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   2021| December  | Volume 8 | Issue 6  
    Online since January 20, 2022

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Mentorship in surgical training – To Rejuvenate
Rajarajan Venkatesan
December 2021, 8(6):107-109
  1,053 121 -
Applied features of perforasomes in the revascularization and reconstruction of chronic limb-threatening ischemia in the diabetic foot
Ilayakumar Paramasivam, Balakrishnan Thalaivirithan Margabandu, Poorani Palanisamy, Prethee Martina Christabel, Narayanan Sritharan, Jaganmohan Janardhanan
December 2021, 8(6):110-113
Chronic limb-threatening ischemia in the diabetic foot is a spectrum disease characterized by the failure of wound healing and increased risk of amputation. The interspecialty consolidating services between the vascular and plastic surgeon with applied perforasome approaches both in the timely revascularization and early reconstruction culminate in the stable and shoeable foot or foot residuum.
  958 98 -
Comparative study of the effects of two suturing techniques of End-to-side arteriovenous anastomosis on early outcomes of radio-cephalic fistulas
Sameer Vilas Vyahalkar, Avinash E Chaudhari, Pooja G Binnani, Amar Vilas Kulkarni, Amit Prakash Nagarik, Kailash K Jawade, Shantanu S Chandrashekhar
December 2021, 8(6):130-136
Introduction: Radiocephalic arteriovenous fistulas (AVFs) for dialysis have significantly high maturation failure rate. Many surgical technique-related factors are known to impact the outcomes of AVF surgery; anastomotic suturing technique is one such factor for which the published data is sparse. Patients and Methods: We retrospectively analyzed the data of patients who underwent end-to-side radio-cephalic AVF surgery during a 2-year period and grouped it according to the two techniques of anastomotic suturing: Anchor technique and parachute technique. Comparative analysis was done to study the effect of the technique on well-defined outcomes within the first 6 months of surgery. Results: A total of 119 AVFs (anchor technique = 65, parachute technique = 54) were included in the study. The aggregated primary patency at 6 weeks and 6 months was 85.7% and 78.1% respectively and successful use of fistula was seen in 62.2%. The parachute technique was associated with lower immediate access thrombosis (3.7% vs. 15.4%, P = 0.019) and primary failure (31.5% vs. 43%, P = 0.033) than the anchor technique. The groups did not differ statistically in outcomes like early access failure (P = 0.376), maturation failure (P = 0.105), primary patency at 6 weeks (P = 0.07) and at 6 months (P = 0.083) and successful use of fistula at 6 months (P = 0.196). Conclusion: In this retrospective single-center study, the parachute technique of anastomotic suturing was associated with lower incidence of immediate access failure of radio-cephalic AVF as compared to the anchor technique, although other early outcomes were similar with both techniques. The effects of different suturing techniques on surgical outcomes of AVF should be studied in large randomized trials.
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Preoperative factors influencing functional rehabilitation after major lower limb amputation and validation of a preoperative scoring tool
Sivaram Premnath, Michael Cox, Aurelien Hostalery, Ganesh Kuhan, Timothy Rowlands, John Quarmby, Sanjay Singh
December 2021, 8(6):120-129
Introduction: The ability to walk with prosthesis is a major determinant of functional independence after major lower limb (MLL) amputation. The Blatchford Leicester Allman-Russell Tool (BLARt) score is a potentially valuable tool that can predict the functional outcome after MLL amputation. The study aimed to identify preoperative factors that influence functional rehabilitation after MLL amputation and validation of BLARt score. Methods: This retrospective study analyzed 71 patients referred for rehabilitation postamputation. The level of functional outcome at 6 and 12 months were recorded using Special Interest Group in Amputee Medicine grading. Preoperative factors and BLARt score were analyzed for association with functional outcome. Results: BLARt score was found to have a significant correlation with functional outcome in 6 and 12 months. BLARt showed a fair to good predictive ability with an area under the receiver operating characteristic curve of 0.713 (SE 0.61, 95% confidence intervals 0.593–0.832) and 0.705 (SE 0.061, 95% confidence intervals 0.585–0.825) for the nonfunctional outcome at 6 and 12 months, respectively. Preoperative mobility was the only significant risk factor that was associated with functional mobility (P = 0.02). Conclusion: With the validation analysis showing a fair to good predictive ability, BLARt score does serve its proposed role in risk stratification.
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Role of Cardio-biomarkers (NT-Pro BNP and Troponin I) in cardiac risk stratification of patients undergoing major vascular surgeries
Rakesh Kumar Jha, Vembu Anand, Vikram Patra, Rishi Dhillan, Rohit Mehra, T Suresh Reddy
December 2021, 8(6):114-119
Objective: The objective is to assess the role of cardio-biomarkers, namely, N-Terminal Pro-hormone Beta Natriuretic Peptide (NT-ProBNP) and Cardiac Troponin I (cTnI) in prediction of postoperative cardiac events (POCEs) in noncardiac patients undergoing major vascular surgery and compare their efficacy with Revised Cardiac Risk Indices (RCRI) in preoperative period. Materials and Methods: Quantitative analysis of cTnI and NT-ProBNP was done in pre- and post-operative period in patients, who underwent elective major vascular surgeries between April 2018 and April 2020 at a tertiary care hospital. The ability of both the cardio-biomarkers, either alone or in combination were assessed for the prediction of POCE and results were compared with RCRI in preoperative period. The relationship between postoperative quantitative values of both the biomarkers and development of POCE were also analyzed. Results: A total of 170 patients were enrolled and the incidence of POCE was observed in 15.9% (27) of our patients. The “cut-off” values of cTnI, and NT-ProBNP in preoperative period were found to be 0.011 μg/L and 335 pg/mL and in postoperative period were 0.024 μg/L and 438 pg/mL, respectively. In preoperative period, biomarkers, either alone or in combination, outperformed RCRI in prediction of POCE and when individual biomarker was assessed, NT-ProBNP had better efficacy than cTnI. In postoperative period, predictive ability of both the biomarkers were similar, however, combination of both significantly improved the prediction of POCE as represented by increase in area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy. Conclusion: As compared to RCRI, cardio-biomarkers were better predictor of POCE in preoperative period and their efficacy in forecasting POCE continued even in postoperative period.
  866 75 -
Intramuscular scalp hemangioma in an adult female: A rare case report
Tushar Rajendra Sharma, Deep Nareshkumar Patel, Ankeet J Shah
December 2021, 8(6):181-184
Hemangiomas are the benign tumors of vascular origin. They are the most common tumor in infants and children (10% incidence) but rare in adults. They are more common in girls. They are more commonly found in head and neck region and most commonly located in skin and subcutaneous tissue. They are rarely found in the intramuscular location (0.8% incidence). This article represents a rare case report of intramuscular scalp hemangioma located in the right temporalis muscle in a 26-year-old female presented with chief complaint of headache, which was confirmed by radiological investigations. Surgical excision was done, and approximately 2 cm × 2 cm-sized lesion was excised.
  625 27 -
Anatomical variants of the obturator artery and their clinical importance
Swapna Thampi, Aswathy Maria Oommen, Sreekumar Rajasekharan, Suja Robert Sarasammal
December 2021, 8(6):142-146
Context: The obturator artery (OA) originates from the internal iliac artery (IIA), and it runs on the lateral pelvic wall to leave through the obturator canal. It can have a varied source of origin. A small pelvic space makes it susceptible to injury during repair of femoral and inguinal hernias and pelvic surgeries. Unexpected injury of an aberrant OA can be avoided only with a thorough knowledge of its anatomy. Aim: This study aims to estimate the prevalence and describe the course of aberrant obturator arteries. Settings and Design: A descriptive, cross-sectional, cadaveric study was conducted in the Department of Anatomy, Government Medical College, Thiruvananthapuram, India. Materials and Methods: Sixty-four hemipelvices were dissected. Variations in the origin, course, and relations of the OA were observed and noted. Statistical Analysis Used: The results were tabulated, and the prevalence of each variation was calculated. Results: Variations were seen in 40.6% cases. OA originated from inferior epigastric artery (23.4%), external iliac artery (3.1%), posterior division of IIA and iliolumbar artery (1.5%), superior gluteal artery (6.2%), internal pudendal artery (1.5%), and inferior gluteal artery (3.1%) cases. Arterial corona mortis, a tortuous anastomotic channel connecting OA (originating from IIA) and inferior epigastric artery was seen along with venous connections in one specimen. Conclusions: Aberrant origins of OA pose a high risk for significant hemorrhage in trauma and various surgeries. Hence, a sound anatomical knowledge of its origin and course is vital while repairing fractures and hernias in this region.
  598 50 -
Radiofrequency ablation of varicose veins, How do I do it?
Robin Man Karmacharya, Satish Vaidya, Amit Kumar Singh, Prasesh Dhakal, Sushil Dahal, Niroj Bhandari, Sohail Bade, Sahil Bade, Prabha Shrestha
December 2021, 8(6):153-156
Radiofrequency ablation (RFA) is one of the recent yet adequately studied minimal invasive surgery for varicose veins. The aim of this manuscript is to share our technique of RFA for varicose veins. The technique has been revised over time and has been standardized over all the surgeons doing this procedure in our institute. We have been using few of the terms to define specific scenario in relation to the procedure.
  540 98 -
Pharmacomechanical catheter-directed thrombolysis: An emerging therapy for deep vein thrombosis – A case series
Arumugam Aashish, Balasubramaniyan Amirtha Ganesh, Selvaraj Karthikeyan, Srinivasan Giridharan
December 2021, 8(6):168-171
Venous thromboembolism comprising pulmonary embolism and deep-vein thrombosis (DVT) is a major health problem with DVT accounting for two-third of them. Lower extremity DVTs account for 25%–50% of them and have long-term chronic venous complications which are termed as postthrombotic syndrome. The armamentarium in DVT management includes systemic anticoagulation, mechanical thrombectomy, and catheter-directed thrombolysis (CDT). Despite the benefits of therapy, CDT has its own limitations. Pharmacomechanical CDT (PMCDT) is an emerging percutaneous therapy which improves the treatment efficacy and reduces the incidence of long-term complications. Here, we present a series of three cases where PMCDT was used in acute to subacute DVT with poor response to anticoagulation therapy.
  586 46 -
Acute-on-Chronic mesenteric ischemia successfully managed by superior and inferior mesenteric artery reimplantation and cholecystectomy for gangrenous gallbladder
Ajay Savlania, B Sriharsha, Lileshwar Kaman
December 2021, 8(6):172-174
Acute-on-chronic mesenteric ischemia (CMI) leading to gallbladder gangrene is a rare event, and successful use of mesenteric arterial reimplantation with regard to contaminated field is not reported. In contaminated field from gangrenous gallbladder due to acute-on-CMI, reimplantation of the superior and inferior mesenteric artery (SMA and IMA, respectively) for revascularization is a feasible option, and was used to revascularize in this patient. SMA and IMA require one anastomosis at the aorta, and it was successfully used in contaminated field to revascularize the threatened bowel. In acute-on-CMI, with contaminated field, reimplantation of SMA makes one of an option in surgical armamentarium of using autologous tissue and it reduces number of anastomosis in infected field. Acalculous gangrenous cholecystitis is a rare pathology associated with acute-on-CMI.
  572 52 -
Subclavian arterial stent migration from technical error and effective strategic bail out
B Nishan, BK Pavan, SH Mamata, Vivek Anand
December 2021, 8(6):188-192
Stent migration is an inherent complication of stent deployment. Numerous factors are responsible for this dreaded complication. Various techniques are available to bail out the migrated stent.
  566 42 -
Catheter-directed foam sclerotherapy in chronic venous insufficiency patients with active ulcer single-center experience
Mohammed Shahat
December 2021, 8(6):137-141
Introduction: Varicose vein and chronic venous insufficiency (CVI) is one of the most prevalent health problems in Europe and the United States; in some studies, it may reach 60% of population. Patients and Methods: This prospective study involving on 51 patients (C6) is to assess the efficacy and tolerance of sclerotherapy foam in the treatment of great saphenous vein incompetence and ulcer healing in CVI patients at 6 and 12 months and to report our experience regarding the diagnosis and treatment of CVI by catheter directed sclerotherapy (CDS). Results and Conclusion: In our experience, CDS safely can contribute to good ulcer healing rate up to 73% at 6 months for a reasonable cost of money and time which might be considered an attractive strategy for providing efficient vascular service in clinical practice.
  564 43 -
Total endovascular repair with chimney grafts for distal stent graft-induced new entry after Type B aortic dissection
Tadashi Umeno, Satoshi Ohki, Kiyomitsu Yasuhara, Tamiyuki Obayashi
December 2021, 8(6):185-187
The parallel graft technique is valuable for high-risk patients who are unfit for open repair and who have complex aortic lesions, such as distal stent graft-induced new entry (SINE). The patient had undergone thoracic descending aortic graft replacement because of dilatation of the distal aortic arch after optimal medical therapy for Type B aortic dissection. After 9 years, a new entry occurred at the level of the diaphragm. He was treated with thoracic endovascular aortic repair (TEVAR) due to rapid dilatation and his back pain. However, distal SINE occurred 1 month after TEVAR. Therefore, we performed chimney endovascular aortic repair to maintain perfusion to superior mesenteric artery and bilateral renal arteries. When using a prefabricated branched device in a narrow dissected true lumen, the possibility of selectively catheterizing a visceral branch often has no straightforward solution. However, parallel grafting is a flexible technique that had paramount importance for the surgical outcome in our case.
  562 35 -
Prospective evaluation of radiocephalic arteriovenous fistula to determine the causes for non maturity with clinical and ultrasonography-doppler
Sameer Bhuwania, Rajesh Goel, Ravi Bansal, Sanjiv Saxena
December 2021, 8(6):147-152
Introduction: The RC-AVF is the most important tool for hemodialysis considered to be the life line of patients. In our study, we have tried to find the incidence of AVF non maturation and the physical and ultrasonological parameter which can predict its non maturation. Materials and Methods: Radio-cephalic AVF surgery was done taking into account the inclusion and exclusion criteria with a follow up period of 6 weeks. The cases were evaluated pre-operatively and post-operatively using clinical and DUS. Results: 91 cases were studied with a success surgical outcome in 54.9% (50) of patients. The mean age of 46.04 yrs, male sex and less diabetes (46%) was associated with a matured RC-AVF surgical outcome. Mean preoperative artery diameter of > 0.21 ± 0.04 cm and vein diameter of > 0.20 ± 0.03 cm was seen in the matured cases. Incremental test and Resistive index was normal in 62% and 80% of the matured cases respectively, while calcification of feeding artery was associated with poor outcome. Further Clinical examination showed sensitivity 88% and specificity 95% whereas Doppler studies showed a sensitivity of 100% and specificity of 92.6% to successfully diagnose matured cases. Thrombosis (51%) was the most common cause of AVF failure followed by juxta anastomosis stenosis (14%). Conclusion: In this study we found that a thorough pre-operative evaluation of the vessels of RC-AVF can predict its maturation. Also a regular follow-up and use of clinical and imaging studies can help diagnose and timely salvage a failing AVF.
  540 56 -
Guidewire complications during central vein cannulation: A peril underestimated
Anshuman Darbari, Raja Lahiri
December 2021, 8(6):165-167
Medical intervention procedures are never complication-free. Even after years of refinement in techniques and laying out protocols and checklists, errors do occur. Most of them are preventable, but not all of them. In such cases, efficient and timely diagnosis and management of complications is a key to a successful outcome. In this case series, we describe three situations of complications due to guidewire used in central venous cannulations and different approaches toward their successful management.
  548 40 -
Four limb gangrene - A rare presentation
BR Niveda, Jyoti S Karegoudar, V Vijayanath
December 2021, 8(6):162-164
We report a case of a 73-year-old male, who presented with acute gangrene of the left thumb which then progressed to symmetrical peripheral gangrene of digits of all four limbs, with no comorbid diseases. On investigation, there was high D-dimer, normal lipid profile, and two-dimensional Echo. Computed tomography and magnetic resonance angiogram of all limbs revealed atherosclerotic changes. The patient underwent disarticulation of digits under the wrist block. Symmetrical peripheral gangrene, seen in a wide variety of medical conditions presents as symmetrical gangrene of two or more extremities without large vessel obstruction or vasculitis. The fingers and toes (rarely nose, ear lobes, or genitalia) are affected. It may manifest unpredictably in conditions associated with sepsis, diabetes mellitus, low-output states, vasospastic conditions, myeloproliferative disorders, or hyperviscosity syndrome. It carries a high mortality rate with a very high frequency of multiple limb amputations in survivors.
  544 39 -
A case of squamous cell carcinoma due to neglected AV fistula for dialysis
Jayabal Pandiaraja
December 2021, 8(6):175-177
Squamous cell carcinoma is a malignancy arising from keratinocytes. Arteriovenous (AV) fistula is one of the rare conditions causing chronic inflammation of skin and underlying structure. AV fistula can create catastrophic complications such as squamous cell carcinoma if neglected. There are very few reports of squamous cell carcinoma due to Av fistula. Most of the cases require surgical excision of squamous cell carcinoma with ligation of AV access if infiltrated. Early detection of cutaneous malignancy will reduce the morbidity and mortality related to malignancy and it also salvages the AV fistula.
  536 37 -
Novel use of forearm perforator in vascular access
T Krishna Prasad, Nayan J Timbadiya
December 2021, 8(6):178-180
A 65-year-old male was initiated on hemodialysis through a radio-cephalic arteriovenous fistula. He required a proximal brachiocephalic fistula due to a failing radiocephalic fistula. Both fistulae could be functionalized simultaneously due to a forearm cephalic perforator vein. The radiocephalic fistula was subsequently ligated, allowing the patient to use the mature brachiocephalic fistula instead of a bridging temporary/tunneled catheter.
  534 37 -
John Hunter - Father of scientific surgery
Shivanesan Pitchai
December 2021, 8(6):157-158
  528 36 -
Peroneal nerve palsy due to pseudoaneurysm following total knee arthroplasty: A case presentation
Jennifer Sitther Solomon, Pranay Pawar, Bobby John, Anil Luther
December 2021, 8(6):159-161
Total knee arthroplasty (TKA) is among the commonly performed orthopedic procedures with a very good safety profile. Vascular injuries following TKA are very rare and usually identified intraoperatively or in the immediate postoperative period. Popliteal artery pseudoaneurysms post-TKA are very rare, and their management can be quite challenging. We describe a case that presented more than 3 months after the index surgery with a peroneal nerve palsy due to a pseudoaneurysm.
  520 31 -