JUMP GRAFT FOR AV GRAFT FAILURE

CRF PATIENTS NEEDING DIALYSIS ARE ON THE RISE AND SO DOES VENOUS ACCESS SURGERIES.NEEDLESS TO SAY COMPLICATIONS CONCERNING SUCH SURGERIES DO POP OUT TIME AND AGAIN AND WE AS VASCULAR SURGEONS SHOULD BE WELL VERSED WITH THEM.

WE RECENTLY HAD A PATIENT FROM CANADA WHO HAD A RIGHT ELBOW AV GRAFT CREATED SOME TWO YEARS BACK FOR HEAMODIALYSIS.ITS WAS NICE TO SEE SUCH FISTULAS WORKING FOR THAT LONG.HE NEVER HAD A NATIVE VESSEL FISTULA CREATED IN HIM FOR THE SAME.HE HAD PACE MAKER INSERTION ON HIS LEFT SIDE AND THIS MAY HAVE BEEN THE PROBABLE REASON FOR FISTULA CREATION ON THE RIGHT ARM.BY THE TIME HE WAS TO LEAVE FOR INDIA HE WAS SUGGESTED BY HIS VASCULAR SURGEON TO UNDERGO ANGIOPLASTY FOR A CRITICAL STENOSIS AT THE VENOUS END BUT FOR REASONS UNKNOWN HE NEVER GOT IT DONE.HE HAD A COUPLE OF DIALYSIS SESSIONS DONE HERE IN OUR NEPHROLOGY UNIT BEFORE THE EXPECTED HAPPENED.HIS FISTULA GOT THROMBOSED AND WAS ALMOST 2 DAYS OLD WHEN THE PATIENT RETURNED TO US AND I GOT A CALL TO INTERVENE.SINCE THE GRAFT WAS ALREADY THROMBOSED WE THOUGHT OF TAKING HIM UP FOR SURGERY RATHER THAN OPTING FOR THROMBOLYSIS. WE EXPLORED AND FOUND TOTAL OCCLUSION OF THE VENOUS END.DID A JUMP GRAFT TO THE VEIN ALONG WITH GRAFT THROMBECTOMY.

PATIENT IS DOING FINE WITH A PATENT AV GRAFT AND IS ON REGULAR FOLLOWUP.HE IS SLATED TO RETURN TO CANADA IN THE LAST WEEK OF FEB.2012.HAPPY THAT ALL HIS APPREHENSIONS RELATING TO OUR SKILL AND THE OUTCOME OF SURGERY HAVE BEEN LAID TO REST. HE CAN NOW GO BACK TO CANADA WITH THE ASSURANCE THAT WE INDIAN DOCS. ARE AS GUD AS OUR WESTERN COUNTERPARTS IF NOT....

VENOUS ACCESS FOR DIALYSIS IN THE GROIN COSTING PATIENT HIS LIFE

TIED PROXIMAL AND DISTAL VESSELS

Creating Venous access for dialysis is a common surgery done all over the world by the vascular surgeons,urologists and even the plastic surgeons.Its not uncommon to come across with venous access complications esp.if we use a synthetic graft for AV fistula creation.Needless to say we should only attempt creating venous access if we are well verse with its probable complications and are up for it.

We recently had a patient in his late sixties who came with copious pus exuding from the groin wound which was sutured with drains .This patient was discharged from a reputed hospital a couple of days back.History of the patient revealed creation of a venous access in his groin by using a synthetic graft only few months ago.I learn from the attendants that the operating surgeon told the patient had no choice but to go for this surgery as attempts to salvage the elbow fistula by endovascular means failed in him(Patient had a steal syndrome ).The surgery was done in a different hospital and the removal of infected synthetic graft was done at some other hospital (graft excision by urologist)before the patient finally landed with us.The discharge summary was suggestive of graft excision with vein patch repair of the femoral artery a few days back.The patient started bleeding profusely from the groin and went into shock.We had no other choice than to shift the patient to the Emergency OP and explore the wound.The investigations done in our hospital by then revealed that the patient was in severe sepsis with deranged biochemical parameters.

Wound exploration revealed a large rent in the common femoral artery.Vein patch was conspicuous by its absence.We had no choice other than to tie off the vessels to save the life of the patient.Doing a bypass simultaneously to restore the circulation of the limb was not done in view of the critical situation of the patient.Postoperatively patient kept deteriorating due to ongoing sepsis and was on ventilatory support.The affected lower limb became cold due to irreversible ischemia and and was finally amputated.Even this did not help and the patient finally died.

I learn the from the attendants that the patient spent something like 25-30 lakh rupees in a span of just four months related to the venous access creation and thereafter before turning to us.The situation leaves alot of questions that went unanswered.Firstly was there really no other choice than to create a venous access in the groin using synthetic graft?Secondly was doing a patch venoplasty the best of surgical procedures in a grossly infected groin in a patient who I suppose was hemodynamically better than when we received him in our ICU?

Not sure about the first question but i feel the vessels should have been tied as vein patchplasty is never a good option in a situation like this. This way the groin could have been left open and closed later with or without VAC therapy.

POST OPERATIVE GRAFT INFECTION IN A REDO CASE OF THORACOFEMORAL BYPASS

LIFE IS STRANGE.IT KEEPS THROWING CHALLENGES AND ITS UPTO YOU TO COPE WITH THEM.THEY TEST YOUR SENSIBILITIES TO THE CORE AND KEEP YOU ON YOUR TOES.BUT THEN THATS LIFE. UNPREDICTABLE....

WE RECENTLY HAD A SIMILAR CASE WITH US.THIS GENTLEMAN IN HIS FIFTIES CAME TO US IN EMERGENCY WARD WITH CRITICAL LIMB ISCHEMIA OF BOTH THE LEGS.HE HAD UNBEARABLE PAIN IN HIS LEFT LEG.ON EXAMINATION WE REALISED HE HAD IRREVERSIBLE ISCHEMIA OF THE LEFT LEG AND THE RIGHT LEG SEEMED SALVAGABLE THOUGH SIGNS AND SYMPTOMS WERE SUGGESTIVE OF ADVANCED ISCHEMIA.INTERESTINGLY THIS PATIENT UNDERWENT LEFT AXILLO-UNIFEMORAL BYPASS(TO ME THIS WAS NOT THE BEST TREATMENT OPTION AT THE OUTSET) TWO MONTHS BACK AT SOME OTHER CENTRE.THE GRAFT GOT OCCLUDED AND ALL ATTEMPTS TO RECANALIZE IT INCLUDING THROMBOLYSIS FAILED.THIS PATIENT HAD JUXTARENAL AORTIC OCCLUSION AS THE UNDERLYING PATHOLOGY WITH PORCELAIN(HEAVILY CALCIFIED)ABDOMINAL AORTA.PROBABLY THIS WOULD HAVE BEEN THE REASON FOR ATTEMPTING AX-FEM BYPASS IN HIM EARLIER.

WE DID A DECENDING THORACO-BIFEMORAL BYPASS IN THIS PATIENT BY CREATING A RETROPERITONEAL TUNNEL AS SUGGESTED BY KEAGY ET AL IN HIS PATHBREAKING ARTICLE PUBLISHED IN VARIOUS INTERNATIONAL VASCULAR SURGERY JOURNALS.WE REVASCULARISED THE LEFT LOWER LIMB STUMP FOR THE PURPOSE OF TISSUE HEALING.

THE REAL STORY BEGINS HERE.THE SURGERY WENT OFF WELL BUT POST OPERATIVELY THE PATIENT DEVELOPED WOUND DEHISCENCE IN THE LEFT GROIN,LEFT ABOVE KNEE AMPUTATION STUMP AND IN THE CHEST WITH GRAFT EXPOSURE .SUBSEQUENT INVESTIGATIONS REVEALED SEVERE HYPOALBUMINEMIA AS THE UNDERLYING CAUSE OF RAMPANT WOUND DEHISCENCE.

HYPOALBUMINEMIA AS WE ALL KNOW IS ASSOCIATED WITH POOR WOUND HEALING,DECREASED COLLAGEN SYNTHESIS,IMPAIRED IMMUNE RESPONSES LIKE MACROPHAGE ACTIVATION ETC AND DELAYED RECOVERY OF BOWEL FUNCTION POSTOPERATIVELY.

I MUST THANK THE PLASTIC SURGERY DEPARTMENT OF OUR HOSPITAL WHO FINALLY TREATED THIS COMPLICATION WITH AN EXTERNAL OBLIQUE FLAP.RECENTLY THIS PATIENT CAME FOR FOLLOWUP AND THE WOUND LOOKS HEALTHY.THE CHEST WOUND WAS DEBRIDED AND WOULD BE READY FOR RESUTURING IN A FEW DAYS FROW NOW.

I AM TRAINED IN ONE OF THE BUSIEST VASCULAR SURGERY CENTRES IN THE COUNTRY BUT HAVE NEVER SEEN AN AWFUL COMPLICATION LIKE THIS WHEREIN ALL SUTURE LINES GIVE IN.I REALIZE WHY PEOPLE PREFER GOING TO EXPERIENCED SURGEONS FOR THEIR AILMENTS (THEY HAD SEEN IT ALL I GUESS....).

I WOULD BE FAILING IN MY DUTY IF I DONT THANK MY PATIENT FOR HAVING PERSEVERENCE AND FAITH IN OUR CAPABILITIES.

Intravascular Leiomyosarcoma Of The Femoral Vein:Is It Rare?

Intravascular leiomyosarcomas are extremely rare.Going by the literature fewer than 40 cases have been reported so far wherein the tumour arose from the femoral vein.

Leiomyosarcomas usually arise from the muscular layers of the uterus or from the GI tract.Its an uncommon occurence for them to arise from the blood vessels.We report to you a case of leiomyosarcoma arising from the femoral vein.

A 40 years old male came to us with the complaints of swelling from the right upper thigh which he noticed some 2 weeks back.The swelling was associated with localised pain.There was no history of peripheral oedema and the initial radiological evaluation was suggestive of tumour arising in the vicinity of blood vessels.Further evaluation with MRI indicated the possibility of leiomyosarcoma.Doppler venous scan done for the status of deep veins was suggestive of chronic DVT of the popliteal and proximal superficial veins.Its surprising that the patient never had any symptoms of DVT like limb oedema etc.

At surgery the mass was found to be arising from the SFV from just where it drains into the CFV involving almost 10 cms of the venous segment.It was closely adherent to the femoral artery which was excised alongwith for wider surgical clearance.The femoral artery was reconstructed with ePTFE graft. SFV was not not reconstructed though because of chronic changes.

The histopathology specimen consisted of typical spindle cells disposed in interlacing fascicles with areas of hemorrhage.The final diagnosis was proved by IHC studies.

The postoperative course was uneventful.The patient is doing well and is referred to the medical oncologist for chemotherapy/ radiation therapy since these tumours are known to metastize to lung liver and scalp.

DISCUSSION

Clinical presentation depends on the extraluminal/intraluminal growth of the tumour mass.If extraluminal it can result in nerve compression causing pain and if intraluminal it can mimicthe symptoms of DVT.

Management of such cases are challenging because of very low incidence with most of the data available in literature being single reports.

Perineal Infrascrotal Bypass Saves Another Life

Its been a while when I last posted.Was keeping busy.Hope you guys had a terrific Diwali.Some interesting and at times pleasant challenges keep coming across to you in your day to day chores and you feel blessed that God has chosen you among others to do the needful.

On the night of dusshera we had a difficult case to handle.This guy in his late thirties came with massive bleeding from his groin area along with forefoot gangrene.A detailed history was not surprising though.He was a parentral drug addict who used to take injections in his femoral artery unabated.Examination revealed he had severe infection of the groin which was extending way into his right retroperitoneal space and involved quite a bit of the abdominal wall.Doing a Obturator foramen bypass was ruled out due to the above mentioned findings.So was doing a axillo-popliteal bypass.I being not a keen follower of this surgery(AX-POP) is a different issue altogether.The only option left was to do a perineal infrascrotal femoro-femoral crossover bypass.FortunatelyI had experience doing same kinda case a year back which is published in my blog in 2010.Encouraged by the outcome in that case we went ahead with the same procedure in this gentleman.Its about a month now and this guy is doing great.He had three subsequent surgeries to heal his groin and foot wounds and now is back on his legs.Really happy for him.

To me this is a fantastic vascular surgical procedure which needs a little more skill but is worth the effort.This is my second case of the series.The first case was done more than a year ago and is still in my followup.Not sure what makes this graft work with those so called anatomical twists and turns around the bulbous part of urethra.Seems its the short length of the graft that does the trick.

CDT OF POPLITEAL ARTERY THROMBOSIS:MY FIRST CASE IN APOLLO HOSPITAL

THERE IS NOTHING MUCH TO WRITE FOR THE MONTH AS I AM SETTLING DOWN IN LUDHIANA AND GETTING USED TO THE WORK CULTURE HERE.WE RECENTLY DID A CATHETHER DIRECTED THROMBOLYSIS(CDT) FOR A 65 YEARS OLD MALE WHO PRESENTED WITH ACUTE RIGHT LOWER LIMB ISCHEAMIA. WE WERE NOT SURE WHETHER IT WAS AN EMBOLIC/INSITU THROMBOTIC EPISODE AND THEREFORE WENT AHEAD WITH CDT OF THE POPLITEAL ARTERY.THE PERFUSION OF THE LIMB IMPROVED AS TIME PASSED AND THE PULSES WERE RESTORED FINALLY.PATIENT HAD A BLEEDING EPISODE WHICH WAS MANAGED BY BLOOD TRANSFUSION .SURPRISINGLY WE DID NOT FIND ANY UNDERLYING LESION LIKE A POP.ANEURYSM OR PAD IN HIM.I WOULD HAVE LOVED TO DO THIS CASE IN THE OPERATION THEATRE WITH AN ENDOVASCULAR SUITE.WE DONT HAVE ONE RIGHT NOW BUT WOULD SOON BE EQUIPPED WITH THIS.THINGS WOULD BE ALOT EASIER THEREAFTER FOR THE SURGEON AND FOR THE PATIENT( IT WILL AVOID BIG INCISIONS) AS DECISION MAKING AND PROMPT STATE OF THE ART INTERVENTION WOULD BE POSSIBLE AND ACCESSIBLE. MOST OF THE VASCULAR CASES TODAY NEED HYBRID INTERVENTIONS(THE WAY ENDOVASCULAR SURGERY IS EXPANDING) AND THEREFORE ENDOVASCULAR SUITE IN THE OPERATION THEATRE IS A MUST ESP.FOR HOSPITALS WHO ARE CONCERNED WITH THEIR PROFESSIONAL STANDING.

FINALLY JOINED APOLLO HOSPITAL LUDHIANA AS SENIOR CONSULTANT IN VASCULAR SURGERY

ITS INDEED A MATTER OF GREAT PRIDE TO BE ASSOCIATED WITH APOLLO GROUP OF HOSPITALS MORE SO WHEN ITS YOUR OWN STATE WHERE YOU WERE BORN AND BROUGHT UP.COMING BACK FROM GERMANY SPENDING 2 MONTHS LIFE HAD BEEN QUITE HECTIC WITH THINGS PILING UP AND REQUIRING URGENT ATTENTION.FINALLY GOT A HOME OF MY CHOICE,SCHOOL FOR KIDS AND JOINED SPS APOLLO HOSPITAL LUDHIANA AS SENIOR CONSULTANT IN VASCULAR SURGERY.PLANNING STARTING A FULL FLEDGED AORTIC PROGRAM HERE INCLUDING ENDOVASCULAR MANAGEMENT OF AORTIC DISSECTIONS.LONG JOURNEY BUT WE WILL DO IT WITH ALL YOUR WISHES AND THE BLESSINGS OF MY PARENTS.

I SHOULD.

I CAN.

I WILL.(WITH ALL HUMILITY)

THATS FOR NOW.WILL KEEP YOU POSTED.