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   Table of Contents - Current issue
October-December 2020
Volume 7 | Issue 4
Page Nos. 329-451

Online since Thursday, December 24, 2020

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Martyred by the microbe Highly accessed article p. 329
Kalkunte R Suresh
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2020 – The year of COVID Highly accessed article p. 333
Robbie K George
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Inferior vena cava filter thrombosis: An overview Highly accessed article p. 335
Murtuza Razi, He Xu, Gu Jianping, Mohammed Jameeluddin Ahmed
The leading long term and undervalued impediment associated with inferior vena cava (IVC) filter placement is said to be increased risk of venous thrombosis within and below the IVC. Anticoagulation remains the mainstay treatment preference for the management of deep-vein thrombosis (DVT) and pulmonary embolism (PE). Now and then, it is not viable due to bleeding complications or, occasionally, breakthrough PE associated with this treatment method. In these patients, the development of vena cava filters was a significant advancement in their management. Patients with IVC filters predominantly the ones placed with permanent filters are considered to be at a greater risk for the development of recurrent DVT. Cautious applications of IVC filters, along with retrieval of temporary IVC filters in good time, significantly diminishe the risk of IVC thrombosis. The proof of connection of IVC thrombosis with each of the following factors is known: Population demographics, history of or preexisting hypercoagulable states/anticoagulation, the manner in which the thrombus is assessed, and the duration since the filter employment. Most cases of IVC filter thrombosis are asymptomatic. Contrast-enhanced computed tomography is a preferred imaging modality compared to Doppler sonography. Here in this article, we attempt to discuss briefly the present ideas concerned with the indications of IVC filters along with the prevalence, risks, and management of IVC filter thrombosis.
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Economic impact of Coronavirus disease of 2019 pandemic on vascular surgeons in India p. 340
Prem Chand Gupta, Ishita Joshi, Pritee Sharma, G V R K Acharyulu, Gnaneswar Atturu
Introduction: Coronavirus disease of 2019 (COVID-19) pandemic has affected virtually everyone in every walk of life globally including all health-care services. The economic impact of such disruptions in vascular surgery services on vascular surgeons in India is unclear. This study aims to understand the economic impact of COVID-19 pandemic on vascular surgeons practicing in India. Materials and Methods: A questionnaire consisting of 15 questions was created using Google Forms and circulated through E-mail and WhatsApp groups dedicated to vascular surgeons in practice and/or training in India and was available for 2 weeks. Only vascular surgeons who are currently practicing in India were eligible to participate in the study. Results: One hundred and eighty-four out of 400 (46%) members that are thought to be currently practicing or in training in India participated in the study. 98.91% completed all the questions. 90.2% (n = 166) of the respondents were aged below the retirement age of 60. Thirty-four worked in government job, 89 in private sector on salary basis, and 58 in private sector as fee for service. Seventy-one percent of the respondents (including trainees) reported a negative impact on their monthly income due to COVID-19 pandemic ranging from 10% to 90%. Seventy-six percent of the respondents believed that there will be a further negative impact in the coming few months. Sixty-nine percent claimed that they did not have alternative sources of income. 82.6% were not aware of measures to overcome such adverse economic impact and have not taken any preventive steps or measures. Conclusion: The results of the study show that COVID-19 pandemic had a significant negative economic impact on majority of the vascular surgeons practicing in India resulting in a 50% or more reduction in their income. Skills and knowledge about financial resources, financial resilience, and risk management are needed to prevent or overcome future crisis.
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Arterial thoracic outlet syndrome – The need for early detection and surgical correction and how to do subclavian artery repair without resection p. 346
Sekar Natarajan
Objective: Arterial compression at the thoracic outlet is rarely diagnosed before embolization occurs. Decompression, embolectomy, and resection of the subclavian artery and interposition graft repair is the most common method of treatment. This is a retrospective analysis of a single surgeon experience with subclavian artery repair without resection for arterial thoracic outlet syndrome. Materials and Methods: Sixty limbs underwent surgery for arterial compression at the thoracic outlet in 57 patients over the last 29 years (1989–2018). There were 24 males and 33 females. The age group varied from 10 to 60 years. Thrombointimectomy and repair of the subclavian artery were done on 54 of the 57 symptomatic limbs. Three patients underwent prophylactic decompression of the thoracic outlet on the contralateral asymptomatic side. Results: Fifty-two patients had complete cervical rib, two had abnormal first rib, and three patients had fracture clavicle with nonunion. Fifteen patients presented with severe rest pain and pregangrenous changes in the finger tips. All the rest presented with ischemic changes of varying degrees in the upper limb. The duration of symptoms ranged from 2 to 300 days. All patients underwent decompression of the thoracic outlet in the form of scalenectomy and cervical rib or first rib resection. Thrombointimectomy and repair of the poststenotic dilatation without resorting to resection were done in 54 limbs. Only three patients required resection of the artery. One patient had end-to-end anastomosis and two others had interposition grafts. In addition, 43 patients had additional transbrachial embolectomy to clear the distal artery. Two patients had cervicodorsal sympathectomy. No patient underwent major amputation, but two patients required finger amputation. Palpable wrist pulse could be achieved in 45 patients. Patients were followed for an average of 2 years. Palpable pulse disappeared at 6-month follow-up in four patients. These four and another three patients with palpable pulse and the remaining 12 patients with no wrist pulse continued to have minor ischemic symptoms in the fingertips. Long-term follow-up did not reveal any aneurysm or stenosis at the subclavian repair site. Conclusion: Cervical rib though a congenital condition can remain asymptomatic till a later age. Arterial compression is rarely diagnosed before embolisation occurs. The distal artery may not be completely cleared of thrombi, and about 30% of the patients continue to suffer from ischemic symptoms even after successful surgery. Hence, all patients with complete cervical rib should be investigated and followed up with duplex scan for evidence of arterial compression. They should be advised prophylactic decompression when they develop duplex evidence of arterial compression. Intimectomy and subclavian artery repair produce good long-term results, and unnecessary resection of the subclavian artery should be avoided.
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Graft-related complications after open surgery of abdominal aortic aneurysm – An 8-year follow-up study p. 351
Vineeth Kumar, Prakash Goura, Sreekumar Ramachandran, Unnikrishnan Madathipat, Ashutosh Kumar Pandey, Sriram Manchikanti, Neelamjingbha Sun, Shivanesan Pitchai
Introduction: Open surgery repair (OSR) is generally considered as a single definitive procedure and requires minimal postoperative follow-up once immediate survival is established. There are many studies which focus on endovascular aneurysm repair reintervention, only few contemporary studies report graft-related reinterventions after open repair. The present study describes the incidence of graft-related complications following OSR for abdominal aortic aneurysm (AAA) and its management. This study also analyse the factors which can preoperatively predict the occurrence of graft related complications, so that necessary steps can be taken to prevent such complications. Materials and Methods: This is a single-center prospective analysis of 165 patients who underwent elective open repair for AAA over a period of 8 years from January 2008 to December 2016. Demographics, preoperative, perioperative, and postoperative data were recorded in a structured data collection sheet after reviewing patient records and institutional electronic medical records after obtaining clearance from the Institutional Ethics Committee. Results: The overall incidence of graft-related complications in our study was 6.6%. The most common graft-related complication in our study is iliac graft limb occlusion 3.6% followed by graft infection of 1.5% and anastomotic pseudo aneurysm of 1.5%. The graft-related reintervention rate is 5.1% and graft-related mortality is 1.5% in 8-year follow-up. The risk factors for graft-related complications are preoperative uncontrolled DM, aorto-iliac aneurysms, use of bifurcated graft, and postoperative wound infection. Conclusions: This study showed that aggressive control of DM preoperatively and anastomosing distal Y-limb of graft to femoral artery rather than external iliac artery may decrease the complications. The majority of graft-related complications occurred 2 years after surgery. Hence, we suggest that those patients with above risk factors should be put on a short-interval surveillance program.
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Postoperative complications in geriatric patients in vascular surgery: A tertiary care center experience p. 356
Royson Jerome Dsouza, Prabhu Premkumar, Vimalin Samuel, Albert Kota, Dheepak Selvaraj
Introduction: The frequency of operations in geriatric population has been on a rise due to longevity and better medical care. Developing countries such as India have a significant proportion of geriatric patients who require various surgical interventions. There is limited data on various postoperative complications that are seen in geriatric vascular surgery patients. Methodology: A retrospective study was conducted in patients aged 65 and above who were operated under the department of vascular surgery, between 2013 and 2018. The patients' inpatient and outpatient records were analyzed to obtain the required data. Results: The study included 437 patients. The most common postoperative complication was surgery related (24.5%), followed by cardiac complications (13.5%). The overall mortality rate was 2% (n = 9). The 30-day readmission rate was 15.7%, of which peripheral arterial occlusive disease was seen in 92.7% of the patients. The patients who underwent endovascular procedures had fewer postoperative complications compared to those who underwent open procedures (14.3% vs. 23.3%). The incidence of intensive care unit transfers was 19.9%. The primary amputation rate was 21.5% and the secondary amputation rate was 21.6%, with a limb salvage rate of 78.4%. Conclusion: Postoperative complications are significant in geriatric patients. Recognizing the increasing and complex nature of geriatric patients, special measures must be taken to minimize the in-hospital complications.
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Carotid endarterectomy 20-year experience in a low-volume center p. 361
Felipe Gerardo Rendón Elías, Gabriel Anaya Medina, Marely Hernández Sánchez, Carlos Miguel Salas Rios, Gustavo Armando De La Cerda Belmont, Luis Humberto Gómez Danés
Introduction: Carotid endarterectomy (CEA) is the first choice in the treatment of extracranial carotid occlusive disease but exists the controversy if this surgical procedure must be done just in center of high volume. Objective: The aim of the study is to assess if it is safe to perform CEA in a low-volume center and trying to answer some controversial questions about the preoperative, transoperative, and postoperative management. Design: This was a retrospective and observational case study. Patients and Methods: Details of 328 consecutive patients operated upon for carotid stenosis from September 1998 to December 2018 were analyzed. Results: Perioperative mortality was 0%. Perioperative neurological morbidity was 0.6% with major strokes and 1.2% minor strokes and transient lesions of cranial nerves were 4%, and there was no reoperation for bleeding or thrombosis. Conclusion: The zero percent mortality and low complication rate in our hospital are related to improved preoperative patients' evaluation, surgeons' increasing experience, and to surgical and anesthesiologic technique, so following a strict protocol, performing a CEA in a low-volume center is safe.
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Evaluation of carbon dioxide angiography in lower limb angioplasties of peripheral arterial disease patients with borderline chronic kidney disease compared to the standard contrast agent p. 370
Nikhil Vilas Chaudhari, Sandeep Agarwal, Varinder Singh Bedi, Ambarish Satwik, Ajay Yadav, Apurva Srivastava
Introduction: Assessment of carbon dioxide (CO2) angiography for its efficacy and limitations in lower limb angioplasties for chronic limb-threatening limb ischemia needs to be evaluated in detail, as the use of CO2 as a contrast agent has a distinct advantage over conventional iodinated contrast medium (ICM) in patients with borderline chronic kidney disease (CKD), with respect to nephrotoxicity caused by the later. Aims and Objectives: To study the quality of angiography images obtained with CO2 as a contrast agent and the efficacy of CO2 angiography in guiding lower limb angioplasties for critical limb ischemia. Design: This was a prospective, observational, comparative, cohort study. Study Period: September 2017–December 2018. Materials and Methods: Patients of critical limb ischemia with raised serum creatinine level (>1.49 mg/dL) who were not on the dialysis and undergoing endovascular revascularization were enrolled in the study. Hand injections were made using CO2 Angioset. Intraoperative evaluation of image quality obtained using CO2 was done by two vascular surgeons and compared with conventional contrast medium. Necessary therapeutic intervention was performed using CO2 angiography image if reliable image was acquired using the same. Results: A total of 100 patients were evaluated consisting of 176 arterial segments, out of which 145 segments required use of ICM and 31 segments were intervened using CO2 only as a contrast agent (19 superficial femoral artery, 6 common iliac artery, 2 pop artery, 3 external iliac artery, and 1 anterior tibial artery). Assessment of scores given by the observer 1 and observer 2 was performed by their comparison for the statistical significance using McNemar–Bowker test and was found to be statistically significant with P = 0.02. Kendall's Tau b coefficient is 0.74 (significant) and Cohen's kappa is 0.63 (significant). Good-quality images were seen in above the knee (ATK) segment in 39.3% and moderate in 57.8%. However, below the knee (BTK) segments received poor image quality score in majority, i.e., 82.6%. There was significant reduction observed in the total volume of ICM. No major adverse reaction/complication encountered during the procedures was observed, except pain being the most common and distressing complication. Conclusions: CO2 angiography is a very useful tool in the armamentarium of vascular surgeon, especially while performing angioplasties for peripheral arterial disease in borderline CKD patients, not on dialysis, because it not only reduces the amount of iodinated contrast used but also has good imaging ability in ATK vessels. It was fought with multiple issues while imaging BTK vessels, leading to reduction in its reliability and feasibility in that segment.
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Limb salvage following below-the-ankle angioplasty in critical limb ischemia p. 376
B Nishan, K Siva Krishna, V Vishal Hudgi, VP Ahsan, Vivek Anand
Aim: The aim was to report limb salvage following below-the-ankle (BTA) angioplasty as an adjunct to proximal angioplasty in patients with critical limb ischemia (CLI). Methods: We performed a retrospective analysis of CLI patients who underwent BTA angioplasty as an adjunct to proximal angioplasty between 2013 and 2018 and followed for 6 months. Patient demographics and outcomes were recorded. Outcomes were determined by major amputation (primary outcome), wound healing, and mortality (secondary outcome). Results: Between 2013 and 2018, 59 BTA angioplasties were performed in 52 patients. Patients were divided into two groups based on the results of BTA angioplasty. Successful BTA angioplasty was accessed using post angioplasty angiogram showing a complete plantar arch and improved TcPO2 measurements (preoperative and postoperative). Group 1 (41) includes patients with successful BTA angioplasty and Group 2 (11) includes patients with unsuccessful BTA angioplasty. Patients were followed up for 6 months. Demographics and comorbidities did not influence outcomes in both groups. At the end of 6 months, wound healing, major amputation, and mortality were 92%, 4%, and 4%, respectively, in Group 1 and 9%, 90%, and 54%, respectively, in Group 2. Successful BTA angioplasty has a significant role in preventing major amputation, improved wound healing, and decreased mortality (P < 0.001 [significant]). Conclusions: BTA angioplasty for CLI is technically safe and feasible with satisfactory results for limb salvage.
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Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance p. 380
Preeti Shivshankar Awari, P Vatsalaswamy
Background: Critical limb ischemia (CLI) has been a burden on society where revascularization of arteries is the first line of treatment. If the antegrade approach is not possible, retrograde approach through pedal–plantar loop can be done, resulting in better prognosis. For the same reason, assessment of blood vessels of foot in general is practiced before any intervention. Having information about normal anatomy and anatomical variants of these blood vessels could be of great help to the interventionist to reduce the postoperative complications. Context: The authors studied formation of plantar arterial arch, normal anatomy, and anatomical variations in plantar metatarsal arteries (PMTAs) regarding their origin in 50 formalinized adult cadaveric feet. Results and Conclusion: Variations in formation of plantar arterial arch as predominant lateral plantar artery supplying to most of the PMTAs were noted. Common stump of origin for the first and second, then for second and third, and also for the third and fourth PMTAs was found. In two feet, we found common stump of origin for the first PMTA and first dorsal metatarsal artery originating from deep plantar arch. Medial branch from medial plantar artery joined the first PMTA to supply the great toe deep to the transverse metatarsal ligament. In about 28% of specimens, the foot length was ranging from 21.1 cm to 22 cm and the distance between the plantar arterial arch and the posterior margin of heel was ranging between 12 and 13.5 cm. Fibular plantar marginal artery was present in all specimens. Implications: In the retrograde approach for the revascularization in cases with CLI, most of the surgeons are trying the approach through plantar pedal loop or direct puncture of metatarsal arteries. Data collected on plantar metatarsal normal anatomy and anatomical variations can be kept in mind while doing any intervention with better prognosis.
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Interest of a standardized treadmill test to evaluate pressure drops and stiffness indices under short stretch bandages p. 385
Ravul Jindal, Florence Balet, Pascal Filori, Taranvir Kaur, Shabjot Dhillon, Shiwangi Thapa, Piyush Chaudhary
Introduction: Under short stretch bandages (SSB), the pressures drop over time. These pressures are documented in non standardized-way and vary from one study to another. Objective: A standardized stress test on a treadmill should help to better understand this evolution and thus to document with more precision the behavior of 3 bandages in use. Materials and Methods: Three bandage kits (Urgo K2, Kit Biflex and a kit consisting of padding + 2 cotton SSB2 were tested in 30 subjects (60 legs) before and after a treadmill test (3 km/h, 6% slope for 30 min or 1.5 km). Results: Before the test, the bandages were applied with nonsignificantly different resting interface pressures (respectively 40.58 ± 2.7 mmHg, 41.05 ± 2.17 mmHg, 38.16 ± 2.98 mmHg). When standing, the pressures were significantly different between Urgo K2, Kit Biflex and SSB2(55.58 ± 6.15 mmHg, 57.3 ± 6.53 mmHg versus 62.3 ± 5.07 mmHg for SSB2). Similarly, the static stiffness indexes (SSI) showed significant differences (15 ± 5.05mmHg and 16.25 ± 6.28 mmHg versus 24.13 ± 4.65 mmHg for SSB2). After the test, resting pressures drop but more significantly under the SSB2 compared to the other 2 multilayer bandages (resting pressures: 31.95 ± 2.66 mmHg and 34.61 ± 2.28 mmHg vs. 25.95 ± 3.15 mmHg for SSB2). However, the SSI is not significantly different from the SSI calculated before the treadmill test (15.41 ± 4.44 mmHg and 15.66 ± 4.85 mmHg vs. 25.06 ± 4.98 mmHg). Conclusions: The treadmill test makes it possible to quantify and to compare the drop in pressure under different bandages in the same conditions. This test could be useful in clinical research before the clinical phases of development, especially in the case of venous leg ulcer. On the other hand, in case of mixed ulcers, the drop in pressure in lying position in multilayer bandages ensure a continuation of the arterial influx in case of mixed ulcers.
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Posttraumatic cavernous internal carotid artery pseudoaneurysm causing massive epistaxis: Our experiences at a tertiary care teaching hospital of eastern India p. 389
Santosh Kumar Swain, Ishwar Chandra Behera, Somnath Jena
Background: Pseudoaneurysm of the cavernous internal carotid artery (ICA) is an uncommon clinical incidence. This may cause massive epistaxis and pose a life-threatening situation for patient. Aim: The aim of this study to acquaint the clinicians with this rare cause of the massive epistaxis due to posttraumatic pseudoaneurysm of the cavernous ICA. This study evaluates the details of patient's profile including presenting symptoms, investigation, treatment, and outcomes. Materials and Methods: Data of seven patients with cavernous ICA pseudoaneurysm presenting with epistaxis from March 2018 to April 2020 were retrospectively reviewed. Results: The age range of the patients was from 22 to 64 years. Duration of head trauma to the epistaxis ranged from 1 month to 4 months. All had history of head trauma. All were managed by endovascular coil embolization. Conclusion: Cavernous ICA pseudoaneurysm can cause life-threatening epistaxis. Patients present with severe epistaxis and history of head trauma should be thought for traumatic pseudoaneurysm of cavernous ICA. Endovascular coil embolization of the pseudoaneurysm is an important option for effective treatment.
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Outcomes from our model for a nurse-led vascular renal access surveillance clinic p. 395
Alison McGill, Nigel Pinto, Mandy Zweedyck, Jason Jenkins
Background: A patent arteriovenous fistula (AVF) with adequate flow is essential for performing successful hemodialysis. However, the literature currently reports 1-year patency rates of 69%–74%. Surveillance of AVFs has been proposed to prevent failure of fistulas with the associated morbidity and mortality. We implemented a renal access surveillance clinic with the aims of detecting stenoses and arranging treatment to avoid underdialysis and thrombosis of AVFs. Methods: The nurse-led vascular renal access surveillance clinic (VRAC) of the Royal Brisbane and Women's Hospital was created in 2015. The surveillance program is run by a full-time vascular clinical nurse with experience in renal access. Over the 3-year period of 2015–2017, 1006 patients were in the surveillance program. We compared the rates of intervention on fistulas and the incidence of thrombosed fistula in the 5 years preceding the initiation of our VRAC surveillance program, with the 3 years after it was commenced. Results: Our results show that our rates of intervention on threatened fistulas have increased since the program was established, and that the percentage of thrombosed fistulas has remained stable. Allowing this early triage has expedited management and freed more outpatient clinic time. Conclusion: We have compared outcomes before and after implementation of a nurse-led dialysis access surveillance program and have found that the percentage of thrombosed fistulas has remained stable as the rates of intervention have increased for threatened fistulas.
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Central venous occlusion in dialysis patients – Novel surgical management p. 399
Amitabha Chakrabarti, Manujesh Bandyopadhyay, Sathish Kumar
Introduction: The progress in the management of maintenance hemodialysis and renal transplant has led to longer survival and also increased incidence of delayed complications. One of its dreadful complications is central venous occlusion which needs a satisfactory management. Materials and Methods: Bilateral subclavian vein occlusion, innominate vein occlusion, or superior vena cava occlusion remains the most dreadful scenario for central venous stenosis and central venous obstruction (CVO) in dialysis patients. In these patients who are refractory to endovascular options, surgery must be considered. We hereby describe our experience of managing these complications by a novel surgery of draining the area proximal to CVO to the right atrium by reinforced Polytetrafluoroethylene graft. Results: Three of our patient's symptom relief, salvage of arteriovenous fistula, and primary graft patency (mean – 20 months) were achieved satisfactorily. No postoperative mortality or no severe morbidity noted. Anticoagulation orally used up to 3 months of operation. One patient had graft occlusion and mild symptom recurrence. Conclusions: All the current endovascular options for CVO in dialysis patients are prone to recur. Extra-anatomic central venous bypass grafting draining into right atrial appendage is a novel management to relieve the complications. A satisfactory conduit with long-term patency and minimum thrombotic complications is still not available. Randomized control trials with long-term follow-up are needed to develop appropriate treatment algorithms.
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Outcomes of endovascular procedures in salvage of arteriovenous fistulas via the transradial route: A prospective study p. 405
Pranay Pawar, MK Ayyappan, Kapil Mathur, Radhakrishnan Raju
Aim: To evaluate the primary patency and predictors of technical failure of arteriovenous fistulae (AVF) following transradial percutaneous transluminal angioplasty (PTA). Materials and Methods: This was a prospective study being conducted to evaluate the primary patency and predictors of technical failure of AVF following transradial PTA. This will help us identify high-risk patients and plan interventions in them at an earlier time to avoid access loss. The time period of the study was from October 2016 to October 2018 in the Department of Vascular and Endovascular Surgery at Sri Ramachandra Medical College, Chennai, Tamil Nadu. A total of 44 patients were included in this cohort and they were all followed up in the outpatient department and via telephonic contact for a period of 1 year. All the patients who underwent endovascular AVF salvage fitting the inclusion criteria were included in the study. The demographics of the patients were recorded at admission and patients were investigated for the cause of fistula dysfunction at the treating physicians discretion and an ultrasound Doppler was ordered for all patients to ascertain the cause of the stenosis. The statistical analysis was done by the ANOVA and t-test. Results: A total of 44 patients were included in this cohort and they were all followed up for a period of 1 year. The 30-day, 90-day, 6-month, and 12-month primary patencies were 84.1%, 81.8%, 63.63%, and 43.18%, respectively. Our technical success was 88.6%. In our study, we found that longer lesion lengths (>4 cm) were prone to early loss of primary patency and this was statistically significant. We found that patients above 60 years of age had lower primary patencies and the presence of diabetes mellitus also lowered the primary patency. Fistula maturation age did not show a correlation with patency in our cohort. Male patients had a higher patency rate and juxta-anastomotic stenoses postangioplasty had a higher primary patency due to the shorter lengths. Radiocephalic fistula angioplasties had a higher patency as compared to brachiocephalic angioplasty. Conclusion: Ours is the first study in India to proactively and preferably use the transradial approach over the transvenous approach, as it confers many benefits. The challenges of the transradial route are the smaller size of the radial artery in the Indian population as compared to the western population.
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Single-Staged arm basilic vein transposition for arteriovenous fistula surgery - clinical pearls and outcomes p. 411
Kapil Baliga
Background: Arm basilic vein transposition (aBVT) is a well-established arteriovenous (AV) access modality for the end-stage renal disease (ESRD) to ensure hemodialysis. Purpose: The purpose was to discuss the clinical pearls and evaluate the outcomes of single-stage aBVT procedure. Methods: This was a retrospective case series Results: Twenty-four patients with ESRD underwent single-stage aBVT as an AV access procedure. A majority (58.33%) of patients aged between 45 and 65 years. Diabetic nephropathy was the most common cause of renal failure. The patency achieved was 83.33% at the end of a 12-month follow-up period. Conclusion: The single-stage procedure is a safe, efficient, and cost-effective option for these patients, especially in the developing regions of the world. Here, we elaborate on the simple tips and pointers to ensure an effective single-stage procedure to minimize complications of kinks, thrombosis, or early failure and achieve faster time to cannulation and a longer cannulation length.
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Assessment of risk factors in established cases of venous thrombosis p. 415
R Chithra Barvadheesh, R King Gandhi, B Sai Dhandapani, Ganesh P Uchit
Background: Despite prevalence of venous thrombosis (VT) in Indians, there are few prospective studies. Objective: To analyze the demographic profile, proven risk factors, and coagulation profile of south Indian patients with proven VT. Materials and Methods: This single-center prospective observational study was conducted among patients with proven VT from August 2013 to July 2019. Hypercoagulable workup (serum homocysteine, activity of protein C, protein S and anti-thrombin III, antiphospholipid antibodies immunoglobulin [IgM] and IgG, factor V [Leiden] mutation) was performed. Results: Out of 295 patients (mean age 56 years; male 64%) of VT, 85.76% had deep vein thrombosis (DVT) whereas 14.24% had superficial vein thrombosis (SVT). Patients with DVT were significantly older than those with SVT (P < 0.05). DVT was most common in the femoropopliteal segment 132 (52.17%), followed by the iliofemoral segment 78 (30.83%). Unprovoked primary cases (58%) were common. A total of 123 (41.69%) patients had identifiable provoking risk factors, of which malignancy 30 (24.39%) and postsurgery status 29 (23.58%) were the most common causes. A total of 101 (34.47%) patients were tested for coagulation abnormalities of whom 14 (13.86%) had normal profiles. Hyperhomocysteinemia was the commonest coagulation anomaly 59 (58.41%). Factor V (Leiden) mutation tested in 48 (16.27%) patients of which six (12.5%) were positive. Conclusions: Study population of VT revealed male predominance. Immobilization due to either medical or surgical causes, emerged as a major risk factor. The most common modifiable factor is postoperative care and the common coagulation anomaly is hyperhomocysteinemia.
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Defining the factors leading to stroke due to retrograde embolism in arterial thoracic outlet syndrome by literature search and report of two cases p. 420
Aneesh Mohimen, Ajay Kumar Dabas, Jitesh Goel, Ravi K Anadure
Context: Stroke due to retrograde embolization in a case of arterial thoracic outlet syndrome (aTOS) is rare, and little is known about predisposing factors. Objective: The aim of this study is to analyze the predisposing factors and mechanisms of stroke in aTOS based on literature survey and experience with two cases. Materials and Methods:Data Sources and Selection: Databases MEDLINE, PubMed, Scopus, and Cochrane Library were searched, supplemented by scanning of reference lists of relevant publications. All publications with subclavian artery/axillary artery stenosis/occlusion, either due to bony and/or muscular abnormality, in the thoracic outlet, with stroke, till January 2020 were included. Data Extraction: The clinical and anatomical details such as gender, age, side affected the type of stroke (anterior/posterior), bony/skeleton abnormality, upper limb symptoms, and their duration, were noted and analyzed. Data Synthesis: A systematic analysis of the accessed reports was performed. Statistical Analysis: The measure of the significance of the association of various factors was calculated with z-test. Results: Forty-eight articles describing 58 patients were identified. Fifty-five patients were analyzed. The involvement of the right upper limb (P = 0.00001), age <40 years (P = 0.00001), and the presence of upper limb ischemic symptoms (P = 0.00001) significantly predispose to the development of stroke in aTOS. Twenty-seven percent had a recurrent stroke. Conclusions: Stroke is a rare complication of aTOS. A possible explanation exists for retrograde embolism; however, validation is required by further studies. Stroke in young with upper limb ischemia or absent pulses merits a search for aTOS.
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Curiosity is the mother of invention: Guidewires and catheters p. 429
Pritee Sharma
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Internal carotid to external carotid transposition for symptomatic carotid stenosis with associated coil p. 432
Nicolas Ramly, Animesh Singla, Eric Farmer
The significance of dolichoarteriopathies of the internal carotid artery (ICA) both in isolation and in the context of the proximal stenosis is a topic of contention. The majority of asymptomatic cases are treated conservatively, however symptomatic cases which can present as transient ischemic attacks or stroke, often require surgical intervention. Herein, we discuss unique surgical management of a patient with a symptomatic high-grade left internal carotid artery (ICA) stenosis and concurrent ICA coiling in which an end-to-side anastomosis onto the external carotid artery was performed.
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Kommerell diverticulum with right-sided aortic arch with aberrant left subclavian artery p. 435
Sourabh Mittal, Anil Sharma, Sunil Dixit, Mohit Sharma
The right aortic arch with aberrant left subclavian artery is the most common cause of vascular ring and can be either asymptomatic or symptomatic owing to mass effect. Removal of Kommerell diverticulum and division of the ligamentum arteriosum through a left thoracotomy is currently advocated in symptomatic patients and patients with large diverticulum (>5 cm) to avoid inherent complications.
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Gangrene of penis in a patient with chronic kidney disease on dialysis p. 438
Hussam Alzaarir, Abdellah Rizziki, Achraf Miry, Adnane Benzirar, Amal Bennani, Omar El Mahi
Gangrene of the penis in patients with chronic kidney disease undergoing hemodialysis is a rare occurrence. Such patients often have associated comorbidities such as type II diabetes mellitus and systemic hypertension. These conditions accelerate the process of atherosclerosis, which, along with calcium deposition, causes partial or complete obstruction of the blood vessel lumen, leading to ischemic necrosis at the tip of the penis. This adds to the preexisting morbidity and mortality in such patients. In most cases, appropriate medical management is advocated to prevent the deposition of calcium in the lumen.
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Surgical correction of traumatic common femoral artery aneurysm in intravenous drug abuser p. 441
Prasesh Dhakal, Pratima Thapa, Sushil Dahal, Niroj Bhandari, Sohail Bade, Prabha Shrestha, Robin Man Karmacharya, Amit Kumar Singh, Satish Vaidya
Trauma is an uncommon cause of common femoral artery aneurysm (CFAA). We present a 31-year-old male with a history of intravenous drug abuse with an incidental finding of the right leg CFA aneurysm during ultrasonography Doppler for deep vein thrombosis. The aneurysm was surgically excised and repaired with polytetrafluoroethylene graft as good peripheral veins were not available due to the history of repeated puncture. Peroperative finding was a right-sided CFA aneurysm measuring about 3 cm × 1 cm with the distal end 1 cm below profunda femoris. In cases of growing CFAA, surgical excision and anastomosis between proximal and distal segments using a conduit are the treatment modality.
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Letter to the editor- step-by-step guide to averting and managing a central line insertion misadventure p. 444
Srineil Vuthaluru, Asuri Krishna
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Free grammar check for your manuscript p. 445
Himel Mondal, Shaikat Mondal
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Anthologies in vascular surgery-part 4 p. 447

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