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.

LARGE HEPATIC ARTERY PSEUDOANEURYSM-A DIAGNOSIS MISSED ON FIRST LAPROTOMY

Aneurysms at any and every level of the vascular system have been reported worldwide with significant inroads made in the treatment modalities over the last two decades.At times the aneurysm is picked by a diagnostic modality done for a different cause.Aneurysms like the ones of the cealiac axis,hepatic artery,superior mesenteric artery etc are not very common to come across and may even go undiagnosed till some eventuality happens.Traumatic aneurysms/Pseudoaneurysms of the hepatic artery are still all the more rare to come across.Basically the age old saying that was taught to us when we were in medical schools still holds true"FIRST SURGERY IS THE BEST SURGERY".Preoperative diagnosis if the health of the patient permits and more importantly a thorough examination of the vicera and tissue during laprotomy becomes mandatory more so in traumatic cases so as not to miss any injury.


We report to you a case of large hepatic artery pseudoaneurysm tackled by us in the recent past.This guy met with a road traffic accident, underwent laprotomy and splenectomy was done.He had hepatic artery injury as well which went unnoticed.Patient recovered and was discharged only to come back with pain abdomen,swelling in the epigastrium and significant loss of apetite after 6 months.CT scan and angio were suggestive of large hepatic artery pseudoaneurysm compressing the adjacent structures.Interventional radiologist did attempt doing coiling for the lesion without success.The case was referred to me and we planned a relaprotomy for the patient to fix the lesion.

Redo surgeries are never easy and pose a pleasant challenge to the operating surgeons especially in cases like these.Anyways the pseudoaneurysm was excised in totality and the hepatic artery was repaired.Follow-up CT angio is fine and the patient is totally asymtomatic.

The idea of reporting this case is its rarity and the importance of a thorough check at the first laprotomy for the mortality operating hepatic aneurysms is still high going by the small data available on net.

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.