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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 7 | Issue 3
Page Nos. 205-327

Online since Saturday, September 12, 2020

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EDITORIALS  

“COVID & The Clots” Highly accessed article p. 205
Kalkunte R Suresh
DOI:10.4103/ijves.ijves_124_20  
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Management of an infrarenal aortic aneurysm – A tale of twin cities! Highly accessed article p. 208
Edwin Stephen
DOI:10.4103/ijves.ijves_110_20  
Guidelines for the management of an abdominal aortic aneurysm vary among vascular surgery societies. The debate between endovascular and open repair for elective repair is still on while an attempt is made to draw a balance between scientific evidence, cost-effective health care, and providing what is best for the patient. As endovascular hardware, software, and skills of the vascular surgeons improve, is the scalpel getting blunt? Will open surgical repair be a forgotten twin in the management of aortic surgery or should a conscious effort be made to preserve this skill? It is time to have guidelines relevant to the Indian subcontinent that encompasses these issues.
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INVITED COMMENTARY Top

Retroperitoneal approach to the abdominal aorta: Tips and tricks Highly accessed article p. 211
Aniket Pradhan, Sewa Singh, Nandan Haldipur
DOI:10.4103/ijves.ijves_88_20  
In the era of endovascular repair of abdominal aneurysms (AAA) the use of traditional open surgical repair of AAA is declining. The preferred option for patients with AAAs who are young or have challenging anatomy that is not suitable for Endovascular repair is open surgical repair. Most Vascular Surgical units are familiar with the transperitoneal (TP) approach to AAA. Another useful approach to AAA is retroperitoneal (RP). Our unit has found RP a more suitable approach for repairing the AAAs with challenging anatomy and in patients with poor physiological function. RP approach provides excellent access to the juxta/supra renal aorta. In addition, patients undergoing RP have less post-operative morbidity and shorter hospital stay compared to those undergoing TP repair. Our unit recommends RP approach as the preferred option to repair AAAs unsuitable for endovascular repair. Given the relative lack of familiarity with this technique as it is not widely practised, we have described the technique/our experience and its advantages over conventional open surgery.
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REVIEW ARTICLE Top

Endovascular aneurysm repair for infrarenal abdominal aortic aneurysm: How, why, and when! Highly accessed article p. 216
Raghu Lakshminarayan, Rakesh Kapur
DOI:10.4103/ijves.ijves_89_20  
Endovascular aneurysm repair is an established method for the treatment of infrarenal aortic aneurysms. The operator needs to remain abreast with evolving technology and be conversant with the proper use of pre and postoperative imaging and its interpretation, limitations of devices and of the technique itself, and the IFUs.
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ORIGINAL ARTICLES Top

Arteriovenous graft patency outcomes and prognostic factors: A single-center study p. 222
Rajendra Prasad Basavanthappa, Ranjith Kumar Anandasu, Ashwini Naveen Gangadharan, Luv Luthra, J P Vivek Vardhan, Chandrashekar Anagavalli Ramswamy, Sanjay C Desai, Adharsh Kumar Maruthu Pandian
DOI:10.4103/ijves.ijves_72_19  
Aim/Purpose: Functional, long-lasting vascular access is essential for maintaining effective long-term hemodialysis. Various factors including demographics and comorbid conditions have influenced the patency rates. As per the KDOQI reports, vascular access-related complications account for 15%–20% of hospitalizations in end-stage renal disease (ESRD) cases. This study aims to analyze various factors and to study the patency rates and complications of brachioaxillary arteriovenous (AV) prosthetic grafts for dialysis access at a single center. Materials and Methods: This was a single-center prospective study, which was conducted in Ramaiah Medical College Hospital, Bengaluru. All patients who underwent brachioaxillary AV prosthetic graft surgery for dialysis access over a period of 5 years from July 2012 to June 2017 were included. Follow-up of cases was done up to 2 years, and any complications encountered during the study period were recorded. Results: A total of 408 patients were included, in which 77% were male, with a mean age of 60.1 years. The most common comorbidity associated was hypertension (68%) followed by diabetes (36%), and the mean axillary vein diameter was 5.2 mm. The primary patency rates at the end of 1 and 2 years were 61.5% and 49%, respectively, and the secondary patency rates at the end of 1 and 2 years were 70% and 59%, respectively. Conclusions: In ESRD patients, in whom an autogenous fistula is not possible, prosthetic AV grafts are a suitable choice for vascular access and provide satisfactory patency rates for hemodialysis access. Thrombosis, secondary to venous intimal hyperplasia, is the most common complication and generally occurs by the 3rd month. Interventions will improve long-term patency rates and should consist of thrombectomy and thrombolysis in addition to balloon angioplasty. However, complications will still be encountered and their early recognition with aggressive surveillance and appropriate management is necessary to prolong overall graft survival.
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Prevalence of venous thromboembolism risk factors in pregnant women p. 225
Harivardhani Varre, Manasa Badveli, Sahitya Bammidi, Usha Suresh Mudragada, Prem Chand Gupta, Gnaneswar Atturu
DOI:10.4103/ijves.ijves_77_19  
Introduction: Venous thromboembolism (VTE) is the leading cause of maternal mortality in the Western population. Studies have shown that the incidence of VTE may not be different in the Indian population. The aim of this study is to understand the prevalence of VTE risk factors in Indian pregnant women. Materials and Methods: Two hundred antenatal and postnatal women attending the Gynecology outpatient clinics between April 1, 2019 and July 31, 2019, were sampled using pragmatic approach. Green-top guidelines (Royal College of Obstetricians and Gynecologists) were used to identify the risk factors. Descriptive statistics were used to analyze and present the data. Results: The mean age of the women was 26.18 (range 20–41). In the sampled population, 39 (19.5%), 41 (20.5%), and 110 (55%) women were in the first, second, and third trimester, respectively. Ten women (5.3%) were in the postpartum period. Out of 200 pregnant women, 2 (1%) had the previous history of VTE putting them in the high-risk group and 40 (20%) had one or more intermediate risk factors (immobility, OHSS, medical comorbidities, and surgical procedures). Eleven women (5.5%) had three or more risk factors and 40 women (20%) had two or more of the low-risk factors. Overall, 80 of 200 pregnant women (40%) had VTE risk factors that would require DVT prophylaxis during and/or postpartum period. Conclusion: The study highlights that a significant proportion of pregnant women in India have VTE risk factors. Routine VTE risk assessment and thromboprophylaxis could identify the women at risk and reduce the incidence of VTE in pregnant women.
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Comparative analysis of early outcomes of radiofrequency ablation and 1470-nm endovenous laser ablation in the treatment of great saphenous vein insufficiency p. 227
D Prabakar, Saleem Jahangir
DOI:10.4103/ijves.ijves_82_19  
Background: Minimally invasive Endovenous Thermal Ablation Therapy has revolutionized the treatment of varicose veins. Comparison of radiofrequency ablation (RFA) and Endovenous Laser Ablation (EVLA) needs to be more elaborated in the context of better management of patients. The objective of this study is to compare 1470-nm endovenous laser Ablation (EVLA) and radiofrequency ablation (RFA) in the treatment of patients with great saphenous vein Insufficiency. Methods: There were 100 consecutive patients presenting to our department with a great saphenous vein insufficiency treated between June 2018 and June 2019 who were included in the study. The first randomly selected 50 patients (group 1) received 1470-nm EVLA and the other 50 patients (group 2) received RFA. Patients were assessed on the second day, the first week, and the first month in terms of post-operative complications, return to routine activity and work, and postoperative pain. Results: 50 patients were allocated to each group. There was no statistically significant difference between two groups in terms of postoperative pain. Time to return to daily activity was 5.1 ± 1.12 hours in the EVLA group and 6.9 ± 0.93 hours in the RFA group (P = 0.001), whereas time to return to work was 6.7 ± 1.03 days in the EVLA group and 7.4 ± 1.07 days in the RFA group (P = 0.003). Minor complications in EVLA and RFA group were ecchymosis 26% and 32% (P = 0.509) edema 24% and 34% (P = 0.271), and induration 14% and 22% (P = 0.298), respectively. No major complication were observed in any group. Conclusion: EVLA using a 1470-nm radial fiber is an acceptable and efficacious treatment option over RFA in management of symptomatic varicose veins patients in terms of early outcome. However, long term follow up and more studies on larger populations are required to establish the superiority of either method.
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The utility of venous bifurcation for anastomosis with small-caliber veins in distal forearm radiocephalic arteriovenous fistula: Retrospective analysis of 52 fistula cases p. 231
Shobhit Sharma, Sudipta Bera, Ashwani Kumar, Vivek Gupta
DOI:10.4103/ijves.ijves_84_19  
Context: Distal forearm radiocephalic (RC) arteriovenous fistula (AVF) is the gold standard for vascular access for hemodialysis. The use of venous bifurcation to facilitate anastomoses in small-caliber vessels is well known in microvascular surgery. Small-caliber cephalic vein (CV) is frequently encountered during AVF creation in the distal forearm. We present here the utility of this technique for the creation of distal RC AVF in small-caliber CVs. Objective: The objective was to assess the utility of venous bifurcation for distal forearm RC AVF creation in small-caliber CV. Methodology: Fifty-two cases with CV diameter <2.5 mm on color Doppler study and RC AVF created in the distal forearm between January 2015 and 2019 are reviewed for operative time, fistula maturation time, and patency rate. Patients were selected for fistula creation after clinical and color Doppler assessment. Cephalic venous bifurcation in the distal forearm was used for end-to-side anastomosis whenever feasible. Patients were followed up periodically for fistula maturation and patency. Results: Venous bifurcation was used in all 52 cases with a functional maturation rate 48/52 (92.30%). Functional primary patency rate was 46/52 (88.46%) at 6 months and 20/28 (71.42%) at 1 year. The mean fistula maturation time was 37.19 days. Conclusion: A cephalic venous bifurcation is almost always available for RC AVF in the distal forearm. Its utilization improves the success rate and feasibility of fistula creation in small-caliber veins without any delay.
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Contrast-Enhanced ultrasound in endovascular aneurysm repair follow-up: Our experience p. 237
Cristina Busoni, Dalmazio Frigerio
DOI:10.4103/ijves.ijves_88_19  
Background: Endovascular aneurysm repair (EVAR) is actually the most common surgical technique used in the treatment of abdominal aortic aneurysm (AAA), worldwide. In EVAR, as we know, the most common complication is endoleak (EL), which is the most common cause of failure in the endovascular treatment of AAA. We can deduce that the surveillance and mid-term/long-term follow-up is mandatory and very important to detect EL. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in EVAR follow-up because its ability to detect EL (especially if they are at low flow like type II) and because it is a cheap technique, reducing direct costs and X-ray exposure to the patients. Methods: We started using CEUS as the first-level examination to detect EL in every EVAR patients. CEUS is performed at 3–6–12 months after EVAR and then annually. Computed tomography scan is performed to every patient, to confirm the diagnosis of EL and in any case of sac enlargement without evidence of EL during CEUS. The procedure consists in the administration of 2.5 ml SonoVue® (Bracco Farmaceutici-Milano) bolus followed by 5 ml sodium chloride 0.9% and is performed on Philips IU22 (Philips, Netherlands). We used to start collecting time at the end of the bolus injection. Results: In our 31 patient population, we recorded 13 cases of EL (41.93%), in particular, 3 cases of type I-III (9.68%) and 10 cases of type II (32.25%); in the whole group, sensibility and specificity (Se and Sp) of CEUS to detect EL (not type-specific) were 92% and 100%, respectively. These data are as other data of more important case-series. Conclusions: CEUS is considered the gold standard technique to detect early EL for more authors worldwide. In our experience, we can confirm this matter because CEUS has high Se and Sp (about 100%, in any cases).
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The role of angioembolization in the management of hemorrhagic urovascular emergencies: Retrospective Cohort Study p. 241
Amit Kumar Mishra, Lalgudi Narayan Dorairajan, Ramanitharan Manikandan, Ajith Ananthakrishna Pillai
DOI:10.4103/ijves.ijves_96_19  
Introduction: Transarterial embolization is an effective method in the management of hemorrhagic vascular emergencies irrespective of its etiology. The aim of this study is to evaluate the role of angioembolization in the management of urovascular bleed and to evaluate the morphological and functional impact in the embolized organ in the medium-term follow-up. Materials and Methods: The hospital records of 11 patients with 12 renal units and two patients with hematuria of bladder origin who underwent angioembolization from the period of October 2012 to October 2015 were retrospectively reviewed. Data on clinical indication, technique, site, and type of bleeding were recorded. The outcome measures such as success rate, preprocedural requirement of blood transfusion, and periprocedural complications were analyzed. Results: Indications for angioembolization included blunt renal trauma (2), metastatic renal cell carcinoma (1), postpercutaneous nephrolithotomy (3), postpercutaneous nephrostomy (1), angiomyolipoma (2), renal biopsy (2), postpartial nephrectomy (1), cervical cancer with intractable radiation cystitis (1), and postradical cystectomy with internal iliac artery pseudoaneurysm (1). Out of these, two patients had secondary bleed and required a second session of angioembolization. The meantime between the first presentation and embolization was 34.46 h (4–96 h). Mean preprocedural blood transfusion requirement was 4.9 units (3–8 units). None of these patients required postprocedural blood transfusion. There was no serious postprocedural complication. There was no incidence of hypertension or renal impairment in the medium-term follow-up. Conclusion: The procedure carries low morbidity and a high rate of preservation of organ function. Hence, it should always be considered in the management of postoperative bleeding before embarking on surgical exploration.
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Pseudoaneurysms in dialysis access – Outcomes of surgical repair p. 245
T Krishna Prasad, Maneesh Sinha, HS Harsha, K Prasannakumar, Venkatesh Krishnamoorthy
DOI:10.4103/ijves.ijves_98_19  
Context: This study documents the outcomes of pure surgical attempt to salvage pseudoaneurysms (PSAs) in dialysis access. Considering that the long-term outcomes of surgical salvage are nearly the same as that of stent-graft use, it is possible if sufficient evidence accumulates to suggest that a surgical salvage of PSA can be considered as an equally safe option. Objectives: The literature on pure surgical repair of PSA is sparse. At a reported 6-month patency rate of 75%, open surgical salvage offers a reasonable option for salvaging a vascular access complicated by PSA formation. We report our results of attempted surgical salvage of PSA and an overview of the available literature on the use of endograft and surgical repair of PSA. Methods: This was a retrospective review of all patients presenting with PSA between January 2009 and November 2018. The methods of salvage include primary repair or excision with interposition of graft, the primary outcome being to obtain a functional access. Results: During the above period, of the 1462 fistulae created, 32 (2.1%) presented with PSA. The average time from the access creation to the presentation was 24.26 months. The overall technical salvage rate was 31% (n = 10), with the salvaged fistulae having a 3 patency rate of 60%, the mean follow-up being 14.5 months. Conclusion: About 31% of fistulae with PSA could be salvaged with a 3-month patency of 60%. Surgical salvage therefore appears to be a durable option for PSA in patients undergoing hemodialysis.
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Superficial-vein thrombosis of the lower limb: A pathology that is not always benign p. 250
Abdellah Rezziki, Alzaarir Hussam, Anane Oussama, Abutayf Taha, Benzirar Adnane, El mahi Omar
DOI:10.4103/ijves.ijves_5_20  
Objectives: The value of our observations is to take stock of the interest of the medical and surgical management of superficial vein thrombosis. Case Report: We report three patients with severe superficial vein thrombosis whose symptoms were painful induration along the course of the superficial veins of the lower limb. The diagnosis was confirmed by venous Doppler, follow-up was marked by the occurrence of thromboembolic complications (pulmonary embolism) in one patient. Results: All patients received emergency treatment-anticoagulation for a week with relay by Vitamin K antagonists, surgery as an emergency consisted of ligation of the saphenofemoral junction (SFJ) under local anesthesia in one patient (Case 2). One of the patients had a pulmonary embolism 3 days later, and this patient did not receive surgical ligation. The third patient has progressed well on anticoagulant therapy. Discussion: Superficial vein thrombosis of the lower limbs has long been considered as benign with the natural course often leading to resolution of the thrombus and in rare cases complications which can affect the prognosis of the patient. Anticoagulation should be started urgently especially before extensive thrombosis and surgical ligation of the SFJ considered to prevent thrombus propagation. Conclusion: Superficial vein thrombosis is often considered to have a benign course once diagnosed. Experience from our short series suggests that the management should be more aggressive and robust with anticoagulation and consideration of ligation of the SFJ where thrombosis is extensive and reduce the dreaded complication of a pulmonary embolism. Therapeutic recommendations concerning this disease have a relatively weak level of certitude as no treatment has been proved of benefit. We thought interesting to talk through observational clinical cases and expose our personal attitude to a serious superficial vein thrombosis.
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Evaluation and management of accidental intra-arterial injection in the antecubital fossa p. 254
Jayesh Patel, Pratiksha Shah, Fenil Gandhi
DOI:10.4103/ijves.ijves_7_20  
Introduction: Intra-arterial (IA) drug injection is a rare, but a potentially serious medical emergency. It is most commonly seen as an iatrogenic complication when administering an intravenous (IV) medication. Accidental IA injection was defined as an IV injection administered in the upper limb for any illness, which was followed by sudden severe pain in the limb followed by bluish discoloration of any part of the affected limb. Aim: The aim of the study is to identify the risk factors early on for limb amputation following IA injection, to assess the efficacy of the various modalities of the treatments administered, and to establish a standardized treatment plan for IA injection to achieve limb salvaging. Materials and Methods: A total of 12 cases of accidental IA injection were studied for the efficacy of early evaluation and management of each. The patients were studied based on Rutherford classification, clinical history, and Doppler findings. Results: Ten out of the twelve patients presented early, and limb salvation was achieved. Conservative treatment and upper limb fasciotomy proved to aid with the limb salvation. However, two out of the twelve patients presented after 12 h with complains of blackening of the digits. In these patients, limb salvation was not achieved and Ray's amputation was performed. All the patients recovered well, with proper functioning of the upper limb. Conclusion: Early evaluation and management of a case of accidental IA injection is of utmost importance due to its serious complications. Finally, all medical professionals must be regularly trained to prevent such mishaps from happening.
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Iatrogenic intra-arterial injection in the upper limb: A pragmatic guide for the on-call vascular surgeon p. 260
James Michael Forsyth, Peter John Webster, Nandan Haldipur
DOI:10.4103/ijves.ijves_41_20  
Background: Peripheral venous cannulation is one of the most commonly performed procedures to establish venous access in the hospital setting. Inadvertent arterial cannulation is a rare event but can have serious consequences including ischemia and limb loss, especially if medication is administered through the device. Vascular surgeons should have an understanding of the management of this potential complication Methods: We reviewed the risk factors, mechanism, pathophysiology, and management options for inadvertent upper limb arterial cannulation and injection. Results: Inadvertent arterial cannulation and administration of medication has a reported incidence of 1 in 3440 cases. Several risk factors were identified including difficult venous access, difficulty in communication, and aberrant vascular anatomy. Both arterial injury from the misplaced cannula and injection of medication can cause ischemic events through a number of mechanisms. We recommend that patients sustaining an inadvertent arterial injury should have an urgent clinical assessment and be managed according to the degree of upper limb ischemia as per the Rutherford classification. We provide a pragmatic management algorithm to aid the vascular surgeon when encountering such a situation. Conclusion: Iatrogenic arterial injury is a rare but potentially serious complication of peripheral venous cannulation. Prompt recognition and management of ischemic complications is essential for favorable outcomes. Our pragmatic management guide should aid the vascular surgeon in managing this situation.
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HOW I DO IT Top

Venous ulcer management: Frontier unconquered p. 265
Edwin Stephen, Vimalin Samuel
DOI:10.4103/ijves.ijves_48_20  
Every vascular surgeon or physician involved in ulcer care aims at healing an ulcer as soon as possible and recurrence is a dreaded reality that they have to face. There are several adjuncts to surgery that aid healing. A lot needs to be done and known about– what are the options available beyond surgery that expedite healing and prevent recurrence? This is frontier that is yet to be conquered.
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HISTORICAL VIGNETTE Top

William harvey and the circulation: The concept, challenge, and controversy p. 270
Devender Singh, Basavarajendra Anurshetru, Aryala Shalini
DOI:10.4103/ijves.ijves_89_19  
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CASE REPORTS Top

A case report of retrograde open mesenteric stenting for acute mesenteric ischemia p. 273
Ankur Aggarwal, Manju Bharat, Sunder Narasimhan
DOI:10.4103/ijves.ijves_74_19  
Occasionally, acute mesenteric ischemia cases present with vessels, which are very difficult to cannulate via the percutaneous method. Furthermore, there is a dire need to preserve as much bowel as possible in these cases. Another problem is the long operative time required for open revascularization in these cases and the associated risks. We present such a case of acute mesenteric ischemia with gangrenous distal ileum in an 87-year-old female with multiple comorbidities who was treated with retrograde open mesenteric stenting and resection and anastomosis of the gangrenous segment of the bowel. We recommend vascular surgeon involvement in all cases of laparotomies for acute mesenteric ischemia and we should consider retrograde open mesenteric stenting if cannulation of mesenteric arteries via percutaneous approach is not possible.
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Intramuscular vascular malformation in triceps: A case report with literature review p. 277
Punit Tiwari, Harmeet Kaur, Vivek Jha, Kunal Bansal
DOI:10.4103/ijves.ijves_80_19  
Vascular anomalies comprise a widely heterogeneous group of tumors and malformations. The tendency of radiologists and pathologists to report the intramuscular vascular anomalies as hemangiomas may mislead the treating surgeon which affects the diagnosis and management plan. The International Society for the Study of Vascular Anomalies classification has helped clear the confusion created by interchangeable terminology like hemangioma for such lesions. The vascular tumors may involute with time and deserve a conservative trial, whereas the symptomatic vascular malformations will eventually need surgical intervention. Mass lesions with normal skin without any discoloration, venous engorgement, or inflammatory signs can be easily passed for a lipoma. The high index of suspicion and availability of ultrasound and color Doppler help in the early detection of vascular anomalies. In the case presented herein, the vascular malformation symptomatic for about two decades was excised successfully with a plane of dissection through surrounding normal triceps muscle. This case highlights that the correct classification of vascular anomalies cannot be overemphasized because it guides the management plan according to the type of lesion and helps in setting up a genuine database for scientific research.
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Renal artery aneurysm p. 281
Rahul Lakshminarayanan, I Devarajan, Sabarish G Kumar, Sritharan Narayanan
DOI:10.4103/ijves.ijves_83_19  
Renal artery aneurysm (RAA) is a rare presentation, accounting for <1% of all splanchnic aneurysms. Renal aneurysms may present as hypertension, flank pain, hematuria, or with signs of rupture, but are often asymptomatic. We are hereby presenting one such case that we encountered in our clinical practice. A 67-year-old male diagnosed incidentally with left RAA 2.5 cm in size, without any local or systemic complications, underwent open repair with interposition vein graft repair and had an uneventful postoperative course.
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Endovascular therapy for high output failure due to iatrogenic iliac-caval fistula p. 284
Rajeev Menon, Kalyanraddi Chikkagoudar, Nageshwara Rao Koneti, Shweta Bhakru, Bhargavi Dhulipudi
DOI:10.4103/ijves.ijves_85_19  
50-year-female presented with features suggestive of high output cardiac failure. She had lumbar discectomy seven years back. Meticulous diagnostic evaluation revealed a large right iliac to lower inferior vena caval communication with continuous shunt. The fistula was closed successfully using a 12 mm muscular ventricular septal occluder. Patient improved dramatically in 24 hours.
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Endovascular management of ruptured giant aneurysm of superior mesenteric artery p. 287
Ganesh Kumar Marada, Sandeep Agarwal, Varinder Singh Bedi, Ajay Yadav, Apurva Srivastava
DOI:10.4103/ijves.ijves_87_19  
Ruptured aneurysm of superior mesenteric artery (SMA) is an emergency with high mortality rates. Open surgery is most commonly preferred, but is highly morbid. Endovascular approach can be a feasible option with minimal morbidity and early recovery. We report a case of giant ruptured SMA aneurysm which was managed by endovascular intervention, not been reported in literature till date.
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A rare case of perforator vein aneurysm p. 290
B Nishan, Vishal Hudgi, K Sivakrishna, BK Pavan, Vivek Anand
DOI:10.4103/ijves.ijves_92_19  
We report the case of a 41-year-old male with a left perforator vein aneurysm (PVA) in the popliteal fossa, with no local symptoms. Early diagnosis is necessary in order to prevent the thromboembolic events or other major complications. Duplex scanning and computed tomography (CT) scanning are considered to be important noninvasive diagnostic methods for the diagnosis of PVA. CT confirmed a fusiform PVA in the left popliteal fossa. Open tangential perforator vein aneurysmectomy was done through a posterior approach in the left popliteal fossa.
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Intravenous leiomyomatosis p. 294
Deepak George John, Krishna Muralitharan, K S Saravana Krushna Raja, N Sritharan
DOI:10.4103/ijves.ijves_94_19  
Intravenous leiomyomatosis is a rare clinical entity which arises from the uterus and extends into the venous system reaching up to the inferior vena cava (IVC), right atrium (RA), and pulmonary vasculature. Very few cases have been reported with intracardiac extension. Complete resection of the tumor is essential for favorable outcomes. However, this requires a multidisciplinary approach with appropriate imaging and planning. We report a case of uterine leiomyomatosis with extension to the IVC, RA, right ventricle, and superior vena cava.
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Atypical presentation of Covid-19 – Peripheral arterial thrombosis p. 297
Ishan Gohil, Darshak Patel, Vivek Wadhawa
DOI:10.4103/ijves.ijves_67_20  
The present ongoing pandemic of Coronavirus Disease 2019 (COVID-19) has been viewed to be typically affecting the respiratory system chiefly the lungs parenchyma, but it has been more and more evident that severe acute respiratory syndrome coronavirus-2 is not exclusive to his single system. Here, we report a rare case of a 55-year-old female presented with the left brachial thrombus as an atypical presentation of COVID-19.
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Blunt traumatic true aneurysm of lateral plantar artery: A rare entity p. 300
Elamaran Elamurugan
DOI:10.4103/ijves.ijves_1_20  
Traumatic lateral plantar artery aneurysms to the foot is a rare entity, for the amount of trauma the foot is subjected. In the literature, till now, cases reported were after penetrating injury to the sole or associated with bony injuries. No cases of blunt trauma incidence have been reported till now. Management is by open surgical repair or endovascular repair. Pain on walking was the reason the patient attended us. In this study, we discuss a case of blunt traumatic lateral plantar artery aneurysm with its presentation and management.
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Endovascular aneurysm repair with aorto-uni-iliac device: Review of indications and outcomes with a case report of the deployment in a low-lying dominant accessory renal artery p. 302
B Nishan, K Sivakrishna, Hudgi Vishal, VP Ahsan, Vivek Anand
DOI:10.4103/ijves.ijves_2_20  
We present a patient requiring aorto-uni-iliac (AUI) endovascular aneurysm repair with a review of indications and outcomes of this procedure. A 72-year-old male presented at Jain Institute of Vascular Sciences due to infrarenal saccular abdominal aortic aneurysm with a maximum diameter of 4.5 cm. A low-lying, the dominant left accessory renal artery with inadequate length from the origin of the left accessory renal artery to aortic bifurcation (50 mm) precluded the deployment of a bifurcated device (since the length of the aorta from the origin of the left accessory renal artery to aortic bifurcation was inadequate for the contralateral limb to open). Hence, AUI stent-graft deployment, with occlusion of the contralateral common iliac artery and crossover femorofemoral bypass was performed.
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Management of a curious case of a large recurrent truncal vascular anomaly in a young adult p. 306
Nilanjan Roy, Basil Badarudeen, Hari Janardhanan Pillai
DOI:10.4103/ijves.ijves_4_20  
Venous malformations (VMs) as the name implies contain only venous blood which is slow moving and are hence classified under low-flow vascular malformations. Sclerotherapy is the main modality of treatment for small VMs. However, bigger lesions require surgical excision in addition to interventional procedures. Hereby, we present a successfully resected case of a large, diffuse, multiloculated, and multiplanar vascular anomaly of the trunk, which presented to us after incomplete resolution following multiple sittings of interventional therapy. Surgical excision was tricky and challenging because of its large size and complex anatomical involvement. Complete resolution of the lesion was achieved with no neurological deficit. There was full recovery of movements at the shoulder joint on follow-up.
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Extradigital glomus tumor of left forearm: An unusual cause for persistent forearm pain p. 309
Devender Singh, Shilpa Polineni, Basavarajendra Anurshetru, Aryala Shalini
DOI:10.4103/ijves.ijves_8_20  
Glomus tumors are rare, benign, and vascular neoplasm of the glomus body, accounting <2% of all soft tissue tumors. The most common site is the subungual region of the fingers and toes. Extradigital sites, including the forearm, are uncommon and usually misdiagnosed because of their rarity and nonspecific presentation. Diagnosis is often delayed due to low level of suspicion. A strong clinical suspicion, magnetic resonance imaging, and a properly planned surgery remain the treatment. We report a 70-year-old male presented with a very small painful left forearm swelling for the last 20 years who had undergone surgical excision.
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LETTER TO EDITOR Top

The prevalence of and risk factors for peripheral arterial occlusive disease in human immunodeficiency virus-infected omani patients: The first study in GCC p. 312
Srineil Vuthaluru, Aditya Baksi
DOI:10.4103/ijves.ijves_98_20  
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VASCULAR CLINICS Top

1. Anthologies in vascular surgery - Part 3 p. 313

DOI:10.4103/0972-0820.294899  
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2. Vascular Images & Techniques - Part 4 p. 316

DOI:10.4103/0972-0820.294903  
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