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   Table of Contents - Current issue
May-June 2022
Volume 9 | Issue 3
Page Nos. 211-271

Online since Sunday, August 21, 2022

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Lymphedema – The stepchild of vascular surgeons Highly accessed article p. 211
Edwin Stephen
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Recognition of those at risk of lymphedema, benefits of subclinical detection, and the importance of targeted treatment and management p. 215
Neil B Piller
Primary and secondary lymphedemas, irrespective of their cause, remain a significant issue around the world, impacting physical, functional, and psychological well-being, family relationships, and the ability of the affected person to undertake work and household tasks. Often, an accurate, objective differential diagnosis is not (or cannot) be made, sometimes resulting in treatment, which is suboptimal, or which does not achieve expected outcomes due to the impact of a range of comorbidities on lymphatic load or functioning. Diagnosis, Management, and targeted treatment of these comorbidities such as chronic edema, lipedema, and phlebedema will allow improved outcomes for the lymphedemas. To treat and manage lymphedemas well, there is a lifelong cost both to the affected individual, the family, and the health-care system. However, for those with lymphedemas irrespective of its stage, there are significant leverage points for obtaining a good outcome through an accurate differential diagnosis, but it is the group who are at risk of lymphedema where we can have the greatest impact with respect to optimizing their health and well-being. The solution is multifaceted involving three major components: (1) the recognition of those at elevated risk of developing lymphedema and the reduction or management of those risks; (2) the early detection of the subclinical stages of lymphedema; and (3) appropriately targeted and sequenced treatment delivered in a holistic sense within a compassionate caring community environment with appropriate integrated and continuing health professional support. We also need to be aware that high-level technology and equipment is not always needed for an accurate assessment of the lymphedema or its risk, with simple tape measurements and associated volume calculations along with the use of the pitting test and the Stemmer sign being acknowledged as dependable and informative. While the evidence is increasing that lymphovenous or lympho-lymphatic anastomoses, and lymph node transfers are of benefit when created in the earlier stages of lymphedema (and perhaps in those detected as being at a high risk of developing it), complex and invasive treatments are most often not needed when the lymphedema is detected early. In these stages, simple management strategies work well when we employ our knowledge of the importance of weight control, self-management through exercise and activity programs (which can include yoga and tai chi breathing techniques) and skin care, massage with compression provided by bandaging, garments, or wraps, in an environment of integrated professional functioning and advice. In today's COVID environment and when services are not available nearby or what the patient cannot travel, when it is not possible to physically see a therapist or other health professional, telemedicine and its associated information and interactive education programs are of increasing importance. We must together ensure that the information about lymphedema, its risk factors, treatments, and management is made available in clinics and community health facilities, so everyone has access to it and is aware of who to approach for continuous and integrated holistic care.
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Incidence of Anastomotic Pseudoaneurysm of Arteriovenous Fistula in Hemodialysis Patients Having Non-Cuffed Catheters as Vascular Access – Association or Causation? p. 223
Sameer Vilas Vyahalkar, Pooja G Binnani, Amar Vilas Kulkarni, Arif Hoda, Umesh Tulsidas Varyani, Amit Prakash Nagarik, Avinash E Chaudhari
Background: Anastomotic pseudoaneurysm affecting arteriovenous fistula created for hemodialysis is an unusual and catastrophic complication. There is lack of clinical data in literature about its incidence and management. Aims and Objectives: To study the incidence and understand the aetiology of anastomotic pseudoaneurysm of arteriovenous fistula (PA-AVF) occurring in first six months after surgery. Materials and Methods: Cohort study based on retrospective analysis of three-year data of case-series of PA-AVF occurring in first six months after AV fistula creation for hemodialysis. Results: Among the 283 AV fistula surgeries (215 distal forearm radio-cephalic AVF and 68 brachial artery or cubital region AVF), 7 patients (2.4%) developed PA-AVF within 1 to 8 weeks after AV fistula surgery. Over-extended dependence on non-cuffed hemodialysis (HD) catheter was a common factor among patients developing this complication. All the patients had a prolonged stay (34 to 75 days) of non-cuffed HD catheters before development of PA-AVF. Diagnosis of HD catheter-related blood stream infection (HD-CRBSI), which overlapped with development of PA-AVF, was proven in 4 patients, two of which also had surgical site infection. One patient had traumatic PA-AVF and in two patients the cause could not be established although features consistent with CRBSI were present. Excision of pseudoaneurysm and ligation of radial artery was done in all cases. Conclusion: Infection is the most common cause of anastomotic pseudoaneurysm of AV fistula. Our study points towards extended use of non-cuffed hemodialysis catehters as a risk factor for development of PA-AVF. Prevention and early aggressive management of CRBSI and surgical site infections along with a limited use of non-cuffed HD catheters for the minimum required duration is the key to reduce the incidence of this complication
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A single-center 5-year experience of iatrogenic vascular injuries and their outcomes p. 229
Ajay Kumar Dabas, Anand Katiyar, Sachin Srivastava, Amitoj Singh Chadha, Ratheesh Kumar Janardhanapillai, Keshavamurthy Ganapathy Bhat, Davinder Singh Chadha
Introduction: Diagnostic and therapeutic interventions can lead to iatrogenic vascular injuries (IVIs). The spectrum of IVIs, their management, and outcomes is presented. Materials and Methods: This prospective observational study from January 2016 to December 2020, included all successive IVIs managed by the vascular surgery department. IVI was defined as vascular injury manifesting as hemorrhage/vessel occlusion/and/or retained foreign body in vasculature. Those due to trauma and/or <30 days follow-up were excluded. Reasons for IVI, presentation, vessels involved, and outcomes were analyzed. Results: Thirty-eight IVIs were analyzed. Age ranged from 3 days to 77 years. Sixteen were due to cardiology, seven due to orthopedics, four cases in end-stage kidney patients, 4 cases due to invasive arterial monitoring, and two following cardiac surgery. One case each was following laparoscopy, spine surgery, thrombectomy, endovascular aneurysm repair, and umbilical catheterization. Manifestations were limb ischemia (lower limb-13, upper limb-6), pseudoaneurysms-10, retained foreign body-4 (superior vena cava and/or right atrium-3; external iliac artery-1), hemorrhage-2, arterio-venous fistula-2, and compartment syndrome-1. Common femoral artery (with/without superficial femoral artery) was affected in 13, forearm arteries in 8, popliteal artery and crural arteries in three each, and one case, each of profunda femoris, carotid artery, external iliac artery branch, and thoracic aorta. IVIs were managed by thrombectomy in 13, arterial repair in 11, endovascular procedures in 5, bypass in 4, conservative in 3, and by laparotomy and open retrieval of a balloon in one case each. Four developed surgical site infections, three died, three suffered amputations, three had motor deficits, and two developed acute kidney injury. Conclusion: IVIs have heterogeneous presentation. Both open and endovascular skill sets are required for management. IVIs carry high morbidity and mortality.
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Role of neutrophil-lymphocyte ratio and mean platelet volume in the outcome of atherosclerotic peripheral vascular disease interventions p. 236
SK Balaji, C Saravanan Robinson, Sudharsan Reddy Yalamuru, Sabarish G Kumar, Adharsh Kumar Maruthupandian, Syed Mohammed Ali Ahmed, MV Bharat Arun, Ruru Ray
Purpose: Classically, neutrophils have been neglected in the pathophysiology of atherosclerosis. However, recent studies have highlighted their role. Similarly, the role of platelets in peripheral artery disease (PAD) has become evident now. The significance of neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) has been independently studied and found that elevated values are associated with poor outcomes of atherosclerotic peripheral vascular disease interventions. However, the measure of association of NLR and MPV to the outcomes of intervention has not been studied. Hence, this study was undertaken to examine the measure of association of NLR and MPV to the outcomes of atherosclerotic peripheral vascular disease interventions. Methodology: This is a prospective study conducted between January 1, 2020, and September 30, 2021, with 6 months of follow-up. Patients aged 21 years or more, diagnosed to have atherosclerotic peripheral vascular disease, and undergoing interventions (endovascular and open procedure) are included in the study. Patients <21 years, not willing for any intervention, and with acute presentations were excluded. The primary endpoint assessed is graft patency at 6 months, and the secondary endpoints assessed are clinical improvement (which is a combined measure of change in ankle–brachial index, Rutherford grade, and ulcer status) at 1 and 6 months, redo procedure, and amputations within the follow-up period. Results: From January 2020 to September 2021, a total of 156 patients with atherosclerotic peripheral vascular disease fulfilled the inclusion and exclusion criteria. We observed that in 109 (69.9%) patients who had completed 6-month follow-up, 91 (83.5%) patients had graft patency and 18 (16.5%) patients had occluded graft. Independent receiver operating characteristic curve analysis of MPV and NLR showed that lower mean NLR and MPV values (cutoff taken as 10.15 for MPV) are associated with increased graft patency at 6 months than higher mean NLR and MPV values (NLR, P < 0.001; MPV, P = 0.024). Discriminant analysis model developed with MPV and NLR as the set of predictors showed that NLR and MPV together are good predictors of graft patency at 6 months (Wilk's lambda: χ2 = 45.54, P < 0.001). However, logistic regression analysis has shown that, in comparison to NLR, MPV is not a strong predictor of graft patency. Lower mean NLR value was associated with lower amputation rate (P < 0.001), lower mortality rate (P < 0.001), and higher clinical improvement rate at 1st month (P < 0.001) and at 6 months (P < 0.001) than patients with higher mean NLR. However, there was no statistically significant difference between two groups in predicting chance of redo procedure (P = 0.424). There was no statistically significant difference between the mean MPV values among patients who underwent amputation (P = 0.864), died (P = 0.640), or had redo procedure (P = 0.883), except for clinical improvement outcome where lower mean MPV value was associated with higher rate of clinical improvement at 1st month (P < 0.001) and 6 months (P < 0.001) than higher mean MPV value. Conclusion: In patients with atherosclerotic peripheral vascular disease, NLR value is a better predictor of outcomes after intervention than MPV, and lower mean NLR values are associated with increased rate of graft patency, clinical improvement, fewer amputations, and deaths.
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Prevalence of thrombophilia in indian patients with deep venous thrombosis – An 8-year single-center study p. 243
Vivek Agrawal, Sanjeev Kumar Deshpande, Brijesh Biswas, Suresh Reddy Thupakula, Vembu Anand
Background: Thrombophilia is a recognized risk factor for deep venous thrombosis (DVT) and its recurrence. Routine thrombophilia testing is controversial because of low yield and high cost. However, screening for thrombophilia helps in deciding the duration of anticoagulant treatment. The aim of this study is to determine the prevalence of thrombophilia in DVT patients in India. Materials and Methods: This was a retrospective, prospective, observational study done from April 2012 to April 2020. Thrombophilia screening was done in DVT patients who were <40 years, with unprovoked DVT, or with recurrent DVT. Homocysteine, antithrombin III, protein C and S, factor V Leiden, and lupus anticoagulant (LAC) were assessed. Follow-up was done to assess post thrombotic syndrome (PTS), pulmonary embolism (PE), and recurrence of DVT. Results: One hundred and sixty-six patients selected for thrombophilia out of which 163 were males. Patients were ranging age from 35 to 70 years. 82 (49.4%) patients had abnormal thrombophilia. 66 had one abnormal factor, while 16 had more than one. A total of 102 abnormal factors found in 82 cases, of which 41 had hyperhomocysteinemia, 20 protein S deficiency, 12 protein C deficiency, 15 factor V Leiden mutations, 8 antithrombin III deficiency, and 6 LAC. 10.2% of patients developed PTS, 16.3% recurrence, 2% PE, and 0.3% mortality. Conclusion: DVT patients are at a substantial risk of recurrence. Although laboratory evaluation of thrombophilia is costly but it is essential for monitoring therapy in certain sets of patients. Identification of thrombophilic condition is worth and affects the overall standard clinical management. In our study we found prevalence of thrombophilia in about 50% of DVT patients who are <40 years, with unprovoked DVT or with recurrent DVT. Out of which hyperhomocysteinemia is most common. But more studies including RCTs are required for further clarifications.
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Vein valves – From discovery to repair to bioprosthesis p. 248
MK Ayyappan, Jithin Jagan Sebastian
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Perioperative management of a double hit - Acute limb ischemia in a patient with acute myocardial infarction p. 251
Karthikeyan Sivagnanam
This case report highlights our experience in managing two cases of acute lower limb ischemia with simultaneous acute coronary events. One patient was detected with acute ST-elevation myocardial infarction while being evaluated for acute lower limb ischemia and another patient had NSTEMI with acute left ventricular failure and delayed presentation of acute lower limb ischemia. Both had good outcomes.
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Ultrasound-Guided thrombin injection of a pseudoaneurysm with concomitant deep vein thrombosis p. 253
Mark Awad, Enrico Ascher, Natalie Marks, Anil Hingorani
The formation of a pseudoaneurysm (PSA) is one of the most common complications following arterial catheterization. These pseudoaneurysms have the potential to cause life-threatening complications. One such extremely uncommon complication is the development of deep vein thrombosis (DVTs). Successful treatment of a PSA can be hindered in patients receiving anticoagulants and special considerations are necessary in such cases. We present a 70-year-old female who developed a postarterial catheterization PSA which was treated with Ultrasound-Guided Thrombin Injection (UGTI) while the patient was receiving apixaban for treatment of a PSA-induced DVT. Peri-procedural imaging helped correctly identify this complex pathology, guide thrombin injection, and observe in real-time instantaneous thrombosis of the PSA while confirming adjacent femoral artery patency. Given the risk of associated complications, patients with a PSA who are receiving anticoagulation should undergo an UGTI for PSA closure. Anticoagulation may cause difficulty in achieving complete thrombosis of PSAs, but recent research has suggested that UGTI remains the preferred method with high overall success rates. Patients receiving anticoagulation undergoing this procedure may benefit from serial postprocedure duplex scans to assess for incomplete PSA closure, thrombosis, or recurrence.
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Iatrogenic superior gluteal artery pseudoaneurysm due to iliac bone marrow biopsy treated with endovascular coil embolization p. 256
K Ariharan, K Nagarajan, M Vivekanandan Pillai, M Amuthabharathi
Superior gluteal artery pseudoaneurysms are uncommon with the main causes being trauma and iatrogenic. They have been treated by coil embolization, open surgery, or thrombin injection. A 36-year-old female with leucocytosis underwent bone marrow biopsy following which she developed pain and left lower limb weakness. Magnetic resonance imaging showed hematoma in the left pyriformis muscles probably compressing the sciatic nerve. A computed tomography angiogram confirmed a left superior gluteal artery partially thrombosed pseudoaneurysm which was subsequently treated by coil embolization. A high degree of suspicion of this complication early imaging and management can prevent significant blood loss and mortality.
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Ex vivo Repair of renal artery branch aneurysm in fibromuscular dysplasia p. 260
Neelamjingbha Sun, Ashutosh Kumar Pandey, Sriram Manchikanti, Shivanesan Pitchai
Renal artery aneurysm is a rare disorder with an incidence of < 1%. We describe a case of fibromuscular dysplasia with right renal artery branch aneurysm, who had uncontrolled renovascular hypertension. The patient was successfully managed with ex vivo repair and reconstruction of the renal artery using reverse saphenous vein graft, followed by autotransplantation of the right kidney. Although surgically demanding, the technique is feasible and yielded good results.
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Penetrating atherosclerotic aortic ulcer with pseudoaneurysm: Role of hybrid procedure with d-TEVAR p. 263
Murugesan Ramaiya Periyanarkunan, Elango Swamiappan, Ganesan Chinnasamy, Jayasree Rajapandian
We present a case of penetrating atherosclerotic aortic ulcer with pseudoaneurysm which was managed by a hybrid partial debranching thoracic endovascular aneurysm repair (d-TEVAR) procedure. A 68-year-old professional singer with multiple comorbidities presented with mid-chest pain radiating to the back for the past 2 months. Computed tomography aortogram revealed a penetrating atherosclerotic ulcer near the summit of the left subclavian artery (LSA) at the distal aortic arch. In view of the high risk of an open-heart surgery, TEVAR procedure with partial debranching of the aortic arch vessel was proposed. As the aneurysm was close to the origin of the LSA, an adequate proximal landing zone was not available. Hence, a bypass from the left common carotid artery to the LSA was done. Following this, an endovascular procedure was performed and the stent graft was placed covering the origin of the LSA. Check aortograms after the procedure revealed patent stent and complete obliteration of the pseudoaneurysm. There was no endoleak noted and the left carotid to subclavian artery bypass was functioning well. The postoperative period was uneventful. Follow-up over a 6-month period was satisfactory. The key elements of a successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough planning, and careful procedural execution. This case demonstrates that a hybrid procedure with partial debranching and thoracic endovascular repair of penetrating aortic ulcers is a safe and less-invasive alternative for elderly, high-risk patients.
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Venolymphatic malformation p. 267
K Saraswathi Gopal, N Nagammai, Srividhya Srinivasan
Vascular lesions are the most common congenital and neonatal abnormalities. About 60% of anomalies occur in the head-and-neck region due to its complex vascular anatomy. There is confusion in the descriptive terminology for the vascular entity and eponyms. Thus, appropriate classification based on clinical examination and imaging is essential for proper diagnosis and treatment. Thus, the aim of this article is to report a case of venolymphatic malformation with comprehensive knowledge about classifications, pathogenesis, clinical presentation, and its management.
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Erratum: Spectrum of vertebral artery pathologies on imaging: Case series p. 271

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