Global vascular guidelines on the management of chronic limb-threatening ischemia: A brief purview Kalkunte R Suresh Indian Journal of Vascular and Endovascular Surgery 2019 6(3):147-157

How informed are you about informed consent? Edwin Stephen Indian Journal of Vascular and Endovascular Surgery 2019 6(3):158-161 The past decade has seen a rise in the awareness of patients, and their attendants have about their disease, options for treatment and their legal rights, thanks to easy access to the Internet, however accurate it may be. Surgeons need to be aware of the need to consent, which is now termed as “prior informed consent” as it is required by law to be taken prior to any examination or intervention. This article is meant to give the reader a quick overview about informed consent.

Introduction to translational research in vascular surgery/medicine Thushan Dhananja Gooneratne, Gnaneswar Atturu Indian Journal of Vascular and Endovascular Surgery 2019 6(3):162-170 Translational research is the process of applying the knowledge gained from basic research to clinical practice. Over the past three decades, translational research has transformed from a simple bi-directional flow from basic science to clinical care to a multifaceted, translational research spectrum that has the patient as the centerpiece. Globally, the vascular diseases spectrum has also been continuously changing with the aging population, change in lifestyle, and diabetic epidemic. This review aims to introduce new and exciting translation research concepts in the field of vascular surgery and medicine in general that could transform the management of patients with vascular diseases. An overview of contemporary translational research in the management of atherosclerosis, aneurysmal disease, and peripheral arterial disease is also highlighted.

Clinical profile of abdominal aortic aneurysms undergoing open surgical repair: A single-center experience PT Afshan, Shivanesan Pitchai, Sreekumar Ramachandran, Prakash Goura, Harishankar Ramachandran Indian Journal of Vascular and Endovascular Surgery 2019 6(3):171-175 Introduction: An abdominal aortic aneurysm (AAA) is defined as an aortic diameter at 1.5 times the normal diameter at the level of the renal arteries, which is approximately 2 cm. Existing data of clinical profile of AAA are mainly based on screening studies in the Western population. Materials and Methods: This is a retrospective observational study which included 165 patients who underwent conventional open repair for elective AAAs in a single center from January 2008 to August 2016. Results: The mean age of the patient cohort was 64.9 years with majority (92.7%) of them being a male cohort (male: female, 12.75:1). The mean size of the aneurysm was 6.8 cm. Ninety-six percent of the patients were hypertensive, 86% were smokers, 4.2% of patients had chronic obstructive pulmonary disease, and 16% of patients had preoperative renal dysfunction. Fifty-four percent of the patients had significant coronary artery disease (CAD), of which 19% underwent coronary intervention. Eighty-two percent of patients had infrarenal and 18% had juxtarenal AAA. Thirty-three percent of the patients who underwent open repair had concomitant common iliac artery aneurysm/ectasia. Conclusion: Clinical profile of AAA in this study shows a significantly high preponderance for males, hypertensive patients, and smokers, which have already been established as significant risk factors. Moreover, majority of the patients had significant CAD detected by routine preoperative cardiac evaluation which shows the significant coexistence between AAA and CAD in our population. Apart from coronary angiogram, evaluating patients with dobutamine stress echocardiography for inducible ischemia will act as a guide to detecting patients who are likely to benefit from revascularization and who are at increased risk of periprocedural cardiac events.

From compression to injections: Prostaglandins paving a new direction for venous leg ulcer treatment Rajendra Prasad Basavanthappa, Ashwini Naveen Gangadharan, Sanjay C Desai, AR Chandrashekar Indian Journal of Vascular and Endovascular Surgery 2019 6(3):176-181 Objective: Venous ulcers play a major burden on the patient and health-care system in terms of morbidity and medical expenditure. The objective of the study was to evaluate the efficacy of prostaglandin E1 (PGE1) administered via intravenous infusion in the healing time of venous leg ulcer and to evaluate the safety of prostaglandin intravenous infusion. Materials and Methods: This was a prospective observational study at a single tertiary care center. Patients who had proven venous ulcers of the legs which are not healing for more than 3 months with conventional therapy were included. About 500 μg PGE1 was given in equally divided doses over 5 days as intravenous infusion along with regular compression therapy. Ulcers were followed up every 3 weeks for 18 weeks and measurement of ulcer area done. Results: A total of 47 patients with 50 ulcers were included in the study with a mean age of 55.9 years. About 50% of ulcers healed 9 weeks after PGE1 administration and 92% healed after 18 weeks of treatment. The estimated healing time of 25%, 50%, and 75% of the patients treated with PGE1 was 40, 63, and 86 days, respectively, which was statistically significant compared to the previous studies with compression therapy alone. The only factor to independently affect healing time was found to be the initial ulcer size. There were no major adversities with PGE1 administration, 2 patients developed minor symptoms, in the form of hypotension and tachycardia, which were managed with stoppage of infusion for short duration. Conclusion: The study shows the effectiveness of PGE1 in reducing the healing time of VLUs, thereby allowing patients for lesser hospitalization and quicker return to work and life producing improvement in the quality of life. The adverse effects were also very minor with PGE1 treatment, overall, acceptable and were well tolerated by the patients.

Prof. Emerick Szilagyi: An empiricist vascular surgeon Srujal Shah Indian Journal of Vascular and Endovascular Surgery 2019 6(3):182-183

Treatment of infected aortic aneurysms: Case reports and review of the literature Pranay Pawar, Jithin Jagan, Radhakrishnan Raju, MK Ayyappan, Kapil Mathur Indian Journal of Vascular and Endovascular Surgery 2019 6(3):184-186 Management of infected aortic aneurysms remains one of the most challenging clinical problems for the vascular surgeon, as they are rare and difficult to treat. Curative treatment is achieved by removal of all infected native tissue followed by a vascular reconstruction. Endovascular repair can also be used as a “bridge therapy” to reduce the mortality in these patients.

Distalization of left subclavian artery for cerebral revascularization during hybrid repair of complex and contained rupture of aortic arch aneurysm Harishankar Ramachandran Nair, Shivanesan Pitchai, Vineeth Kumar, Unnikrishnan Madathipat Indian Journal of Vascular and Endovascular Surgery 2019 6(3):187-189 A ruptured aortic arch aneurysm is imminently fatal unless expeditiously intervened. Hybrid thoracic endovascular aneurysm repair has revolutionized the therapeutic paradigm, in a complex clinical setting, in particular, compared to demanding and particularly riskier open reconstruction with its attendant cardiac and neurological sequelae. Herein, we describe a 52-year-old male who presented with a ruptured aortic arch aneurysm and concomitant innominate artery aneurysm with occluded left common carotid artery (CCA). Computed tomography (CT) aortogram visualized large retrosternal hematoma precluding sternotomy without circulatory arrest and distal end of aneurysm abutting ostium of theleft subclavian artery (LSA). Therefore, staged reimplantation of LSA to descending thoracic aorta (DTA) and extra-anatomic LSA to right CCA bypass were performed through posterolateral thoracotomy followed by Zone 0 deployment of the aortic stent graft. The patient keeps good health and remains asymptomatic at 2 years of follow-up. Repeated CT aortogram done immediate postoperatively and at 13 months showed patent graft and no endoleak. Hybrid arch repair by supra-aortic debranching facilitated by distalized LSA on DTA is a viable therapeutic option in patients with complex arch and innominate artery aneurysms that mandate Zone 0 coverage during endovascular aneurysm repair.

Endovascular stenting of spontaneous isolated dissection of superior mesenteric artery S Roshan Rodney, Vivekanand , M Vishnu, Sumanth Raj, Hemant Chaudhari, CP S Sravan, Vaibhav Lende, Hudgi Vishal, K Siva Krishna, B Nishan Indian Journal of Vascular and Endovascular Surgery 2019 6(3):190-193 Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare condition often presenting with vague signs and symptoms. Although the disease entity is rare, the potential for morbidity and mortality is high. Computed tomographic angiography is the preferred imaging modality for identification of SID-SMA. It may be managed by conservative, surgical, or endovascular treatment based on clinical presentation, but there is no general consensus regarding the treatment strategy. Here, we describe a case of SID of SMA treated successfully with percutaneous endovascular stent placement.

Emergency endovascular management of ruptured mycotic aneurysm of the iliac artery using “bare stent-graft technique” S Roshan Rodney, Vivek Anand, M Vishnu, Sumanth Raj, Hemant Chaudhari, CP S Sravan, Vaibhav Lende, Dharmesh Davra, Piyush Kumar Jain, Hudgi Vishal, K Siva Krishna, B Nishan Indian Journal of Vascular and Endovascular Surgery 2019 6(3):194-197 Mycotic aneurysm of the aortoiliac region remains a life-threatening condition, especially if an aneurysm has already ruptured by the time of surgery. The mortality is increased further when it is associated with Salmonella infections, especially in the presence of risk factors for atherosclerosis. We report a case of a 50-year-old man who presented with ruptured mycotic aneurysm of the left common iliac artery secondary to infection with Salmonella paratyphi. He underwent emergent endovascular repair of the aneurysm with the “bare stent-graft technique.” Postoperative recovery was eventful. This case demonstrates that it is possible to safely manage mycotic aneurysms by endovascular means, following targeted perioperative antibiotic therapy.