FEMORAL ARTERY ENDARTERITIS POST ANGIO-AN UNKNOWN ENTITY

FEMORAL ARTERY ENDARTERITIS IS STILL A RELATIVELY UNKNOWN ENTITY ESPECIALLY AMONG VASCULAR SURGEONS AND CARDIOLOGISTS.NO DOUBT ITS REPORTED INCIDENCE IN LITERATURE IS LESS THAN 1%.

WHAT EXACTLY IS FEMORAL ENDARTERITIS?BASICALLY ITS THE INFECTION OF THE FEMORAL ARTERY AND ITS SURROUNDING TISSUE POST CONVENTIONAL ANGIOGRAM.PATIENT PRESENTS TO YOU WITH PAIN IN THE GROIN GENERALLY WITHIN A WEEK AFTER ANGIO ALONG WITH SYMPTOMS OF SEPSIS AND LOCALISED INFECTION /CELLULITIS IN THE GROIN EXTENDING INVARIABLY OVER THE ABDOMINAL WALL WITH PUS DISCHARGE AT THE PUNCTURE SITE.

WE REPORT A CASE OF FEMORAL ARTERY ENDARTERITIS IN A 73 YEARS OLD MAN WHO REPORTED TO OUR CENTRE IN MOHALI WITH SYMPTOMS OF SEPSIS(HIGH GRADE FEVER,LOW HEAMOGLOBIN,LEUKOCYTOSIS,DERANGED RENAL FUNTION TESTS AND REACTIVE THROMBOCYTOSIS)ALONG WITH SEVERE GROIN PAIN AND SWELLING EXTENDING OVER THE ABDOMINAL WALL.THIS PATIENT UNDERWENT ANGIOGRAM THROUGH THE FEMORAL ROUTE SOME TEN DAYS BACK.HE WAS PUT ON STRONG ANTIBIOTICS BUT TO NO AVAIL.A DOPPLER SCAN AND A CT ANGIO RULED OUT MYCOTIC PSEUDOANEURYSM OF THE FEMORAL VESSELS.

WE TOOK HIM UP FOR IMMEDIATE SURGERY AND FOUND FLORID INFECTION AND CREAMISH YELLOW COLORED PUS EXTENDING FROM THE PUNTURE SITE TO THE GROIN THE ABDOMINAL WALL (SUGGESTIVE OF STAPYLOCOCCUS INFECTION).WE DID A WIDE DEBRIDEMENT OF THE GROIN AND THE FEMORAL ARTERIAL WALL AND REPLACED IT WITH VENOUS PATCH.THE FEMORAL ARTERY WAS COVERED WITH THE TISSUE AROUND TO PREVENT A BLOWOUT.THE GROIN IS LEFT OPEN TILL THE LOCAL INFECTION SUBSIDES AND THE PATIENT IS READY FOR SECONDARY SUTURING.

I FEEL THOUGH UNCOMMON BUT STILL THIS ENTITY LARGELY GOES UNREPORTED /UNDERREPORTED.I HAPPENED TO TALK ABOUT THIS WITH MY COLLEAGUES IN CARDIOLOGY AND VASCULAR FRATERNITY BUT ALL I GET TO KNOW IS THAT THEY HAVE READ ABOUT IT BUT NEVER SEEN IT.ANYWAYS IN A SITUATION LIKE THIS TREATMENT OPTIONS ARE LIMITED AND THE OPERATING SURGEON HAS TO BE VERY AGGRESSIVE IN HIS LINE OF ACTION FOR THESE PATIENTS MAY NEED REPEATED DEBRIDEMENTS AND A POSSIBLE OBTURATOR FORAMEN BYPASS TO SAVE THE LIMB FROM AMPUTATION.

THE ABOVE PICTURE PUBLISHED SHOWS YOU THE SITE OF PUNCTURE WITH PUS DISCHARE ALONG WITH CELLULITIS OF THE NEIGHBOURING TISSUE.

ME GOING INTERNATIONAL- COVERED EUROPE,CANADA,AMERICA.WHAT NEXT DUDE?

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ੳਸਲੋ 11ਸਤੰਬਰ (ਰੁਪਿੰਦਰ ਢਿੱਲੋ ਮੋਗਾ) ਮੋਗਾ ਦੇ ਜੰਮਪਾਲ ਅਤੇ ਡਾ ਸੁਬੋਧ ਸਿੰਗਲ ਤੇ ਪ੍ਰੋ ਕਿਰਨ ਸਿੰਗਲ ਦੇ ਹੋਣਹਾਰ ਸਪੁੱਤਰ ਡਾਂ ਗੋਰਵ ਸਿੰਗਲ(ਵਾਸਕੂਲਾਰ ਸਰਜਨ) ਨੇ ਮੈਡੀਕਲ ਸਾਇੰਸ ਚ ਹੋਰ ਚਮਤਕਾਰ ਕਰਦੇ ਹੋਏ ਭਾਰਤ ਚ ਪਹਿਲੀ ਵਾਰ ਕੈਸਰ ਨਾਲ ਗ੍ਰਸਤ ਮੁੱਖ ਖੂਨ ਨਾੜੀ ਦਾ ਸਫਲ ਆਪ੍ਰਰੇਸ਼ਨ ਕਰ ਪੀੜਤ ਮਨਹੋਰ ਲਾਲ ਗੌਬਿੰਦਗੜ ਵਾਸੀ ਨੂੰ ਇੱਕ ਨਵਾ ਜੀਵਨ ਦਾਨ ਦਿੱਤਾ।ਆਪਣੀ ਮੁੱਢਲੀ ਵਿਦਿਆ ਮੋਗੇ ਦੇ ਮਸ਼ਹੂਰ ਸਕੂਲ ਸਕੈਰਡ ਹਾਰਟ ਸਕੂਲ ਤੋ ਪ੍ਰਾਪਤ ਕਰ ਡੀ ਐਮ ਸੀ ਲੁਧਿਆਣਾ ਤੋ ਡਾਕਟਰੀ ਡਿਗਰੀ ਹਾਸਿਲ ਕੀਤੀ। ਵਾਸਕੂਲਾਰ ਸਰਜਰੀ ਚ ਮਾਹਿਰਤਾ ਇਹਨਾ ਨੇ ਨਿਜ਼ਾਮ ਇੰਸਟੀਚਿਉਟ ਆਫ ਮੈਡੀਕਲ ਸਾਇੰਸ(ਨਿਮਸ) ਹੈਦਰਾਬਾਦ ਤੋ ਪ੍ਰਾਪਤ ਕਰ ਉਥੇ 7 ਸਾਲ ਸੇਵਾ ਕੀਤੀ।ਸਰਕਾਰ ਤੋ ਸਕਾਲਰਸਿ਼ਪ ਪ੍ਰਾਪਤ ਕਰ ਵਾਸਕੂਲਾਰ ਸਰਜਰੀ ਚ ਉੱਚ ਮਾਹਿਰਤਾ ਡੂਸਲਡਰੋਫ ਅਤੇ ਹਮਬਰਗ(ਜਰਮਨੀ) ਤੋ ਕੀਤੀ। ਡਾ ਗੋਰਵ ਸਿੰਗਲ ਨੇ ਦੱਸਆ ਕਿ ਦਿਲ ਨੂੰ ਖੂਨ ਪਹਿਚਾਉਣ ਵਾਲੀ ਮੁੱਖ ਖੂਨ ਨਾੜੀ ਦਾ ਕੈਸਰ ਗ੍ਰਸਤ ਹਿੱਸਾ ਕੱਢ ਉਸ ਥਾਂ ਪਲਾਸਟਿਕ ਦੀ ਪਾਇਪ ਡਾਕਟਰੀ ਵਿੱਧੀ ਨਾਲ ਪਾ ਦਿੱਤੀ ਗਈ। ਇਹ ਆਪ੍ਰਰੇਸ਼ਨ 7 ਘੰਟੇ ਚੱਲਿਆ।ਡਾਂ ਸਿੰਗਲ ਨੇ ਦੱਸਿਆ ਕਿ ਮੁੱਖ ਖੁਨ ਨਾੜੀ ਸ਼ਰੀਰ ਦੇ ਅਸੁੱਧ ਖੁਨ ਨੂੰ ਦਿਲ ਦੇ ਜਰੀਏ ਫੇਫੜਿਆ ਤੱਕ ਪਹੁੰਚਾਉਦੀ ਹੈ ਅਤੇ ਫੇਫੜੇ ਅਸੁੱਧ ਖੁਨ ਨੂੰ ਸੁੱਧ ਕਰ ਦੂਸਰੀ ਨਾੜੀ ਜਰੀਏ ਪੂਰੇ ਸ਼ਰੀਰ ਚ ਪਹੁੰਚਾਉਦੇ ਹਨ।ਪੀੜਤ ਮਨੋਹਰ ਲਾਲ ਇਸੇ ਸਾਲ 16 ਜੂਨ ਨੂੰ ਗੰਭੀਰ ਹਾਲਾਤ ਚ ਉਹਨਾ ਕੋਲ ਪਹੁੰਚਾਇਆ ਅਤੇ ਜਾਂਚ ਉਪਰੰਤ ਪਤਾ ਚੱਲਆ ਕਿ ਉਸਦੀ ਮੁੱਖ ਖੂਨ ਨਾੜੀ ਕੈਸਰ ਗ੍ਰਸਤ ਹੈ, ਸੋ 18 ਜੂਨ ਨੂੰ ਸੱਤ ਘੰਟੇ ਚੱਲੇ ਲੰਬੇ ਆਪ੍ਰਰੇਸ਼ਨ ਕਰ ਕੈਸਰ ਗ੍ਰਸਤ 15 ਸੈ ਮੀ ਨਾੜੀ ਕੱਟ ਉਸ ਦੀ ਥਾਂ ਡਾਕਟਰੀ ਵਿੱਧੀ ਨਾਲ ਪਲਾਸਟਿਕ ਪਾਇਪ ਫਿੱਟ ਕਰ ਦਿੱਤੀ ਗਈ।ਹੁਣ ਮਰੀਜ ਮਨੋਹਰ ਲਾਲ ਪੂਰੀ ਤਰਾ ਤੰਦਰੁਸਤ ਹੈ। ਮਿਲਣਸਾਰ ਡਾਂ ਸਿੰਗਲ ਦਾ ਮੋਬਾਇਲ ਨੰਬਰ 9779780353 ਹੈ ਅਤੇ ਵਧੇਰੇ ਜਾਣਕਾਰੀ www.gauravsingal.blogspot.com ਤੇ ਵੀ ਪ੍ਰਾਪਤ ਕੀਤੀ ਜਾ ਸੱਕਦੀ ਹੈ।
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ARTICLE IN A LEADING HINDI NEWSPAPER DAINIK JAGRAN REGARDING AWARENESS CONCERNING CAROTID ARTERY DISEASE AND ITS TREATMENT

अब मुश्किल नहीं अधरंग का इलाज
यूं तो सभी बीमारियां दुखदाई व तकलीफदेह होती हैं परंतु कुछ बीमारियां ऐसी होती हैं जिनके कारण मरीज की जिंदगी मृत्यु से भी बदतर हो जाती है। ऐसी ही एक नामुराद बीमारी है- अधरंग, लकवा या पैरालईजिज। इस बीमारी में मरीज के शरीर का एक अंग या शरीर का एक हिस्सा काम नहीं करता। कई मामलों में मरीज की जीभ भी रुक जाती है। ऐसी स्थिति में मरीज या तो परमानेंट चारपाई से जुड़ जाता है या फिर दूसरों पर निर्भर होकर रह जाता है। कई बार तो उसे अपनी रोजाना दिनचर्या, यानी मलमूत्र त्याग के लिए रेंग कर शौचालय तक जाना पड़ता है। यहां तक कि वह अपने तौर पर न तो खाना खा सकता है और न ही पानी पी सकता है। अधरंग क्यों होता है? : वास्कुलर सर्जन डा. गौरव सिंघल के अनुसार 80 प्रतिशत अधरंग का कारण रक्त का थक्का (ब्लड क्लाट) होता है जो रक्त की नस से टूट कर दिमाग वाली नस में चला जाता है और वह दिमाग को जाने वाली रक्त सप्लाई को बाधित कर देता है। जिस कारण शरीर का कोई अंग या कोई हिस्सा बेकार (निष्कि्रय) हो जाता है। पैरालाइजिज अटैक से 20 प्रतिशत लोगों के रक्त की नाड़ी फट जाती है, जिसे ब्रेन हैमरेज कहा जाता है, इससे इंसान की मृत्यु भी हो जाती है। डा. सिंघल के अनुसार पैरालाइजिज अटैक होने से 2/3 लोग अपाहिज हो जाते हैं, जबकि 1/3 की मृत्यु हो जाती है। उन्होंने बताया कि बढ़ती आयु, उच्च रक्तचाप, अत्याधिक मोटापा, शूगर आदि भी अधरंग के लिए काफी हद तक जिम्मेदार होते हैं। यही नहीं अधरंग के 2/3 लोगों में शूगर व रक्तचाप की बीमारी पाई जाती है। लक्षण : अस्थायी तौर पर किसी अंग का काम न करना, बोलने में दिक्कत आना, अचानक गिर जाना या बेहोश हो जाना, मुंह टेढ़ा हो जाना, आंखों के आगे अंधेरा छा जाना आदि इस बीमारी के मुख्य लक्षण हैं। अत: उपरोक्त लक्षण सामने आने पर उन्हें हल्के में न लें तथा तुरंत विशेषज्ञ डाक्टर से संपर्क करें। समाधान : डा. गौरव सिंगल के अनुसार 80 प्रतिशत लोगों, जिनके खून में थक्का (ब्लड क्लाट) अधरंग का कारण बनता है, में दिमाग का रक्त सप्लाई करने वाली नाड़ी (जिसे करोटिड आर्टरी) कहा जाता है में ब्लाकेज पाई जाती है। उन्होंने बताया कि अब इस ब्लाकेज को खोलना असंभव नहीं है। इस नाड़ी को खोल कर इसमें जमा रक्त का थक्का हटा कर इसे साफ कर दिया जाता है और मरीज पहले वाली स्थिति में आ जाता है। इस आप्रेशन के बाद मरीज को पुन: पैरालाइजिज अटैक का डर भी नहीं रहता। डा. सिंघल के अनुसार इस सर्जरी को करोटिड एण्डारट्रेक्टमी यानि सीईए कहा जाता है और यह सबसे कामन वास्कुलर सर्जरी है जिसमें सिर्फ 60 मिनट लगते हैं। जिसके करने के एक दिन बाद ही मरीज घर चला जाता है और इस पर लगभग 80 से 90 हजार रुपये खर्च आता है।
इस पृष्ठ की सामग्री जागरण द्वारा प्रदान की गई. © 2009

PEOPLE WHO CHANGED MY LIFE FOR EVER-A TRIBUTE

I STILL REMEMBER THE DAY WHEN I JOINED NIZAM INSTITUTE OF MEDICAL SCIENCES HYDERABAD IN 2002 AS A VASCULAR TRAINEE UNDER PROF.RAMAKRISHNA PINJALA.I WAS AN AVERAGE GENERAL SURGEON TO SAY THE LEAST.WITH AN AVERAGE GENERAL SURGICAL TRAINING BEHIND ME I WAS JUST WONDERING WHAT WAS I UPTO INSPITE OF PUTTING IN 10 GOOD YEARS OF MY LIFE INTO MEDICAL PROFESSION AS A STUDENT.ALL I HAD WAS A BURNING PASSION TO DO SOMETHING GOOD IN LIFE.TO MAKE LONG STORY SHORT I WAS LOOKING FOR THE RIGHT DIRECTION IN MY SURGICAL CAREER.AND AS ALWAYS HAPPENS IN A TYPICAL MASALA INDIAN MOVIE THOUGH THIS TIME IN REAL LIFE(READ REAL AND NOT REEL)I CAME ACROSS DR PINJALA AS A MENTOR AND A TRUE GUIDE.HE NOT ONLY TAUGHT ME THE BASICS OF VASCULAR SURGERY BUT WENT A STEP FURTHER STATING THE GLOBAL PRESENCE OF THIS SPECIALITY AND WHAT EVERYONE OF US CAN DO TO MAKE OUR PRESENCE FELT IN THE VASCULAR COMMUNITY.IT WAS UNDER HIM THAT I FIRST CAUGHT UP WITH THE PHRASE"THINK GLOBAL ACT GLOBAL".

THIS PHRASE OF HIS LEFT AN INDELIBLE MARK AS IF SOMETHING GOT CHISELLED ON MY HEART.

AND THEN STARTED WHAT I CALL AS THE SECOND INNINGS OF MY VASCULAR SURGICAL CAREER WHEN I MET THIS GREAT MAN BY THE NAME PROF.WILHELM .SANDMANN WHO HEADS THE VASCULAR SURGERY DEPARTMENT IN HEINRICH HEINE UNIVERSITY DUSSELDORF GERMANY.I NEVER KNEW BY THEN THAT MY CAREER WAS TO CHANGE FOR EVER.HE IS AN INSTITUTION IN HIMSELF ,SOMEONE WHO HAS MASTERED THE ART OF VASCULAR SURGERY.NO DOUBT HE IS ONE OF THE MOST RESPECTED NAMES IN VASCULAR SURGERY IN EUROPE AND THE UNITED STATES.I STILL REMEMBER THE LETTER HE EMAILED ME WHEN I APPROACHED HIM THROUGH A COMMON FRIEND TO GET TRAINED UNDER HIM .HE ASKED ME THE KIND OF VASCULAR SURGERIES I WAS INTERESTED IN AND BELIEVE ME I WROTE PRACTICALLY EVERY POSSIBLE VASCULAR SURGERY THAT I COULD THINK OF AND CAN YOU IMAGINE WHAT THE REPLY WAS?HE EMAILED ME SAYING"WHAT ALL YOU DESIRE TO LEARN FROM US LIKE THORACO-ABDOMINAL ANEURYSMS ,ANEURYSMS AT ANY AND EVERY LEVEL,REDO AORTIC CASES ETC IS OUR DAILY ROUTINE AND YOU ARE WELCOME'.I BECAME AN INSTANT FAN OF HIS AND WOULD ALWAYS REVERE HIM IN THE LIST OF MY ALL TIME GREATS.ITS A PITY THAT HE RETIRES THIS OCTOBER BUT THEN ALL GOOD THINGS HAVE TO COME TO AN END.

CONTRAINDICATIONS TO CAROTID ARTERY STENTING

WITH EMERGING TRENDS AND A SCIENCE THAT KEEPS REINVENTING ITSELF ITS NO SURPRISE TO COME ACROSS DIFFERENT TREATMENT MODALITIES EVEN ON A ROUTINE BASIS.PROBABLY NO OTHER SUBJECT IN VASCULAR SURGERY HAS RECEIVED SO MUCH ATTENTION AS IS THE TREATMENT OF CAROTID ARTERY DISEASES.WE HUMANS ARE PRONE TO GET HOOKED INSTANTANEOUSLY TO THINGS THAT ARE TERMED" NEW ARRIVALS" IN THE MARKET.FIRST RESULTS OF EVA-3S STUDY ARE ALREADY OUT AND THE GAME IS LOST BY THE STENTS AS THIS STUDY CLEARLY STATES THAT THE STROKE AND DEATH IN SYMTOMATIC CAROTID STENOSIS POPULATION WERE LOWER WITH ENDARTRECTOMY THAN WITH STENTING AT 1 AND 6 MONTHS.THE NON INVASIVE CHARACTER OF THE STENTING IS USED AS THE PRIMARY ARGUEMENT AGAINST OPERATIVE TREATMENT.ADDED TO THIS PROBABLY IS THE HUMAN INCLINATION TO AVOID SURGICAL PROCEDURES FOR INNATE FEAR OF KNIFE AND STUFF.
CONTRAINDICATIONS TO CAROTID ARTERY STENTING ARE IN PLENTY WHICH UNFORTUNATELY MOST OF OUR MEDICAL FRATERNITY IS UNAWARE OF OR ELSE PRETENDS TO .I FEEL AT THE END OF THE DAY ITS THE PATIENT WHO SHOULD BE THE FINAL BENEFICIARY AND EVERYTHING ELSE IS SECONDARY.
CAROTID ENDARTRECTOMY(CEA)IS A SAFE 60 MINUTES SURGICAL PROCEDURE DONE ON A ROUTINE BASIS WORLDWIDE WITH GRATIFYING RESULTS .THE PATIENT IS USUALLY DISCHARGED FROM THE HOSPITAL IN A DAY OR TWO POST PROCEDURE.IF AT ALL ECONOMY HAS SOME ROLE TO PLAY ,ITS JUSTIFIED TO SAY THAT IN A COUNTRY LIKE INDIA CAROTID ENDARTRECTOMY IS A FAR CHEAPER OPTION THAN STENTING EVEN AFTER TAKING INTO ACCOUNT THE SAFETY OF BOTH THE PROCEDURES.
I AM STATING FEW CONTRAINDICATIONS TO CAROTID STENTING THAT HAVE EVOLVED OVER A PERIOD OF TIME AND HAVE BEEN PUBLISHED IN VARIOUS VASCULAR SURGERY BOOKS AND VASCULAR SURGERY JOURNALS.
1)HEAVILY CALCIFIED PLAQUE
2)SOFT PLAQUE
3)DIFFULELY DISEASED CAROTID VESSELS
4)SEVERELY TORTUOUS AND ATHEROMATOUS AORTIC ARCH AND ITS BRANCHES
5)TORTUOUS CAROTID VESSELS
6)STRING SIGN
7)FREE FLOATING AND PEDUNCULATED THROMBUS
9)RECENT STROKE
10)SEVERE RENAL IMPAIRMENT PRECLUDING SAVE USE OF CONTRASTS
11)PRESENCE OF CONTRAINDICATIONS TO ANTIPLATELET AGENTS
12)INTERNAL CAROTID ARTERY SIZE LESS THAN 3 MM.

NOTE:ITS NOT EASY TO REPLACE A PROCEDURE LABELLED TO BE A "GOLD STANDARD".CAROTID ARTERY ENDARTRECTOMY(CEA)IS STILL THE GOLD STANDARD .PROBABLY IN HIGHLY SELECTED CASES CAROTID STENTING DOES HAVE A ROLE TO PLAY LIKE REDO SURGERIES OF THE CAROTID VESSELS, UNFAVORABLE ANATOMY LIKE VERY HIGH CAROTID BIFURCATION & RADIATION ARTERITIS .PLEASE SEE THIS 3 MINUTES VIDEO RELEASED BY THE "SOCIETY FOR VASCULAR SURGERY"(SVS) IN AUGUST 2008 TO EDUCATE MEDICAL FRATERNITY AND PUBLIC ALIKE ABOUT THE HAZARDS OF CAROTID ARTERY STENTING.DO GO THROUGH THIS.

MESENTERIC ISCHAEMIA(ACUTE&CHRONIC)

Mesenteric ischaemia as such is not uncommon in any clinical setting.Unfortunately it goes unnoticed largely because of the symptoms with which the patient first presents to the clinician or else because of the clinical acumen of the physician .But clinicians are not to be blamed for this in totality for the simple reason that we really don’t have proper diagnostic facilities around to be sure what the patient is going through.Added to this is the disparity in the symptomotology and the signs with which the patient presents.By the time the diagnosis is made (generally on the operation table during laprotomy),the patient is already on death bed waiting for the final call.Acute mesenteric ischaemias generally present with severe pain abdomen which is “OUT OF PROPORTION TO CLINICAL FINDINGS”.Abdomen is generally soft and the pain the patient complains of is unexplainable .This delays the diagnosis and by the third or the forth day of presentation patient develops peritonitis and gangrene of the gut.The prognosis is dismal in such cases.Situation is no better in chronic mesenteric ischaemic patients.These patients are generally thin built for they have “FOOD FEAR”.Any small intake of food leads to pain abdomen and therefore these patients largely keep themselves fasting.The basic thing is to be strongly suspicious of a clinicopathological entity like this and when ever you come across a patient with unexplained pain abdomen with lean and thin built suspect mesenteric ischaemia and refer the patient to a vascular surgeon before its too late.

I present to you a similar case which we operated upon recently.This patient who was lean and thin came to us with unexplained pain abdomen,uncontrolled hypertension inspite of taking four antihypertensives and bilateral lower limb claudication.It was the strong clinical suspicion of chronic mesenteric ischaemia in him that clinched the diagnosis and probably saved him from an impending disaster.We got a conventional angio done in him which was suggestive of aorto-iliac block with ostial near total occlusions of the cealic axis,superior mesenteric artery and right renal artery.

We did an aorto-bifemoral bypass along with conventional “TRANSAORTIC ENDARTRECTOMY OF THE CAELIAC,SMA AND RIGHT RENAL VESSELS”.Patient did fine postoperatively and was discharged on the fifth post operative day.Presently he is on just one antihypertensive.

The plaque that has been removed has been displayed .Hope you can make out and appreciate the plaque extensions going into the caeliac,sma and renal arteries.

The carry home message is”BE STRONGLY SUSPICIOUS OF UNEXPLAINED PAIN ABDOMEN AND CONSIDER MESENTERIC ISCHAEMIA IN SUCH CASES UNLESS PROVED OTHERWISE”.

IVC THROMBECTOMY AS A LIFE SAVING SURGERY

ACUTE VENOUS THROMBOSIS IS VERY COMMON IN INDIAN SCENARIO.
WE AS DOCTORS COME ACROSS SUCH PATIENTS IN OUR DAILY ROUTINE.THERE CAN BE DIFFERENT CAUSES FOR ACUTE THROMBOSIS.IT CAN EITHER BE DUE TO INBORN ERRORS IN THE BLOOD OR ELSE IT CAN BE ACQUIRED.GENERALLY IT INVOLVES THE LOWER LIMB VENOUS SYSTEM BUT UPPER LIMB DVT IS NOT UNCOMMON.INFERIOR VENA CAVA THROMBOSIS PER SE IS NOT VERY COMMON TO COME ACROSS IN DAILY PRACTICE.GENERALLY IT IS ASSOCIATED WITH THROMBUS ANYWHERE ELSE WHICH GETS PROPAGATED TO INVOLVE THE IVC.THE OTHER USUAL CAUSE IS RENAL CELL CARCINOMA WHICH PROGRESSES TO INVOLVE THE IVC. THE TREATMENT OF IVC THROMBOSIS IS ALL THE MORE CONTROVERSIAL BECAUSE OF ITS RARITY.WHETHER TO GO AHEAD WITH INTERVENSION OR TO FOLLOW CONSERVATIVE MANAGEMENT IN PATIENTS WITH ACUTE PRESENTATION IS STILL UNCLEAR.


I REMEMBER A PHRASE FROM A REPUTED VASCULAR SURGEON WHICH SAYS”ITS CHALLENGING TO DO SOMETHING NEW IN AN INSTITUTION WHERE EVERYONE HAS AN OPINION BUT NO ONE THE EXPERIENCE”.

THIS PATIENT 50 YEARS OLD A CASE OF NEPHROTIC SYNDROME CAME WITH ACUTE RENAL FAILURE TO OUR HOSPITAL.HE HAD MASSIVE SWELLING OF BOTH HIS LEGS AND SCROTUM AND HAD GENERALISED ANASARCA..SUBSEQUENTLY HE WAS FOUND TO HAVE BILATERAL RENAL VEIN THROMBOSIS AND ACUTE THROMBOSIS OF BILATERAL LOWER LIMB VENOUS SYSTEM INVOLVONG THE IVC TILL THE HEPATIC VEINS.THE LIKELY CAUSE FOR ACUTE THROMBOSIS IN THIS PATIENT WAS PROTEIN LOSSING NEPHROPATHY. THE EXCESSIVE URINARY PROTEIN LOSS IS ASSOCIATED WITH DECREASED ANTITHROMBIN III, A RELATIVE EXCESS OF FIBRINOGEN, AND CHANGES IN OTHER CLOTTING FACTORS; ALL LEAD TO PROPENSITY TO CLOT. NUMEROUS STUDIES DEMONSTRATED A DIRECT RELATIONSHIP BETWEEN NEPHROTIC SYNDROME AND BOTH ARTERIAL AND VENOUS THROMBOSIS.THIS CLOT CAN DAMAGE THE KIDNEYS,CAN BREAK AND TRAVEL THROUGH THE BLOOD STREAM TO THE LUNGS A CONDITION CALLED AS PULMONARY THROMBOEMBOLISM WHICH MAY PROVE TO BE FATAL. THIS PATIENT WAS SUBJECTED TO DIALYSIS.AND DIFFERENT OPTIONS WERE THOUGHT OF REGARDING THE FURTHER COURSE OF TREATMENT.CONSERVATIVE TREATMENT WAS VIRTUALLY RULED OUT AS THIS WOULD HAVE LED TO SEVERE MORBIDITY HAD THE PATIENT SURVIVED.THROMBOLYSIS WAS ALSO RULED OUT BECAUSE OF THE EXTENSIVE THROMBUS LOAD.IT WAS AGREED UNANIMOUSLY BETWEEN THE NEPHROLOGY TEAM AND MYSELF TO GO AHEAD WITH IVC THROMBECTOMY THINKING THAT IT WOULD REVERT HIS RENAL STATUS TO NORMAL,WOULD PREVENT THROMBOEMBOLISM,PREVENT LIMB LOSS FROM VENOUS IMPEDIMENT AND PREVENTCHRONIC VENOUS INSUFFICIENCY IN THE LONG RUN.IVC THROMBECTOMY THROUGH MIDLINE LAPROTOMY INCISION WAS DONE .TOTAL IVC CLEARANCE WITH BILATERAL COMMON FEMORAL VEIN THROMBECTOMY WAS DONE. THIS PATIENT HAD MIDGUT MALROTATION WHICH WAS FOUND INTRAOPERATIVELY MAKING IT ALL THE MORE UNIQUE.POSTOPERATIVELY PATIENT DID FINE AND WAS DISCHARGED FROM THE HOSPITAL ON ORAL ANTICOAGULANTS ON THE TENTH POSTOPERATIVE DAY.PRESENTLY HE IS OFF DIALYSIS AS HIS RENAL PARAMETERS HAVE COME TO NORMAL.


THE IMPORTANCE OF THIS CASE LIES IN THE SPEEDY RECOVERY THE PATIENT MADE WHEN IT SEEMED HE IS A HIGH RISK CASE FOR SURGERY. HE IS NOW LEADING A NEAR NORMAL LIFE.HIS LOWER LIMB SWELLING HAS DECREASED REMARKABLY. HIS RENAL PARAMETERS ARE WITHIN NORMAL RANGE..THIS PATIENT NEEDS TO BE IN REGULAR FOLLOWUP OF HIS NEPHROLOGIST AND MY OWNSELF.