Sunil Agarwal

Surgical management of thoracic outlet syndrome: a 10-year experience

Background:  Thoracic Outlet Syndrome (TOS) refers to compression of the neurovascular structures in the region between the scalene muscles and the first rib, or by anatomical abnormalities such as cervical rib, fibrous bands and other variations in the scalene musculature.

Neurological complications in carotid body tumors: A 6-year single-center experience

OBJECTIVE Carotid body tumors are considered rare. However, there has been an increase in the number of these tumors managed at our center in recent years. Delayed presentation with large tumors is common. We studied the clinical profile, interventions, and outcomes of these tumors and assessed the factors influencing operative neurological morbidity and recurrence. METHODS This retrospective study was conducted at the Christian Medical College in Vellore, a tertiary care center in south India. We analyzed the inpatient and outpatient records of patients diagnosed to have carotid body tumors undergoing excision from January 1, 2005 to December 31, 2011. Patients diagnosed to have vagal paragangliomas were excluded. RESULTS Thirty-four of 48 tumors were excised from 32 patients (11 female, 21 male). Average age at presentation was 38.2 years, and three patients had familial bilateral tumors. All patients presented with a painless neck mass. There were 27 Shamblin group III, six Shamblin group II, and one Shamblin group I tumor. Eleven Shamblin group II/III tumors were associated with transient cranial nerve palsy or paresis (32.3%). Two Shamblin group III tumors were associated with perioperative stroke (5.8%). Preoperative embolization was done in 17 tumors, 12 of which were associated with neurological complications (two stroke, nine nerve palsy, one hemianopia). One patient underwent thrombolysis for a middle cerebral artery thrombus and recovered completely on follow-up, and another with a capsuloganglionic infarct managed conservatively had minimal persistent disability. Three patients had persistent nerve palsy (8.8%). Although complications were more common in patients with higher Shamblin group tumors, the difference was not statistically significant. CONCLUSIONS The overall rate of neurological complications is higher with tumors of higher Shamblin groups. Preoperative embolization was not effective in reducing neurological complications. The rates of postoperative stroke and permanent cranial nerve palsy after resection of large tumors are acceptable.

A 7-year Experience with Thoracoscopic Sympathectomy for Critical Upper Limb Ischemia

Severely symptomatic arterial insufficiency of an upper limb not suitable for revascularization is a difficult condition to manage. Thoracoscopic sympathectomy (TS) can be an effective procedure in this setting. Our experience with 18 consecutive thoracoscopic sympathectomy (TS) procedures over a period of 7 years has been reviewed. Indications, operative technique, complications, and outcome of surgery are analyzed. We performed 18 TS procedures on 17 patients during this period. There were no deaths. One patient had intraoperative hemorrhage necessitating conversion to open thoracotomy. Mean postoperative hospital stay was 2.3 days. Follow-up ranged from 6 to 72 months. All patients demonstrated clinical benefit from the procedure. Thoracoscopic sympathectomy is a useful option in patients with severely symptomatic hand and digital ischemia from occlusive small arterial disease like thromboangitis obliterans.

Venous thromboembolism: a problem in the Indian/Asian population?

Venous thromboembolism (VTE) is a common and potentially life threatening condition. It continues to be under diagnosed and undertreated. Awareness among Indians regarding this potentially life-threatening disease is low. Contrary to earlier belief, the incidence of VTE in Asia and India is comparable to that in Western countries. The risk of VTE is especially high in hospitalized patients, in a majority of whom it is clinically silent. It is one of the commonest causes of unplanned readmission and preventable death. In the United States, it is responsible for more deaths than accidents. Thromboprophylaxis is highly effective in reducing the incidence of VTE without any increase in clinically significant bleeding. It is worth emphasizing that prevention of VTE is much easier and cheaper than its treatment.

Doppler Adson’s Test: Predictor of Outcome of Surgery in Non-Specific Thoracic Outlet Syndrome

IntroductionOutcome of surgery in non-specific thoracic outlet syndrome (TOS) is variable. Duplex imaging of the subclavian artery during Adson’s maneuvre may help predict outcome.Patients and methodsA retrospective study of 16 cases of non-specific TOS who had pre-operative duplex imaging of the subclavian artery during Adson’s maneuvre was done and their outcomes following surgical decompression of the thoracic outlet studied.ResultsOf the eight cases with a positive Adson’s test, seven (87.5%) had a complete response of symptoms following surgery while in the eight cases with a negative test, only four (50%) had a favorable response to surgery.ConclusionDuplex scanning of the thoracic outlet during Adson’s maneuvre may help predict outcome of thoracic outlet decompression surgery in cases of non-specific TOS.

Clinical profile of aortoiliac occlusive disease and outcomes of aortobifemoral bypass in India.

OBJECTIVE Aortoiliac arterial occlusive (AIOD) disease is common in India. The clinical presentation and etiology are different than in the West. Intervention is frequently required for advanced lower extremity ischemia, but the results have not been systemically evaluated. We studied the clinical profile and midterm results of patients undergoing aortobifemoral bypass for AIOD at a tertiary care center in south India. METHODS Clinical data of patients undergoing aortobifemoral bypass for AIOD over a 6-year period from January 1, 2005 to December 31, 2010 were retrospectively analyzed. Clinical presentation and factors affecting outcome were evaluated. Graft patency and mortality were included as study end points. RESULTS Ninety-nine patients (mean age, 52 years) with AIOD who underwent aortobifemoral bypass were included. Etiology included atherosclerosis in 79 patients, thromboangiitis obliterans in 15, Takayasus arteritis in two, and hematological conditions in 3. Smoking (82%), hypertension (40%), and diabetes (30%) were the most common risk factors; ischemic heart disease (4%), obesity (2%), and dyslipidemia (3%) were rare. Eighty-one percent of patients presented with critical limb ischemia. Mean duration of symptoms was 22 months (range, 4 months to 9 years). Concomitant infrainguinal arterial occlusive disease was identified in 81%, but intervened upon in only 2%. In-hospital mortality was 3%. Causes of death included myocardial infarction in two and colon ischemia in one. Major morbidity included nonfatal myocardial infarction (3%), pneumonia/atelectasis (5%), and renal dysfunction (2%). Groin wound complications occurred in 20%, seroma/lymph leak in 13%, infection in 7%, and anastomotic hemorrhage in 2%. Multidrug-resistant and polymicrobial infections were common. Early graft thrombosis (30 days) occurred in 15 patients; 8 of 11 reintervened grafts were salvaged. Four more grafts thrombosed during a mean follow-up of 2 years (range, 0-5 years) and two became infected. Overall study major limb loss rate was 10% (primary, 2%; secondary, 8%). Delayed presentation and smoking were more common in patients developing complications. There was no significant difference in overall complication rates between patients with thromboangiitis obliterans and atherosclerosis (P = .66). CONCLUSIONS Despite earlier age at presentation, atherosclerosis remains the predominant etiology of aortoiliac arterial occlusive disease in Indian patients. Results of open revascularization are comparable to those in the Western literature. Thromboangiitis obliterans is the underlying pathology in a minority of patients with no significant difference in operative outcome. Patients frequently present late with critical limb ischemia, but this does not affect outcome.

Percutaneous Cyanoacrylate Glue Embolization for Peripheral Pseudoaneurysms: An Alternative Treatment

Post-traumatic pseudoaneurysms are rare in the peripheral arteries and usually occur as a late sequel of trauma. Surgery has traditionally been considered as the gold standard of therapy for traumatic peripheral pseudoaneurysms. We report 2 cases of post traumatic pseudoaneurysms successfully treated by percutaneous cyanoacrylate glue (N-Butyl 2 cyanoacrylate) embolization. This method offers complete exclusion of the pseudoaneurysm, at the same time avoiding the morbidity of open surgery.

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.

Endovascular management of posttraumatic arteriovenous fistulae.

Surgery is considered to be the treatment of choice for vascular injuries caused by trauma. However, endovascular techniques are emerging as an alternative means of treatment. In this article, we describe three patients with posttraumatic arteriovenous fistulae in different body regions that were managed using endovascular techniques. Each case had its unique set of associated problems requiring innovative methods and a multidisciplinary approach. While the short-term results are encouraging, long-term follow-up of posttraumatic arteriovenous fistulae that have been treated with endovascular techniques is still required.

An unusual etiology of a subclavian artery aneurysm.

Abstract A 22-year-old woman presented with a 3-month history of a pulsatile swelling in the right supraclavicular region. A CT angiogram revealed an aneurysm arising from the distal right subclavian artery. At surgery, the subclavian artery was almost entirely replaced by a well-vascularized tumor mass. The vascular tumor along with the native vessel was excised and replaced with a vascular prosthesis. Biopsy was suggestive of an epithelioid hemangioma (EH). In conclusion, an EH is a rare vascular tumor. The presence of vascular hyperplasia with plump endothelial cells protruding into the lumen is the most important discriminator in establishing the diagnosis of EH. Vascular neoplasms presenting as aneurysms should be considered, especially if other etiologies can be excluded.