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   Table of Contents - Current issue
April-June 2020
Volume 7 | Issue 2
Page Nos. 107-203

Online since Wednesday, June 17, 2020

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Reign and domain of the nimbus Highly accessed article p. 107
Kalkunte R Suresh
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Role of open vascular surgery in this era of endovascular interventions Highly accessed article p. 113
Sekar Natarajan
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Guidance for diabetic foot management during COVID-19 pandemic Highly accessed article p. 116
Rajesh Kesavan, V B Narayana Murthy, Ashu Rastogi, Arun Bal
The Indian COVID-19 situation is and will demand more and more hospital bed capacity to manage. With diabetic foot disease (DFD) being a leading cause of hospital bed occupancy, managing these patients based on evidence-based guidelines can significantly reduce the rates of hospitalization. Every hospital bed that is not needed for a patient with DFD , gives room for occupancy by a patient suffering from COVID-19. The goal of doctors treating diabetic foot is aimed at early successful treatment of infections and preventing amputations, decreasing the hospital stay of inpatients, and effective cost reduction. Hence, changing our way of approach to managing a patient with diabetic foot and implementing new and unique ways is the need of the hour at this time of crisis. This guidance also has a section on managing diabetes in people with diabetic foot during the COVID19 pandemic.
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Coronavirus and interventional radiology department: Evidence-based measures to limit transmission – Indian scenario Highly accessed article p. 121
Amol Lahoti, Ankita Lakhotiya, Vivek Ukirde, Akshay Gursale, Sagar Satpute, Ashank Bansal
As we face a countrywide lockdown in view of the international pandemic of coronavirus disease 2019 and deal with never seen before circumstances all over the world including India, health-care personnel are fighting like soldiers and are often first to get affected in view of the direct exposure because of the limited availability of knowledge and personal protection equipments (PPEs). Radiology emerging superspecialty interventional radiology (IR) entails a greater risk of acquiring, transmitting infection due to the close patient contact and invasive patient care the service needs to offer. Due to the high density, limited working space we have, and working in air-conditioned setup that is needed for cath lab and ultrasonography machines, this makes it imperative to set specific guidelines to limit transmission and utilize resources in the best possible way. A multitiered, scientific approach suited to our environment needs to be devised and monitored at the administrative and departmental level, taking into account the IR team and patient contact-operating points. We present an overall systematic scientific review of the infection control measures that cover the different dynamics of utmost patient care and staff protocols without hampering the patient treatment for an interventional department setup. The IR and radiology department should be prepared and educated to continue the servicing emergency procedures and important elective procedures following the strict aseptic precautions, so health-care workers' and patients' safety is maintained. The team members should understand the disease dynamics, routes, and source of transmission and should take utmost precautions to prevent transmission to colleagues and patients by properly suing PPE.
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The prevalence of and risk factors for peripheral arterial occlusive disease in human immunodeficiency virus-infected omani patients: The first study in GCC p. 125
Ahmed Al-Aufi, Khalifa Al-Wahaibi, Edwin Stephen, Abdullah Balkhair, Ibrahim Abdelhedy, Hanan Al-Maawali
Aim: To assess the prevalence of peripheral arterial occlusive disease (PAOD) in human immunodeficiency virus (HIV)-infected Omani patients and to assess the potential risk factors in this group. Methodology: This was a single-center, cross-sectional study. All patients attending the infectious disease clinic between July 2017 and March 2018 were included in the study; their peripheral pulses were examined and pre- and postexercise ankle–brachial pressure index (ABPI) was measured. Normal ABPI was considered as being in the range of 1.0 ± 0.1, and a reduction of >15% postexercise ABPI was considered as a cutoff limit to define PAOD. The Edinburgh Claudication Questionnaire was answered by all patients, and CD4 count, viral load, albumin and Vitamin D (25-OH) levels, and glycated hemoglobin (HbA1c) were measured. The data were analyzed using IBM SPSS Statistics version 22. Results: Eighty-eight patients who were retroviral positive were enrolled in the study. Fifty-three (60.2%) patients were male and 35 (39.8%) were female, with a mean age of 43 years (24–71). The dorsalis pedis artery pulsation was absent bilaterally in 3 (3.4%) patients. None of the patients had a history of claudication; 1 (1.1%) had an abnormal ABPI; 17 (19.2%) had a reduction of >15% postexercise ABPI; 7 (8%) had CD4 count <200; 4 (4.5%) had detectable viral load; albumin level was <25 g/L in 5 (5.8%); 15 (17%) had Vitamin D (25-OH) <50 nmol/L; and 4 (4.5%) had an abnormal HbA1c. Conclusions: The prevalence of PAOD in HIV-infected patients is higher compared to the general population as was evident from an abnormal postexercise ABPI. Risk factors that stood out while not having a significant P- value were low values of CD4 counts and Vitamin –D levels.
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Comparative study of outcomes between single-vessel versus multiple-vessel infrapopliteal angioplasties in patients with chronic limb-threatening ischemia p. 129
Hemant K Chaudhari, KB Sumanthraj, Vivek Anand, Vishnu Motukuru, S Roshan Rodney, C P S Sravan, K Sivakrishna, KR Suresh
Purpose: To determine whether the number of infrapopliteal arteries undergoing endovascular treatment is associated with the limb salvage and wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This was a single-center, prospective, nonrandomized study comprising 143 CLTI patients who underwent successful infrapopliteal angioplasty without or corrected inflow femoropopliteal disease, at Jain Institute of Vascular Sciences, Bengaluru, between May 2017 and October 2018. Patients were divided into two groups, based on either a single vessel (SV group, n=91) or a multiple infrapopliteal vessels (MV group, n =52) were angioplastied. Patients with isolated femoropopliteal revascularization, femorodistal bypass, prior vascular intervention, technical failure, and lost to follow-up were excluded. Primary outcomes were limb salvage and wound healing at 6th month. Secondary outcomes were changes in ankle–brachial index (ABI), toe–brachial index (TBI), transcutaneous oxygen saturation (TcPO2), plantar arch quality (PAQ), major adverse cardiac events (MACE), and all-cause mortality at 6th month. Results: Baseline characteristics were comparable in both groups. The wound healing rate (70.12% vs. 62.79%) and limb salvage rate (93.51% vs. 90.70%) at 6th month were comparable among SV and MV groups (P = 0.88 and 0.59, respectively). The mean wound healing time was significantly better in MV group (83 ± 40 vs. 108 ± 43 days) (P = 0.003). MACE (6.59% vs. 9.80%), mortality (15.38% vs. 17.30%), PAQ [complete (31.87% vs. 36.54%), incomplete (48.35% vs. 57.69% ) and absent arch (19.78% vs. 5.76%) in SV and MV groups, respectively], and changes in ABI, TBI, and TcPO2among both groups were comparable, except TcPO2changes at 1 month which showed a significant improvement in MV group (P = 0.03). Conclusions: MV infrapopliteal angioplasties are associated with shorter wound healing time, but have no effect on limb salvage and wound healing rates at 6th month.
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Comparison of outcome of various modalities in trans-atlantic inter-society consensus d femoropopliteal disease p. 136
Anjangi Kishore Kumar, Vembu Anand, Rishi Dhillan, Vikram Patra, Pranati Swain, GN Tripathy
Background: This study aimed to assess the role of various modalities of treatment for trans-atlantic inter-society consensus document (TASC D) femoropopliteal disease. Methods: This was a retrospective and prospective study from January 2015 to December 2018; 153 patients who were admitted at Army Hospital Research and Referral with TASC D femoropopliteal disease and underwent hybrid procedure, endovascular or open surgery were included in the study. Results: 58.8% (90/153) patients underwent femoropopliteal bypass. 27.4% (42/153) patients underwent the hybrid procedure and 13.72% (21/153) patients underwent endovascular procedure. The primary patency rate of open surgery at 1 year is 85.6%, hybrid procedure (iliac stenting and fem-pop bypass is 78.9%, transfemoral thrombectomy and balloon angioplasty is 91.2%), endovascular procedure (primary superficial femoral artery drug-eluting balloon angioplasty is 94.4%, atherectomy is 70.3%). Secondary patency rate of open surgery and hybrid procedure was 94.6%, endovascular surgery was 50%. There was no significant difference in limb salvage rate in all three groups. Acute coronary syndrome occurred in 4% of patients in open femoro-popliteal bypass group, 5% patients in the endovascular group, 3.8% in the hybrid group. Cerebro-vascular accident (CVA) in 1.5% patients open fem-pop group and 1.5% patients in the endovascular group in follow-up period. Conclusion: Although open revascularization remains the treatment of choice for advanced atherosclerotic diseases involving femoropopliteal segment (TASC D), endovascular and hybrid procedures are not inferior to open surgery. There is a role for hybrid procedures as they augment the technical success rate of pure endovascular interventions for complex TASC D femoropopliteal lesion. Hybrid procedures can be an alternative in patients with multiple comorbidities giving equal short-term results and decreased morbidity.
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The validity of the mangled extremity severity score scoring system for lower limb vascular trauma in a tertiary care center p. 141
Aryala Shalini, Devender Singh, Sunil Dachipalli, Sashikanth Maddu, Lavanya Ram
Purpose: Among all the scoring systems to predict limb salvage versus amputation after a complex trauma, MESS scoring system is considered to have good sensitivity and specificity. MESS scoring system is most widely used scoring system for the last more than 25 years. However when we applied MESS scoring system in our set of patients, it would not correlate with the need of amputation (for MESS score more than 7) and resulting in significant number of limb salvage. Methods: This a prospective study of 60 patients over a period of two years from June 2017-June 2019. All the patients of lower limb vascular trauma were examined and operated by the same team involving vascular surgeon, orthopedic surgeon and plastic surgeon. MESS scoring system was applied for all the patients. Patients with life threatening injuries were excluded in this study. Results: Between June 2017-2019, 60 patients were entered into the study. The majority were male with mean age of 30 years (Range 11-65years). Road traffic accidents with open injuries were the commonest mechanism of injuries (60%) and popliteal artery was involved in majority of injuries. Out of 35 patients of MESS score more than 7, in 28 patients leg was salvaged with the help of vascular,orthopedics and plastic reconstructions and remaining 7 patients underwent secondary amputation. The hospital stay and the finances involved in the treatment was high in patients with MESS score more than 7, where revascularisation was performed. However in the end psychological assessment of these patients and their family members was very encouraging. Conclusions: With the availability of a dedicated trauma team (which include vascular, orthopedic, plastic surgeons & anaesthetist) and improvement in the diagnostic and treatment modalities, the rate of limb salvage has increased significantly, hence reducing the prediction of MESS scoring system for an amputation. We conclude from our study that majority of lower limbs were salvaged in spite of MESS score being more than 7. We suggest with a word of caution for an amputation directly with a MESS score of more than 7 in all patients.
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Inferior Mesenteric Artery Revascularizatıon during Abdominal Aortic Surgery p. 145
Mehmet Ali Şahin, Edip Temiz, Bahadır Külah, Erkan Kuralay
Introduction: The incidence of ischemic colitis development after elective abdominal aorta surgery is 2%. However, it may rise to 32% in ruptured aneurysm operations. Inferior mesenteric artery (IMA) revascularization reduces the incidence of ischemic colitis. Materials and Methods: Our study included 87 patients who underwent abdominal aorta aneurysm surgery. IMA revascularization was applied in 32 patients. Four techniques are used for IMA revascularization. Carrel button technique is used in seven patients; direct IMA anastomosis to the main body of aortic graft is performed in 15 patients. IMA anastomosis is performed to the left limb of aortic graft in seven patients. IMA is extended by Dacron graft in six patients and saphenous vein is used for extension only one patient. Results: Colonic mucosal ischemia was observed in two patients with IMA revascularization, whereas in five patients without IMA revascularization. The clinical picture of ischemic colitis was evident in two patients without IMA revascularization. Average gaseous and stool output time after surgery were significantly earlier in patients with IMA revascularization. The average gaseous output time is 17 h with IMA revascularization, whereas 28 h in patients without IMA revascularization after surgery (P = 0.001). The average stool output time is 38 h after surgery in IMA revascularization but 55 h patients without IMA revascularization (P = 0.001). Conclusion: IMA revascularization is a considerably effective procedure for the prevention of ischemic colitis. Despite the low incidence, ischemic colitis carries high morbidity and mortality risk. IMA revascularization should be considered in the presence of the risk of the development of ischemic colitis.
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Open surgical reconstruction of the extracranial internal carotid artery aneurysm at the base of the skull: An experience of five cases in a tertiary vascular surgery center p. 150
Suraj Wasudeo Nagre, Saptarshi Paul
Aim: Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report the short term results of open surgical repair done in our center to formulate a standardized surgical technique of ICA reconstruction with best results. Subjects and Methods: From 2017 to 2019, totally five ICA reconstructions were performed for extracranial internal carotid artery (EICA): two male patients and three female patients (mean age, 34 years). The cause was atherosclerosis (n = 3 patients), trauma (n = 1 patient), and syndromic (associated with a complex congenital cardiac condition, n = 1 patient). The symptoms were mainly swelling and pain, in one case. Results: All patients underwent open extracranial surgical reconstruction at the skull base; interposition grafting using reverse saphenous vein graft was used in three cases, after resection of the aneurysm, and direct end to end anastomosis was employed in two cases of saccular aneurysms. The ICA was patent on the postoperative angiogram in all cases. All patients are doing well on follow-up. Conclusion: Venous graft bypass and direct ICA to ICA anastomosis for EICA can be performed safely with an open surgical approach and produces durable satisfactory results.
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Outcome of Re-Using radiofrequency ablation catheter for varicose veins treatment p. 154
Edwin Stephen, Albert Abhinay Kota, Deepak George John, Vimalin Samuel, Andrew Dheepak Selvaraj, Prabhu Premkumar, Sunil Agarwal
Objective: The objective of the study is to evaluate the success of re-use by assessing the recanalization rates following radiofrequency ablation (RFA) with Closure Fast® catheter in patients with symptomatic varicose veins. Methods: This retrospective study approved by the institutional review board analyzed the occlusion rates of the great saphenous vein (GSV) in patients who underwent RFA between January 1, 2015, and December 31, 2016. A record of the number of times the RFA catheter was re-used was maintained. The catheter was used for a maximum of five systems. Follow-up was performed postoperatively at 1 week and 6 months with an ultrasound to assess failure by looking for recanalization. Results: In this study, 272 GSV endoablations (RFA) were performed in 238 patients. The mean age was 47.68 (standard deviation ± 13.05). Majority of the patients were male (76.9%). 27.3% (73 GSV) of the venous systems received a first fire with the RFA catheter. At the first follow-up on week 1, 97.7% (266 GSV systems) had complete occlusion, 2.3% (6 GSV systems) had partial recanalization, and none had complete failure. Recanalization rates at 1 week with 1st, 2nd, 3rd, 4th, and 5th re-use were 0%, 2%, 2%. 4.1%, and 3.8%, respectively. At 6-month postoperative follow-up, 96.5% (250) had complete occlusion, 2.7% (7) had partial recanalization, and 0.8% (2) had complete recanalization. Recanalization rates at 6 weeks with 1st, 2nd, 3rd, 4th, and 5th re-use were 1.4%, 2.1%, 2.3%. 6.4%, 5.9% respectively. There was no statistical significance with the recanalization rates at 1st week and at 6 weeks. 4.2% (10) of the patients were lost to follow-up. None of the patients had any complications. Conclusion: The results of GSV occlusion rates are encouraging when the RFA catheter was re-used and cut the cost of treatment substantially, thereby making RFA ablation more affordable to the common human.
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Step-by-step guide to averting and managing a central line insertion misadventure p. 158
Edwin Stephen, Serina Ruth Salins, Ibrahim Abdelhedy, Mujahid AlBusaidi, Abdul Hakeem AlHashim, Rashid AlSukaiti, Hamed AlAamri, Hanan AlMawali, Khalifa AlWahaibi
Background: Central venous cannulation or catheterization (CVC) forms the core of managing critically ill patients. Inadvertent arterial or venous injury, despite the use of duplex ultrasound (DUS), can lead to significant and devastating complications, especially when large-bore cannulas are used. This article explains the way we managed four different scenarios and suggests a step-by-step guide to insertion of a CVC and management of a misadventure. Methods: We maintained the records and followed up four adult patients requiring hemodialysis who had misadventures with CVC insertion between March 2018 and January 2019, with large-bore (>7Fr) cannulas. They were all followed up for 6 months. Results: Four patients, 2 males and 2 females, between 25 and 82 years of age, underwent CVC insertion in an intensive care setting. The youngest had a carotid-jugular arteriovenous fistula that was detected after discharge and managed successfully by open surgery. The eldest, a male patient, had a perforation of the external iliac vein, which was managed successfully with endovascular balloon inflation. The third patient had femoral artery pseudoaneurysms, which were managed successfully with serial DUS compression. The fourth had an inadvertent puncture of the right common carotid artery during the insertion of jugular CVC and was managed by manual and DUS compression. Conclusion: DUS has reduced the incidence of complications from the insertion of CVC. However, in order to further reduce or nullify the possibility of arterial punctures during CVC insertion, whether it be a small (<7Fr) or large (>7Fr) cannula, the operator needs to follow certain basic steps, be aware of potential complications and know how to approach an inadvertent arterial/venous/nerve injury. The literature mostly deals with how complications were managed while we impress on the need for prevention. The authors recommend that clinical guidelines be formulated and followed in hospitals.
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Complex aortic aneurysm repairs p. 164

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Anthologies in vascular surgery-Part II. p. 178

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Peripheral Bypass – Looking back into the past p. 181
Sunil Rajendran, Harishankar Ramachandran Nair
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Juxtarenal aortic occlusion with situs inversus totalis: Surgical management of a rare association p. 185
Ashutosh Kumar Pandey, Harishankar Ramachandran Nair, P M Vineeth Kumar, Shivanesan Pitchai
Situs inversus totalis (SIT) is a rare entity characterized by mirror-image reversal of the viscera. The coexistence of SIT and Leriche syndrome has been rarely described. The authors describe the surgical management of juxtarenal aortic occlusion in a patient with SIT which was successfully managed with open aortic endarterectomy and distal bypass. The malposed organs are at a greater risk of operative injury, but surgical management is feasible with proper determination of the anomalies on preoperative imaging.
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Idiopathic proximal ulnar artery aneurysm p. 187
S Roshan Rodney, Vivek Anand, M Vishnu, Sumanth Raj, Hemant Chaudhari, C P S Sravan, Vaibhav Lende, Hudgi Vishal, K Siva Krishna, B Nishan
Ulnar artery aneurysms are very rare, usually caused by repetitive blunt trauma to the ulnar artery, leading to the formation of an aneurysm. Other etiologies reported in the literature were vasculitis, anatomic abnormalities, or infections. This case report is regarding a 29-year-old male who presented with proximal ulnar artery aneurysm with distal embolization. He underwent aneurysm resection with ligation of the ulnar artery. Histopathology of the aneurysmal wall showed true aneurysm of the ulnar artery.
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Arteries gone astray: Adult presentation of arterial tortuosity syndrome p. 190
Sofia Mohan, Prajna B Kota, Amish P George, Shyamkumar N Keshava
Arterial tortuosity syndrome (ATS) is a rare genetic arteriopathy with tortuosity of large- and medium-sized arteries, transmitted in an autosomal recessive fashion. Over the years, better cross-sectional imaging has heightened the chances of diagnosing this entity. So far, less than hundred cases have been reported in literature. Most of these are seen in infants and children. A 36 year old lady presented to us with a pulsatile swelling in the right supraclavicular region. She was diagnosed to have ATS based on her imaging characteristics. As she had no significant vascular compromise, she was reassured and advised yearly follow-up.
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Emergency vertebrobasilar stenting in recurrent medial medullary ischemic stroke p. 193
Rahul Pathak, Imran Gafoor, Vishal Kumar, Saket Jethani
Intracranial stenting and angioplasty have been used widely to treat atherosclerotic symptomatic vascular stenosis when conventional medical therapy fails to eliminate ischemic symptoms. We describe a case report of middle-age diabetic male with endovascular stent deployment for the treatment of atherosclerotic vertebrobasilar artery stenosis with acute recurrent medial medullary ischemic stroke. Application of a drug-eluting stent coronary stent without previous balloon dilatation resulted in vessel reopening and good clinical improvement. Emergency primary intracranial stent deployment can be technically feasible and improve the outcome in acute vertebrobasilar artery occlusion whenever indicated.
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Persistent thrombosed median artery – A rare cause for acute wrist pain: A case report and review of literature p. 197
B Nishan, Vishal Hudgi, K Siva Krishna, I Surya Kiran, Vishnu Motukuru
Persistent median artery (PMA) is an anatomical variation of the hand vascularity arising from brachial artery in early embryonic life. The presence and thrombosis of PMA may result in several complications such as carpal tunnel syndrome. Early diagnosis and treatment of acute thrombosis of PMA is important because many complications and the need for surgery can be prevented with early anticoagulation therapy. In this report, we present the findings of a thrombosed PMA causing wrist pain in a 37-year-old male. Early anticoagulant therapy provided a complete resolution of the symptoms.
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Successful endovascular exclusion of an isolated iliac artery aneurysm causing “May–Thurner effect” p. 201
Nicolas Ramly, Animesh Singla, Jim Iliopoulos
May–Thurner syndrome is a well-recognized entity, often described as the right common iliac artery (CIA) compression of the left common iliac vein (CIV), however, other configurations are possible. It is often associated with lower limb edema, recurrent varicose veins, and unprovoked deep femoral vein thrombosis. Herein, we present an unusual case where aneurysmal dilation of the right CIA resulted in the compression of the bilateral CIVs resulting in a bilateral May–Thurner effect. The management of this patient and the pathophysiology of May–Thurner syndrome are also discussed.
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