VERTEBRAL ARTERY REIMPLANTATION IN A CASE OF VERTEBRAL ARTERY DISEASE( VBI)

VERTEBRO-BASILAR INSUFFICIENCY CAN LEAD TO POSTERIOR CIRCULATION STROKES TO THE EXTENT OF 25% BUT USUALLY GOES UNDETECTED.THIS IS AN UNFORTUNATE SITUATION FOR THE PATIENT FOR HE LANDS UP WITH STROKE AND IS HANDICAPPED FOR LIFE IF HE SURVIVES.THE UNDERLYING REASON PROBABLY IS THE SUBTLE SYMPTOMS WITH WHICH THE PATIENT FIRST APPROACHES HIS PHYSICIAN AND TO AN EXTENT THE ATTENDING DOCTORS RARELY THINK ON LINES OF VERTEBRO-BASILAR INSUFFICIENCY(VBI) AS THE UNDERLYING REASON FOR THE SYMPTOMATOLOGY WITH WHICH THE PATIENT FIRST PRESENTS TO THEM. THE PROBLEM DOES NOT END HERE.THE TREATMENT IS STILL CONTROVERSIAL .NOT MANY CASES ARE REPORTED AS COMPARED TO THE CAROTID ARTERY DISEASE WHICH IS WIDELY PREVALENT.FORTUNATELY MORE AND MORE VASCULAR SURGERY CENTRES ARE NOW GEARED UP AND THEREFORE ARE COMING UP WITH GUIDELINES AS WHEN TO INTERVENE IN PATIENTS WITH VERTEBRAL ARTERY DISEASE.THIS IS A HEALTHY SIGN.A CLOSE ASSOCIATION WITH A NEUROLOGIST CERTAINLY HELPS A BIG WAY IN PLANNING THE TREATMENT STRATEGY. WE REPORT TO YOU A SIMILAR CASE OF VERTEBRAL ARTERY DISEASE .THIS PATIENT 65 YEARS OLD MALE CAME TO US WITH SYMPTOMS OF POSTERIOR CIRCULATION. HE HAD DROP ATTACKS.FOUR VESSEL NECK DOPPLER AND SUBSEQUENTLY ANGIO REVEALED NON SIGNIFICANT DISEASE OF THE CAROTIDS. BOTH HIS VERTEBRALS WERE SIGNIFICANTLY DISEASED.THE LEFT VERTEBRAL ARTERY WAS OCCLUDED AND THE RIGHT VERTEBRAL ARTERY HAD 80%OSTIAL STENOSIS.AFTER A DETAILED DISCUSSION WITH THE NEUROLOGIST WE CONCLUDED TO INTERVENE IN THIS PATIENT.STENTING WAS AN OPTION BUT WE OPTED FOR SURGERY INSTEAD AS THE VESSEL WAS VERY TORTUOUS AND THE OSTIAL LESION WAS HEAVILY CALCIFIED.

WE WENT THROUGH THE RIGHT SUPRACLAVICULAR APPROACH AND REIMPLANTED THE RIGHT VERTEBRAL ON THE RIGHT COMMON CAROTID VESSEL.
THE PATIENT IS DOING FINE AND IS ASYMPTOMATIC TILL DATE.

Septic Thrombophlebitis Of The Superior Vena Cava Involving The Internal Jugular Veins Causing Septic Thromboembolism:Case Report

Creamish yellow thrombus suggesstive of staph.aureus infection visible protruding out of the right internal jugular vein(pic.1&2).


Septic thrombophlebitis is a condition characterized by venous thrombosis, inflammation, and generalized bacterimia.It generally goes undiagnosed and under reported.Though a rare disease,it has high mortality rates even in the best of hands(upto 50%).

Suppurative thrombophlebitis of the IJV/SVS almost always happen due to central venous lines.Most of these cases are treated conservatively but certain cases demand surgical intervention esp.those who fail to respond to medical management.Occasional surgical approach consists of resection/ligation or thrombectomy of the concerned veins.

We present to you a similar case of septic thrombophlebitis in a burns patient who had severe MRSA infection refractory to all possible antibiotics.Needless to say this patient had central venous lines inserted from both the jugular veins one after the other to maintain parentral nutrition and drug intake.The left jugular puncture site healed to an extent but the right jugular puncture site showed signs of inflammation.Duplex venous scan was suggestive of right IJV thrombosis.X-ray chest showed multiple bilateral rounded non cavitating lesions suggestive of multiple pulmonary abcesses.Patient was in septic shock with grossly deranged heamatological parameters and was on ianotropic support.She was in delirium and all possible efforts by our intensivists to save her in the ICU did not seem to help her out.It is then that the concerned consultant(Plastic surgeon) did talk to me out of sheer frustration of losing her. I had read about this entity before but had never come across a case like this.Only few articles and case reports are available on the internet for reference.

We had limited options in this case and took the patient up for surgery.We excised the right internal jugular vein and found a creamish yellow clot(something unique for me atleast) at it junction with the subclavian vein.It was realized on the operation table that the suppuration was extending into the SVC and that something more has to be done.Postoperatively we gave her thrombolysis along with heparin infusion.The goal of fibrinolytic therapy is to dissolve the fibrin sheath over the thrombus for the drug to act.Otherwise this thrombus can act as a nidus for resistant infection and a source of septic emboli as was in our case.Much to our surprise a seemingly hopeless case where we almost gave up ,we were able to save the patient.

At the time of writing this article the patient is out of the ICU and recovering in the hospital.She is to undergo skin grafting by our cosmetic surgeon.

The idea of writing this article is to keep our minds and eyes open and to think a step further to be ahead of others.

ILIAC VESSELS RECONSTRUCTION (BYPASS/INTERPOSITION GRAFT) IN A RECURRENT CASE OF CHONDROSARCOMA OF THE ILIAC BONE

INTRAOPERATIVE PHOTOGRAPHS SHOWING THE ILIAC ARTERY RECOSTRUCTION ALONG WITH ILIAC VEIN TO IVC BYPASS WITH PTFE GRAFT.

What to do when a young patient aged 28 years comes to you with a glimmer of hope in his eyes?A rejected case from a couple of medical institutes around,it seemed he still had faith in God.Well we still are ordinary beings doing our bit to reach people and help them in every possible way through our services.
This gentleman came to us with history of left sided condrosarcoma of the iliac bone resected 2 years back at some other hospital with reconstruction of the left iliac artery.He had recurrence of the tumour extending into the pelvis and the left groin.He had massive swelling of the left lower limb of recent onset and his pulses were not palpable.He also had an old history of DVT of the same limb but was irregular taking anticoagulants.
A redo case is always a pleasant challenge esp.in a patient weighing 130 kgs.Its always a team effort of various specialities that helps in a challenging situation like this and I are fortunate to have in my company good young surgeons who think positively and aggressively and importantly enjoy each other’s success.
The tumour was resected in totality including a secondary lying in the left renal region.Iliac artery was reconstructed with a interposition graft as it was badly entagled by the tumour mass.Venolysis was done for the left Iliac vein and local thrombus was removed though it showed chronic changes. Since the limb was massively swollen with discoloration of the foot we deemed it necessary to do a bypass for this vessel and try our best to save the limb.We finally did a left iliac vein to Inferior vena cava bypass with a PTFE graft.
The patient is doing fine and the limb swelling has reduced remarkably.He is now on oral anticouagulation and both the Grafts are patent.

Venous Injury During Aortic Aneurysm Repair:A Fatal Complication

Aortic aneurysm surgeries are done worldwide on an elective/emergent basis. The last two decades has seen immense changes in the way Vascular surgeons approach aneurysms.May be its the endovascular approach to an aneurysm or else the intraoperative approach per se,the situation has changed for the betterment of patients.Mortality rates have come down significantly,thanks to the ever changing science thats giving us varied options to make lives of patients and the operating surgeons a bit easy.Still there are questions to be addressed.

Venous injuries are not unknown during aortic surgeries more so in cases of Abdominal Aortic Aneurysms(AAA).These so called iatrogenic injuries lead to a significant intraoperative blood loss and can prove fatal.Not sure what the figures are but I am pretty convinced these injuries have a high mortality/morbidity rate which goes unreported.
We recently encountered a case of AAA which looked relatively straight forward.In the process of taking distal control individually we ended up injuring the IVC at the junction where the two iliac veins drain into it.Thereafter started the process of taking control of the venous bleed and all I can say is those 40 odd minutes gave us one hell of a time.Probably my inclination doing venous thrombectomies did bail me out and we finally emerged unhurt but learnt a good lesson ’DISASTER STRIKES YOU WHEN YOU LEAST EXPECT IT’.

Still not sure what the best approach is?Surgeons have tried different things like balloon occlusion of the iliac arteries rather than taking distal control individually or else taking control of the vessels without dissecting them cicumferentially. Balloon occlusion is not a bad approach I guess.Anyways a good lesson learnt.

As young and enthusiastic Vascular Surgeons we guys try to do things copybook.No harm in doing things as projected in the standard textbooks but somewhere down the lane experience does count and I suggest my fellow colleagues esp.the young guns to read more about COMPLICATIONS IN VASCULAR SURGERY and be upto it.

ACUTE ISCHEMIC HEPATITIS(AIH) AS A COMPLICATION OF SUPRACELIAC AORTIC CLAMPING(SCC) :CASE REPORT

Aortic surgeries are done all over the world by the vascular surgery community in large numbers.Its a major surgery and therefore adequate planning goes into it before the surgery is undertaken except in emergent situations like ruptured AAA etc.Inspite of the best efforts of the surgeon/surgical team end result may not be favorable in some cases.

I have till date presented a goody goody picture about the vascular surgery cases we do as routine but everyday is not Sunday.We present to you such a case wherein the patient developed complications due to supraceliac clamping.

Supraceliac clamping becomes mandatory in certain Vascular emergencies and therefore is an important tool in the toolkit of a Vascular surgeon but is not without complications.Significant heamodynamic changes take place due to SCC and therefore the Anaesthesia team should closely team up with their Vascular Surgeons.

Acute ischemic hepatitis is a known complication of SCC but not reported widely. Acute ischemic hepatitis is caused by poor hepatic perfusion and most often is associated with circulatory failure. AIH may also be caused by regional impedance of blood flow to the liver, specifically after celiac axis occlusion or supraceliac aortic clamping.Although the definitive diagnosis of AIH is established by histopathology, it is acceptable to make a diagnosis of AIH based solely on clinical and biochemical criteria, like

(1) Hypotension or low cardiac output

(2) Increase in serum transaminases, specifically an acute rise in AST to more than 1,000 IU/L

(3 ) Brief elevation of serum transaminases that lasts from 5 to 10 days.

(4) The serum bilirubin increases but rarely more than four times normal.

Mortality in patients with AIH is quite high with some reports claiming it to the tune of 60%(HICKMAN&POTTER).

Our patient had supraceliac clamping that lasted almost for 30 minutes.Intra and Post operatively patient developed hypotension and was supported by vasopressors( This may have added insult to injury).Patient went into hepatic encephalopathy and inspite of our best efforts could not be saved.

THE MESSAGE IS VERY CLEAR.THOUGH UNCOMMON,AIH SHOULD ALWAYS BE AT THE BACK OF OUR MINDS WHEN GOING IN FOR SCC AND THE CONCERNS SHOULD BE PASSED ON TO THE ATTENDANTS/PATIENTS DIRECTLY BEFORE UNDERTAKING A PROCEDURE LIKE THIS.

External Carotid Artery Revascularisation: An Important procedure in the kitty of a Vascular surgeon

PIX 1:ECA ENDARTRECTOMY WITH PATCH PLASTY

PIX 2:ASCN.AORTA TO ECA BYPASS WITH SILVER DACRON GRAFT


External carotid artery serves as an important collateral to the brain in cases where internal carotid artery(ICA) gets occluded.Christopher .Zarins has done a lot of work on external carotid revascularization.Its an established fact that ECA(external carotid artery)carries 30%blood to the brain in cases where ICA gets occluded.ECA therefore serves as an important collateral to brain in such situations.

There are instances wherein the patient is symptomatic inspite of the fact that the ICA is occluded.The patient may still have lateralizing symptoms pertaining to the territory of the otherwise occluded internal carotid artery.

Many physicians still feel as to what is the cause of the symptoms with the ICA of the concerned cerebral hemisphere being occluded.It becomes mandatory for the concerned physician to look for the status of the ECA if the ICA is occluded and the patient has recurrent symptoms pertaining to the territory of the concerned cerebral hemisphere.Its not uncommon to come across an ECA with significant stenosis which may well be the source of emboli leading to recurrent TIA’S. There are also been instances where the Common carotid artery and ICA of the same side are occluded with a narrowed patent lumen of the ECA.Even these patients can be symptomatic for the reason that there is no forward flow in the ECA leading to recurrence of symptoms.

We report to you two cases done by us with a follow-up period of more than a year.Both these patients are doing fine and are asymptomatic till date.One of these patients had significant ECA stenosis with ipsilateral ICA occlusion.The other patient had both CCA and ICA occlusion with a patent ECA.Both these patients were symptomatic and had recurrent lateralizing symptoms before they approached us.

We did an ECA endartrectomy in the first case and a Aorto-ECA bypass with graft in the second case.This second case also had significant triple vessel disease of the coronaries.Therefore we did a CABG along with it.



NOTE:The external carotid artery (ECA) is an important collateral pathway in patients with ipsilateral internal carotid artery (ICA) occlusion and recurrent symptoms. An ipsilateral ECA revascularization can improve cerebral perfusion or eliminate the source of emboli.

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.