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   Table of Contents - Current issue
January-March 2020
Volume 7 | Issue 1
Page Nos. 1-104

Online since Monday, March 16, 2020

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Footprints on the sands of time: From the doyens of our specialty Highly accessed article p. 1

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Game changers in vascular and endovascular surgery Highly accessed article p. 13
Varinder S Bedi, Nikhil Sharma
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”Geometry-based cannulation technique” for cannulation of great saphenous vein during radiofrequency ablation of varicose veins at a university hospital of Nepal Highly accessed article p. 18
Robin Man Karmacharya
Background: Radiofrequency ablation is an established minimal invasive treatment modality of varicose veins. This technique involves accessing the great saphenous vein (GSV) through which radiofrequency ablation catheter is inserted. Some established puncture techniques like in-plane and out-plane techniques are also not devoid of limitations. Aims and Objectives: To know the applicability of “Geometry based cannulation technique” in terms of mean cannulation attempts and percentage of successful cannulation. Materials and Methods: We are doing “Geometry based cannulation technique” for the cannulation of GSV. For cannulation 18G needle of length 3 cm attached with 10 ml syringe (cannulating needle) partly filled with normal saline is used. Doppler ultrasonography is done with Siemen's Acuson P300 machine with linear probe of frequency 7.5–12 MHz. The depth from the skin to the upper part of vein is measured in cm and is termed as distance “A.” The tip of the cannulating needle is positioned on the middle of the probe and gently pressed down the skin to form the shadow in the Doppler. The needle is readjusted such that the shadow corresponds to the GSV. Then, the needle is moved distally to A distance. Then the needle is made rotated 45° and skin is punctured to the length (distance B) calculated from the Pythagoras theorem as square root of 2A2. Then the angle is decreased to about 30° and further 2–3 mm advancement of the cannulating needle is done such that it lies inside the target GSV. Results: From 459 cannulations in the time frame of August 2013–December 2018, we found that mean cannulation attempts were 1.4 (standard deviation 0.72, 1–3 attempts). In 429 GSVs (95.5%), there were successful cannulations, whereas in 20 GSVs (4.5%), there was failure in cannulation. The cannulation of GSV has higher success if the diameter of GSV is more than 5 mm and the depth is less than 10mm. Conclusion: “Geometry based cannulation technique” for cannulation of GSV is a novel technique and can be used with high success.
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Can Mangled Extremity Scoring System (MESS) solve the mess of vascular trauma p. 22
Shamayal Rabbani, Mohd Azam Haseen, Amjad Ali Rizwi, Mohd Hanif Beg
Introduction: Trauma is the new scourge of humankind as without utmost and urgent care, it can result in the loss of limb and life. Civilian trauma is mostly caused by road traffic accidents with resultant skeletal, vascular, and neurological injuries. Vascular injuries most commonly involve the extremities and occur in young males. Materials and Methods: Ours is prospective observational study, in which 50 patients of the lower limb vascular injury were included in the study. Results: All of them were male, and mostly, they were in the second and third decades of life. Popliteal artery was the most commonly injured vessel, and road traffic accident was the most common mode of injury. Fifty-six percent (n = 28) had favorable outcomes with 8% mortality (n = 4). Twenty-six (52%) patients had bony involvement, the most commonly injured bone was tibia (n = 16, 32%). The mean warm ischemia time was 15.56 ± 14.03 (range: 3–48) h. Mangled Extremity Severity Score (MESS) scores were significantly different in salvaged and nonsalvaged limbs (P = 0.004). The sensitivity and negative predictive value of MESS were very high (100%), but the specificity and positive predictive value for unfavorable outcomes were low (57.14% and 64.71%). Skeletal injury, neurological involvement, and a blunt mechanism of injury were found to have a significant association with an unfavorable outcome in the patients. Conclusion: We concluded that MESS cannot be completely relied on, and the surgeon's clinical assessment and experience are necessary to decide the plan of management. Warm ischemia time is not the most important factor affecting limb survival, and other factors such as neurological and bony involvement need to be considered. MESS helps to frame the data for the clinician and can help in counseling patients, and their families that poor outcomes are more likely when MESS score is high. Further, large-scale, multicenter randomized trials are necessary for the identification of other risk factors and their incorporation into scoring systems.
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Analysis of patients with venous thromboembolism in a multi-specialty tertiary hospital in South India Highly accessed article p. 29
Pranay Pawar, MK Ayyappan, Jithin Jagan, Naveen Rajendra, Kapil Mathur, Radhakrishnan Raju
Objectives: The objective of this study is to ascertain the incidence of venous thromboembolism (VTE) in Indian patients at a tertiary care center with emphasis on the data pertaining to demographics, management, and temporal trends. Materials and Methods: This was a retrospective cross-sectional Level II audit study carried out in the Department of Vascular Surgery at our institute from January 2012 to December 2017. The patients were identified from the electronic medical records by the International Classification of Diseases code. Consecutive patients were identified from the above-mentioned time period, and data on demographics, presentation, site, predisposing factors, etiology, primary referring specialty, and management were recorded. Results: This was a 6-year retrospective study and a total number of 1010 patients were included in the study that presented primarily with VTE. There were a total of 518,111 admissions in this period with a VTE incidence of 19.49/10,000 cases. Males contributed to 55% of patients in this study. Acute deep-vein thrombosis (DVT) (<14 days of presentation) contributed to 66% of the patients. The age group between 41 and 60 years had the maximum incidence of DVT of 43.9%. Provoking factors were found in 48.8% (493) of the cases. Conclusions: VTE is a common disease and is associated with reduced survival and significant morbidity. More locoregional registries like ours are the need of the hour and will help large institutions identify their lacunae and address areas, which need attention, like thromboprophylaxis and uniform management.
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Diagnosis and treatment of carotid body tumors: A retrospective analysis of a single-center experience over 12 years p. 34
Mohammed A Rashaideh, Firas M Neshwati, Mohammed As'ad, Eyad Ajarmeh, Elham Alsharayeh, Nadia Yasin
Introduction: Carotid body tumor (CBT) is a neuroendocrine tumor, located at the carotid artery bifurcation. Management of such tumors is challenging due to the silent presentation and difficulties encountered during surgical excision which is the standard treatment method. Aim: This study aimed to report our experience in the diagnosis and management of CBTs. Materials and Methods: A retrospective analysis of all CBTs treated at our center during the period from January 2005 to March 2017. The analysis was based on data collected from histopathology database, hospital records, and the follow-up notes from the clinic. Results: A total of 32 CBTs were excised in 28 patients. There were 22 females and 6 males, with a mean age of 44 years. Twenty-four patients had unilateral tumors and bilateral tumors were present in four patients (15%). The mean size of the tumors was 3.5 cm. Surgical excision was achieved under general anesthesia in all cases. Intraoperatively, vascular repair in any form was needed in 41% and permanent cranial nerve injury was detected in 16% of cases. Histopathologically, incomplete excision was found in 13% of cases, and no metastasis was detected. During the follow-up period, there was only one case of recurrence. Conclusions: CBTs are challenging pathology. Despite the lack of recommendations for treatment, early resection is performed to avoid the complications associated with the increased size and the malignant transformation. Routine follow-up for all patients is advised due to the potential recurrence of these tumors.
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Effect of academic detailing on improvement in venous thromboembolism prophylaxis for critically ill and surgical patients in a tertiary care teaching hospital p. 39
Bijoy Kumar Panda, Vinod Kumar, MN Ketkar, Jignesh Shah
Background: Routine utilization of venous thromboembolism (VTE) risk assessment tool and prophylaxis has been suggested to prevent morbidity and mortality caused due to hospitalized VTE. At our tertiary care teaching hospital, underutilization of VTE thromboprophylaxis was a concern. Aim: This prospective interventional study evaluated the effect of academic detailing on improvement in VTE prophylaxis after risk assessment for critically ill and surgical inpatients at an Indian tertiary care teaching hospital. Methods: A focused group academic detailing for medical practitioners was performed. After the assessment of VTE risk with the help of Caprini VTE risk assessment model, inpatients were monitored for thromboprophylaxis according to risk score. Utilization improvement was assessed by comparing with our published results of the historical preeducation control group. The main outcome measures were VTE risk assessment in hospitalized patients, proportion of prophylaxis in risk categories post education, comparison with findings of the preeducation historical comparison group to assess the improvement of thromboprophylaxis in intensive care unit (ICU), and surgical ward. Results: Thromboprophylaxis was adopted in 288 (56.4%) postacademic detailing as compared to 46 (35.2%) preacademic detailing in the historical control group. The overall prophylaxis for VTE improved significantly with an absolute difference of 21%. The positive impact of academic detailing was significantly observed in ICU compared to surgical ward for VTE prophylaxis. Fear of bleeding and unproven VTE in follow-up Doppler prospective studies in postsurgical patients were the reasons for underutilization. Conclusions: An improvement for VTE prophylaxis was observed in ICU compared to surgical ward. The overall prophylaxis for at-risk VTE inpatients also improved, particularly in higher and highest-risk inpatients.
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To evaluate the role of two-dimensional perfusion angiography as a predictor in wound healing outcomes in patients of critical limb ischemia p. 44
Ganesh Kumar Marada, Varinder S Bedi, Sandeep Agarwal, Ajay Yadav, Ambarish Satwik, Dhruv Agarwal, Apurva Srivastava
Aim: The study was aimed to evaluate the role of two-dimensional (2D) perfusion angiography (PA) as a predictor in wound healing outcomes in patients of critical limb ischemia. Subject and Methods: It was a pilot study conducted over a period of 16 months after taking informed consent and institutional ethical clearance. The study included 40 patients of which 8 were lost to follow-up, hence the prospective data of 32 patients was collected and analyzed. Patients were subjected to endovascular intervention and 2D perfusion software was applied to the digital subtraction angiography images and its parameters were assessed. Transcutaneous oxygen tension (TcPO2) was measured pre- and postintervention and patients were closely followed up for the time taken for wound healing. Results: The median age was 62 years ranging from 30 to 85 years. Most common comorbidity was diabetes (21/32 patients). The mean Ankle–Brachial Index in the study was 0.55 and mean TcPO2 at admission was 26.5 mm of Hg. Most common involved angiosome was percutaneous transluminal angioplasty angiosome. Fifteen patients underwent direct, 9 indirect, and remaining 8 patients underwent revascularization in both territories. The mean percent improvement in TcPO2 was higher in indirect when compared to direct revascularization but it was not statistically significant. The time taken in wound healing was significantly higher in diabetics when compared to nondiabetics with P = 0.03. Most reliable parameter in 2D PA was area under the curve (AUC) which correlated with increase in volume of tissue perfusion. Patients with >100% improvement in AUC showed significantly better wound healing rates when compared to patients with <100% improvement (P = 0.04). Conclusion: This proved 2D PA as a reliable method for immediate assessment of improvement in microcirculation and as a predictor for wound healing. It can also be used as a real-time tool in optimizing the need and determining the end point for revascularization.
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Topical NATROX® oxygen wound therapy on patients with ischemic foot ulcers – A case series p. 50
S Roshan Rodney, Vivekanand, M Vishnu, KB Sumanthraj, Hemant Chaudhari, Dharmesh Davra, Piyushkumar Jain, CP S Sravan, Vaibhav Lende, Hudgi Vishal, K Sivakrishna, B Nishan
Background: The essential role of oxygen in wound healing is well documented, and recent developments in the delivery of topical oxygen therapy have made this a more viable treatment in practice. This article examines the role of topical oxygen – the NATROX® Oxygen Wound Therapy System in wound healing and looks at the impact of increased oxygenation on ulcer healing through a case series where the NATROX system was used in patients with ischemic foot ulcers. Materials and Methods: Topical oxygen therapy was evaluated in patients with ischemic foot ulcers in a tertiary referral specialist center. Results: During this case series of six patients, four patients had a complete healing before the study completion and two patients wounds were on a healing trajectory (average reduction in wound size of 60 %) during the follow-up, which eventually healed. Conclusion: NATROX® is an innovative topical oxygen delivery system that warranty further research to assess its potential impact on wound healing.
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Perioperative complications after revascularization in diabetic and nondiabetic chronic limb-threatening ischemia patients and its relation with preoperative hemoglobin A1c p. 54
S Roshan Rodney, Vivekanand, M Vishnu, KB Sumanthraj, Hemant Chaudhari, Dharmesh Davra, Piyushkumar Jain, C P S Sravan, Vaibhav Lende, Hudgi Vishal, K Sivakrishna, B Nishan
Background: Hemoglobin A1c (HbA1c) reflects average blood glucose over a 2–3 month period. Patients with an elevated HbA1c with and without diabetes have an increased risk of adverse outcomes following surgical intervention. Our aim is to determine whether elevated plasma HbA1c level is associated with high perioperative morbidity and mortality in chronic limb-threatening ischemia (CLTI) patients undergoing peripheral revascularization. Materials and Methods: This is a single center, retrospective analysis of 307 CLTI patients who underwent lower limb revascularization (open/endovascular/hybrid) at Jain Institute of Vascular Sciences over a 1-year period from January 2018 to December 2018. Patients were categorized into two groups as either diabetic or nondiabetic based on their history and preoperative plasma HbA1c level ≥6.5% or <6.5%, respectively. Diabetics were stratified into four subgroups (HbA1c ≥6.5%–7.4%, HbA1c 7.4%–8.9%, and HbA1c ≥9%) and controlled diabetes mellitus (HbA1c <6.5%) and nondiabetics into two subgroups (HbA1c <6.0 and HbA1c ≥6%–6.5%. The primary endpoints include perioperative major adverse cardiac event (MACE), major adverse limb event (MALE), and mortality. Results: Of 307 patients, 253 (82.4%) were diabetics and the rest 54 (17.6%) were nondiabetics. On comparison with other HbA1C groups, among diabetics those with HbA1c >9% had a significantly higher incidence of perioperative MACE 7 (12.07%), MALE 3 (5.17%), and death 6 (10.34%), and among nondiabetics, those with HbA1c levels (6%–6.5%) had a higher incidence of perioperative MACE 3 (9.68%), MALE 1 (3.23%), and death 1 (3.23%), but the difference was not statistically significant. Conclusion: HbA1c levels serve as an independent predictor of untoward events in CLTI patients with or without diabetes undergoing revascularization.
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A comparative study of postrevascularization limb salvage rate in early versus delayed presentation of rutherford class IIb acute lower extremity ischemia p. 58
Hemant Kadu Chaudhari, Vivekanand, Vishnu Motukuru, KB Sumanthraj, S Roshan Rodney, Hudgi Vishal
Background: Acute limb ischemia (ALI) is the most common vascular emergency with potential morbidity and mortality, which can be prevented by early appropriate treatment. Delayed presentation because of diagnostic delays and referrals continues to be a challenge for vascular surgeons. The purpose of this study is to evaluate the postrevascularization limb salvage rate in patients with delayed presenting ALI Rutherford Class IIb and compare it with early presenting ALI in a tertiary referral center in India. Materials and Methods: Fifty-one patients with Rutherford Class IIb acute lower limb ischemia, who underwent revascularization over a period of 2 years from June 2015 to May 2017 at Jain Institute of Vascular Sciences, Bengaluru, were evaluated in this study. Patients were divided into early presenting (<24 h) (n = 10) and delayed presenting (>24 h–14 days) (n = 41), and both the groups were compared with respect to limb salvage at 1 year. Patients with prior vascular intervention, posttraumatic ALI, and Rutherford Class I, IIa, and III were excluded. Results: Both the groups were comparable with respect to demographics, lesion characteristics, and comorbidities. The mean age in the early and delayed presenting groups was similar. Majority of the patients were male. The most common level of occlusion was femoropopliteal segment. All patients underwent transfemoral/transpopliteal thrombectomy + angioplasty/stenting. Fasciotomy was performed in almost half of the patients based on clinical need. The limb salvage rate was 91.67% in the early presenting group, whereas in the delayed presenting group, it was 72.73%, but the difference was not statistically significant (P = 0.178). None of the patients in the early presenting group had morality, whereas it was 12.20% in the delayed group, which was statistically not significant (P = 0.249). Conclusion: In patients with Rutherford Class IIb ALI in spite of delayed presentation, good limb salvage rate can be achieved if revascularized.
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Impact of vascular access type on health-related quality of life in patients undergoing hemodialysis: A cross-sectional observational study p. 63
Parag Sonawane, Rohit Maheshwari, Abhishek Singh, Arvind Ganpule, Ravindra Sabnis, Mahesh Desai
Objective: Patients undergoing hemodialysis (HD) have a poor health-related quality of life (HRQoL). HRQoL may differ across geography and ethnicity. This study aimed to compare HRQoL in patients undergoing HD by arteriovenous fistula (AVF) and central venous catheter (CVC) in a cohort of Indian population. Methods: This was a cross-sectional observational study conducted between March 2016 and June 2016. All patients undergoing HD (more than 2 months) who had vascular access using AVF or CVC were eligible to participate in the study. Sociodemographic characteristics were noted, and HRQoL was assessed using the Short Form 36 questionnaire. Results: A total of 58 patients were included in this study, 31 in CVC group and 27 in AVF group, without any crossover. The mean (standard deviation) age was 47.4 (18.1), and the median (range) duration of HD was 14 months (2 months–120 months).Overall, patients who underwent AVF for vascular access had significantly (P < 0.05) higher HRQoL score than those who underwent CVC. There was no significant difference of HRQoL score for majority of the parameters for sex and age, for all the parameters for duration of HD. Conclusions: Overall, results showed that patients who had vascular access using AVF showed better HRQoL as compared to CVC in patients with HD.
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VASCULAR CLINICS: Images & Techniques 2 p. 67

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Anthologies of vascular specialty articles - 1 p. 76

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Remembering the discovery of platelets: Max Schultze (1865) and Giulio Bizzozero (1882) p. 78
Karthikeyan Sivagnanam
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Endovascular repair of spontaneous common carotid pseudoaneurysm with covered stent graft p. 80
Hemant Kadu Chaudhari, Vishnu Motukuru, Vivek Anand, KB Sumanthraj, S Roshan Rodney
Extracranial carotid pseudoaneurysms are rare. They commonly occur secondary to blunt or penetrating trauma and rarely of spontaneous etiology. Rupture is one of the fatal complications; hence, surgical or endovascular treatment is warranted. We report a case of spontaneous common carotid pseudoaneurysm in a middle-aged female, which was successfully treated with a covered stent-graft.
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A rare case report of extensive extracranial internal carotid artery aneurysm and its endovascular management p. 83
Dhanesh R Kamerkar, Rajendra Chavan, Bhushan D Shinde, Kritika Tiwari
Aneurysms of the extracranial carotid arteries can occur as a result of atherosclerotic degeneration, traumatic injury, dissection, or local infection or as a complication after carotid endarterectomy. Extracranial carotid artery aneurysm (ECAA) is an uncommon but important clinical entity. Carotid aneurysms are extremely rare in comparison with atherosclerotic occlusive disease of the same location. These aneurysms are also rare in comparison with aneurysms involving the intracranial carotid arteries and their branches. The reported incidence of incidental intracranial aneurysms discovered in autopsy studies ranges from 0.8% to 18%. The incidence of ECAA is largely unknown, but it represents only 1%–1.5% of procedures performed for extracranial cerebrovascular disease at major referral centers.
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Giant aneurysm of the ileocolic artery presenting as abdominal mass p. 88
Raja Lahiri
An aneurysm of the abdominal splanchnic artery is a relatively rare vascular disorder. Since it is characterized by nonspecific clinical manifestations, an aneurysm in this uncommon location is usually diagnosed following complications. A 55-year-old female presented with a pulsatile lump in her right iliac fossa. Contrast-enhanced computerized tomography diagnosed it as aneurysm of the superior mesenteric artery (SMA). However, on exploration, SMA was found to be free, and the aneurysm was seen to be arising from the ileocolic artery ending in the appendicular branches. Ligation followed by excision of the sac along with the cecum and appendix was done followed by ileoascending anastomosis. Isolated aneurysms of the SMA branches are rare. Most cases are diagnosed after the occurrence of complications. Due to the high risk of rupture and ligation, they can interrupt the circulation to the target organs, and therefore, surgery is indicated even in the absence of complications.
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Hemophilic pseudotumor of abdomen: A rare case report p. 91
Anil Luther, Amit Vipan Mahajan, Sukhdev Pandey
Hemophilic pseudotumor is one of the rare complications of hemophilia, which occurs due to repetitive bleeding resulting in an encapsulated mass of clotted blood and necrosed tissue. Complications and symptoms arise due to pain and compression of surrounding structures. We present a rare case of pseudotumor of the abdomen in a 35-year-old male with severe hemophilia B. Pseudotumor was treated successfully with excision of tumor.
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A novel technique of tunneled venous conduit retrieval for femoropopliteal artery bypass p. 94
George Varghese Kurien, Manoj P Nair, Lincoln Samuel, Nikhil Joe Jacob
We would like to report a novel technique in the use of endoscopically retrieved reverse saphenous vein for femoropopliteal bypass grafting. A common mishap encountered while tunneling reversed saphenous vein is avulsion of side branches. At our center, we improvised and used an autoclaved Fogarty catheter case to tunnel the reversed saphenous vein. We found this technique to be safe, cheap, and reproducible even in a low-volume center.
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Jet flow aneurysm of inferior mesenteric artery p. 96
Sam Pon Raj, Edwin Stephen, Albert Kota, Vimalin Samuel, Dheepak Selvaraj, Prabhu Premkumar, Sunil Agarwal
A 56-year-old male was evaluated for postprandial abdominal pain and was detected to have an inferior mesenteric artery (IMA) aneurysm associated with critical ostial stenosis of the celiac and superior mesenteric arteries. He underwent aneurysmorrhaphy of the IMA along with revascularization of the superior mesenteric artery with graft from the aorta using a 6-mm ringed polytetrafluoroethylene graft and made an uneventful recovery.
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Posttraumatic subclavian artery pseudoaneurysm: An endovascular approach p. 99
Ilayakumar Paramasivam, Shabnam Fathima, N Sritharan, Krishna Muralidharan, Jayanth Vijaykumar
The use of minimally invasive vascular techniques for vascular injuries is on the rise. We report a case of stab injury with pseudoaneurysm of the subclavian artery treated with “covered” stent of the subclavian artery. The patient presented a month after the injury and was hemodynamically stable. Hence, a computed tomography angiogram of the arch of the aorta and left upper limb was performed and taken up for elective stenting of the left subclavian artery. The completion angiogram showed complete exclusion of the pseudoaneurysm, with normal runoff to the upper extremity. In conclusion, penetrating arterial trauma in inaccessible sites can be successfully managed with minimal morbidity by endovascular means.
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Revascularization in Mönckeberg medial calcific sclerosis p. 102
Jithin Jagan Sebastian, Pranay Pawar, MK Ayyappan, Kapil Mathur, Naveen Rajendra, Radhakrishnan Raju
Mönckeberg medial calcific sclerosis (MMS) is a rare disorder of medial calcification for which open repair has always been the standard. We present two unusual cases of MMS affecting different arterial segments, for which bypass was done. The first patient presented with extensive aortoiliac medial calcification. She had a near normal ankle brachial index on one side and critical limb ischemia on the other. A femorofemoral crossover bypass was carried out. The patient improved symptomatically. The second case involved a femoropopliteal segment Mönckeberg sclerosis for which a femoro-distal bypass was carried out. Both patients continue to remain asymptomatic after 2 years of follow-up. Open surgical repair remains the ideal method of repair in this rare condition of medial calcific sclerosis. The disease progression is very slow in these patients, and usually one segment of artery is involved.
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