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   Table of Contents - Current issue
July-September 2021
Volume 8 | Issue 3
Page Nos. 195-302

Online since Tuesday, July 6, 2021

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Hope for the future p. 195
Kalkunte R Suresh
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Asymptomatic carotid stenosis: Are we under treating? Highly accessed article p. 197
Edwin Stephen
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Venous thromboembolism in COVID 19 infection: Prevalence and practice of prophylaxis - A narrative Highly accessed article p. 199
U Vasudeva Rao, MD Wasim
The aims of this review are to ascertain the true prevalence of venous thromboembolism (VTE) in critically ill COVID 19 patients, to explore the strategy regarding prophylaxis and whether intensified prophylaxis is required for critically ill patients and to review the published guidelines to identify areas where clarity is required. An electronic search of the literature on VTE in COVID patients with reference to prevalence and prophylaxis was made using PubMed as the main search engine. A snowball search was followed to retrieve additional relevant data. The database consisted of prospective and retrospective studies and systematic reviews. The results showed that the reported incidence of VTE varies from <10% to more than 60%. Majority of studies reported a higher incidence of VTE in critically ill COVID 19 patients. Few authors, therefore, suggested a higher dose of low molecular weight heparin (LMWH), but this approach has not been validated. There is also a suggestion to extend the prophylaxis postdischarge. There are also reports of thromboprophylaxis with LMWH improves outcome in critically ill patients. This review confirms the generally held view that the incidence of VTE is higher in COVID 19 patients who are critically ill. However, whether they will benefit from a higher or intensified dose of Heparin is not fully assessed, with opinion equally divided among researchers there are few other grey areas like prophylaxis post discharge and in ambulatory patients.
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Evolution of patient safety in surgery p. 205
Sobhana Iftekhar Tani, Nandan Haldipur
Medicine since its inception has continued to evolve. The past few decades have seen many specialties branching out. This is been to the increasingly complex nature of the field consequent to advances in technology and understanding of the human body. In addition to advancing technology, there is a relatively recent focus on safety. Studies have shown that there are a significant number of errors with serious consequences that occur among surgical patients. Many of these errors are preventable. Several factors play a role which includes nontechnical aspects such as human factors. This is most evident in high-pressure complex situations such as an operating theatre. This prompted the World Health Organization (WHO) to take up global patient safety challenges. With the motto of “Safe Surgery saves lives,” the WHO has undertaken numerous regional and global initiatives to improve patient safety and pioneered the implementation of the surgical safety checklist. Patient safety has evolved as an important part of surgical practice. This article presents a brief narrative of the development of patient safety in the surgery, its expansion, and future direction.
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Peripheral vascular system thrombosis and COVID-19: A chilling revelation p. 208
Syed Mohammed Ali Ahmed, C Saravanan Robinson, DN Sharmila, SK Balaji, Sudharsan Reddy Yalamuru
Introduction: As the COVID-19 pandemic reaches, its zenith a worrying trend has been noticed of late, that is arterial and venous thrombosis in patients presenting with COVID-19. Arterial and venous thrombosis was found in patients with asymptomatic state to severe affliction and most of them had a delayed presentation. Materials and Methods: An observational study was carried out by the Department of Vascular Surgery, Madurai Medical College. There were around 15200 total admissions between March 15, 2020, to September 30, 2020, in corona specialty hospital and trauma care center affiliated to Madurai medical college, out of which: (1) Acute deep venous thrombosis (DVT) was seen in 349 patients. (2) Acute limb ischemia (ALI) was found in 75 patients, out of which 70 patients had lower limb involvement and 5 patients had upper limb involvement. (a) Class 3–50 patients. (b) Class 2b–15 patients, (c) Class 1–10 patients. (3) Acute mesenteric ischemia was seen in 8 patients. Conclusion: COVID-19 is associated with an increased incidence of arterial and venous thrombosis of peripheral vascular system wherein arterial thrombosis, presenting, as ALI is profound and has a multi fold increased incidence than in non-COVID-19 patients and venous thrombosis is much higher than the non COVID-19 state.
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Chronic venous insufficiency in pregnant women p. 213
Nabnita Patnaik, Nihar Ranjan Pradhan
Objective: C-hronic venous insufficiency (CVI) occurs in up to 80% of pregnant women, while around seven of every 1000 pregnant mothers face venous thromboembolism and pulmonary embolism. A review of the literature on CVI in pregnant women reveals considerable guidance for their treatment. Pregnancy causes significant hemodynamic changes within the circulatory system. Pregnancy has significant effects on the lower extremity venous system. Increasing venous pressure and blood volume, in combination with reduced flow rates within the deep veins, predisposes pregnant women to both primary and secondary CVI. This article highlights the specific physiologic and hemodynamic changes that occur during pregnancy and examines the nonpharmacologic, pharmacologic, and invasive interventions that are appropriate for both prophylaxis and treatment of CVI. Methods: This study is a review article of the key literature related to CVI in pregnancy. Results: Consequences of pregnancy can result in venous disease only during pregnancy or, particularly in the multiparous patient, can progress to CVI. Significant hemodynamic changes occur in the lower extremities during pregnancy. Conclusions: There is a paucity of data available to construct guidelines for care, particularly in pregnant patients with symptomatic superficial venous insufficiency. The physiologic changes throughout the arterial and venous systems during pregnancy are well documented.
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Brachiobasilic arteriovenous fistulas: A comparative outcome of different operative techniques p. 216
Mayank Yadav, Sumit Pratap Singh, Mohd Azam Haseen, Renu Yadav, Mohammed Haneef Beg
Introduction: Brachiobasilic arteriovenous fistula although little complex to create provides a suitable alternative to radiocephalic and brachiocephalic fistula, due to its autogenous nature and protective deep-seated anatomy of basilic vein. The purpose of this study was to evaluate the outcome among various techniques of brachiobasilic fistula (BBF) in terms of patency and complication rates. Methods: We retrospectively identified 50 patients in which BBFs were constructed between January 2015 and January 2018. The basilic vein was transposed in 16 patients and elevated in 34 patients: 14 as a single-stage technique and 20 with a two-stage (delayed elevation) technique. Results: The mean age of patients in this study was 50.8 years, with 72% of them having diabetes mellitus. There was no significant difference in the primary and secondary patencies among various techniques at 6, 12, 18, and 24 months. Neither there was any significant difference found in the complication rates between different techniques used to create BBF. The overall primary patency rates are 78% and 60% and secondary patency rates are 82% and 68% at 1 and 2 years, respectively. Conclusion: BBF can be considered as a true alternative before prosthetic grafts in patients with exhaustive cephalic veins.
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Graft patency and determinants of outcome in infrainguinal bypasses - A retrospective study p. 222
Sunil Rajendran, Sreekumar Ramachandran, P Sankara Sarma, Madathipat Unnikrishnan
Context: Chronic lower limb ischemia, an important marker of atherosclerosis, is a common clinical problem prevalent in all socioeconomic groups in our country and across the globe. Infrainguinal bypass is mandated in a subset of patients with critical limb ischemia to provide immediate limb salvage as well as excellent long-term results. Aim: The purpose of our retrospective study is to elucidate the effect of various known factors on the long term patency of infrainguinal bypass grafts performed in our patient population at a tertiary referral hospital. Methods: We retrospectively reviewed follow up data of 110 patients who had undergone infrainguinal bypass grafting over a period of ten years in our Institutional vascular registry. Graft patency rates and factors affecting thereof over this period were studied and the data statistically analysed. Overall cumulative patency rates were calculated by the life table survival method and compared with that of the patency rates of above-knee bypass procedures in the world literature. Patency rates in a different subset of patients were calculated and compared using the Wilcoxon (Gehan) test and Fisher's exact test to assess the influence of various factors in the long term outcome of the procedure. Results: Cumulative patency in terms of graft survival probabilities based on the life table analysis was 0.84, 0.80, and 0.64 at 30, 60, and 90 months respectively. Grafts in patients who had continued to smoke post-operatively had failed when compared with those who did not smoke (P = 0.01). Cumulative patency rates of non- diabetics were higher as compared to non-diabetics (0.70 vs 0.44; P = 0.04). Conclusion: Our study shows that continued smoking and diabetes are the determinant factors associated with graft occlusion. Strict avoidance of smoking and optimal control of diabetes is likely to improve graft function and long-term patency in patients undergoing infra-inguinal bypass grafting.
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Sympathectomy in postvascular surgical patients with severe pain in distal limb and/or small ulcers p. 228
Vinay Naithani, Budhi Prakash Bhatia, Dinesh Kumar Chanda, Ashok Sharma
Introduction: Sympathectomy is used principally in patients of inoperable peripheral vascular disease, small vessel disease, and vasospastic disease. It is useful to alleviate symptoms of rest pain and as an adjunct to heal ischemic ulcers. Aim and Objective: This is a clinical study to evaluate the role of sympathectomy in postvascular surgical patients with persistent pain in distal limb (causalgia) with or without ischemic ulcers on the foot or hand. Materials and Methods: This study was performed between February 2015 and February 2020. We did 823 arterial surgical interventions including embolectomies, endarterectomy with patch arterioplasty, and interposition grafting in upper or lower limb vessels. These patients were diagnosed on clinical bases and with investigational modalities such as arterial Doppler study and computed tomography angiography. All these patients had chronic vascular obstruction. Out of them, we selected 54 patients having persistent pain distal limb (causalgia) not relieved by medications. Besides causalgia, 24 patients had ischemic ulcers either on foot or hand. Postoperative arterial Doppler study was satisfactory in these patients. Their complaint persisted for 3–4 months in spite of all medications. Chemical sympathectomy was tried in 21 patients but was ineffective. We did thoracic sympathectomy in 28 patients and lumbar sympathectomy in 26 patients on side affected. Observation and Results: There were 46 males and 8 females. Majority of these patients were in active phase of life with a mean age of 35 (±2). Pain was relieved in all patients. Ischemic ulcers present in 24 patients also healed within 3–6 weeks. Conclusion: Although no clear guidance exists for the role of sympathectomy in postsurgical patients, we observe it is a boon for postvascular surgical patients with persistent pain and small ischemic ulcers.
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A prospective study of surgical revascularization in patients of buerger's disease from North India p. 231
Mohd Azam Haseen, Md Ghazanfar, Mohd Aslam, Mayank Yadav, Sumit Pratap Singh, Sayyed Ehtesham Hussain Naqvi, Manju Gupta, Mohammed Haneef Beg
Introduction: Buerger's disease, also known as thromboangiitis obliterans (TAO), is vasculitis of small- and medium-sized arteries and veins, which may involve both upper and lower extremities. It is strongly related to smoking and fairly common in the Indian subcontinent. Diagnosis is based on history, clinical examination, and angiography. The single most important modality of treatment is smoking cessation. As only few patients have suitable anatomy for surgical revascularization, the aim of this study is to evaluate the feasibility and outcome of surgical revascularization in TAO patients of North India. Methods: This is a prospective observational study involving 50 patients of TAO diagnosed by modified Shionoya criteria who underwent surgical revascularization. Computed tomographic angiography was done in all patients to see their suitability for surgical revascularization. Graft patency at 6 months postsurgery, pre- and post-operative ankle–brachial pressure index (ABPI), and visual analog scale (VAS) score for pain were calculated and compared. Results: All patients were male bidi smokers, with a mean age of 29.8 ± 9.5 years. Intermittent claudication was present in 42%, rest pain in 58%, and ulcer in 40%. Most common area of blockage was tibioperoneal trunk (62%) and tibial arteries (52%). The most frequent bypass procedure was popliteotibial done in 32 (64%) patients, followed by femoropopliteal bypass in 8 (16%) patients. Majority of our patients were symptom free at 6 months postsurgery. The mean VAS score for pain at the time of presentation was 6.08 ± 1.77, which decreased to 1.62 ± 1.23 at the end of 6 months. The mean preoperative ABPI was 0.45 ± 0.12 which improved to 0.73 ± 0.09 at 6 months postsurgery. A total of 46 (92%) limbs were salvaged while overall our graft patency rate was 70% at 6 months. Conclusion: We conclude that surgical revascularization is feasible in properly selected patients of TAO with acceptable results.
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Carotid artery diseases and endarterectomy: Historical milestones p. 238
Srujal N Shah
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Popliteal artery entrapment syndrome: Our experience of two patients with bilateral entrapment p. 240
Dhanesh R Kamerkar, Nachiket Purandare, Nupur Sarkar, Bhushan Shinde, Shishir Jaiswal
The true incidence of popliteal entrapment cannot be estimated due to a lack of awareness, misdiagnosis, and the relative rarity of presentation. Likely, only the most severe cases present for evaluation and workup and obtain a true diagnosis. We are presenting four legs of popliteal entrapment in two patients at different times.
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Iatrogenic preauricular arteriovenous fistula in underlying slow-flow venous malformation and its endovascular management p. 244
Pawan K Garg, Pushpinder S Khera, Preetham Pathvardhan, Sarbesh Tiwari, Taruna Yadav, Binit Sureka
Arteriovenous fistula (AVF) is direct abnormal communication with the shunting of blood from an artery to a vein without intervening capillary network. AVF in preauricular location is uncommon, and most of the cases are posttraumatic or iatrogenic. The endovascular route is the preferred approach for treating such a lesion with better cosmetic outcome, however surgical excision may be required for complex cases.
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Off-pump open repair of false aneurysm of aortic isthmus: This technique is still relevant p. 247
Adama Sawadogo, Hongbo Wang, Nicolas D'Ostrevy, Lionel Camilleri
Pseudoaneurysm is a rare long-term complication following coarctation of aorta repair. Thoracic endovascular aortic repair is the most common approach. However, under some circumstances, this cannot be performed. Therefore, the traditional open approach is indicated. Although the potential ischemia of spinal cord is related to this approach, it remains an efficient alternative. The authors report a case of late pseudoaneurysm of the distal aortic arch following coarctation of aorta repair in a 26-year-old male that has been successfully repaired by left thoracotomy.
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Differential hypothermic arrest with double-arterial cannulation p. 250
Rahul Sharma, Jignesh Kothari, Kinnaresh Baria, Archit Patel, Devvrat Desai
Thoracic aortic aneurysm (TAA) is a dilation of the aorta of >150% of its normal diameter for a given segment. Weakening of aortic walls results in saccular, fusiform, or diffuse dilation. The incidence of TAA is about 10 for every 100,000 adults, with 20% being of familial origin. TAA carries a high risk of morbidity and mortality, with surgery and thoracic endovascular aortic repair being the definitive treatment. In this case report, we present an innovative approach for addressing concomitant coronary artery disease and TAA repair using double-arterial cannulation and differential hypothermic circulatory arrest without any postoperative neurological sequelae.
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Thoracic endovascular repair for catastrophic aorto-enteric fistula secondary to esophageal stent: Case report and literature review p. 253
Krishna Kotecha, Animesh A Singla, Daniel Nguyen
Secondary aorto-enteric fistula (SAEF) following esophageal stenting is a rare but recognized pathology. These are multifactorial in etiology and can lead to life-threatening catastrophic hemorrhage. With the advent of thoracic endovascular covered stent technology, a minimally invasive means of addressing is problem has emerged. We aim to discuss the pathophysiology and underlying principles in managing this difficult problem. Prompt early recognition and multidisciplinary care are critical to success.
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Giant hepatic artery aneurysm: A rare case report p. 257
S Arun Prasath, Vella Duraichi, N Sritharan, S Prathap Kumar, P Ilayakumar, I Devarajan
Hepatic artery aneurysms (HAAs) are extremely rare entities. Given the high mortality rates with rupture, they should be treated early with either open or endovascular repair. We present a case of a 60-year-old man with HAA treated successfully by open surgical repair.
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Lower leg compartment syndrome detected by peripheral angiography p. 261
Sanjeev Kumar Singla
Compartment syndrome occurs when the pressure within a defined compartmental space increases past a critical pressure threshold jeopardizing the blood supply. Compartment syndrome can occur in any area of the body with closed compartments. The below-knee leg is the most likely compartment to develop acute compartment syndrome, followed by the forearm, thigh, and arm. Rapid diagnosis and treatment can be life or limb saving. Any delay in evaluating and treating patients with lower extremity compartment syndrome can be devastating for the patient. High suspicion is needed to diagnose the condition. The classic signs of compartment syndrome, the “6 P's,” can be deceiving. Advanced diagnostic techniques like peripheral angiography at the earliest can be lifesaving.
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Management of thigh hemangioma by laser ablation p. 264
Rusy S Bhalla, R Ashish Kapadia
Intramuscular hemangiomas are 0.8% of soft-tissue swellings. They can be present in adipose tissue or intramuscular compartment. Conventional management includes Compression, sclerotherapy, embolization, corticosteroids, and surgical excision. The laser is now advocated for hemangiomas due to no cosmetic deformity and high effectiveness. Presenting a case of Thigh hemangioma involving Vastus lateralis muscle.
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First global use of a covera plus covered stent graft for successful endovascular repair of a ruptured popliteal artery aneurysm p. 266
Harinder Singh Bedi, Jiten Singh, Vikram Arora
Popliteal artery aneurysms (PAAs) are the most common of all peripheral aneurysms. However, a ruptured PAA (rPAA) is rare, accounting for approximately 2% of all PAAs. We report a large rPAA successfully treated with endovascular repair using the Covera Plus covered stent graft. The patient did well. This is the first reported use in the world of a Covera stent for a rPAA.
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Lifesaving successful embolization of aggressive vertebral body hemangioma and a large pulmonary arteriovenous malformation p. 269
Prashant Gajanan Pote, Pankaj Banode, Shishir Rawekar
Vertebral hemangiomas are incidental finding and most of the time do not necessitate immediate attention unless symptomatic. Vertebral hemangiomas can be very aggressive to the extent that they can produce cord compression and paraplegia/paraparesis. Such cases need evaluation with magnetic resonance imaging to assess the cause, extent, and mass effect on the spinal cord. Transcatheter embolization and decompression surgery are well established modes of treatment as single or combined approach. Pulmonary arteriovenous malformation (AVM) is caused by the direct communication of main pulmonary artery with pulmonary vein, leading to a high-flow right-to-left shunt. This usually presents clinically as hypoxia, cyanosis, and dyspnea. The clinical signs and symptoms vary depending on the size, number, and flow of fistula as well as the associated vascular malformations. Transcatheter embolization is a treatment of choice for pulmonary AVM. However, this method may result in incomplete resolution if the malformation is large in size or supplied by multiple feeding arteries. Surgical resection may be considered in those kinds of cases. As AVM can lead to hemodynamical instability, these lesions need to be addressed first. In this case, pulmonary AVM came to notice post surgical decompression. Here, we report a case of aggressive vertebral body hemangioma and a large pulmonary AVM in the same patient, which were treated by embolization in two different settings.
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Homocysteinemia-induced upper-extremity deep-vein thrombosis: A sinister at high altitude p. 274
Saurabh Sud, Yogesh Kumar, Saurabh Bhardwaj, Deepak Dwivedi
Hyperhomocysteinemia is a rare condition which predisposes to arterial and venous thrombosis. Plasma homocysteine levels are influenced by many genetic factors and environmental factors. Increased levels of homocysteine at high-altitude areas (HAA) can predispose to upper-extremity deep-vein thrombosis (UEDVT). Therefore, awareness by the medical authorities regarding this entity at HAA as a sole cause of UEDVT needs to be established. Prompt reduction in the homocysteine level can be therapeutic as well as prophylactic in preventing the morbidity.
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Multiple penetrating descending thoracic aortic ulcers and intramural hematoma with a right massive hemothorax in a young male p. 277
Surya Satya Gopal Palanki, Sreekanth Yerram, Srinivas Bhyravavajhala, Amaresh Rao Malempati
Penetrating aortic ulcer and intramural hematoma is one of the causes of acute aortic syndromes and can present as an emergency. It is common in older individuals with multiple risk factors and rarely presents as hemothorax on the right side. We present a young male without significant risk factors who presented acutely with the right massive hemothorax. On evaluation, he had multiple ulcers in the descending thoracic aorta, which was successfully managed with a stent graft. This case illustrates the rarity of presentation at a young age and rarity of manifestation with the right hemothorax.
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Non healing venous ulcer: An interesting presentation p. 280
Pranay Pawar, Konda Samuel Paul Pradeep, Amit Mahahan, Anil Luther
Chronic leg ulceration affects 1–2% of the population and is associated with poor healing, frequent ulcer recurrence, and significant morbidity. Venous reflux can be identified in more than 70% of ulcerated legs. Coexistent arterial disease may be a factor in up to 20% of patients, but the clinical significance is poorly understood. We describe a patient who presented with a lower-limb ulcer, which was treated as a misdiagnosed case of venous ulcer for 12 years, following femoral pseudoaneurysm ligation.
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A case of brachial artery infected aneurysm secondary to infective endocarditis from intramuscular steroid use p. 283
Thomas Lovelock, Anastasia Dean, Ayushica Saran, Thodur Vasudevan
Infected aneurysms are a subset of aneurysms associated with infection. Approximately 10% of infected aneurysms involve the upper extremity. Infected aneurysms present a management challenge as patients are often unwell with concomitant infective endocarditis or septicemia. We present a case of a brachial artery infected aneurysm secondary to mitral valve infective endocarditis likely due to intramuscular anabolic steroid use. A 52-year-old male presented with a 24-h history of lethargy, blurred vision, and ataxia. He had a background history of intramuscular anabolic steroid use for the past 5 years. Swelling of his left arm localized to his cubital fossa was noted. Blood cultures were positive for Cardiobacterium hominis. Transthoracic echocardiography demonstrated a large vegetation on the mitral valve. Magnetic resonance imaging angiography demonstrated a right middle cerebral artery aneurysm. Computed tomography angiography of the left arm demonstrated an abrupt filling defect of the distal 2 cm of the brachial artery, with surrounding fat stranding and aneurysmal degeneration of the artery. Following successful aneurysm coiling, the patient underwent excision and debridement of the infected aneurysm. Histopathology was consistent with infected thromboembolism with aneurysmal degeneration of the artery. The patient underwent mitral valve replacement 10 days later. The brachial artery is the most common site of upper extremity infected aneurysms. Open surgical resection of the infected tissue is accepted as the gold standard. The rich collateral supply of the upper extremity permits ligation and debridement without needing simultaneous revascularization. We present this case to draw attention to an interesting manifestation of a rare pathology.
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Iatrogenic ulnar artery pseudoaneurysm: Emergency repair p. 286
Murugesan Ramaiya Periyanarkunan, Ganesan Chinnasamy, Murugan Sukumar Murugan, Soundarya Elavarasan
We present a patient with a rare vascular emergency of iatrogenic right ulnar artery pseudoaneurysm presented as an expanding hematoma with right forearm compartment syndrome following a percutaneous coronary intervention done to place stent in the left anterior descending artery through right transulnar approach (radial nondominant). A 71-year-old female was referred with a mass on the flexor aspect of the right forearm associated with severe localized pain, tenderness, and weakness of distal forearm and hand. Investigations had revealed a right ulnar artery pseudoaneurysm. Ultrasonography of the right forearm demonstrated a pseudoaneurysm with thrombus formation arising from the right ulnar artery and using a hand Doppler, no blood flow detected distal to the swelling. Surgical repair by an open approach was done to remove the hematoma and the ulnar artery puncture site was repaired. The postoperative period was uneventful.
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Delayed salvage of renal function in acute suprarenal aortic occlusion p. 290
Ashutosh Kumar Pandey, Tom Thomas Katoor, P M Vineeth Kumar, Harishankar Ramachandran Nair, Shivanesan Pitchai
Acute suprarenal aortic occlusion, though rarely reported carries a high morbidity and mortality. Renal ischemia is one of the usual presenting features. Limb salvage and renal preservation depend on prompt diagnosis and management. A young patient with acute suprarenal aortic occlusion having renal failure and limb ischemia was managed with suprarenal thrombectomy and aortobifemoral bypass at our centre. Even though the presentation was delayed, renal functions were restored post procedure. This case highlights that renal revascularisation can be attempted in select cases with delayed presentation.
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The persistent sciatic artery aneurysm a cause of recurrent limb ischemia – A rare case report p. 293
Dhanesh R Kamerkar, Nitin Pathak, Nachiket Purandare, Nupur Sarkar, Bhushan Shinde, Shishir Jaiswal
A persistent sciatic artery (PSA) is a rare vascular anomaly. It can cause complications, including acute and chronic limb ischemia, aneurysm formation, and compression of adjacent tissues during early embryonic development, the sciatic artery usually disappears when the superficial femoral artery has developed properly. PSA is usually an incidental finding and is exceedingly rare to find bilaterally. We are presenting a rare case of unilateral PSA aneurysm presented as an episode of recurrent acutely ischemic limb.
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Endovascular management of post COVID-19 arterial thrombosis p. 297
Ganesh Kumar Marada, Varinder Singh Bedi, Sandeep Agarwal, Ajay Yadav, Ambarish Satwik, Apurva Srivastava
Thrombotic complications have been reported widely in patients with severe coronavirus disease 2019 (COVID-19) infection. There has been an increasing trend of arterial thrombosis leading to significant morbidity and mortality. We report a case of a patient with COVID-19 related pneumonia who presented with acute limb ischemia.
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Anthologies in Vascular Surgery - Part 6 p. 301

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