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   Table of Contents - Current issue
August 2021
Volume 8 | Issue 5 (Supplement)
Page Nos. 1-105

Online since Monday, August 30, 2021

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BEWARE: The soothsayer was not a dreamer p. 1
Tapish Sahu, Dipit Sahu
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Vaccination ‘Hit’ by Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) p. 3
Natarajan Sekar
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D-Dimer and thrombosis in COVID-19 Highly accessed article p. 6
Jecko Thachil
The coronavirus disease 2019 (COVID-19) pandemic has taken medical community by surprise, but it also saw significant advances in understanding of infection induced coagulopathy. Pulmonary and macrovascular thrombosis is one of the hallmarks of this pandemic and has intrigued vascular surgeons world over. In this review, the lessons learnt from COVID-19 coagulopathy are summarised with some perspectives on role of newer concepts of immune mediated thrombosis and endothelial inflammation. D-dimers have become one of the most discussed inflammatory marker and also one of the commonest blood tests ordered in the COVID-19 pandemic. Its usefulness in management of COVID induced thrombosis has been a matter of debate and this article looks in to evidence based application of D-dimer in clinical practice. Role of Heparins, Direct Oral Anticoagulants (DOACs) and anti-platelets in prophylaxis and management of vascular thrombosis has also been summarised.
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Contralateral deep-vein thrombosis in lliac vein stenting – Incidence, etiology, and prevention p. 11
Venkataprasanna K Shanmugham, Venkatesh Bollineny, Prasenjit Sutradhar, Robbie K George
Iliocaval venous obstruction is a significant contributor to venous hypertension. Recanalization and stenting of chronic deep venous obstructions are minimally invasive and have been proven to be safe and effective with low complication rates over the past few decades. Common iliac vein (CIV) stents are usually extended into the inferior vena cava (IVC) to some extent to ensure adequately that key areas of stenosis are adequately treated. This may lead to contralateral CIV jailing and increase the risk of contralateral deep-vein thrombosis (DVT). The reported incidence of contralateral DVT after CIV stent placement from different studies varies from 1% to 15.6%. The predicted risk factors are noncompliance with anticoagulation, underestimation of the postthrombotic venous disease, preexisting IVC filter, incorrect stent placement, preexisting contralateral internal iliac vein thrombosis, malignancy, and thrombophilia. Literature suggests that the use of intravascular ultrasound, newer dedicated stents, and Z-stent modification reduces the incidence of contralateral DVT. Precise stent deployment technique and proper attention to other hematological risk factors are the key to preventing this complication. This article will review the incidence, mechanism, risk factors, and technical aspects of how to avoid this unfortunate complication. We will also review the newer dedicated venous stents.
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Our approach and review of current concepts of catheter directed procedures in acute limb ischemia p. 18
Amrita Patkar, Rishabh Gadhavi, Neha Kalwadia, R Sekhar
Acute lower limb ischemia (ALI) is defined as sudden reduction of limb perfusion, leading to a threat to viability of the extremity. With better access to technology and better training in endovascular management in peripheral arterial disease, catheter-directed procedures are an attractive and feasible option in ALI patients. This article deals with our approach to ALI, the basic guidelines and clinical pathway adopted for its management, the hardware and drugs used, and also intraoperative and postprocedural care. It also briefly delves into our experience in using this protocol as also the recent modifications to standard techniques that have been employed, keeping in mind drawbacks such as bleeding and failure of recanalization when employing standard procedures. All patients who presented with ALI from the period of June 2016 to May 2021 with a short history of symptoms <14 days, Class 1, 2a, 2b ALI, and those that were fit and adequately consented for the procedure were studied. Those with age over 80 years, history of gastrointestinal bleed, and history of central nervous system bleed in the last 30 days were automatically excluded from undergoing these procedures. During this period, we saw 112 ALIs in our department, of which 74 cases were primarily deemed suitable for catheter-directed procedures, 60 for catheter-directed thrombolysis, 6 for AngioJet, and 8 using the CAT6 Penumbra catheter. 6 (8.1%) cases subsequently failed the procedure and were converted to open surgery, of which only 2 of 6 had limb/s salvaged, meaning that 4 of 6 converted cases had major amputations. The high amputation rates (25 out of 112, i.e. 22.32%) were clearly attributable on audit, to a delayed referral to a tertiary care center, leading to a large number of Class 3 cases. In our part of the world, open surgical embolectomy is still the mainstay of treatment for ALI. However, an endovascular approach is an option that may be used in selected cases. The structural, personal, and technical conditions of each department must be considered before advocating this modality for therapy in patients.
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Outcomes with aspirin and clopidogrel versus aspirin and rivaroxaban in infrainguinal endovascular revascularization for critical limb ischemia p. 25
B Nishan, Vishal Hudgi, K Siva Krishna, VP Ahsan, Roshan Rodney, K B Sumanth Raj
Background: The purpose of the study was to assess the benefits of dual antithrombotic therapy in the management of peripheral arterial disease in Indian population. Methods: We conducted a prospective review of patients on dual antithrombotic therapy who underwent infra-inguinal endovascular revascularisation at JIVAS for 18 months. Objectives: To study the outcomes with aspirin + clopidogrel (CA) versus aspirin + rivaroxaban (RA) after infrainguinal endovascular revascularization for critical limb ischemia. The main objective was to assess primary patency of vessel after endovascular revascularization. The secondary objectives were to study limb salvage, major adverse limb events (MALEs), major adverse cardiac events (MACEs), bleeding events (major and minor), and wound healing. Results: In the present study, a total of 104 patients underwent infrainguinal revascularization and fulfilled the inclusion criteria, of which 48 received RA and 56 received CA. The mean age was 49.8 years with no significant differences in the baseline demographics and comorbidities between the two groups. The primary objective of vessel patency was assessed measuring the ankle brachial index which was 0.91 in the RA group and 0.96 in the CA group and remained the same on follow-up till 6 months and mean trans cutaneous oxygen pressure of around 34 in both the groups. There was no significant difference in the incidence of MALE (2.1% in RA vs. 7.1% in CA; P = 0.2), MACE (6.3% in RA vs. 10.7% in CA; P = 0.4), wound healing (81% RA vs. 75% CA; P = 0.4), safety parameter of bleeding (6.3% RA vs. 3.6% CA), creatinine, and liver function tests (LFT) during the study period. Conclusion: Both the antithrombotic regimens can be considered safe and efficacious in the postoperative management of patients undergoing infrainguinal revascularization; with maintenance of primary patency, comparable wound healing, incidence of MALE and MACE, and safe with no bleeding; and no impairment in the serum creatinine and LFTs during follow-up.
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Endovascular management and outcomes of aortoiliac occlusive disease p. 31
Madhur Kumar, Apratim Roy Choudhury, Puneet Garg, Anubhav Gupta, Yatish Agarwal
Introduction: Aorto-iliac Occlusive Disease (AIOD) involves the infra-renal aorta and the iliac arteries. Recent studies advocate endovascular management in TASC C and D lesions also. It involves balloon angioplasty with or without stent deployment.5 The aim of this retrospective study is to evaluate the results of endovascular balloon angioplasty and primary stenting in patients of AIOD. Methods: Twenty-five patients with Aorto-iliac occlusion disease who met the inclusion criteria during 1-year study period were included. Patients with acute thrombosis, abdominal aorta or iliac artery aneurysm and additional common femoral artery occlusion were excluded. The TASC II classification was used to define the characteristics of the lesions. The baseline data, procedural details and follow-up results were analysed. Results: Amongst 25 patients studied, age ranged from 40-75 years. Self-expanding metallic stent was employed in all patients. Technical success following primary stenting was achieved in all patients. Procedural times for TASC-II A, B, C and D lesions were 90+ 30, 110+ 40, 135+35 and 155+ 45 minutes, respectively. During follow-up, the cumulative primary patency rates at 1 month and 6 months were 100%. Cumulative primary patency rates at 1 year were 91.67%. Conclusion: Short- term outcomes of balloon angioplasty and stenting for Aorto-iliac artery occlusions in terms of primary patency rates were excellent.
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Assessment of quality of life between patients undergoing pharmacomechanical catheter-directed thrombolysis versus conservative management with iliofemoro-popliteal deep-vein thrombosis p. 36
S V R Krishna Yeramsetti, Shrikant Pandurang Ghanwat, Tapish Sahu, Virender Sheorain, Tarun Grover, Rajiv Parakh
Background: Pharmacomechanical catheter-directed thrombolysis (PCDT) has revolutionized the treatment of acute deep-vein thrombosis (DVT). Assessment and comparison of quality of life (QOL) in patients treated with anticoagulation alone and PCDT need to be elaborated more in the context of better management of patients. The objective of this study was to compare and assess QOL using health-related QOL (HRQOL) which includes short form-36 (SF-36) and VIENES QOL/sym scoring systems in anticoagulation alone group and patients treated with PCDT. Methods: There were 130 consecutive patients presenting to our department with acute iliofemoro-popliteal DVT (IFPDVT) with <2 weeks duration treated between April 2018 and April 2019 were included in the study. Sixty-five patients received anticoagulation alone and the other 65 patients received PCDT along with anticoagulation. Patients were assessed at baseline, the 1st month, and the 6th month in terms of QOL, deep venous patency (DVP), and deep venous reflux (DVR). Results: There was a statistically significant difference between the two groups in terms of QOL at 1st and 6 months. Mean physical component score and mental component score were statistically significantly better in PCDT than the conservative group at 1 and 6 months, respectively (P = 0.001). Mean venous insufficiency epidemiological and economic study (VEINES) QOL and VEINES SYM scores were significantly better in PCDT group than conservative group at 1 and 6 months, respectively (P = 0.001). Conclusion: QOL, DVP, and DVR are significantly better when PCDT is offered as an initial option when compared to anticoagulation alone. HRQOL (SF 36 and VEINESQOL/SYM score) should be considered as an outcome measure in clinical studies on patients with IFPDVT along with other comparison parameters with respect to QOL. However, long-term follow-up is required to establish the superiority of PCDT in IFPDVT patients.
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Left common iliac vein compression in patients with may-thurner syndrome: A 10-year retrospective study in an australian cohort p. 41
Warren Clements, Ronny J D Kuang, Jarrel Seah, Heather K Moriarty, Thodur Vasudevan, Amanda Davis, Jim Koukounaras
Objectives: This study aimed to assess what diameter constitutes clinically-significant left common iliac vein (LCIV) compression in patients with May-Thurner syndrome (MTS). Materials and Methods: Nineteen patients with MTS were over a 10-year period. Minimum LCIV diameter was compared to 100 asymptomatic controls and 27 age- and gender-matched controls. Results: Mean LCIV diameter in MTS group was 3.82 mm (standard deviation [SD] 1.38), control group (mean 7.17 mm SD 3.19, P < 0.0001), and matched control group (mean 6.86 mm SD 3.03, P = 0.007). Statistical threshold analysis showed in MTS patients, a LCIV diameter of 4.7mm or less had an 87.5% sensitivity and 72.7% specificity for the diagnosis. Conclusions: Patients with MTS had a minimum LCIV diameter threshold of 4.7mm, and this can be used in correlating the diagnosis of MTS on computed tomography. However, minimum diameters less than 4.7 mm are also seen in the general population and as such compression alone does not constitute a diagnosis of MTS.
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A higher body mass index means worse satisfaction outcome in obese patients undergoing varicose vein surgery p. 46
Sivaram Premnath, Elafra Nour, Amr Abdelhaliem, Timothy E Rowlands, Ganesh Kuhan
Introduction: Obesity (body mass index [BMI] >30) and lower limb venous disease (LLVD) is a common problem, yet there is a sparsity of evidence in its management. The aim was to carry out a satisfaction survey on such patients following their venous surgery from a single center. Methods: Three hundred and thirty procedures carried out from January 2017 to April 2018. Eighty-seven patients with BMI > 30 were selected and case notes reviewed retrospectively. Data on demography, risk factors, Clinical, Etiology, Anatomy, Pathology (CEAP) status, operative data, and complications were collected. Fifty-three patients had a telephone follow-up to assess satisfaction in terms of symptoms and appearance. Logistic regression analysis was carried out to identify factors contributing to a worse outcome. Results: The mean age was 53.1 (50.6% were male). The mean BMI was 36.11 (30–56). CEAP grade of more than 3 was present in 69.8% (44/87). Most patients were treated by radiofrequency ablation (81.6% [71/87]). Significant complications occurred in 3.4% (3/87) after surgery. The median follow-up was 22 months (14–30). Symptoms improvement was reported in 74% (39/53), while 5.6% (3/53) reported worse symptoms. In terms of appearance, 71.6% (38/53) reported improvement, while 7.5% (4/53) reported worse appearance. Logistic regression analysis identified BMI to be a significant risk factor (odds ratio 1.257 (95% confidence interval 1.004–1.575). Conclusions: The higher the BMI, the lesser the patient satisfaction after varicose vein surgery. Obese patients with LLVD can be treated successfully with a high satisfaction rate for BMI class 1 and 2.
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Hybrid and percutaneous salvage of a thrombosed native arteriovenous fistula: 1-year outcomes p. 50
Rahul Agarwal, Viswanath Atreyapurapu, Pritee Sharma, Vamsi Krishna Yerramsetty, Pradeep Burli, Gnaneswar Atturu, Prem Chand Gupta
Context: Outcomes of salvage procedures for thrombosed native arteriovenous fistulas (AVFs) are studied. Aims: The aim of this study is to assess the short- to mid-term results of percutaneous and hybrid approaches used for salvage of thrombosed native AVF. Settings and Design: This study design was a single-center, descriptive, prospective study. Materials and Methods: All patients undergoing hybrid or percutaneous salvage procedure between July 2018 and September 2019 were included in the study. Patient demographics, clinical, and operative details and follow-up data at 1 year were collected from a prospectively maintained database and subjected to statistical analysis. Salvage procedure selection and techniques were studied. Statistical Analysis: Chi-square test and Fisher's exact test. P < 0.05 was considered statistically significant. Results: Out of 135 patients undergoing salvage procedure during the study period, 85 patients were included in the study based on inclusion and exclusion criteria. The age of the study population ranged from 18 to 75 years with a mean of 53.33. 75.3% (n = 64) were males. Seventy-seven (90.58%) patients were hypertensive, 45 (52.94%) were diabetic, and 22 (25.88%) had coronary artery disease. The mean time to procedure from the failure of AVF was 8.22 days. The most common type of AVF was brachiocephalic (45.88% [n = 39]), followed by radiocephalic (36.47% [n = 31]) and basilic vein transposition (BVT) (17.64% [n = 15]). Stenotic sites were juxta anastomotic in 42 (49.41%), cephalic arch or axillary swing segment (for BVT) in 28 (32.94%), and intervening segment in 54 (63.52%). Sixty patients underwent hybrid salvage and 25 underwent percutaneous salvage procedure. Technical success was 88.23% on table and 83.53% at 24 h. Primary, primary assisted, and secondary patency was 67.86%, 82.14%, and 89.29% at 6 months and 50%, 68.75%, and 83.33% at 12 months. Anastomotic thrombosis was associated with significantly high technical failure (35.7% vs. 12.67%, P = 0.049). Conclusions: A combination of open and endovascular procedures to salvage thrombosed native AVF's is feasible and is associated with good short- and mid-term patency. A thrombosed anastomosis in a failed AVF decreases the success rate of salvage procedures.
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Factors affecting the long term patency of arteriovenous access for hemodialysis: A single center experience p. 55
Ashwini Naveen Gangadharan, Rajendra Basavanthappa Prasad, Ranjith Kumar Anandasu, J P Vivek Vardhan, Chandrashekar Anagavalli Ramswamy, Sanjay C Desai, Adharsh Kumar Maruthu Pandian, Nivedita Mitta, Hemanth Kumar
Objective: The objective of the study was to analyze and evaluate the possible factors in the long-term patency of arteriovenous (AV) access for hemodialysis (HD). Materials and Methods: This was a cross-sectional study recruiting patients from January 2019 to December 2019. All patients who have a working HD vascular access, either AV fistula (AVF) or AV graft which has been working for at least 2 years were included and collected demographic data along with other parameters such as timing of creation, interventions, dialysis sessions, and antiplatelet therapy among others. Results: We included 81 patients with AV access patent more than 2 years; 22.5% were aged >65 years, 39.6% were diabetic, 68.5% were hypertensive, and 26.1% had vascular disease. Analysis revealed that the patient factors such as current tobacco usage and side of creation and technical factors such as maturation time, number of dialysis sessions, and single-center dialysis have a significant effect on the patency of the AV access, while the factors such as past tobacco usage, diabetes, hypertension, use of jugular catheter before access creation, and cannulation technique could not establish any statistical effect on the patency of AV access. Conclusion: There is a complex interaction of factors that may affect the patency of an individual AV access. These need to be carefully considered when selecting surgical site or technique, adjuvant treatments, and follow-up protocols for AVFs.
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Use and adherence to oral anticoagulants in a tertiary care hospital p. 60
M Pradhyumna, Atiya Rehman Faruqui, Sunil S Joshi
Background: In patients at risk of thromboembolism, oral anticoagulants (OAC) are effective, but there are limited data from India on OAC use and adherence. This study in a tertiary care hospital aims to record the pattern of prescription of OAC and medication adherence over 6 months. Materials and Methods: Medications prescribed were recorded, and a follow-up at 3 and 6 months was done to record outcomes and adherence to medication. Modified Morisky medication adherence scale (MMAS-8) was used and compliance to monthly International Normalized Ratio (INR) monitoring was recorded. Results: Of the 140 patients included, mean age was 55.32 (±18.04 years), and 84 (60.0%) were males. Indications for OAC were deep vein thrombosis 64 (45.7%) and atrial fibrillation 42 (30.0%). After initial injectable anticoagulants, majority of patients were shifted to Vitamin K antagonists. Most common OAC was nicoumarol 73 (52.1%), followed by warfarin 43 (30.2%), dabigatran 12 (9.2%), and apixaban 12 (9.2%). Over 6 months, 12 patients were lost to follow-up and 16 (11.4%) deaths were recorded. Monthly INR was done by 23 patients till the 3rd month but only by five patients between 3rd and 6th month. By the 3rd month, 19 (86.3%) and between 3rd and 6th month 4 (13.7%) patients were nonadherent. At 6th month, 78 (86.6%) had a MMAS-8 score of 8 (high adherence). The presence of a caretaker in 37 (41.2%) emerged as the most important factor contributing to adherence. Conclusion: Early identification of patient-specific barriers for INR monitoring and adherence to medications should be sought in patients with thromboembolism.
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Operative management and outcomes of peripheral vascular trauma in pediatric and adolescent population p. 66
Madhur Kumar, Subrata Pramanik, Anubhav Gupta
Introduction: Unique characteristics of vascular injuries in children such as pronounced vascular spasm and lack of tissue support over small, thin-walled vessel make vascular repair challenging. This retrospective study was done to evaluate the management and outcome of pediatric and adolescent peripheral vascular trauma. Methodology: Fifteen patients with peripheral vascular trauma who met the inclusion criteria during the study period (August 2019-July 2020) were included. Data were analyzed retrospectively. Results: Majority, 12( 80%) of patients suffered blunt trauma. Primary repair in 13(86.66%) patients was the most common surgical technique employed. All the patients had associated long bone fracture dealt with internal fixation. Four (26.66%) cases had median nerve injury which was amenable to direct repair. Associated venous injury in 5 (33.33%) was also repaired. No mortality, re-operations, or amputation was noted. Conclusion: Excellent limb salvage rate was achieved. Initial revascularization without delay should be the norm. Associated neurological involvement determines postoperative functional outcome. Clinical evaluation with Doppler assessment saves time and crucial in vascular injuries prone to spasm.
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Arthur B. Voorhees, Jr.: Inventor of prosthetic vascular graft – A birth centennial tribute p. 69
Sunil Rajendran, RC Sreekumar, Jiny Chandran
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Lower limb vascular anomalies and malformations with contrast-enhanced magnetic resonance angiography: A case series p. 72
S Krishna Kiran, PC Shaji, Sunil Rajendran, TN Gopinath, J Jagdish
Contrast-enhanced magnetic resonance angiography is a valuable technique in the assessment of vascular anomalies of the lower limb. This is an ideal investigation in children and young adults as it is non-invasive and poses no radiation risk. We present a series of cases to highlight this.
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Early catheter-directed thrombolysis without bowel resection in acute mesenteric ischaemia for a symptomatic COVID-19 patient p. 75
Aniruddha Sanjoy Bhuiyan, Prashant Balani, Vijay N Dalal, Govardhan S Maheshwari
Newer evidence states that COVID-19 pneumonia induces a hypercoagulable state leading to vascular and microvascular thrombotic events. Acute mesenteric ischaemia (AMI) is a potentially fatal vascular emergency with overall mortality of 60%–80%.However, till date, only a few cases of superior mesenteric artery thrombosis in COVID-19 positive patients are reported and most have succumbed to COVID-19 or mesenteric ischemia. Physicians treating COVID-19 usually treat respiratory symptoms and may completely overlook any other uncommon pathology. This case report emphasizes that a patient with early detection and management of acute mesenteric ischaemia being symptomatic for COVID-19 can avoid major bowel surgery and negates any morbidity or mortality associated with the same.
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Iliac vein stenosis and venous hypertension after polytetrafluoroethylene arteriovenous loop graft in the thigh for hemodialysis access p. 77
Natarajan Sekar, Kamala Sekar Kanagasabai
Central venous stenosis occurs commonly as a complication of central venous catheterization. It is most often seen after arteriovenous (AV) graft or proximal AV fistula in the ipsilateral upper limb. Iliac vein stenosis after thigh AV graft has not been reported in the literature. Successful endovascular management of an iliac vein stenosis after AV loop graft in the thigh is presented here.
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Role of digital subtraction angiography in diagnosis of fibromusculardysplasia p. 80
Christine Wang, Animesh Singla, Krishna Kotecha, Daniel Nguyen
Fibromuscular dysplasia (FMD) is a vascular disease characterized by abnormal arterial wall architecture, usually visualized angiographically as the classic “string of beads” sign. We present the diagnostic dilemma of a 51-year-old woman admitted for a spontaneous renal infarct, with initial examination and investigations equivocal. She was consequently assessed for thromboembolic and vasculitic disease, before proceeding to digital subtraction angiography (DSA). This invasive method elucidated an area of focal FMD, previously not seen on computed tomography angiography (CTA). This is unusual due to CTA's high sensitivity and specificity but could be attributed to the less common subtype of FMD which requires combined imaging modalities to arrive at a diagnosis. Hence, there may be a role for the dual use of CTA and DSA in young patients presenting with a spontaneous renal infarct in the absence of other diagnoses.
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Delayed thrombectomy firing the last shoot p. 83
Mohammed Shahat, Hesham Abo Elayoon
Cervical carotid artery not common entity trauma, especially the blunt one. here, we are presenting a case of animal bite in the neck which caused internal carotid artery (ICA) thrombosis ICA. The patient showed rapid deterioration in the first 24 h that make us obliged to do thrombectomy patient show partial improvement after the surgery. ICA delayed thrombectomy may play role in the management of late ICA thrombosis.
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Successful endovascular reconstruction of acute lower limb ischemia secondary to embolic aortoiliac occlusion using endologix AFX unibody stent graft p. 86
Yunyi Wang, Animesh Singla, Vikram Puttaswamy
Embolic aortoiliac occlusion presenting with acute lower limb ischemia is uncommon and represents a challenge for appropriate management. Several techniques for reconstruction are available, taking into account patient's demographics, surgical risk, and aortoiliac anatomy. Several endovascular and open surgical options exist. We present a novel management strategy, with the use of an endovascular aneurysm stent graft for the reconstruction of native aortoiliac system in a middle-aged female. This allowed for successful revascularization of her lower limb ischemia, while maintaining options for future intervention. Long-term data on this option for the management of acute aorto-iliac occlusion are limited.
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Running out of vascular access in chronic kidney disease patients - A case report on translumbar dialysis catheter p. 90
Nishant Agrawal, Yadav Waghaji Munde, Jignesh Navinchandra Shah, Prajakta Sunil Lanjewar, Sunil Jawale
Vascular access is the key in patients with end-stage renal disease requiring hemodialysis. After some years, failure of conventional access is a major cause of morbidity and mortality in patients on chronic hemodialysis. Translumbar tunneled dialysis catheter may be a salvage option in such cases for long-term hemodialysis, thereby improving survival and acting as a bridge for renal transplantation.
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A rare neck mass: Hemangioma of external jugular vein p. 93
Devender Singh, Basavarajendra Anurshetru, Shalini Aryala
Intraluminal primary tumors of the body veins are rare clinical entities with few cases have been reported in the literature. Hemangiomas as a primary tumor, arising in the jugular vein are extremely rare. We present a case of right neck mass, was initially treated as venous thrombosis and finally diagnosed with hemangioma of external jugular vein on histopathological examination. Although rare, this case highlights the need of suspicion of a vascular tumor in cases of neck swelling for proper investigation and treatment.
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Single-stage ruptured internal carotid artery aneurysm clipping with contralateral carotid endarterectomy: Tips and tricks p. 96
Swaroop Gopal, Abinash Dutta, Rudrappa Satish
Concomitant ruptured intracranial aneurysm and severe contralateral internal carotid artery (ICA) stenosis pose a surgical dilemma. There are no guidelines. Most reports suggest an ipsilateral association. The outcome depends on planning and strategy. This 49-year-old male with ruptured C6 segment ICA aneurysm had 90% calcific carotid stenosis contralaterally. He underwent simultaneous surgery for both. The surgical steps involved and the reason behind the sequence of steps are unique to this situation and led to a good outcome. The strategy and the technicalities involved are discussed in this report.
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Miraculous escape in a case of penetrating neck injury by arrow p. 99
Raja Lahiri, Subhendu Sekhar Mahapatra
Penetrating neck injuries due to arrowheads have become extremely rare in most of the nations. Although the basic principles of management remain the same as that of other penetrating injuries, certain extra precautions need to be taken while managing such cases. A 56-year-old man who suffered from an arrow injury to the neck had a lucky escape from any significant injury to vital structures. The patient underwent successful surgical removal of the arrowhead. Knowledge of the various principles of management of such injuries is key to a successful outcome.
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Intraoperative transesophageal echocardiographic detection of large mobile aortic thrombus in a patient with iron deficiency anemia presenting as acute limb ischemia p. 102
GN Chennakeshavallu, Sruthi Sankar
Quantitative and qualitative abnormalities in red blood cells are associated with arterial thrombosis. We report a case of a middle-aged female with iron deficiency anemia (IDA) presenting as bilateral acute limb ischemia (ALI) and on evaluation with transesophageal echocardiography (TEE) a large mobile thrombus was detected in the descending thoracic aorta. Her limbs were salvaged with successful bilateral surgical embolectomy and fasciotomies. The aortic thrombus was resolved with anticoagulation and correction of iron deficiency. We conclude that TEE evaluation of aorta is warranted in middle age females with IDA presenting as ALI.
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Erratum: Peripheral vascular system thrombosis and COVID-19: A chilling revelation p. 105

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