Interposed Saphenous Vein Graft Aneurysm Presenting As Recurrent Popliteal Artery Aneurysm:An Unusual Presentation

fig.1(new interposed vein graft)
fig.2(aneurysmal sac opened)
fig.3(popliteal artery aneurysm with proximal ectasia)


Popliteal aneurysms are the most common peripheral aneurysms to come across though they are not very common otherwise.Saphenous vein graft getting aneurysmal is all the more rarer though cases are reported wherein the interposed saphenous vein turned aneurysmal.
We present to you an unsual case recently done by us wherein the reversed saphenous vein graft turned aneurysmal with proximal ectasia.

A 70 years old gentleman came to our out patient department with large pulsatile swelling in the popliteal region.He had pain in the leg and was not able to extend his limb at the knee joint.Physical examination revealed large pulsatile mass in the popliteal fossa with a scar on the medial aspect of leg and thigh.History revealed that he was operated upon for popliteal artery aneurysm in 2003 in some hospital by a Vascular surgeon and reversed saphenous vein graft was harvested from the other leg and interposed to replace the aneurysmal segment.He did fine all these years till he noticed the recurrence of swelling that kept increasing slowly and started hurting him.He had only one functioning kidney and the angiogram revealed a large(5cms)popliteal artery aneurysm with ectasia of the proximal vessel.The aneurysm was partially thrombosed as is generally the case with most aneurysms.Popliteal aneurysms though are notorious for even presenting with acute thrombosis leading to limb loss.
Patient was operated successfully with the ectatic/aneurysmal saphenous vein graft replaced by another vein graft.
Its rare to come across aneurysms of the RSVG.Still rarer to come across aneurysm of the vein graft in the popliteal region mimicking a popliteal artery aneurysm.Went through the internet to know more about this but could not come across a single detailed article.

Axillary Vein Valve transfer for CVI:An Intraoperative Video

Chronic venous insufficiency is a difficult clinical problem to tackle.Different treatment modalities are in vogue for the same.In desperate situations wherein the patient has non healing large painful venous ulcer/ulcers with gross incompetence in the deep venous system vein valve transfer is attempted to give relief to the patient esp.in old cases of DVT wherein the insitu valves are beyond repair.We did a similar case and recorded it.Kindly have a look.

PERIPHERAL STENT REMOVAL :A CHALLENGE

(PICTURE OF THE STENTS REMOVED)
The advent of stents has revolutionised vascular and endovascular surgery .More and more vascular procedures are now carried out in the cath lab with peripheral stenting ruling the roost.A veritable deluge of change has been seen in the approach to endovascular work.Elemental and vital questions arise as to who is entitled to be an endovascular surgeon?How does one acquire this entitlement?Who is entitled to enter it?The interests of the new specialty often conflict with the aspirations of other fields and therefore the tussle.Cardiologists without saying consider endovascular surgery to be their birth right(Atleast it appears that way)inspite of the fact that the anatomical knowledge of the vascular system they carry is dismal.Not only that, to confuse and complicate the issue further we now have radiologists who claim themselves to be the best interventionists.

There is a reason for me to be highlighting the above mentioned facts.We had a patient recently with a chronic occlusion of the left iliac artery involving the common and external iliac arteries extending till the femoral.Unfortunately this guy landed up with the cardiologist who as usual felt the vessel was stentable.There he goes and he ends up rupturing the iliac vessel with the patient in shock.A Vascular Surgeon probably is only required to deal with the final eventuality.We took him up and what do we see?Peripheral stents three in number extending from left common iliac till the proximal superficial femoral vessel going across the femoral bifurcation/Profunda(Almost 25cms in length).We had no other option than to remove the stents and then do a unilateral ilio-femoral bypass.

Removing a stent is hardly ever attempted and poses challenge to the operating surgeon as it is badly stuck to the vessel wall.

ITS GOOD TO BE AGGRESSIVE BUT IT SHOULD NOT BE A CASE OF MISPLACED AGGRESSION.ITS TIME OUR DEAR FRIENDS(READ CARDIOLOGISTS)LEARN WHAT VASCULAR SURGERY IS ALL ABOUT.

IATROGENIC FEMORAL ARTERY INJURY LEADING TO LIMB LOSS:WHEN WILL WE GROW UP?

IATROGENIC(PROCEDURE RELATED) PSEUDOANEURYSM OF THE RIGHT FEMORAL ARTERY IN THE THIGH THAT WENT UNDIAGNOSED FOR A MONTH AFTER BONE FIXATION(BY AN ORTOPEADICIAN IN A PRIMIER INSTITUTE) LEADING TO FOOT DROP AND FINALLY AN AMPUTATION OF THE RIGHT LIMB.WHEN WILL WE GROW UP AS DOCTORS/SURGEONS?ITS TIME WE ACCEPT VASCULAR SURGERY AS AN INDEPENDENT SPECIALITY AND NOT INDULGE IN UNFAIR PRACTICES.HOW LONG DOES IT TAKE TO FEEL FOR THE LOWER LIMB PULSES?ITS A MESSAGE TO ALL MY COLLEAGUES FROM DIFFERENT MEDICAL/SURGICAL SPECIALITIES TO KINDLY ASSESS THE LOWER LIMBS FOR PULSES WHEN EXAMINING A PATIENT ESP.TRAUMA PRE AND POST PROCEDURE.PLEASE RECOLLECT THE BASIC THINGS YOU WERE TAUGHT AS SURGICAL TRAINEES.NOTHING CAN REPLACE A THOROUGH PHYSICAL EXAMINATION.THIS YOUNG MAN WHO IS JUST IN HIS TEENS(15 YEARS OLD)FOR NO FAULT OF HIS LOST HIS LIMB AND IS HANDICAPPED FOR LIFE.WHAT WRONG DID HE DO?GOING TO THE WRONG DOCTOR?BUT HOW DOES HE KNOW WHO IS RIGHT AND WHO IS WRONG?ITS TIME FOR ALL OF US TO DO SOUL SEARCHING RATHER THAN GOING IN FOR WITCH HUNTING.LETS PLEDGE WE ALL GO BACK AGAIN TO THE BASICS WE WERE TAUGHT IN OUR MEDICAL SCHOOLS AND PRACTICE THEM. PLEASE GIVE THE CONCERNED SPECIALITIES THEIR DUE AND REALIZE YOUR LIMITATIONS AS A PERSON AND AS AN ATTENDING PHYSICIAN.THINK OF THE SOCIETY AS A WHOLE AND NOT JUST YOURSELF.

EMAIL FOR CORRESPONDENCE
drgauravsingal2@gmail.com

MY ARTICLE CONCERNING A RARE SURGERY GOT PUBLISHED IN CANADA,AMERICA AND NINE COUNTRIES OF EUROPE-I AM HUMBLED

ਲੀਅਰ ਨਾਰਵੇ(ਰੁਪਿੰਦਰ ਢਿੱਲੋ ਮੋਗਾ)-2 june-
ਪੰਜਾਬੀ ਕੋਮ ਸੰਸਾਰ ਦੀਆਂ ਗਿਣੀਆ ਚੁਣੀਆ ਕੋਮਾ ਚੋ ਇੱਕ ਹੈ,ਜਿੰਨਾ ਦੇ ਖੂਨ ਵਿੱਚ ਕੁੱਝ ਕਰਨ ਵਿਖਾਉਣ ਦਾ ਜਮਾਦਰੂ ਜਜਬਾ ਹੁੰਦਾ ਹੈ। ਚਾਹੇ ਉਹ ਯੁੱਧ ਦਾ ਮੈਦਾਨ ਹੋਵੇ ਜਾ ਖੇਡ ਦਾ,ਚਾਹੇ ਉਹ ਬ੍ਰਹਿਮੰਡ ਦੀ ਉਚਾਈਆ ਨੱਪਣ ਦਾ ਕਲਪਨਾ ਚਾਵਲਾ ਵਰਗੀ ਸ਼ੇਰ ਦਿਲ ਪੰਜਾਬਣ ਦਾ ਦਿਲ ਹੋਵੇ ਜਾ ਫਿਰ ਅੱਜ ਇਨਸਾਨਿਤ ਲਈ ਰੱਬ ਦਾ ਦੂਜਾ ਨਾਮ ਡਾਕਟਰੀ ਦਾ ਕਿੱਤਾ ਹੋਵੇ।ਅਣਗਿਣਤ ਪੰਜਾਬੀ ਹਨ ਜਿੰਨਾ ਨੇ ਆਪਣੇ ਹੁਨਰ ਮਹਿਨਤ ਸਦਕੇ ਦੁਨੀਆ ਵਿੱਚ ਵੱਖਰਾ ਨਾਮ ਕਮਾਇਆ ਹੈ।ਇਹਨਾ ਨਾਮਾ ਚ ਹੀ ਇੱਕ ਨਾਮ ਮੋਗੇ ਦੇ ਜੰਮਪਲ ਡਾਂ ਗੋਰਵ ਸਿੰਗਲ ਦਾ ਹੈ।ਜਿੰਨਾ ਦੇ ਪੰਜਾਬੀ ਹੋਣ ਤੇ ਸਾਨੂੰ ਪੰਜਾਬੀਆ ਨੂੰ ਮਾਣ ਹੈ। ਮੋਗੇ ਦੇ ਸਕੈਰਡ ਹਾਰਟ ਸਕੂਲ ਮੁੱਢਲੀ ਵਿੱਿਦਆ ਹਾਸਿਲ ਕੀਤੀ। ਡੀ ਐਮ ਸੀ ਹਸਪਤਾਲ ਲੁਧਿਆਣਾ ਤੋ ਡਾਕਟਰੀ ਦੀ ਡਿਗਰੀ ਹਾਸਿਲ ਕਰਨ ਉਪਰੰਤ ਹੈਦਰਾਬਾਦ ਦੇ ਮਸ਼ਹੂਰ ਨਿਜਾਮ ਹਸਪਤਾਲ ਚ ਸੇਵਾ ਕੀਤੀ ਪਰ ਪੰਜਾਬ ਅਤੇ ਪੰਜਾਬੀਅਤ ਦਾ ਮੋਹ ਆਖਿਰ ਉਹਨਾ ਨੂੰ ਪੰਜਾਬ ਖਿੱਚ ਲੈ ਆਇਆ।ਕੁੱਝ ਸਮੇ ਪਹਿਲਾ ਗੋਬਿੰਦਗੜ ਪੰਜਾਬ ਦੇ ਇੱਕ ਕੈਸਰ ਪੀੜਤ ਵਿਅਕਤੀ ਜਿਸ ਦੇ ਦਿਲ ਤੋ ਸ਼ਰੀਰ ਦੇ ਦੂਜੇ ਹਿੱਸਿਆ ਨੂੰ ਖੂਨ ਪਹੁੰਚਣ ਵਾਲੀ ਨਾਲੀ ਚ ਕੈਸਰ ਸੀ ਦੇ ਕੈਸਰ ਪੀੜਤ ਨਾੜੀ ਦੀ ਥਾਂ ਪਲਾਸਿਟਕ ਦੀ ਮੈਡੀਕੈਟੜ ਨਾਲੀ ਪਾ ਆਪਣੇ ਕਿਸਮ ਦਾ ਏਸ਼ੀਆ ਚ ਪਹਿਲਾ ਆਪਰੇਸ਼ਨ ਕਰ ਉਸ ਵਿਅਕਤੀ ਨੂੰ ਨਵਾ ਜੀਵਨ ਦਾਨ ਦਿੱਤਾ ਸੀ।ਪਿੱਛਲੇ ਕੁੱਝ ਸਮੇ ਪਹਿਲਾ ਡਾਂ ਗੋਰਵ ਸਿੰਗਲ ਨਾਲ ਹੋਈ ਮੁਲਾਕਾਤ ਦੋਰਾਨ ਉਹਨਾ ਨੇ ਇੱਕ ਅਜਿਹੀ ਦੀ ਘਟਨਾ ਦਾ ਜਿਕਰ ਕੀਤਾ ਕਿ ਇੱਕ 17 ਸਾਲ ਦੀ ਲੜਕੀ ਦੇ ਮੁੱਖ ਖੂਨ ਦੀ ਨਾੜੀ ਜਿਹੜੀ ਸਾਰੇ ਅੰਗਾ ਨੂੰ ਖੂਨ ਸਪਲਾਈ ਕਰਦੀ ਹੈ।ਜਿਸ ਨੂੰ ਅਓਰਟਾ(Aorta) ਕਹਿੰਦੇ ਹਨ ਚ ਆਈ ਕਿਸੇ ਸਮਸਿਆ ਕਾਰਨ ਉਸ ਦੇ ਪ੍ਰੀਵਾਰ ਵਾਲੇ ਲੇ ਕੇ ਆਏ। ਆਮ ਕਰਕੇ ਕਈ ਲੋਕਾ ਚ ਇਹ ਨਾੜੀ ਗੁਬਾਰੇ ਵਾਂਗ ਫੁੱਲ ਜਾਦੀ ਹੈ ਅਤੇ ਫੁੱਲਣ ਕਾਰਨ ਇਹ ਨਾੜੀ ਕਿਸੇ ਟਾਈਮ ਵੀ ਫਟ ਸਕਦੀ ਹੈ ਤੇ ਮੋਤ ਹੋ ਸਕਦੀ ਹੈ।ਇਸ ਬੀਮਾਰੀ ਨਾਲ ਆਈ ਪੀੜਤ ਲੜਕੀ ਦੇ 4 ਜਗਾ ਤੋ ਇਹ ਨਾੜੀ ਫੁੱਲੀ ਹੋਈ ਸੀ ਅਤੇ ਕੁੱਝ ਕਦਮ ਤੁਰਨ ਤੇ ਵੀ ਸਾਹ ਚੜਦਾ ਸੀ ਅਤੇ ਉਸ ਦਾ ਇੱਕ ਹੀ ਗੁਰਦਾ ਸੀ ਨਾਲ ਅਣਕੰਟਰੋਲਡ ਬੱਲਡ ਪ੍ਰੈਸ਼ਰ ਦੀ ਸਿ਼ਕਾਇਤ ਸੀ। ਡਾਕਟਰੀ ਸਾਇੰਸ ਅਨੁਸਾਰ ਇਹ ਬੀਮਾਰੀ ਜਿਆਦਾ ਕਰਕੇ 50 ਸਾਲ ਦੀ ਉਮਰ ਤੋ ਬਾਅਦ ਹੀ ਹੂੰਦੀ ਹੈ ਅਤੇ ਇਸ ਨੂੰ ਤਾਕਾਜਾਸੂ ਅਰਟਰੀਟਿਸ(Takayasu Arteritis) ਕਹਿੰਦੇ ਹਨ, ਇਸ ਬੀਮਾਰੀ ਕਰਕੇ ਉਸ ਨੂੰ ਇਹ ਤਕਲੀਫ ਆਈ ਅਤੇ ਇਲਾਜ ਪੱਖੋ ਉਸ ਦੀ ਛਾਤੀ ਅਤੇ ਢਿੱਡ ਖੋਲਿਆ ਗਿਆ ਅਤੇ ਪਲਾਸਿਟਕ ਦੀ ਨਾੜੀ ਪਾਈ ਗਈ ਜਿਸ ਨੂੰ ਸ਼ਰੀਰ ਦੀਆ ਬਾਕੀ ਨਾੜੀਆ ਨਾਲ ਜੋੜਿਆ ਗਿਆ। ਇਸ ਤਰਾ ਦੇ ਆਪਰੇਸ਼ਨ ਚਾਹੇ ਅੱਗੇ ਵੀ ਹੂੰਦੇ ਨੇ ਪਰ ਇਹ ਆਪਣੀ ਕਿਸਮ ਦਾ ਦੁਨੀਆ ਦਾ ਪਹਿਲਾ ਕੇਸ ਦੀ ਕਿ 17 ਸਾਲ ਦੀ ਉਮਰ ਚ ਲੜਕੀ ਦਾ ਇਹ ਸਫਲ ਆਪਰੇਸ਼ਨ ਕੀਤਾ ਗਿਆ।ਇਹ ਲੜਕੀ ਅੱਜ ਪੂਰੀ ਤਰਾ ਤੰਦਰੁਸਤ ਹੈ ਅਤੇ ਤੁਰ ਫਿਰ ਰਹੀ ਹੈ। ਡਾਂ ਗੋਰਵ ਸਿੰਗਲ ਨੂੰ ਦੂਸਰੇ ਮੁੱਲਕਾ ਤੋ ਵੀ ਉਹਨਾ ਦੀ ਕਾਬਲੀਅਤ ਕਰਕੇ ਨੋਕਰੀਆ ਦੀਆ ਪੇਸ਼ ਕੇਸਾ ਆਈਆ ਹਨ । ਇਨਸਾਨੀਅਤ ਦੀ ਸੇਵਾ ਕਰਨ ਵਾਲਾ ਇਸ ਹੋਣਹਾਰ ਪੰਜਾਬੀ ਤੇ ਸਾਨੂੰ ਪੰਜਾਬੀਆ ਨੂੰ ਮਾਣ ਹੈ।

IS INFRASCROTAL FEMORO-FEMORAL PERINEAL BYPASS AN ANSWER TO UNILATERAL GROIN/GRAFT INFECTIONS?(CASE REPORT)

fig.1(post.op.angiogram)
fig.2(graphic representation of the procedure done)


The menace of drug addiction seems to be ever increasing with all efforts to curb it by educating the youth seemingly unfruitful.Mushrooming de-addiction centres all around stand testimony to this and there seems to be no way out as of now.Unfortunately the drug addicts are increasingly getting hooked to injectables which is scary.The superficial veins get thrombosed with repeated punctures and then starts this cycle of “SELF MUTILATION”wherein the addict repeatedly punctures his otherwise accessible arteries to push that drug in.These guys invariably land up in the emergency department with profuse uncontrollable bleeding from the puncture site.

MYCOTIC aneurysms is a common phenomenon reported in drug abusers especially in this part of India where drug abuse is widely prevalent.We report to you a similar case of drug abuse in a 32 years old male who came to us with profuse bleeding from his right groin.The wound site was tightly bandaged so as to stop bleeding by the practitioner at the periphery so as the patient can make it in time to our centre . General physical examination revealed the patient running down with high grade fever for the last 3 days with chills.

The usual surgical treatment option in a case like this is doing a traditional obturator foramen bypass followed by wide debridement of the infected site with proximal and distal ligation of the femoral vessels.Obturator foramen bypass is too taxing a surgery for the patient and probably the operating surgeon as well for it involves alot of tissue dissection and the probability of localized infection getting disseminated to the fresh surgical site is always there for the inflow site is ipsilateral to site of infection.

Infrascrotal perineal femoro-femoral bypass is a far better option in cases with unilateral groin infection.Though it needs expertise but its worth the effort with far less maceration to the tissues as there is not need to open the abdomen/peritoneum. There are no trials till date comparing these two procedures but the reports coming in from different vascular surgical centres doing the bypass with infrascrotal approach are encouraging as they suggest a significantly better primary patency rate of the graft as compared to the obturator approach.There are only few cases done with the infrascrotal approach till date.Not sure if this has been attempted before in India as not much data is available from India..Would love to know the experiences of my colleagues back in India .

Anyways we did this case with 8mm PTFE graft without much of hassles and our patient is doing fine. I have done a couple of cases with the obturator foramen approach when I was in Hyderabad but found this newly acquired approach a better option as of now.

Surgical Venous Thrombectomy: In or Out?

How many times do we initiate a thing only to stop it and restart it all over again.Same holds true for the surgical management of acute DVT.

It all started in the late forties when people with swollen limbs used to get operated by their attending surgeons and the big clot used to be removed from the veins of their legs.This procedure fell into disrepute and for years together the art of DVT thrombectomy was lost in wilderness.The reason was the recurrence of thrombosis in these patients.Even I was told by one of the vascular surgeons of that era who happened to be a great vascular surgeon himself that the surgery was messy and the patient ended up losing hell lot of blood.

People tried managing these acute DVT patients conservatively without attempting this so called ‘MESSY’ surgery.But something that has potential cannot be curbed for long especially in a scenario where we talk of ‘EVIDENCE BASED MEDICINE’.

There has been a constant tussle between the Europeans and the Americans concerning SURGICAL VENOUS THROMBECTOMY.Europeans esp.Germans kept doing surgeries for patients with acute DVT with good results whereas the Americans were circumspect about this treatment modality and were happy managing these cases conservatively resulting in a significant increase in morbidity.

Much to my surprise the recent guidelines from ACCP(AMERICAN COLLEGE OF CHEST PHYSICIANS) in 2008 finally accepted the role of surgery for ACUTE DVT and approved VENOUS THROMBECTOMY in patients with extensive ILIOFEMORAL DVT.CATHETER DIRECTED THROMBOLYSIS is the other treatment modality they suggest in patients with low risk of bleeding.

Why surgical venous thrombectomy failed in the forties is self evident.Patient selection was poor,concept of full heparinisation and early ambulation was not there and surgeons never had this concept of constructing an AV Fistula along with.With these things in the kitty of a vascular surgeon now,surgical results have improved remarkably and are far better than treating patients with anticoagulation alone.

My personal experience and the experience I carry from my stint with DR W.SANDMANN in Germany(A PERSON WHO CARRIED DOING VENOUS THROMBECTOMIES WITH CONVICTION INSPITE OF ALL ODDS WITH REMARKABLE RESULTS) suggests me to keep practising this treatment modality for the results are good and a slow acceptance by the practicing vascular surgeons all over the world is very much on cards.

Hope more vascular surgeons in India join me to propagate and practice SURGICAL VENOUS THROMBECTOMY as I too need company to tread this long journey of professional life.Afterall its not about 'ME',its about 'US'.


NOT KNOWING IS IGNORANCE BUT NOT WILLING TO KNOW IS DISASTER.