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   Table of Contents - Current issue
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October-December 2019
Volume 6 | Issue 4
Page Nos. 225-331

Online since Friday, December 20, 2019

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EDITORIALS  

Vascular education and training in India TRAIL SO FAR AND THE PLAUSIBLE FUTURE Highly accessed article p. 225
Kalkunte R Suresh
DOI:10.4103/ijves.ijves_95_19  
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Decision-making in Surgery: How to assess the evidence p. 228
Robbie K George
DOI:10.4103/ijves.ijves_97_19  
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ORIGINAL ARTICLES Top

Association of coronary artery disease and peripheral arterial disease in patients undergoing elective open abdominal aortic aneurysm repair p. 231
Harishankar Ramachandran Nair, Shivanesan Pitchai, PM Vineethkumar, Prakash Goura, Sreekumar Ramachandran
DOI:10.4103/ijves.ijves_2_19  
Introduction: Open surgical repair of abdominal aortic aneurysm (AAA) is one of the commonest aortic surgeries performed in tertiary care vascular centres. As association of coronary artery disease (CAD) and peripheral arterial disease (PAD) is high in these patients, need for cardiac risk stratification with or without coronary intervention prior to surgery and its effect on long term survival benefit have been debated. In our institution, all patients who undergo elective aortic aneurysm surgery undergo diagnostic coronary angiogram. Intervention (Percutaneous Coronary Intervention or coronary artery bypass surgery) was performed prior to surgery, if patient was symptomatic/ had multiple critical occlusions in coronary vessels. We also looked into the prevalence of peripheral arterial disease in these patients. Methods: Single centre retrospective study. 199 patients who underwent elective aortic aneurysm repair in the last 10 years were studied. Data was collected from electronic and hospital medical records and analysed. Results: Significant CAD was seen in 105 patients (52.7%) out of which 40 patients (20.1%) underwent preoperative intervention while 65 patients (32.7%) underwent surgery without the same. Prevalence of significant CAD in AAA was high (52.7%) whereas PAD was seen in 26 patients (13.1%). Conclusion: We suggest it worthwhile to assess the coronary status in these patients preoperatively for risk stratification. Prophylactic coronary revascularization should be individualized and can prevent post-operative adverse cardiac events. Medical treatment for concomitant CAD with no obvious inducible ischemia does not confer unfavorable outcomes. Presence of PAD should not be overlooked and should be identified and intervened in the same setting if critical to decrease the morbidity.
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Superficial venous thrombosis: Single-center experience and current recommendations p. 235
Sasank Kalipatnapu, Prabhu Premkumar, Dheepak Selvaraj, Sunil Agarwal
DOI:10.4103/ijves.ijves_25_19  
Introduction: Superficial venous thrombosis (SVT) is an underestimated and underreported disorder. Till date, there are no Indian epidemiological studies which have looked at the community or hospital prevalence rate of SVT. Patients and Methods: A retrospective cross-sectional study was done in the department of vascular surgery including all patients diagnosed and managed for SVT over the period of 2011–2018. All patients with deep vein thrombosis (DVT) were also screened for involvement of the superficial veins. The demographic data, imaging data, further management, and follow-up data were collected from the hospital records. The data were entered into EpiData software and Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA), and data analysis was done in R (version 3.5.0) and Microsoft Excel. Results: There were a total of 119 patients between the ages of 16 and 76 years. There were 84 men and 35 women. The median age of the entire study population was 46 ± 14.18 years. Eighty-one cases had only SVT, whereas 38 patients had both SVT and DVT together. 78 (65.5%) patients were diagnosed based on clinical presentation, whereas 41 (34.5%) patients were diagnosed on imaging done for other causes. In the patients diagnosed on clinical findings, 54 (69.2%) patients underwent a duplex ultrasound to rule out DVT. 77 (64.7%) patients were related to underlying varicose veins. 19% of patients had previous thromboembolic disease. The most common involvement was of the superficial veins in the patients who were clinically diagnosed. 54 (45.4%) patients received anticoagulation. Six patients had systemic venous thromboembolic complications. Conclusions: Anticoagulation should be the mainstay of treatment of patients with SVT. Prospective studies on superficial vein thrombosis are needed to assess and promote awareness of this condition in light of the current understanding of this potentially dangerous condition.
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Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study Highly accessed article p. 242
Vembu Anand, Vivek Agrawal, Rakesh Kumar, Vikram Patra, Pranati Swain, Brijesh Kanti Biswas, Manvendu Jha, Girija Nandan Tripathy
DOI:10.4103/ijves.ijves_29_19  
Aim: Thoracic endovascular aortic repair (TEVAR) is evolving as a gold standard therapy for treating complex thoracic aortic diseases (TAD). It has evolved as first-line therapy for descending thoracic aortic aneurysms (DTAA) and Type B aortic dissection (TBAD) with reduced morbidity and mortality. The aim of this study is to evaluate clinical profiles, treatment variation, results, and complications of TEVAR. We have also highlighted the feasibility of performing complex procedures under mobile C-arm with certain innovative methods. Materials and Methods: A total of 43 patients (34 men and 9 women), mean age 59 years; age range 23–81 years, with TBAD and DTAA, who underwent TEVAR at tertiary care center from July 2012 to April 2019 were included in the study. Management strategies applied as per existing recommendations requiring TEVAR with or without debranching. The primary endpoints were technical success, 30-day mortality. The secondary endpoints were death, stroke, or spinal cord ischemia (SCI) and graft-related complications such as endoleak, migration, kinking, or thrombosis. Follow-up was done at 1, 3, 6, and 12 months and thereafter yearly. Follow-up events included death from all causes, neurological deficits, malperfusion syndrome, and reintervention. Results: Of 43 patients, 14 had TBAD and 29 had DTAA. Sixteen required hybrid repair and rest underwent TEVAR alone. Primary technical and assisted primary clinical success was 96% and 100%, respectively. Three patients developed Type I endoleak, covered with thoracic extender. The mortality rate was 9.5%. One had minor stroke and no SCI. Conclusion: TEVAR is reliable, stable, and safe for the treatment of TAD. It continues to evolve rapidly and will likely establish itself as the first-line procedure with reduced perioperative morbidity and mortality. Utility of hybrid theaters cannot be overemphasized, and the possibilities of performing TEVAR in with portable C-arm will enable the procedure to be performed in the smaller center also.
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A comparison of pharmacomechanical catheter-directed thrombolysis versus anticoagulation alone in the prevention of postthrombotic syndrome following acute lower limb deep-vein thrombosis p. 248
Nikhil Sharma, VS Bedi, Sandeep Agarwal, Ajay Yadav, Ambarish Satwik, Dhruv Agarwal, Apurva Srivastava
DOI:10.4103/ijves.ijves_32_19  
Introduction: Postthrombotic syndrome (PTS) occurs in 20%–60% of patients after acute deep-vein thrombosis (DVT) treated with anticoagulation alone. Residual thrombus after DVT leads to ambulatory venous hypertension which consequently causes PTS. Thus, evacuating the clot during DVT itself might prevent PTS – the “Open Vein Hypothesis.” Pharmacomechanical catheter-directed thrombolysis (PCDT) evacuates the thrombus working on this very hypothesis. PCDT is usually performed using specialized devices which are expensive and not easily available in our country. In this study, we describe a method to perform PCDT using a commonly available and inexpensive guiding catheter in an aim to prevent PTS after DVT. Aims and Objectives: This study aimed to evaluate if in acute DVT, our method of PCDT reduces the occurrence of PTS, as compared to anticoagulation alone. Design: This is a prospective, randomized, comparative, cohort study. Study Period: The study was conducted from June 2016 to May 2017 with 1-year follow-up. Materials and Methods: Patients presenting with acute DVT of <3 weeks' duration who met the inclusion criteria were included in this study. They were subsequently randomized to receive either anticoagulation alone or PCDT which was performed in our vascular cath lab using a 7 Fr. guiding catheter to physically macerate and aspirate the clot with simultaneous instillation of fibrinolytic therapy (recombinant tissue plasminogen activator [RT-PA]) in the thrombus. Results:
  • The technical success rate was 96%. The mean total dose of RT-PA used was 20.24 mg. The need for venoplasty/stenting was 76%. The rates of major bleeding in the both the groups were similar at 4%
  • At 1-year follow-up, the following results were obtained:
The deep vein patency was 84% in the PCDT group as compared to 16 % in anticoagulation only group(controls) (P< 0.001). Deep vein reflux was noted in 16 % of patients in the PCDT group as compared to 52% in the controls (P = 0.016). Furthermore, the PTS (measured by Villalta scale) was seen in 16% in the PCDT group as compared to 48 % in the controls (P = 0.032). Conclusions: Our method of PCDT is safe and effective as it reduces the occurrence of PTS with preservation of valvular competence and vein patency as compared to anticoagulation alone.
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Early and mid-term results of surgical and endovascular intervention in total occlusion of superficial femoral artery: Which one is better? p. 256
Mihriban Yalcin, Osman Tiryakioglu
DOI:10.4103/ijves.ijves_37_19  
Objectives: Lower extremity peripheral artery disease is a common and important type of systemic atherosclerosis. The purpose of this study is to compare safety and effectiveness of balloon angioplasty, primary stenting and femoropopliteal bypass to treat total superficial femoral artery (SFA) lesions. Methods: 181 consecutive limbs from 149 patients who underwent endovascularly or surgically infrainguinal interventions between June 2013 and June 2017 were included in this retrospective study. Seventy-four legs (40.2%) underwent femoropopliteal bypass surgery, 58 legs (31.5%) were treated with balloon angioplasty, and nitinol stents were used in 49 (23.9%) legs. Results: A total of 149 patients were treated; surgically 56 patients and endovascularly 45 + 40 patients. The mean follow-up time was 24 months (range 4–56 months). The patency rates were 86.7% in the angioplasty group, 82.5% in the stent group, and 94.6% in the bypass group at the end of 24 months (P = 0.159). The rate of reintervention was three patients in the bypass group, six patients in the angioplasty group, and seven patients in the stent group (P = 0.159). The mean reintervention time in bypass was 52.075 months, 43.467 months in balloon angioplasty, and 44.075 months in stent group. Conclusions: There was no significant difference between groups in terms of reintervention and patency rates.
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Profile of deep-vein thrombosis patients in service hospital with specific reference to high-altitude thrombosis p. 262
Vivek Agrawal, Vembu Anand, Abhijeet Lal, Abhimannyu Choudhury, Pallab Chatterjee, Atul Kotwal, T Suresh Reddy, Varinder Bedi
DOI:10.4103/ijves.ijves_41_19  
Background: Deep vein thrombosis (DVT) often goes unrecognized and can cause severe morbidity and even mortality. Exposure to high altitude, immobilization, trauma and surgery are commonly recognised risk factors. Thrombophilia is also one of the important risk factors for recurrent thromboembolic events in younger population. Material and Methods: A prospective case series conducted at a zonal service hospital, in the chain of rearward evacuation from high altitude area in north India, among all the patients diagnosed with DVT (N=144) during the study period from Jan 2014 to Dec 2016. After history and clinical examination, the patients proven to have DVT with Colour Doppler Flow Imaging (CDFI) were included in the study. All the patients were treated with low molecular weight heparin (LMWH) initially and overlapped with oral anti-coagulants (OAC). Results: DVT accounted 0.41 % of total hospital admissions. Exposure to high altitude was recognised as the commonest predisposing factor in 25.7% cases. Immobilization, trauma, and surgery were the other common causes identified. Lower extremities, especially left lower limb was found to be most commonly affected in 57.6% cases. Involvement of multiple anatomical venous segments was commonly observed. The incidence of pulmonary embolism was 0.69%. LMWH followed by OAC proved to be an effective treatment modality with 81.2% patients showing improvement,4.9% remaining static and only 13.9% showing worsening.Conclusion: Acute DVT is responsible for the substantial burden of venous thrombo embolism (VTE) in healthy personnel posted to high altitude (HA). Exposure to high altitude, immobilization, trauma and surgery are common predisposing factors of DVT.
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Outcome of major lower-limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka p. 266
Parathan Sriharan, Joel D Arudchelvam, Amanthana Marasinghe
DOI:10.4103/ijves.ijves_49_19  
Introduction: Anuradhapura is located in the North Central province of Sri Lanka which is about 200 kilometres away from Colombo which is the commercial capital of Sri Lanka. About 22 to 25 arterial repairs are done for major limb vessel injuries (popliteal, femoral, iliac, brachial, axillary and subclavian arteries) for 1 year at The Anuradhapura Teaching Hospital. Common causes for major lower Limb arterial injuries include Road Traffic Accidents (RTA) and Trap Guns. Trap Gun is an improvised illegal device used to protect crops from animals in Sri Lanka. This is very prevalent in North Central province of Sri Lanka where the Teaching Hospital Anuradhapura is located. Materials and Methods: This study is a retrospective case note based study reporting the outcome of patients presenting with major lower Limb arterial injuries to the Teaching Hospital Anuradhapura including the injuries caused by the trap gun. Results: 24 patients were included with major lower limb arterial injury following trauma. 8 (33.3%) injuries were following trap gun. Two patients following trap gun injury underwent amputation whereas no one underwent amputation when the cause of injury was other than trap gun. This difference in outcome was significant (P 0.0277). Conclusions: Therefore trap gun injury results in poor outcome probably due to associated severe soft issue injury and contamination.
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Distal forearm radiocephalic arteriovenous fistula creation in calcified vessels: Technical challenges in anastomosis and early outcome p. 269
Shobhit Sharma, Sudipta Bera, Ashwani Kumar, Vivek Gupta
DOI:10.4103/ijves.ijves_56_19  
Background: Calcified vessels are frequently encountered during arteriovenous fistula (AVF) creation in aged patients and outcome is negatively implicated. However, fistula creation in calcified artery is an entity without much technical clarity and guidance. We present our experience and several modifications of standard radiocephalic (RC) AV fistula creations adopted during anastomosis on calcified vessels depending on our experience of fistula creation over the last 7 years. Objective: The objective was to assess the outcome of our technical modifications for RC AVF creation in distal forearm on atherosclerotic radial artery. Methodology: Twelve cases of calcified radial artery noted intraoperatively between July 2017 and 2018 and the first-time RC AVF created at the distal forearm were included in the study. Operative steps with modifications and early outcome were assessed prospectively. Results: All cases were male, with a mean age of 63.08 years. The average external diameter of the radial artery and cephalic vein was 2.74 mm and 2.21 mm, respectively. Venous bifurcation was available for creating “venous branch patch” and utilized for anastomosis in all cases. The mean operative time was 36.25 min. The functional maturation rate was 12/12. The mean maturation time was 34 days (standard deviation 5.74, standard error of mean 1.66). Fistula patency at 6 months and 1 year was 9/12 and 7/12, respectively. One vascular blow out was noted as complication. Conclusion: Some simple adaptations in vessel handling and suturing techniques and the use of “venous branch patch” for anastomosis may improve functional outcome in calcified vessels in distal RC AVF creation. This observation needs more number of cases and longer follow-up to predict the outcome in more assertive way.
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Quality of life after catheter-directed thrombolysis and standard anticoagulation for iliofemoral deep-vein thrombosis p. 274
Jithin Jagan Sebastian, MK Ayyappan, Pranay Pawar, Kapil Mathur, Radhakrishnan Raju, Naveen Rajendra
DOI:10.4103/ijves.ijves_71_19  
Introduction: Acute ilio-femoral deep-vein thrombosis (IFDVT) is associated with the morbidity of postthrombotic syndrome (PTS). There are many younger patients presenting with IFDVT in India. Not much is known of the incidence of PTS in these patients and the quality of life (QOL) after treatment with catheter-directed thrombolysis (CDT) or standard anticoagulation in these patients. Materials and Methods: A prospective, nonrandomized, case–control study was conducted on patients who presented with acute, primary IFDVT (<14 days) to a tertiary care hospital. Patients with iliac and femoral deep vein thrombosis, confirmed by computed tomography venogram, were studied. PTS was assessed by the Villalta score. Disease-specific QOL was measured by Venous Insufficiency Epidemiological and Economic Study (VEINES)-QOL/Symptoms and health-related QOL by the EuroQOL (EQ)-5D questionnaires. Results: A total of 100 patients with acute IFDVT were followed up for a mean of 33 months. Villalta score and QOL scores for 49 CDT patients and 51 patients managed conservatively were calculated. Demographics were comparable between the groups. PTS developed in 29% of patients (18% vs. 39%, P = 0.035). The QOL calculated by VEINES-Sym/QOL (mean 74.29 vs. 70.14, P = 0.006) and EQ-5D (mean 0.50 vs. 1.76, P = 0.004) showed significant difference. Both scores were significant for PTS versus no PTS (P ≤ 0.001). Absolute risk reduction between the groups was 20.8% and the number needed to treat was one in five patients. Conclusion: CDT reduces the incidence of PTS and improves the health-related and disease-specific QOL in a younger population of patients with acute IFDVT, compared to standard treatment with anticoagulation alone.
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Cross-sectional study of upper-limb vessel diameters and their association with arteriovenous fistula maturation in end-stage renal disease patients p. 278
Fayazuddin Mohammed, Gnaneswar Atturu, Sandeep Mahapatra
DOI:10.4103/ijves.ijves_76_19  
Introduction: For creation of upper-limb arteriovenous fistula (AVF), international guidelines recommend a minimum diameter of 2 mm for artery and 2 mm/2.5 mm for vein. However, there are no large-scale studies in Indian patients whose stature and built is different compared to Western population. The aim of this study was to understand the upper-limb vessel diameters and their effect on AVF maturation in Indian patients. Methods: All consecutive patients who underwent AVF creation between November 2018 and May 2019 were included in the study. Demographics, upper-limb vessel diameter, type of surgery, and maturation rate at 6 weeks were recorded. Results: 129 patients were included with a mean age of 44 years (range, 18–80 years). Eighty-nine out of 129 patients (69%) were men. Overall, the mean diameter was 2.5 (range, 1–4.6 mm), 4.63 (range, 1.4–8.6 mm), 2.15 (range, 1–4.8 mm), and 3.13 mm (range, 1–6.8 mm) in the radial artery, brachial artery, and cephalic vein at wrist and elbow, respectively. In the 76 patients who underwent radiocephalic (RC) fistula, the mean diameter was 2.56 (range, 1.4–4.6 mm), 4.68 (range, 2.1–8.6 mm), 2.1 (range, 1–4.8 mm), and 3.0 mm (range, 1–5.9 mm) in the radial artery, brachial artery, and cephalic vein at wrist and elbow, respectively. In the 54 patients who underwent brachiocephalic (BC) fistula, the mean diameter was 2.3 (range, 1–4.3 mm), 4.5 (range, 1.4–6.9 mm), 1.6 (range, 1–3.6 mm), and 3.3 mm (range, 1.4–6.8 mm) in the radial artery, brachial artery, and cephalic vein at wrist and elbow, respectively. At 6 weeks, the maturation rate was 89.1% and 93.2% for RC and BC, respectively. Conclusion: The mean diameter of the cephalic vein at wrist and elbow was significantly less compared to Western population. Following the international guidelines would have taken away the opportunity to have a distal AVF in majority of the Indian patients requiring renal access patients 42 out 64 patients (65%).
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Comparing the efficacy of a combination of artificial lymphatics in the form of silicone tube and compressive therapy versus compressive therapy only in upper limb lymphedema following axillary lymph node dissection in breast cancer patients: A randomized controlled trial p. 283
Adarsh Pratap Singh, Anita Dhar, Anurag Srivastava, Rakesh Kumar, RM Pandey
DOI:10.4103/ijves.ijves_73_19  
Objectives of this Trial: The objectives of this trial were to compare the treatment of lymphedema by creating artificial pathways along with standard compressive therapy versus standard therapy alone in Stage 2 and 3 lymphedema. Materials and Methods: A total of 18 patients were randomized into two groups. Silicone group (n = 8) received the placement of fenestrated silicone tubes subcutaneously from the hand to scapular region along with standard compression therapy, and the control group (n = 10) received standard compression therapy only. Follow-up was for 6 months. Results: A mean reduction of limb volume in the silicone group was 887 ml (25%), whereas in the control group, it was 250 ml (8%) (P = 0.01). All patients, 8 (100%) of silicone group and only 4 (40%) of control group, had ≥10% limb volume reduction at the end of 24 weeks with P = 0.013. More number of patients in the silicone group had a mean reduction in limb circumference of ≥2 cm as compared to the control group at almost all points of measurements along the limb with P < 0.05. There was a significant improvement in the quality of life, especially the functional domain in the silicone group with a P = 0.01. Improvement in pain-free range of motion in all major joints was observed in both the groups. No serious complications were reported. Postoperative ultrasonography and lymphoscintigraphy have shown patency of tubes, lymphatic fluid flow in silicone tubes. Postoperative indocyanine green lymphography showed decreased dermal backflow compared to preoperative. Conclusion: Combination of artificial lymphatics in the form of silicone tubes and standard care leads to a more significant reduction in the limb volume and limb circumference with improved quality of life with no serious complications.
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Analysis of factors delaying healing of ischemic foot wounds in patients who undergo lower limb revascularization p. 291
S Roshan Rodney, Vivek Anand, M Vishnu, Sumanth Raj, KR Girija, Hemant K Chaudhari, Vaibhav Lende, KR Suresh
DOI:10.4103/ijves.ijves_65_19  
Objective: Complete ulcer healing is one of the most important goals of treatment for chronic limb-threatening ischemia (CLTI). The purpose of this study was to analyze the factors of delayed wound healing in CLTI after successful revascularization. Methods: We analyzed factors affecting ischemic wound healing following successful revascularization through a prospective, nonrandomized, single–center, observational study conducted at Jain Institute of Vascular Sciences, Bengaluru, Karnataka, India. We have also analyzed wound healing rate, wound healing time (WHT), and limb salvage rate based on wound locations and WIfI stage in this study. 113 patients with CLTI (Rutherford category 5 and 6) who had undergone successful primary revascularization between August 2017 and August 2018 (13 months) were included in this study with a follow-up of 6 months. Results: The wound healing rates were 0% (1st month), 36.3% (3rd month), and 40.7% (6th month), and the cumulative wound healing rate was 77%. The median WHT was 95 days (WIfI Stage 3) and 105 days (WIfI Stage 4) and the overall limb salvage rate was 91.2%. Multivariate Cox proportional hazards analysis revealed the following as independent predictors of wound nonhealing after initial successful revascularization: WIfI stage 4 (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.2–0.4; P ≤ 0.001); diabetes mellitus (HR, 6.5; 95% CI, 1.3–32.08; P = 0.020); HbA1C >6.5 (HR, 5.1; 95% CI, 1.0–24.9; P = 0.043); and serum albumin <3.20 g/dl (HR, 2.9; 95% CI, 1.3–6.2; P = 0.008). Conclusions: Hence, we recommend that successful revascularization alone does not contribute to complete wound healing and other factors influencing ischemic wound healing have to be addressed and be a part of treatment armamentarium.
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Extending the boundaries of carotid body tumor excision with a maxillofacial surgeon p. 298
SS Daniel Sathiya, Edwin Stephen, Albert Abhinay Kota, Vimalin Samuel, Prabhu Premkumar, Dheepak Selvaraj, Sunil Agarwal
DOI:10.4103/ijves.ijves_15_19  
Introduction: Carotid body tumor (CBT) excision at times requires a multidisciplinary approach. Requests for mandibular swing or mandibular subluxation were received by the department of dental and oral surgery to aid in CBT excision. Methods: Patients who were referred between March 2013 and April 2018 were retrospectively reviewed. Criteria for deciding between mandibular swing and mandibular subluxation for each patient were identified and outcome of the decision was analyzed. Follow-up period was 6 months to 5 years. Results: Of 53 patients operated during the study, 16 patients were referred for intraoperative assistance. Of the 16 patients, 10 were Shamblin 3 with 2 of these being redo cases and others were Shamblin 2. In all cases, the length of internal carotid artery (ICA) from the base of the skull was 1.5 cm or less. Mandibular swing was performed in three patients, all for Shamblin 3 with two of them being the redo cases, and mandibular subluxation was done for 13 patients. One patient who underwent mandibular swing and two patients who had mandibular subluxation had transient hypoglossal nerve palsy and all of them recovered. None of the patients for whom a mandibular swing was done had marginal mandibular nerve weakness. One patient lost a tooth at the mandibular osteotomy site. All patients had an acceptable scar. Among the patients who underwent mandibular subluxation, one patient had postoperative temporomandibular joint pain, which gradually subsided over 3 weeks. Conclusions: Mandibular swing and mandibular subluxation help provide the vascular surgeon with the additional space needed when excising CBTs, which extend close to the base of the skull with 1.5 cm or less of ICA from the base of the skull. The maneuvers help easier dissection and reconstruction of the ICA, reduce nerve injury and operating time, and reduce hospital stay and therefore cost to the patient.
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EXPERT COMMENT Top

Expert comments on “extending the boundaries of carotid body tumor excision with a maxillofacial surgeon” p. 302
Paul Blair
DOI:10.4103/ijves.ijves_100_19  
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IMAGES AND TECHNIQUES Top

VSI CLINICS - Images and Techniques - 1 p. 303

DOI:10.4103/0972-0820.273607  
A new section is being added to IJVES, which essentially depicts the procedures performed by Vascular Surgeons across the country. This would serve as a pictorial library of multitude of vascular pathologies, simple to complex, common to rare and their therapies. We hope this would create awareness among non-vascular specialists about vascular diseases and the treatment modalities offered. This would replace the previous lengthy, text-based CME articles and would be an easier read. It would serve as quick reference to numerous vascular diseases seen by practicing doctors in various specialties across India. These reports are non-referenced, non-peer reviewed articles. Neither IJVES nor publishers hold the copyright to the contents of this articles – Editorial Board
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HISTORICAL VIGNETTE Top

Evolution of extracranial carotid artery disease treatment: From opinion to evidence p. 312
Pritee Sharma
DOI:10.4103/ijves.ijves_99_19  
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CASE REPORTS Top

A rare case of primary leiomyosarcoma of the inferior vena cava with an intra- and extravascular component p. 315
Devender Singh, G Partha Sarathy, Sudheer Moodadla
DOI:10.4103/ijves.ijves_18_19  
Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare vascular tumor. It is frequently seen in the sixth decade of life with a female predominance. The diagnosis is often challenging as patients present with nonspecific complaints such as dyspnea, abdominal discomfort, or back pain. Computed tomography (CT) and magnetic resonance imaging individually or in combination with cavography, ultrasonography, and echocardiography allow an early preoperative diagnosis. Herein, we present a rare case report of primary leiomyosarcoma of the IVC in a 65-year-old female patient who presented with vague abdominal discomfort. Ultrasound of the abdomen detected a mass in the retroperitoneum with mixed echogenicity. CT scan revealed a 10.5 cm × 8.5 cm × 6.3 cm lobulated, heterogeneously enhancing mass with areas of necrosis and involving IVC. The diagnosis of a retroperitoneal mass involving IVC with a possibility of an IVC tumor was made. En bloc resection of the tumor with primary closure of the IVC was performed after careful dissecting from the surrounding structures. Specimen grossly revealed a soft pedunculated tissue mass projecting into the IVC and a large lobulated mass of 13 cm × 12 cm × 10 cm adherent to the surrounding structures. Histopathological report confirmed the diagnosis of primary leiomyosarcoma of the IVC.
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Management of intact giant fusiform aneurysm of distal aortic arch with impeding risk of rupture using midline sternotomy p. 320
Devvrat Desai, Jignesh Kothari, Bhavin Brahmbhatt
DOI:10.4103/ijves.ijves_22_19  
Aneurysm of the distal aortic arch is routinely repaired using left thoracotomy. Here, we are reporting an unusual case of intact giant fusiform aneurysm of the distal aortic arch with managed successfully using midline sternotomy. A 54-year-old gentleman presented with progressive dyspnea and chest pain in the New York Heart Association Class IV. He was diagnosed to have intact giant (11 cm × 11.5 cm × 12 cm) fusiform aneurysm of the distal aortic arch extending up to proximal descending thoracic aorta resulting in the displacement of trachea toward the right and left main bronchus inferiorly with underlying lung collapsed. The patient underwent distal arch replacement through midline sternotomy under deep hypothermic circulatory arrest with continuous selective antegrade cerebral perfusion using the right axillary artery and right femoral artery cannulation. The arch was replaced using 28-mm collagen impregnated, woven polyester graft. He remained stable postoperatively and was discharged on the 10th postoperative day.
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A case report of ulnar artery aneurysm in a 5-month-old infant with a review of literature p. 324
Dhanesh R Kamerkar, BS Ratta, Sravya Datla, Nikita Kuntilla, Bhushan D Shinde, Vishal Sawant
DOI:10.4103/ijves.ijves_23_19  
Aneurysms in the upper extremity vascular system are rare and exceedingly uncommon in young infants. We present a case report of a 5-month-old infant with multiple aneurysms in proximal left ulnar artery. Trauma as etiology was ruled out based on history. Detailed investigation did not reveal any particular etiology. Surgical management involved excision of aneurysm and graft placement. Excision biopsy confirmed giant-cell arteritis on histopathology.
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Inadvertent carotid-jugular conduit: An uncommon yet dreaded jugular venous catheterization complication p. 327
R Vairakkani, K Arun Alex, M Edwin Fernando, B Suhasini, ND Srinivasaprasad
DOI:10.4103/ijves.ijves_28_19  
Carotid-jugular fistula is one of the uncommon complications of internal jugular vein catheterization. It can have serious consequences such as infection, embolization, and high output cardiac failure and requires invasive repair. We describe a case of a common carotid artery-jugular vein arteriovenous fistula following the insertion of a double-lumen catheter for hemodialysis access.
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LETTERS TO THE EDITOR Top

From compression to injections: Prostaglandins paving a new direction for venous leg ulcer treatment p. 330
Pawan Agarwal, Dhananjaya Sharma
DOI:10.4103/ijves.ijves_57_19  
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Reply-letter to editor: From compression to injections: prostaglandins paving a new direction for venous leg ulcer treatment p. 331
Rajendra Prasad Basavanthappa, Ashwini Naveen Gangadharan, Sanjay C Desai, AR Chandrashekar
DOI:10.4103/ijves.ijves_101_19  
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