AVOID THAT STROKE :ACT TIMELY

DON’T BE A VICTIM

A stroke is a term used to describe a cerebrovascular accident.It results either from a rupture of a blood vessel in the brain or else from a blockage of the blood vessel that supplies the brain leading to brain damage.The former causes damage by producing bleeding around the brain cells(hemorrhage)or else can damage the brain cells due to lack of blood supply(infarct) leading to permanent disability like speech defect,weakness of limb etc. (As shown in the pictures)
Strokes are the third commonest cause of death after cancer and heart ailments.These can be prevented and if brought in time to the concerned doctor can be treated as well.

WHAT ARE THE RISK FACTORS FOR STROKE?

The common causes are
Ageing
Smoking
Blood pressure
Diabetes
Obesity
High fat content in the blood

Many people experience transient weakness of any limb or momentary visual impairment.These episodes in medical terminology are called transient ischemic attacks.Please don’t take them lightly as this may be the first indication of a stroke to happen.These symptoms may wane off in 24 hours giving a false sense of security to the patient.
One must be thoroughly investigated especially a Doppler test of the carotid vessels become mandatory.In many instances the carotid Doppler shows significant obstruction in these patients.If neglected it can ultimately lead to total paralysis or death.Such patients should see their vascular surgeon at the earliest .This is because if carotid obstruction is operated timely,a major stroke can be prevented.

Even if you had a stroke earlier with minimal disability you can still be a candidate for carotid surgery to prevent further strokes.

PERITONEOVENOUS SHUNT WITH FEMORAL VEIN FOR INTRACTABLE ASCITES-SOMETHING UNIQUE

Intractable ascites is a very common symptomatology which our internists come across in their daily practice.Its a difficult situation to deal with more so for the fact that the general health of the patient is not great and the renal parameters are also deranged in most of the cases along with the ongoing hepatic problem(Hepatorenal syndrome).These patients frequent their doctors for ascitic tap or else for hepatic encephalopathy and related issues.Surgeons have tried various treatment modalities including venovenous shunts with variable results.These procedures have their own benefits and pitfalls.

In older times LeVeen shunt was used aggressively for intractable ascites but has been replaced by the Denever shunt .Using foreign material has always been dicey as the chance of infection is relatively high more so in these immunocompromised patients with the shunt placed subcutaneously.This issue has been of perennial concern for the attending surgeons and has led to the birth of biological grafts wherein saphenous vein is attached to the rent created in peritoneum for ascitic fluid drainage.Few small series of this mode of treatment modality are available on the net for one and all to see.

We report to you a unique case of intratractable ascites in a 65 years old male who was not a case for TIPS or other traditional VenoVenous shunts for multiple reasons and was referred to me for a possible peritoneovenous shunt.I went through the literature available on net and realized that the probable cause for the occlusion of the saphenous shunt was the small caliber of the vein.So we tried something unique in this case which probably has never been attempted anywhere before in a case like this.We harvested the SUPERFICIAL FEMORAL VEIN from the thigh and anastomosed the proximal end of it to the rent in the peritoneum for ascitic fluid drainage.We found the caliber of the saphenous vein to be small intraoperatively though we never intended to use it otherwise also.

No doubt this is a palliative surgery intended to give better quality of life but till it serves its purpose its worth it.

PALMA PROCEDURE FOR VENOUS CLAUDICATION:IS IT FORGOTTEN

Venous surgeries in our modern day scenario are more or less limited to surgery of the varicose veins.This paradigm shift probably comes from the very fact that different vascular surgery centres have given different results regarding venous surgeries over a period of time.Unfortunately these indifferent surgical results also stem from the fact that the choice of patients was not appropriate and venous surgery was in its infancy.All said and done,venous surgery is here to stay provided we stick to the basic rules of vascular surgery,know basics of venous heamodynamics and pathophysiology and institute timely treatment to the patients.An example to quote is the fresh revival of interest in venous thrombectomies in acute cases especially after the work presented by Germans in different vascular conferences.

We present to you a unique case of a 21 year old young man who came to us with ‘May Turner Syndrome’ which subsequently led to thrombosis of his common and external iliac vein.This patient came with swelling of the left leg and thigh for the last three years and had a recurrent ulcer at his medial ankle region.He was on acitrom for the last almost 3 years but to no avail.He had significant venous claudication and was practically handicapped for life so to speak.We were left with a difficult situation to deal with.A convetional venogram was done which was suggestive of the above mentionted findings.We tried opening the left iliac vein by endovascular methods inspite of me not a keen follower of this methodology and as expected, it did not work.

PALMA procedure was done in him wherein the Great Saphenous Vein was harvested from the right thigh and anastomosed to his left Common Femoral Vein through a crossover procedure thereby restoring the drainage of the left limb through the saphenous vein via Right Iliac Vein.Its almost eight weeks now from the day of surgery and the patient is doing ok.His venous ulcer has healed and the swelling on the leg has reduced remarkably.The patient is on tab.acitrom and compression stockings.I don’t know for how long would this work for him but one thing is for sure i.e its not going to add a great deal to his morbidity.

This procedure is unique for many reasons.One we were never ever taught as to what extra can be done other than routine stuff in patients suffering from CVI resulting from iliac vein thrombosis .Secondly we never came across much of papers presented in National vascular surgery conferences catering to venous diseases other than the usual papers on laser surgery for varicosities.I think its time we have more of venous conferences wherein all these issues are addressed in interactive sessions without any prejudice or else we need to switch back to our standard textbooks for answers for books to me ‘never lie’.

PAPER PRESENTATION ON COMPOSITE CARDIOVASCULAR PROCEDURES IN VSICON 2009

Its always a privilege to interact with your vascular colleagues on a scientific forum as the exchange of knowledge on this platform genuinely helps in shaping you as a better physician.VSICON 2009 the once a year National conference of vascular surgery was held this time in the city of Hyderabad in the last week of October.Being part of the organising committee this time around I was in the thick of things.Though it was hectic but still I savoured every moment of it and came back home with fond memories of the event.
I received great reviews from all my vascular colleagues who matter regarding the vascular surgery blog I started for awareness. The comments ranged from me being very passionate to the blog being purely scientific in its outlook.So I thought for a change I would not give the viewers of this blog a heavy dose of vascular stuff this time around.I am tempted to speak about the COMPOSITE CARDIOVASCULAR SERIES (More so because this incidentally happens to be the largest series in the country)we did but would refrain from doing so for reasons cited above.I think I am incorrigible when it comes to work ethics and somewhere down the lane I am forced to believe I am a typical "VIRGO".
Anyways I would be failing in my duty if I dont thank my colleagues back in hyderabad for still persisting with me as a member of the Organising committee inspite of me leaving for chandigarh for good.A big thanks to all of them for giving me a slot to showcase my work in VSICON2009.

SUBTOTAL AORTIC REPLACEMENT IN A 17 YEARS OLD GIRL OF TAKAYASU ARTERITIS WITH MULTIPLE ANEURYSMS –ONE OF ITS KIND CASE

TAKAYASU ARTERITIS IS A RELATIVELY COMMON ENTITY TO COME ACROSS IN OUR DAILY CLINICAL PRACTICE MORE SO IN ASIAN POPULATION.THESE PATIENTS ARE EITHER ASYMPTOMATIC OR ELSE PRESENT WITH VASCULAR SYMPTOMS.ITS NOT UNSUAL TO FIND A YOUNG WOMAN WITH NO SYMPTOMS INSPITE OF ABSENT PULSES ON THE FOREARM.BUT NOT ALL PATIENTS ARE THAT LUCKY.PATIENTS COME TO YOU WITH SYMPTOMS RANGING FROM MILD PAIN IN THE FOREARMS ON EXERSION TO SEVERE PAIN ABDOMEN ON TAKING SMALL MEALS.CLINICAL REASONING,THOROUGH EXAMINATION AND AWARENESS OF THIS ENTITY IS MANDATORY TO PROCEED FURTHER IN SUCH CASES.TREATMENT OPTIONS IN SYMPTOMATIC POPULATION ARE NOT MANY WITH THE GENERAL VASCULAR TREND FAVOURING SURGERY IN SUCH CASES.THOUGH VASCULAR SURGEONS TEND TO WAIT TILL THE DISEASE PROCESS COMES UNDER CONTROL BEFORE THEY EMBARK ON DOING SURGERIES IN THIS SMALL BUT SYMPTOMATIC POPULATION,THERE ARE SITUATIONS WHERE ‘WAIT AND WATCH’ THEORY DOES NOT HELP.WE REPORT TO YOU A SIMILAR CASE OF TAKAYASU ARTERITIS.

THIS GIRL 17 YEARS OLD CAME TO US WITH UNCONTROLLED RENAL HYPERTENSION INSPITE SHE BEING ON 3 ANTIHYPERTENSIVES,PAIN ABDOMEN ON TAKING SMALL MEALS AND SIGNIFICANT BILATERAL LOWER LIMB CLAUDICATION.A CT ANGIO DONE ON HER WAS SUGGESTIVE OF MULTIPLE LARGE SACCCULAR ANEURYSMS IN THE AORTA(POST LEFT SUBCLAVIAN) INVOLVING THE ORIGIN OF THE LEFT SUBCLAVIAN ARTERY,DESCENDING AORTA,SUPRACELIAC AORTA,ONE IN THE SUPRARENAL REGION AND IN ADDITION AORTO-ILIAC OCCLUSION.SHE THEREFORE PRESENTED WITH MULTIPLE AORTIC ANEURYSMS AND AORTO-ILIAC DISEASE AT THE SAME TIME.HER LEFT KIDNEY WAS SMALL AND NON-FUNTIONAL.WE WERE IN A DILEMMA THE VERY MOMENT WE SAW THE ANGIO BUT WE REGROUPED OURSELVES AND DECIDED SURGERY WAS THE BEST OPTION IN HER EVEN IF IT MEANT OPERATING ON HER WITH THE DISEASE PROCESS STILL ACTIVE.

WE REPLACED THE WHOLE AORTA STARTING FROM THE LEFT SUBCLAVIAN ARTERY(INCLUDING THE REIMPLANTATION OF LEFT SUBCLAVIAN ON THE DACRON GRAFT) TILL THE AORTIC BIFURCATION.AORTIC BIFURCATION WAS REPLACED WITH A STANDARD AORTO-BIFEMORAL GRAFT..IN ADDITION WE DID A LEFT SIDED NEPHRECTOMY.PATIENT IS DOING OK AND IS IN REGULAR FOLLOWUP.

TO DATE GOING BY THE LITERATURE THIS IS THE FIRST OF ITS KIND CASE DONE IN THE WORLD WHEREIN SUBTOTAL AORTIC REPLACEMENT HAS BEEN DONE IN A YOUNG PATIENT OF 17 YEARS WITH THIS KIND OF PRESENTATION.

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?

ਭਾਰਤ ਚ ਪਹਿਲੀ ਵਾਰ ਕੈਸਰ ਨਾਲ ਗ੍ਰਸਤ ਮੁੱਖ ਖੂਨ ਨਾੜੀ ਦਾ ਸਫਲ ਆਪ੍ਰਰੇਸ਼ਨ ਕਰਨ ਵਾਲਾ ਡਾਂ ਗੋਰਵ ਸਿੰਗਲ।
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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SEPTEMBER12,2009 14:37(OSLO,NORWAY)

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