POST OPERATIVE GRAFT INFECTION IN A REDO CASE OF THORACOFEMORAL BYPASS

LIFE IS STRANGE.IT KEEPS THROWING CHALLENGES AND ITS UPTO YOU TO COPE WITH THEM.THEY TEST YOUR SENSIBILITIES TO THE CORE AND KEEP YOU ON YOUR TOES.BUT THEN THATS LIFE. UNPREDICTABLE....

WE RECENTLY HAD A SIMILAR CASE WITH US.THIS GENTLEMAN IN HIS FIFTIES CAME TO US IN EMERGENCY WARD WITH CRITICAL LIMB ISCHEMIA OF BOTH THE LEGS.HE HAD UNBEARABLE PAIN IN HIS LEFT LEG.ON EXAMINATION WE REALISED HE HAD IRREVERSIBLE ISCHEMIA OF THE LEFT LEG AND THE RIGHT LEG SEEMED SALVAGABLE THOUGH SIGNS AND SYMPTOMS WERE SUGGESTIVE OF ADVANCED ISCHEMIA.INTERESTINGLY THIS PATIENT UNDERWENT LEFT AXILLO-UNIFEMORAL BYPASS(TO ME THIS WAS NOT THE BEST TREATMENT OPTION AT THE OUTSET) TWO MONTHS BACK AT SOME OTHER CENTRE.THE GRAFT GOT OCCLUDED AND ALL ATTEMPTS TO RECANALIZE IT INCLUDING THROMBOLYSIS FAILED.THIS PATIENT HAD JUXTARENAL AORTIC OCCLUSION AS THE UNDERLYING PATHOLOGY WITH PORCELAIN(HEAVILY CALCIFIED)ABDOMINAL AORTA.PROBABLY THIS WOULD HAVE BEEN THE REASON FOR ATTEMPTING AX-FEM BYPASS IN HIM EARLIER.

WE DID A DECENDING THORACO-BIFEMORAL BYPASS IN THIS PATIENT BY CREATING A RETROPERITONEAL TUNNEL AS SUGGESTED BY KEAGY ET AL IN HIS PATHBREAKING ARTICLE PUBLISHED IN VARIOUS INTERNATIONAL VASCULAR SURGERY JOURNALS.WE REVASCULARISED THE LEFT LOWER LIMB STUMP FOR THE PURPOSE OF TISSUE HEALING.

THE REAL STORY BEGINS HERE.THE SURGERY WENT OFF WELL BUT POST OPERATIVELY THE PATIENT DEVELOPED WOUND DEHISCENCE IN THE LEFT GROIN,LEFT ABOVE KNEE AMPUTATION STUMP AND IN THE CHEST WITH GRAFT EXPOSURE .SUBSEQUENT INVESTIGATIONS REVEALED SEVERE HYPOALBUMINEMIA AS THE UNDERLYING CAUSE OF RAMPANT WOUND DEHISCENCE.

HYPOALBUMINEMIA AS WE ALL KNOW IS ASSOCIATED WITH POOR WOUND HEALING,DECREASED COLLAGEN SYNTHESIS,IMPAIRED IMMUNE RESPONSES LIKE MACROPHAGE ACTIVATION ETC AND DELAYED RECOVERY OF BOWEL FUNCTION POSTOPERATIVELY.

I MUST THANK THE PLASTIC SURGERY DEPARTMENT OF OUR HOSPITAL WHO FINALLY TREATED THIS COMPLICATION WITH AN EXTERNAL OBLIQUE FLAP.RECENTLY THIS PATIENT CAME FOR FOLLOWUP AND THE WOUND LOOKS HEALTHY.THE CHEST WOUND WAS DEBRIDED AND WOULD BE READY FOR RESUTURING IN A FEW DAYS FROW NOW.

I AM TRAINED IN ONE OF THE BUSIEST VASCULAR SURGERY CENTRES IN THE COUNTRY BUT HAVE NEVER SEEN AN AWFUL COMPLICATION LIKE THIS WHEREIN ALL SUTURE LINES GIVE IN.I REALIZE WHY PEOPLE PREFER GOING TO EXPERIENCED SURGEONS FOR THEIR AILMENTS (THEY HAD SEEN IT ALL I GUESS....).

I WOULD BE FAILING IN MY DUTY IF I DONT THANK MY PATIENT FOR HAVING PERSEVERENCE AND FAITH IN OUR CAPABILITIES.

Intravascular Leiomyosarcoma Of The Femoral Vein:Is It Rare?

Intravascular leiomyosarcomas are extremely rare.Going by the literature fewer than 40 cases have been reported so far wherein the tumour arose from the femoral vein.

Leiomyosarcomas usually arise from the muscular layers of the uterus or from the GI tract.Its an uncommon occurence for them to arise from the blood vessels.We report to you a case of leiomyosarcoma arising from the femoral vein.

A 40 years old male came to us with the complaints of swelling from the right upper thigh which he noticed some 2 weeks back.The swelling was associated with localised pain.There was no history of peripheral oedema and the initial radiological evaluation was suggestive of tumour arising in the vicinity of blood vessels.Further evaluation with MRI indicated the possibility of leiomyosarcoma.Doppler venous scan done for the status of deep veins was suggestive of chronic DVT of the popliteal and proximal superficial veins.Its surprising that the patient never had any symptoms of DVT like limb oedema etc.

At surgery the mass was found to be arising from the SFV from just where it drains into the CFV involving almost 10 cms of the venous segment.It was closely adherent to the femoral artery which was excised alongwith for wider surgical clearance.The femoral artery was reconstructed with ePTFE graft. SFV was not not reconstructed though because of chronic changes.

The histopathology specimen consisted of typical spindle cells disposed in interlacing fascicles with areas of hemorrhage.The final diagnosis was proved by IHC studies.

The postoperative course was uneventful.The patient is doing well and is referred to the medical oncologist for chemotherapy/ radiation therapy since these tumours are known to metastize to lung liver and scalp.

DISCUSSION

Clinical presentation depends on the extraluminal/intraluminal growth of the tumour mass.If extraluminal it can result in nerve compression causing pain and if intraluminal it can mimicthe symptoms of DVT.

Management of such cases are challenging because of very low incidence with most of the data available in literature being single reports.

Perineal Infrascrotal Bypass Saves Another Life

Its been a while when I last posted.Was keeping busy.Hope you guys had a terrific Diwali.Some interesting and at times pleasant challenges keep coming across to you in your day to day chores and you feel blessed that God has chosen you among others to do the needful.

On the night of dusshera we had a difficult case to handle.This guy in his late thirties came with massive bleeding from his groin area along with forefoot gangrene.A detailed history was not surprising though.He was a parentral drug addict who used to take injections in his femoral artery unabated.Examination revealed he had severe infection of the groin which was extending way into his right retroperitoneal space and involved quite a bit of the abdominal wall.Doing a Obturator foramen bypass was ruled out due to the above mentioned findings.So was doing a axillo-popliteal bypass.I being not a keen follower of this surgery(AX-POP) is a different issue altogether.The only option left was to do a perineal infrascrotal femoro-femoral crossover bypass.FortunatelyI had experience doing same kinda case a year back which is published in my blog in 2010.Encouraged by the outcome in that case we went ahead with the same procedure in this gentleman.Its about a month now and this guy is doing great.He had three subsequent surgeries to heal his groin and foot wounds and now is back on his legs.Really happy for him.

To me this is a fantastic vascular surgical procedure which needs a little more skill but is worth the effort.This is my second case of the series.The first case was done more than a year ago and is still in my followup.Not sure what makes this graft work with those so called anatomical twists and turns around the bulbous part of urethra.Seems its the short length of the graft that does the trick.

CDT OF POPLITEAL ARTERY THROMBOSIS:MY FIRST CASE IN APOLLO HOSPITAL

THERE IS NOTHING MUCH TO WRITE FOR THE MONTH AS I AM SETTLING DOWN IN LUDHIANA AND GETTING USED TO THE WORK CULTURE HERE.WE RECENTLY DID A CATHETHER DIRECTED THROMBOLYSIS(CDT) FOR A 65 YEARS OLD MALE WHO PRESENTED WITH ACUTE RIGHT LOWER LIMB ISCHEAMIA. WE WERE NOT SURE WHETHER IT WAS AN EMBOLIC/INSITU THROMBOTIC EPISODE AND THEREFORE WENT AHEAD WITH CDT OF THE POPLITEAL ARTERY.THE PERFUSION OF THE LIMB IMPROVED AS TIME PASSED AND THE PULSES WERE RESTORED FINALLY.PATIENT HAD A BLEEDING EPISODE WHICH WAS MANAGED BY BLOOD TRANSFUSION .SURPRISINGLY WE DID NOT FIND ANY UNDERLYING LESION LIKE A POP.ANEURYSM OR PAD IN HIM.I WOULD HAVE LOVED TO DO THIS CASE IN THE OPERATION THEATRE WITH AN ENDOVASCULAR SUITE.WE DONT HAVE ONE RIGHT NOW BUT WOULD SOON BE EQUIPPED WITH THIS.THINGS WOULD BE ALOT EASIER THEREAFTER FOR THE SURGEON AND FOR THE PATIENT( IT WILL AVOID BIG INCISIONS) AS DECISION MAKING AND PROMPT STATE OF THE ART INTERVENTION WOULD BE POSSIBLE AND ACCESSIBLE. MOST OF THE VASCULAR CASES TODAY NEED HYBRID INTERVENTIONS(THE WAY ENDOVASCULAR SURGERY IS EXPANDING) AND THEREFORE ENDOVASCULAR SUITE IN THE OPERATION THEATRE IS A MUST ESP.FOR HOSPITALS WHO ARE CONCERNED WITH THEIR PROFESSIONAL STANDING.

FINALLY JOINED APOLLO HOSPITAL LUDHIANA AS SENIOR CONSULTANT IN VASCULAR SURGERY

ITS INDEED A MATTER OF GREAT PRIDE TO BE ASSOCIATED WITH APOLLO GROUP OF HOSPITALS MORE SO WHEN ITS YOUR OWN STATE WHERE YOU WERE BORN AND BROUGHT UP.COMING BACK FROM GERMANY SPENDING 2 MONTHS LIFE HAD BEEN QUITE HECTIC WITH THINGS PILING UP AND REQUIRING URGENT ATTENTION.FINALLY GOT A HOME OF MY CHOICE,SCHOOL FOR KIDS AND JOINED SPS APOLLO HOSPITAL LUDHIANA AS SENIOR CONSULTANT IN VASCULAR SURGERY.PLANNING STARTING A FULL FLEDGED AORTIC PROGRAM HERE INCLUDING ENDOVASCULAR MANAGEMENT OF AORTIC DISSECTIONS.LONG JOURNEY BUT WE WILL DO IT WITH ALL YOUR WISHES AND THE BLESSINGS OF MY PARENTS.

I SHOULD.

I CAN.

I WILL.(WITH ALL HUMILITY)

THATS FOR NOW.WILL KEEP YOU POSTED.

MY GERMAN EXPERIENCE:SECOND INNINGS

ITS BEEN A WHILE WHEN I LAST POSTED SOMETHING ON THIS BLOG.THE REASON IS I WAS AWAY TO GERMANY FOR ABOUT 2 MONTHS.
GERMANY HAS ALWAYS BEEN ON THE FOREFRONT WHEN IT COMES TO QUALITY OF LIFE.GERMANS ARE OBSESSED WITH CLEANLINESS AND CRAVE FOR PERFECTION ALL THE TIME.THEY ARE THE ECONOMIC GIANTS OF EUROPE FOR MANY MANY YEARS NOW.HAVING SAID THAT ONE SHOULD TAKE INTO CONSIDERATION THE KIND OF EFFORT THEY HAVE PUT IN TO REBUILD IT AFTER THE WORLD WAR.I HAD BEEN TO GERMANY BEFORE IN 2007 FOR 3 MONTHS AS AN OVERSEAS TRAINEE IN THE DEPARTMENT OF VASCULAR SURGERY IN RENDSBURG.THE EXPERIENCE THAT TIME WAS VERY GOOD BUT I WOULD SAY THAT IT WAS EVEN BETTER THIS TIME AROUND.I WAS IN ONE OF THE LEADING UNIVERSITY HOSPITALS THERE FOR ABOUT 2 MONTHS.THE PURPOSE OF THE VISIT WAS TO FOCUS ON ADVANCED VASCULAR STUFF LIKE THORACO-ABDOMINAL ANEURYSM REPAIRS,AORTIC STENTING AT ANY AND EVERY LEVEL AND SOME PARTICULAR PERIPHERAL VASCULAR PROCEDURES.I NOT ONLY SAW THESE PROCEDURES IN PLENTY BUT ALSO HAD THE OPPORTUNITY TO SEE LUNG TRANSPLANTS WHICH IS A BIG BONUS. I REALLY HAD THE TIME OF MY LIFE PARTICIPATING IN THE DEPARTMENTAL ACTIVITIES STARTING FROM THE MORNING SESSIONS WHICH USED TO BE A PLEASANT INTERACTION BETWEEN THE FACULTY AND THE STUDENTS AND ENDING UP IN THE OPERATING ROOMS.FANTASTIC GUYS WITH FANTASTIC TEMPERAMENT .ALOT TO LEARN FROM THEM.
THE PROPOSAL IS ON FOR A STUDENT EXCHANGE PROGRAM OR A SHORT FELLOWSHIP.THOUGH EARLY DAYS BUT WE WILL MAKE IT FOR SURE IN ALL PROBABILITY BY NEXT YEAR.I THINK WE STAND TO BENEFIT IMMENSELY FROM THIS AS THE YOUNG AND SEEMINGLY YOUNG VASCULAR SURGEONS FROM INDIA WILL GET A PLATFORM TO INTERACT WITH THEM ON A DAY TO DAY BASIS AND SEE QUALITY WORK.

BIFEMORO-CAVAL BYPASS FOR MALIGNANCY IN A 50 YEARS OLD WOMAN:CASE REPORT

INTRAOPERATIVE PICTURES OF THE PROCEDURE DONE AT VARIOUS STAGES OF COMPLETION.



Major surgical venous reconstructions have decreased remarkably in the era of endovascular interventions.Open surgical major venous reconstructions are reserved for patients either with failed endovascular approach or for those who are not candidates for the same.Trauma and Malignancy are the two main conditions wherein open surgical reconstructions of the major veins are still done and probably may continue in the years to come.Graft patency in venous reconstructions has been a major issue of concern.Reason for this being the low flow low pressure state in the venous system.The use of adjunct arteriovenous fistula(AVF) has dramatically increased the patency rates to acceptable levels.
We report to you a similar case of a woman aged 50 years with underlying Malignancy.She had her radiotherapy done and landed up with massive swelling of both the lower limbs more on the thighs than legs.A thorough investigation revealed her left iliac vein to be totally occluded with short length occlusion of the right iliac vein and proximal IVC.She was in a real bad shape as she was not able to walk much and the swelling had involved her groin region as well.There was a strong possibility of a residual tumor in the pelvis and therefore we planned an exploratory laparotomy for her with the intention to clear the tumour and reconstruct the major veins to relieve venous congestion/hypertension.Intraoperatively we found the vessels to be badly stuck with the spine probably because of extended RT sittings she had in the past.
We did a bifemoro-caval bypass with PTFE graft with an adjunct AV fistula in the groin region for better patency rates.Lifelong anticoagulation is recommended with a plan to maintain the fistula as long as possible ,for a mimimum of 12 weeks.Experience with femoro-caval reconstructions is limited.The longest series I could gather from the internet is for 56 patients by Sottiuari et al with a patency rate of 93% at one year for prosthetic iliac vein reconstructions.
This patient is recovering well with the swelling of the thighs decreasing remarkably.She certainly is in a better shape now.
It was indeed a very unique experience doing a surgery like this for we had heard and read such surgeries only in the textbooks but never were a part of it before.The whole credit should go to my teachers who instilled in me the work culture of “PERSISTENCE AND HARD WORK”.