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”.

CLOSURE OF HIGH FLOW AV FISTULA IN KIDNEY FAILURE PATIENTS:DO'S AND DONT'S

THE ABOVE INTRAOPERATIVE PICS.DEPICT THE NORMAL SIZED LEFT ARM AND THE MASSIVELY SWOLLEN RIGHT ARM WITH MASSIVELY DILATED VEINS ON THE SHOULDER ALONG WITH FISTULA CLOSURE PHOTOS.



AS USUAL THIS IS THE BEGINNING OF A NEW MONTH AND I END UP WRITING A NEW ARTICLE IN THIS BLOG.WORKING ON THE CONSTRUCTIVE FEEDBACKS WHICH KEEP POURING IN FROM MY COLLEAGUES I AM PENNING DOWN AN ARTICLE WHICH RELATES TO ALL AND CAN EVEN BE UNDERSTOOD BY A LAYMAN WHO DOES NOT HAVE MUCH MEDICAL KNOWLEDGE BUT IS NOT A DUMB EITHER.ITS ABOUT MAKING AN AV FISTULA AND HANDLING ITS COMPLICATIONS IN KIDNEY FAILURE PATIENTS.

INDIA IS FAST BECOMING A HUB FOR RENAL FAILURE PATIENTS.IF YOU GO BY THE STATISTICS THE SITUATION IS ALARMING.TO HAVE EASY ACCESS TO DIALYSIS AV FISTULAS ARE CONSTRUCTED ON LIMBS JOINING THE NATIVE VESSELS OR AN ARTIFICIAL TUBE WE CALL AS GRAFT.UNFORTUNATELY THESE PATIENTS DO LAND UP WITH COMPLICATIONS WHICH ARE SOMETIMES LETHAL AND CLOSURE OF FISTULA BECOMES MANDATORY TO SAVE THEIR LIVES.

WE RECENTLY HAD A PATIENT WHO HAD AN AV FISTULA CREATED ON HIS RIGHT FOREARM(BRACHIO-CEPHALIC FISTULA) SOME TWO YEARS BACK.HIS RIGHT UPPER LIMB HAD MASSIVE SWELLING WHICH KEPT INCREASING TILL HE BECAME BREATHLESS AND WAS ON THE VERGE OF HIGH OUTPUT CARDIAC FAILURE.SURPRISINGLY THE PATIENT WAS ASKED BY HIS UROLOGIST TO CARRY ON WITH HIS DIALYSIS THROUGH THE SAME SITE AND IN THE PROCESS THE PATIENT HAD CONTAINED RUPTURE OF THE AV FISTULA AND LANDED WITH SEVERE PAIN IN HIS RIGHT ARM.HAD HE PROLONGED A BIT MORE HE WOULD HAVE CERTAINLY DIED.WHAT A TRAGIC SITUATION INDEED?

ANYWAYS WE VASCULAR SURGEONS ARE TRAINED IN ALL THIS AND I CLOSED THAT FISTULA OFF AND REPAIRED HIS MAIN BLOOD VESSEL(BRACHIAL ARTERY) SUPPLYING BLOOD TO THE ARM.EVEN CASES LIKE THESE ARE A CHALLENGE TO US.

ITS MY PERSONAL OPINION THAT A UROLOGIST OR FOR THAT MATTER A PLASTIC SURGEON SHOULD ONLY ATTEMPT VENOUS ACCESS(AV FISTULA)SURGERY IF HE IS WELL EQUIPPED TO HANDLE THE ASSOCIATED COMPLICATIONS OTHERWISE THEY SHOULD LEAVE THE JOB TO THE CONCERNED SPECIALIST(VASCULAR SURGEON IN THIS CASE).A SEEMINGLY SIMPLE SURGERY(AV FISTULA)HAS ALOT OF COMPLICATIONS TO OFFER IN THE LONG RUN BECAUSE OF SIGNIFICANT HEAMODYNAMIC CHANGES THAT HAPPEN IN THE BODY.GOING BY THE CONSUMER PROTECTION ACT AND THE LEGALITIES INVOLVED ITS TIME WE GUYS MARK OUR DOMAIN AND WORK HAPPILY AS A TEAM.

TREAT PATIENT AS YOU WOULD TREAT YOUR OWN RELATIVE.YOU WILL NEVER FALTER.

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.