal hematoma precluding sternotomy without circulatory arrest and distal end of aneurysm abutting ostium of theleft subclavian artery (LSA). Therefore, staged reimplantation of LSA to descending thoracic aorta (DTA) and extra-anatomic LSA to right CCA bypass were performed through posterolateral thoracotomy followed by Zone 0 deployment of the aortic stent graft. The patient keeps good health and remains asymptomatic at 2 years of follow-up. Repeated CT aortogram done immediate postoperatively and at 13 months showed patent graft and no endoleak. Hybrid arch repair by supra-aortic debranching facilitated by distalized LSA on DTA is a viable therapeutic option in patients with complex arch and innominate artery aneurysms that mandate Zone 0 coverage during endovascular aneurysm repair.
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Endovascular stenting of spontaneous isolated dissection of superior mesenteric artery p. 190
S Roshan Rodney, Vivekanand , M Vishnu, Sumanth Raj, Hemant Chaudhari, CP S Sravan, Vaibhav Lende, Hudgi Vishal, K Siva Krishna, B Nishan
DOI:10.4103/ijves.ijves_91_18  
Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare condition often presenting with vague signs and symptoms. Although the disease entity is rare, the potential for morbidity and mortality is high. Computed tomographic angiography is the preferred imaging modality for identification of SID-SMA. It may be managed by conservative, surgical, or endovascular treatment based on clinical presentation, but there is no general consensus regarding the treatment strategy. Here, we describe a case of SID of SMA treated successfully with percutaneous endovascular stent placement.
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Emergency endovascular management of ruptured mycotic aneurysm of the iliac artery using “bare stent-graft technique” p. 194
S Roshan Rodney, Vivek Anand, M Vishnu, Sumanth Raj, Hemant Chaudhari, CP S Sravan, Vaibhav Lende, Dharmesh Davra, Piyush Kumar Jain, Hudgi Vishal, K Siva Krishna, B Nishan
DOI:10.4103/ijves.ijves_92_18  
Mycotic aneurysm of the aortoiliac region remains a life-threatening condition, especially if an aneurysm has already ruptured by the time of surgery. The mortality is increased further when it is associated with Salmonella infections, especially in the presence of risk factors for atherosclerosis. We report a case of a 50-year-old man who presented with ruptured mycotic aneurysm of the left common iliac artery secondary to infection with Salmonella paratyphi. He underwent emergent endovascular repair of the aneurysm with the “bare stent-graft technique.” Postoperative recovery was eventful. This case demonstrates that it is possible to safely manage mycotic aneurysms by endovascular means, following targeted perioperative antibiotic therapy.
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“Internal iliac artery pseudoaneurysm communicating with orthotopic neobladder:” A rare complication of radical cystectomy p. 198
Uma Kant Dutt, Sunil Kumar, Kaliyaperumal Muruganandham, Lalgudi Narayanan Dorairajan, Ajith Ananthakrishna Pillai
DOI:10.4103/ijves.ijves_3_19  
Iliac artery–orthotopic neobladder fistulas are very rare following radical cystectomy. Only two cases are reported in literature. We report a case of a 58-year-old male who had undergone radical cystectomy with orthotopic neobladder surgery about 2 months earlier at our institute and now presented with a history of hematuria and pain abdomen. He was found to have a pseudoaneurysm of the right internal iliac artery communicating with the orthotopic neobladder. Angio-embolization of the right internal iliac artery resolved the problem.
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A case of renal artery and multiple splenic artery aneurysms managed by heterotopic renal autotransplantation with splenectomy and proximal splenorenal shunt p. 201
Bokka Sri Harsha, Ramanitharan Manikandan, Lalgudi Narayanan Dorairajan, Biju Pottakkat, Sreevathsa K
DOI:10.4103/ijves.ijves_24_19  
A 30-year-old female was incidentally detected to have multiple splenic artery aneurysms and a large left renal artery aneurysm along with portal hypertension and splenomegaly during her prenatal workup. She was successfully managed by splenectomy, proximal splenorenal shunt, excision of left renal artery aneurysm, bench reconstruction of the left renal artery with saphenous vein graft, and renal autotransplantation in the right iliac fossa.
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Bovine pericardial graft for revascularization of the lower limb following mycotic aneurysm complicating infective endocarditis p. 204
M Sobhi, M Mohamed, D Bilel, Z Jalel, K Taoufik
DOI:10.4103/ijves.ijves_9_19  
Mycotic aneurysm, which complicates 2.5%–10% of cases of infectious endocarditis, is an important cause of morbidity and mortality despite antibiotic therapy. Elective surgery remains the cornerstone of the treatment of mycotic aneurysms because of the major risk of rupture. For femoral arteries, the surgical treatment is based on the resection of the aneurysm, with revascularization of the territory downstream. The recommended materials for revascularizations are in the first place biological grafts such as veins grafts (great saphenous vein) and homograft. In our observation, faced with the small diameter of the internal saphenous vein and the lack of homograft availability, and considering the high risk of infection recurrence at the operating site, we opted for the confection of biological graft using bovine pericardium and we think that it will be more resistant to infection than prostheses. According to our knowledge, this technique has not been reported before in the literature, and the validation of this technique on a series of cases and in the long term is necessary.
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Leiomyosarcoma of inferior vena cava – An institutional experience p. 208
Harishankar Ramachandran Nair, Shivanesan Pitchai, Tom Thomas Kattoor, Sreekumar Ramachandran
DOI:10.4103/ijves.ijves_6_19  
Primary inferior vena cava (IVC) tumors are rare with the incidence of about 0.05% overall with leiomyosarcoma (LMS) being malignant and the most common. They are late to present and slow growing, seen predominantly in females in their fifth or sixth decades and have a poor prognosis with a 5-year survival rate touching about 35% even with complete surgical resection. We present our experience with two patients diagnosed to have IVC LMS and underwent complete surgical resection of the tumor with reconstruction of IVC using coated polyester graft. In one patient, only infrarenal IVC was reconstructed, whereas in second patient, bilateral renal veins were also reconstructed along with suprarenal IVC. There is no consensus regarding the optimal treatment of this aggressive tumor, but complete excision of the tumor with wide margins with or without IVC reconstruction have been widely accepted as primary modality of treatment. Neoadjuvant or adjuvant chemoradiotherapy have limited role in the management of this rare tumor.
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Vascular leiomyoma of the leg p. 211
B Nishan, Vivekanand , M Vishnu, Sumanth Raj, K Sivakrishna, Hudgi Vishal, Vaibhav Lende, C PS Sravan, Hemant Chaudhari, S Roshan Rodney
DOI:10.4103/ijves.ijves_97_18  
A 48-year-old women with a subcutaneous vascular leiomyoma of the right leg, presented with pain in the right mid-leg medial aspect. Clinical symptoms, radiological images, and histopathological features are reported. Vascular leiomyoma should be included in the differential diagnosis of painful lower-extremity subcutaneous lesions.
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Tunneled hemodialysis catheter placement in persistent left superior vena cava: A rare but potential hemodialysis vascular access p. 215
Himanshu Verma, Prem Mohan Jha, Namrita Sachdev, Rashi Verma
DOI:10.4103/ijves.ijves_8_19  
Persistent left superior vena cava (PLSVC) is a common congenital thoracic venous anomaly. Asymptomatic cases are often diagnosed incidentally during invasive cardiovascular procedures such as the placement of central venous access catheters. It is important for the physicians to be aware of clinical implications that may occur during catheter placement. We describe our experience with PLSVC during the placement of a tunneled hemodialysis (HD) catheter (permcath) through the left internal jugular venous route. The diagnosis was confirmed by contrast-enhanced computed tomography. PLSVC can be a potential site for HD catheter placement.
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Ilioiliac crossover graft: Revival of an old technique – A report of two cases p. 218
Raja Lahiri
DOI:10.4103/ijves.ijves_19_19  
Surgical management of unilateral iliac artery occlusion commonly involves a femorofemoral graft or an aortofemoral graft. We report two cases of atherosclerotic common iliac artery occlusion, one on the left and another on the right, wherein we did a crossover graft to the external iliac artery from the opposite common iliac artery through a single skin incision. The approach and graft placement in both the cases were completely retroperitoneal. Both these patients had an adequate recovery with complete relief of symptoms. This approach has the benefit of avoiding multiple incisions and incisions in the groin area, which tends to get infected easily and is associated with other complications such as lymphorrhea.
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LETTERS TO THE EDITOR Top

What to Write in Each Segment of an Original Article? p. 221
Himel Mondal, Shaikat Mondal, Koushik Saha
DOI:10.4103/ijves.ijves_38_19  
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Preoperative factors predicting the outcomes of arteriovenous fistula surgery p. 222
Pawan Agarwal, Dhananjaya Sharma
DOI:10.4103/ijves.ijves_34_19  
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