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   Table of Contents - Current issue
January-March 2019
Volume 6 | Issue 1
Page Nos. 1-57

Online since Friday, March 8, 2019

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Hypocritic Oath p. 1
Kalkunte R Suresh
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Ringside view of evolution of endovascular therapy in the management of aortic aneurysms p. 3
Varinder Singh Bedi
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President's Address - Vascular Society of India p. 5
SR Subrammaniyan
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Secretary's Appraisal p. 6
S Jeyakumar
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Clinical utility of mobile phone-based thermography and low-cost infrared handheld thermometry in high-risk diabetic foot Highly accessed article p. 7
Robert Boguski, Tanzim Khan, Stephanie Woelfel, Karen D'Huyvetter, Alexandria A Armstrong, David G Armstrong
Literature is replete with robust studies documenting the potential clinical utility and net protective effect of the use of temperature assessment/inflammometry in high-risk diabetic foot. We present a mobile phone-based device (FLIR One Personal Thermal Imager, FLIR, Inc., Wilsonville, OR, USA) and a stand-alone handheld device (Nubee, Duarte California, USA) to provide simple, quantifiable images to assist in rapid clinical visualization. Therefore, the purpose of this manuscript was to highlight the potential day-to-day application of these tools.
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Vascular anomalies: Presentation and response to medical and surgical management, our experiences in the last 5 years p. 10
Robin Man Karmacharya, Bibushan Kalu Shrestha, Bikesh Shrestha, Mohan Devbhandari, Sampurna Man Tuladhar
Aim: Vascular anomalies, lesions of abnormal vascular development pose a significant challenge in some of the cases for diagnosis and management. The International Society for the Study of Vascular Anomalies has classified this condition into two broad types as vasoproliferative or vascular neoplasms such as hemangioma and vascular malformation. We have analyzed all the cases with vascular anomalies that have presented in outpatient department (OPD) in the past 5 years. Materials and Methods: All patients presented to vascular OPD of Dhulikhel Hospital in the year 2013–2017, if patients are diagnosed with vascular anomalies, are included in the study. Details on age, sex, site of the lesion, and medical or operative management performed are analyzed. Results: Of the total 51 vascular anomalies cases, the mean age of the patient was 22.4 years (standard division. 8.4, range 6 months to 51 years). Female-to-male ratio was 2.4:1. Forty cases (70.48%) belonged to vascular malformation while 11 cases (21.56%) were of hemangioma. In case of vascular malformation, 18 cases were of venous malformation while 8 cases were of capillary malformation. There were a total of 14 arteriovenous malformations. The highest number of anomalies was noticed in the lower limb (39.22%) followed by the head (25.49%). Regarding treatment modality opted, in five cases, medical management with oral steroids and propranolol was advised. In 35 cases, surgical resection was done. Conclusion: Vascular anomalies are detected in fairly young patients with preponderance in the female. Treatment of vascular anomalies is complex and is based on stage, type, and location of each anomaly.
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Comorbid conditions responsible for the higher complications and poorer outcome in cardiac and vascular surgery: Time to reconsider hyperhomocysteinemia and its repercussions p. 13
Arun Kumar Haridas, Bharathi Shridhar Bhat
Background: Plasma homocysteine is a perceived risk factor for the cardiovascular diseases. Many studies confirmed its remarkably high level with severity of the disease. There are no studies to correlate plasma homocysteine level and outcome of surgery in patients suffering from cardiovascular diseases. Objective: The purpose of our clinical study is to analyze the correlation of plasma Homocysteine levels in patients undergoing coronary artery bypass grafting (CABG) and various peripheral vascular surgeries regarding various patient variables such as age, sex, and also the severity of disease and outcome of surgery. Materials and Methods: The plasma homocysteine levels of 200 patients undergoing CABG and various vascular surgeries, between January 2016 and January 2018 were analyzed. This was a prospective study, data about patient variables obtained from questionnaires handed out to the patients during the preoperative period. All peripheral arterial diseases patients were symptomatic and belong to Rutherford stage 3, 4, 5, and 6. The severity of disease was evaluated based on coronary angiogram (CAG), who was undergoing CABG and computed tomography (CT) angiograms for patients presenting with peripheral vascular disease (PVD) and peroperative findings. A total of 178 CAG and 100 CT peripheral angiograms assessed. Homocysteine levels were determined by CLIA method and levels of >13 mmol/L taken as hyperhomocysteinemia. All patients had surgical vascular intervention in the form of CABG, peripheral vascular bypass, and thromboembolectomy. The results and complications evaluated postoperatively. Result: Higher homocysteine levels associated with a higher number of triple vessel coronary disease and symptomatic PVD. They had greater severity of the disease. It is also associated with poorer target vessels with an increased morbidity and postoperative fatality. Conclusion: Homocysteine level is one of the independent risk factors for severity of CAD. It can have predictive value in CABG, peripheral vascular surgery, and poor postoperative outcome.
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Iatrogenic vascular injuries: An institutional experience p. 19
C Shanmugavelayutham, P Ilayakumar, K Elancheralathan, B Velladurachi, J Amalorpavanathan, M Rajkumar
Introduction: Iatrogenic vascular injuries are emergency referrals to the vascular surgeon. They can lead to prolonged hospitalization, higher cost, limb loss, mortality, and litigation. Aim: The aim of this study is to analyze the referral patterns and outcomes of iatrogenic vascular injuries managed in our institution from 2008 to 2013. Materials and Methods: Patients with iatrogenic vascular injuries referred to the vascular surgery department of our institution from July 2008 to Sep 2013 were included in this study. Those with isolated injury to superficial venous system were excluded from the study. Data were collected from a prospectively maintained database and analyzed with respect to patient characteristics, mode and type of vascular injury, intervention, and outcomes. Results: The incidence of iatrogenic vascular injuries was progressively on the rise year on year during the study period. The incidence was most common in the age group of 31–45 years contributing about 30%. The incidence was more in males (65%). A significant number of iatrogenic vascular injuries occurred in pediatric population (25%). The most common mode of iatrogenic vascular injuries in children was due to intravascular injections and it accounted for 50% of amputations. There was no difference in the incidence among medical and surgical specialties. Conclusion: Iatrogenic vascular injuries appear to progress day by day. Early and proper management can be a limb or life-saving. Late referral ended up in limb or life loss. Thorough knowledge of anatomy and image-guided interventions can be a preventive measure of iatrogenic vascular injuries.
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Salvage procedures for failing arteriovenous fistula: “An institutional experience” p. 23
Sunil Kumar, Uma Kant Dutt, Suresh Singh, LN Dorairajan, R Manikandan, Ezhilnilvan Sampath, Tepukiel Zaphu
Introduction: Arteriovenous fistula (AVF) is lifeline for patients with end-stage renal disease. A fistula should be mature enough to support efficient hemodialysis. The most important requirement is adequate blood flow through the fistula. This goal is achieved in most AVF. Few fistulas do not mature, i.e., there is inadequate blood flow through the fistula. In this condition, we may close this improperly functioning fistula and create fistula at another site. Closure or ligation of inadequate, but uncomplicated fistula, is not the norm. Another less utilized and described option is to perform some auxiliary procedures to salvage the fistula when indicated. Auxiliary procedure may also be necessary in conditions such as steal syndrome and venous hypertension (VH). We present our experience with some of these auxiliary procedures. Aims: The aim of the study is to retrospective analysis of fistula salvage procedures for failing fistulae in our institution. Settings and Design: This was a retrospective, observational study. Subjects and Methods: A retrospective analysis of AVF was performed during the past 2 years that failed to mature and support an efficient hemodialysis. Another group of patients who had either steal syndrome or VH were also reviewed. Auxiliary procedures were done on all these patients with encouraging results. Results: In four patients, ligation of collateral was done. In one patient in whom there was a side-to-side arteriovenous anastomosis, ligation of distal venous segment was done to reverse VH. Another four patients with steal syndrome underwent partial occlusion of the vein near anastomotic site. In nine patients, endovascular dilation and/or stenting of stenosed segment of the vein was done. Conclusions: In patients with suboptimally working fistula, a lesion-specific auxiliary procedure can salvage and enhance their performance.
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Foot arteriovenous malformation: A single-institutional Experience p. 28
Dheepak Selvaraj, Edwin Stephen, Vimalin Samuel, Albert Kota, Shyamkumar N Keshava, Vinu Moses, Munawwar Ahmed, George Koshy, Suraj Mammen, Prabhu Premkumar, P Boopalan, Sunil Agarwal
Background: Arterio venous malformations (AVM) encompass a wide spectrum of lesions that can present as an incidental finding or produce potentially life- or limb threatening complications. The symptoms, treatment options, results, and prognosis of foot AVMs are relatively poorly known compared with AVMs involving other parts of the body. We present a series of 6 patients with foot AVM that have been managed between July 2015 and January 2018. Aims and Objectives: We plan to review the treatment of peripheral AVMs and options of treatment available. As AVM's form 10-20% of congenital vascular malformations [CVM], they remain challenging to treat and often pose threat to both life and limb due to their unpredictable nature, when compared to venous malformations [VM] or lymphatic malformations [LM]. The least common CVM's are the peripheral AVM's. Material and Methods: Six patients who presented to the Vascular Surgery OPD who underwent treatment with varying modalities are presented here. All the patients presented to our tertiary care center having received treatment elsewhere for a pulsatile swelling of the foot. Prior treatments received were mainly compression bandages / garments and in one case sclerotherapy with alcohol. Results: Two of 6 patients had been offered below knee amputations and we were able to preserve limbs on both patients. Options used were alcohol, Histacryl glue, foam sclerotherapy. Each patient is presented in detail with accompanying images. Conclusions: There is a need to increase awareness about AVM's amongst members of the medical fraternity its diagnosis and management options.
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Subclavian carotid transposition: A single-center experience p. 33
Hemachandren Munuswamy, Duvuru Ram, Sreevathsa Prasad, Suresh Kumar Rajan, Durgaprasad Rath, Bathal Vedagiri Saichandran
Objective: Subclavian carotid transposition (SCT) is generally performed for stenoocclusive disease of the proximal subclavian artery. This study was undertaken to analyze the results of SCT at our center and also highlight the usefulness of this procedure in varied pathologies involving the proximal subclavian artery. Patients and Methods: This retrospective study included 16 consecutive patients from 2011 to 2016 who presented to our department. The study was carried following approval by the Institute Research Committee and the Institute Ethics Committee. The data were collected from the departmental database, and the patients were followed up prospectively and the data were analyzed. Results: The mean age of the patients at presentation was 46.6 years with standard deviation of 11.48. Eleven patients (78%) had total occlusion of the proximal subclavian artery. About 81% of the patients had left-sided SCT. The etiology for SCT was varied with ten patients (62.5%) having proximal subclavian artery occlusion with chronic upper-limb ischemia, three patients (18.75%) with acute subclavian artery occlusion, one patient with bilateral cervical ribs, one patient with dysphagia lusoria with aberrant right subclavian artery (ARSA), and one patient with right common carotid aneurysm. The mean follow-up duration was 64 months. The patency rate was 100% in the study population. There were no immediate occlusions or stenosis noted in our series. Conclusion: SCT is a safe, effective, and durable procedure with long-term patency rates with less morbidity and reintervention rates. It can be safely done for both acute and chronic subclavian artery occlusions and various other conditions too such as dysphagia lusoria due to ARSA and cervical rib with subclavian artery occlusion. Hence, a vascular surgeon should master the art of doing SCT for its good results and for its being effective for varied pathologies.
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Evaluation of radiofrequency ablation for primary varicose veins: A preliminary study p. 37
Jayachandra Reddy Metta, Rohit Mehra, Shyam S Jaiswal, Anand R Bhagwat, Gagandeep Singh
Background: Endovenous radiofrequency ablation is gaining popularity as an alternative to conventional surgical treatment of varicose veins. The initial experience with this treatment modality is presented along with review of literature. Methods: A prospective study of 31 consecutive patients with primary great saphenous vein varicosities was undertaken. The procedure was performed under spinal anesthesia using bipolar radiofrequency induced thermotherapy CELON (Olympus) system with continuous pull-back technique. Additionally, multiple stab phlebectomies were performed to deal with tributary varices. Post-operatively; at one, four, twelve and twenty four weeks, the patients were followed up in out-patient department with clinical examination and ultrasound duplex imaging. The occlusion of great saphenous vein trunk, length of residual patent proximal great saphenous vein and improvement in quality of life using revised Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire were recorded and analysed using appropriate statistical methods. Results: The mean (SD) age of patients was 41.8 (14.1) years with an average BMI of 23.4 kg/m2. Ten patients had C2 disease, four C3, thirteen C4, and two each; C5 and C6 disease. Average length of great saphenous vein ablated was 41.9 cm with a mean ablation time of 62.3 (18.6) seconds. Post procedure total occlusion rate at 24 weeks follow-up, was 93.1% and the quality of life indices showed a statistically significant improvement. Conclusion: Endovenous radiofrequency ablation holds immense promise as a safe and effective modality for the treatment of varicose veins of lower limbs.
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Rudolf Virchow and venous thromboembolism: A recognition after 100 years p. 42
Devender Singh
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Mechanochemical endovenous ablation: Latest varicose vein treatment p. 44
Ravul Jindal, Deepali Verma, Taranvir Kaur, Shabjot Dhillon, Navjot Kaur, Piyush Chaudhary
Superficial dilated veins known as varicose veins develop due to damaged valves. Treatment of varicose veins is very important to undertake because of its acute (bleeding and clot formation) and chronic complications (lipodermatosclerosis and venous ulcers). Various techniques have been used for their treatment in the form of endovenous laser treatment, radiofrequency ablation, steam ablation and others. Now mechanochemical endovenous ablation (MOCA) has emerged as the latest nonthermal technique for the varicose vein treatment. It can be done by two methods as follows: Clarivein (Vascular Insights, US) and Flebogrif (Balton, Poland). We have presented in this case report, efficiency of MOCA technique in a 40-year-old, very pain sensitive male with CEAP classification C3EpAsPrand no deep vein insufficiency. MOCA was done as a day care procedure under local anesthesia. Standard protocol for technique was followed. Postprocedure patient was discharged after 20 min of observation. Follow ups were done at 6 weeks, 3 months and 6 months. Skin changes settled at 6 weeks without complications. In this technique, complications which are usually seen in thermal techniques are comparatively rare. Overall MOCA technique is highly effective modality for the treatment of varicose veins with success rates reaching up to 94%.
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Stent Endarterectomy and patch closure of occluded infrarenal aortic bare metal stent for critical limb ischemia p. 47
Ajay Savlania, Abhiney Reddy, Ashutosh Pandey, M sandeep
The technological advances in the field of percutaneous procedures have facilitated the increased use of endovascular modalities for peripheral arterial disease management with benefit of decreased morbidity. Progression of disease in this group of patients has further led to the rise of difficult-to-manage group of patients. We report a case of occluded bare metal infrarenal aortic stent, which was managed by stent endarterectomy of the stent-bearing segment of aorta followed by repair of aortic segment with patch aortoplasty. The patient is doing fine at 8 months of follow-up. This case describes the feasibility of the management of occluded aortic stents placed for occlusive disease by endarterectomy with explantation of stents as revascularization procedure in good-risk patients for surgery.
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VSICON 2018 Prize Paper Abstracts p. 49

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