Dheepak Selvaraj

A novel cautery instrument for on-site fenestration of aortic stent-grafts: a feasibility study of 18 patients.

Purpose To report the bench-top evaluation and initial clinical use of an instrument for onsite fenestration of aortic stent-grafts. Methods A stainless steel thermal cautery instrument was designed to create circular stent-graft fenestrations from 3 to 10 mm in diameter. Three operators independently bench-tested the instrument on thoracic stent-graft samples to evaluate size, shape, location, and quality of fenestrations created. For clinical use, on-site fenestration was performed 2 days before the endovascular procedure in a sterile room without access to supplemental oxygen. A fenestrator 1 or 2 mm smaller in diameter than the target vessel was used; the edges of the fenestrations were strengthened using flexible radiopaque nitinol wire. The aortic stent-graft was then re-sheathed and sterilized for added safety. Eighteen patients (17 men; mean age 51 years, range 18–80) with a variety of thoracic and juxtarenal pathologies were treated using Zenith TX2, Valiant Captivia, Zenith AAA, and Endurant stent-grafts modified in this manner. Results After successful bench testing, the instrument was used to create 34 fenestrations in aortic stent-grafts deployed in the 18 patients. Size and location of fenestrations obtained were as desired. Subsequent catheterization of the fenestration/target vessel and covered stent deployment were successfully achieved in 31 (91%) fenestrations; 2 fenestrations had type III endoleaks and 1 fenestration was unused. There was no perioperative mortality, stroke, embolization, vessel dissection, renal failure, or graft infection. Follow-up to 1 year in the majority of patients has revealed no new fenestration-related problems. Conclusion This simple-to-use instrument makes on-site creation of aortic stent-graft fenestrations easy, accurate, and precise. The instrument is inexpensive, robust, and easily sterilized.

Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

Purpose: To describe a precannulated fenestrated endograft system utilizing externalized guidewires to facilitate aortic arch endovascular repair and to report its use in 2 patients with challenging anatomy. Technique: For distal arch repair, a fenestration for the left subclavian artery (LSA) is made onsite in a standard thoracic endograft tailored to the patient anatomy; it is precannulated with a nitinol guidewire (NGw), which is passed from the femoral artery and externalized from the left brachial artery prior to endograft delivery system introduction over a parallel stiff guidewire. Steps are then taken to remove guidewire intertwining, prevent NGw wrapping around the delivery system, and orient the LSA fenestration superiorly when the delivery system moves into the arch. Gentle traction on the ends of the NGw during endograft deployment facilitates proper fenestration alignment. A covered stent is deployed in the LSA fenestration. The technique is illustrated in a patient with congenital coarctation of the aorta and descending aortic aneurysm. For total arch repair, endograft fenestrations are made for all 3 arch branches; the left common carotid artery (LCCA) and LSA fenestrations are each cannulated with NGws, which travel together from the femoral artery, pass through a LSA snare loop, and are exteriorized from the LCCA. After endograft deployment, the innominate artery fenestration is separately cannulated using right brachial access. Placement of a parallel externalized hydrophilic guidewire passing through the LCCA fenestration (but not the LSA snare loop) and removal of the LCCA fenestration NGw allows exteriorization of the LSA fenestration NGw from the left brachial artery by pulling the LSA snare. Covered stents are deployed in all 3 fenestrations. The technique is presented in a patient with type B aortic dissection. Conclusion: Use of the precannulated fenestrated endograft system described is feasible and has the potential to make aortic arch endovascular repair simpler, more reliable, and safer.

Visceral ischemia: could it be segmental arterial mediolysis

We present two cases of segmental arterial mediolysis, which can present with dissecting aneurysms or thrombosis of the visceral branches of the abdominal aorta. Segmental arterial mediolysis (SAM) causes ischemic bowel disease and has characteristic CT and angiographic features.

Venous thoracic outlet syndrome: A short review

Venous thoracic outlet obstruction can be either primary or secondary. Effort-induced thrombosis of the upper limb ranges from 1% to 4% of all venous thrombosis has been the focus of discussion in many an international and national journal recently because of an increase in the number of cases being seen, diagnosed, and treated. In this paper, we discuss an overview of the problem and our management approach based on available evidence and share the experience gained from treating patients with effort-induced axillary-subclavian thrombosis or Paget—von Schroetter syndrome, as it is otherwise called.

Management of klippel-trenaunay syndrome from a single center in India: Experience shared

India with a population of about 1.3 billion and diverse cultures holds within its large land mass an encyclopedia of medical cases, several un/underdiagnosed. Klippel-Trenaunay syndrome (KTS) is one such condition. Over the years, as the understanding of our team increased about the condition, we were able to share the same with our colleagues across the institution and publish the brief article. This resulted in an increased referral pattern from within the institution and across the country. At our institution, we managed 127 cases of KTS between October 2009 and December 2017. In this article, we share our experience about managing the cases, lessons learnt, and the challenges we face.

Arterial thoracic outlet syndrome in Klippel-Feil syndrome.

Anomalous first or cervical ribs are present in 0.7% of the general population. Thirty per cent of cervical ribs are complete. Although mostly asymptomatic, these are the most common cause of compression of the subclavian vessels producing an arterial thoracic outlet syndrome (A-TOS). Neurogenic (brachial plexus compression; N-TOS) and venous (subclavian or axillary vein compression) can also occur. Klippel–Feil syndrome (KFS), a complex skeletal and visceral dysplasia syndrome, is associated with cervical ribs in as many as 30% of patients. However, reports of thoracic outlet syndrome in these patients are rare. We present a case and review of arterial TOS in KFS. A 42-year-old man presented with right upper limb claudication and digital emboli (Fig. 1, panel A1). He did not use tobacco or have diabetes, dyslipidaemia or hypertension. Palpation of the neck revealed a bony mass in the posterior triangle with prominent arterial pulsations in the supraclavicular fossa. The radial and ulnar pulses were not palpable. Electrocardiogram was normal. X-ray revealed a complete cervical rib (Fig. 1, panel A2); A-TOS was diagnosed. Computed tomography angiogram diagnosed anomalies of the cervical spine and subclavian artery. There were eight cervical vertebrae with partial fusion of C2, C3. The transitional vertebra (C7) had bilateral complete bony ribs (Fig. 1, panel A3). The subclavian artery had a focal narrowing at the bifurcation of the right brachiocephalic trunk with a post-stenotic dilatation after crossing the anomalous rib (Fig. 2). He did not have a significant family history, low hairline, short neck or limitation of neck movement (classical features of KFS) but had other skeletal anomalies (lumbar ribs) confirming the diagnosis of KFS (Table 1). He underwent excision of the cervical rib with arterial reconstruction by a supraclavicular approach (Fig. 2). As can be seen on the images, the innominate bifurcation was readily accessible using this approach. Following the procedure, the patient was started on aspirin (75 mg daily). KFS has an incidence of one in 40 000. Maurice Klippel and Andre Feil described and classified it into three types (I–III) based on the degree of spinal fusion. Sporadic form or syndromic association with multiple other skeletal, renal, auditory, visual, genitourinary, cardiovascular and neurological abnormalities is described. The classic triad (low hairline, short neck, limitation of neck movement) is no longer diagnostic, as it is present only in 40%. Clarke reclassified KFS into four types based on inheritance, other anomalies and the level of anterior fusion (Table 1). Presentation varies – some are detected incidentally, others present with osteoarthritis or enthesopathies of the cervical spine, spinal canal stenosis, cord compression or symptoms secondary to visceral anomalies. N-TOS in KFS is reported. This is the first report of a KFS patient presenting with arterial TOS. One other patient had episodic colour change suggestive of Raynaud’s but the primary diagnosis was N-TOS. Anomalous first ribs, fibrocartilaginous bands, clavicular fractures or enlarged C7 transverse processes structures are the other causes of extrinsic compression. The clinical presentation is typical; patients complain of upper limb arterial symptoms with a palpable rib and prominent subclavian pulsation in the neck. Diagnosis is confirmed by a plain neck X-ray (anteroposterior view), followed by arterial imaging. This can detect the changes associated with chronic subclavian arterial compression: post-stenotic dilatation, aneurysmal change, localized intimal damage, embolization or thrombosis. Operative management is mandatory in symptomatic patients. This usually involves resection of the offending rib with arterial

A versatile stretch sensor for measuring physiological movement using a centre loaded, end-supported load cell

Abstract Acquisition of movement of some body parts can provide important physiological information. In clinical practice as well as for research purposes different types of sensors such as piezoelectric crystals, conductive rubber and optical displacement sensors are used for such measurements. Each of these sensors is associated with its problems. This paper discusses the use of a stretch sensor constructed using a small metal bar, approximately the size of a zipper slider that can be sewn into a fabric in the form of a belt. A combination of elastic, and Velcro material attached to the metal bar, provides a sensor that is capable of linear, steady state measurement as well as rapid response detecting slow and fast movement of the target. Incorporating the sensor in an elastic belt, allows measurement of physiological movements such as respiratory chest movements, abdominal and limb movements. This paper also discusses the potential use of the novel stretch sensor in measuring change in calf circumference during different manoeuvres, making it a useful assessment tool for calf venous function.

Deep Vein Thrombosis is Not Uncommon in India

Deep vein thrombosis (DVT) has for long been under-diagnosed and ignored as one of the major causes of morbidity worldwide. Knowledge of the pathology and treatment of DVT has progressed many fold over the years. Inspite of it being common, knowledge of diagnosis and treatment of this potentially fatal condition remains limited. In this review article, we look at the DVT and the available options for diagnosis and treatment.

Nonhemophiliac musculoskeletal pseudotumor

A 24-year-old man presented with impending ulceration of a large thigh swelling which appeared after minor trauma. Imaging revealed a large well-encapsulated lesion with no vascularity. He was diagnosed to have a pseudotumor and underwent successful excision of the mass under blood and cryoprecipitate cover. The unusual presentation was suspected to be secondary to a transient drug-induced factor XIII deficiency because the result of the final coagulation study was normal.