Vikas Deep Goyal

Successful Management of Potentially Fatal Vasodilator-Resistant Spasm of a Nongrafted Coronary Artery

SPASM OF THE native coronary artery is a rare but life-threatening complication after coronary artery bypass graft (CABG) surgery. Therefore, the emphasis is placed on early postoperative coronary angiography (CAG) in patients whose condition is inexplicably unstable after the surgery. There are reports in which the coronary artery spasm was relieved with intracoronary infusions of various vasodilators, but in others the spasm could not be relieved and mortalities have occurred. The authors present a case of a postoperative spasm of a nongrafted coronary artery resistant to intracoronary vasodilator administration that needed reoperation with grafting of the affected vessel. Subsequent CAG after 6 days showed relief of the spasm. CASE REPORT A 64-year-old man presented with complaints of uneasiness, chest pain, and a history of syncopal attack 1 day before admission with a history suggestive of variant angina for the last 6 months, for which he was on medical management. He had hypertension and type-2 diabetes mellitus. The patient was an occasional drinker and a nonsmoker. An electrocardiogram showed significant ST-segment depression in the inferior leads. Auscultation revealed bilateral carotid bruit. Echocardiography showed an ejection fraction of 55%. Color Doppler of the carotid arteries revealed bilateral carotid artery disease. Angiography showed 30% stenosis in the left anterior descending artery (LAD), 70% stenosis in the left circumflex artery, and 60% stenosis in the dominant right coronary artery (RCA). In addition, there were 80% and 50% stenoses of the right internal carotid artery and left external carotid artery, respectively. Because the patient was having unstable angina, he was referred for CABG surgery with right carotid artery endarterectomy. The patient underwent off-pump coronary artery bypass graft surgery with right carotid artery endarterectomy. After carotid endarterectomy, saphenous veins were grafted to the obtuse marginal branch of the left circumflex artery and the RCA on the beating heart, with proximal anastomoses to the ascending aorta. The intraoperative course remained uneventful, and the patient was shifted to the cardiac recovery room with minimal inotropic support (epinephrine, 0.01 g/kg/min). Gradual weaning from the ventilator was started, and the patient was put on a pressure support mode of ventilation after 3 hours. At that time, his heart rate was 122 beats/min, arterial blood pressure was 144/92 mmHg, temperature was 37.1°C, and the epinephrine infusion was administered at 0.01 g/kg/min. Just before extubation, the patient had an episode of ventricular fibrillation that was immediately converted with a 200 J DC shock. It was followed by significant STsegment elevation in the anterior chest leads and hypotension with a systolic blood pressure of 50 mmHg. Epinephrine infusion was stepped up, dobutamine infusion was started, and an intra-aortic balloon pump was inserted. Transesophageal echocardiography (TEE) surprisingly showed hypokinesis of the anterior wall, the area being supplied by the LAD that was not grafted. The patient was taken for urgent coronary angiography that, in accordance with the TEE findings, showed severe spasm of the proximal LAD (Fig 1) with patent vein grafts to the obtuse marginal branch and the RCA. Intracoronary vasodilators in the form of nitroglycerin, nicorandil, and diltiazem were administered in an attempt to relieve the spasm, but the spasm remained refractory. The cardiologist also tried to pass a guidewire across the lesion but was not successful. Because of persistent unstable hemodynamics, the patient was taken back to the operating room for grafting to the LAD. The left internal mammary artery (LIMA) was harvested and grafted to the LAD on the beating heart. After grafting of the LAD, the hemodynamics showed marked improvement, with a significant reduction in inotropic requirement. Electrocardiographic and echocardiographic changes also reverted back to normal. The patient was extubated after 12 hours. The IABP was removed the next day. The rest of the intraoperative course remained uneventful. Repeat angiography performed after 6 days showed relief of the LAD spasm (Fig 2). The patient was discharged from the hospital on the 7th postoperative day.

Isolated common iliac artery aneurysm: a rare entity.

Isolated aneurysms in iliac artery are not common. A 65-year-old male patient presented with complaints of pain abdomen, abdominal distension and history of hypertension, Clinical examination revealed pulsatile mass in the right iliac fossa extending upto paraumbilical region with palpable pulsations in all the limbs. Computed tomographic (CT) angiogram was done and it revealed large aneurysm of right common iliac artery. CT chest and abdomen did not reveal aneurysm in thoracic and abdominal aorta. As the size of aneurysm was large and there was risk of rupture, surgical intervention in the form of aneurysmorrhaphy was done. Open surgery was done as the anatomy was not favourable for endovascular intervention. Aneurysmorrhapy was done using 6mm ringed Poly Tetra Fluoro Ethylene graft. Patient recovered well and was discharged after 10 days.

Venous thrombectomy in cases of acute deep vein thrombosis presenting as acute limb ischemia (Phlegmasia Cerulea Dolens): report of 2 cases and review of literature

Deep Vein Thrombosis (DVT) usually presents as swelling of the limb, pain and difficulty in walking. One or more of the predisposing factors like hypercoagulability, trauma, prolonged surgery, malignancy, old age and prolonged bedrest are usually present. It is rare for cases of acute deep vein thrombosis to present as acute limb ischemia and impending gangrene (Phlegmasia cerulea dolens and Phlegmasia alba dolens) [1]. Phlegmasia Cerulea Dolens (PCD) is a rare complication of DVT and carries a high morbidity and mortality rate. It may result in major amputation or death unless treated in an early phase. Guidelines for treatment are still not clearly documented [2, 3]. The mainstay of therapy for acute DVT includes anticoagulants, thrombolytics, antiplatelets and other supportive conservative measures [4–6]. Venous thrombectomy/ embolectomy has not been a common procedure and even in the current era it’s use is limited. There are reports in literature citing the unfavourable results and high complication rate of the procedure, including mortality. Therefore it‘s use was abandoned at most of the centers worldwide. Recent data however suggests more favorable results [7–10]. In most of the published series the main goal was to improve the long term patency of the deep veins. However in these two cases the main goal of treatment was prevention of gangrene and amputation. There are few absolute indications for venous thrombectomy like Phlegmasia cerulea dolens and Phlegmasia alba dolens. Other indications are severe DVT not responding to conservative treatment, iliac vein thrombosis in cases of renal transplant and where there is contraindication to use of anticoagulants. Endovascular treatment for deep vein thrombosis involves the placement of inferior vena cava filters to prevent pulmonary embolism [11] and use of percutaneous suction devices.

Mesenteric Lymph Node Hamartoma (Castleman's Disease) in Association with Superior Mesenteric Arteriovenous Fistula.

We present a case of 21-year-old female patient with history of pain abdomen and abdominal distension. The patient also had oedema of the limbs, puffiness of the face, pallor and palpable mass in the abdomen. Ultrasonography of the abdomen and computed tomographic angiogram was done and it showed presence of vascular mass along with arteriovenous malformation in the mesentry of small gut between distal branches of superior mesenteric artery and vein. Surgical excision of the mass with ligation and division of the arteriovenous malformation was done through midline laparotomy. Histopathological examination was consistent with the diagnosis of Castlemans disease. The Patient recovered well and was discharged after seven days.

Transthoracic Repair of Paraesophageal Diaphragmatic Hernia Presenting with Symptoms Mimicking Cardiac Disease (Chest Pain and Breathlessness)

We discuss a case of 60-year-old female patient, who presented with history of chest pain radiating to left shoulder, breathlessness and postprandial discomfort. Patient was initially suspected to be suffering from cardiac pathology and was evaluated accordingly. Upper gastrointestinal endoscopy also missed the findings of paraesophageal hernia as the gastroesophageal junction was at its normal position. Chest roentgenogram raised the suspicion of diaphragmatic hernia, computed tomogram of chest and abdomen was done later on and showed characteristic features of paraesophageal hernia. Patient underwent transthoracic repair of the paraesophageal hernia along with partial fundoplication and had complete relief from the symptoms after surgery.

Ilio-popliteal redo bypass extending below knee using composite graft in a case of obstructed femoro-popliteal bypass with rest pain and impending gangrene

There are few reports in literature [1]on use of ilio-popliteal redo bypass extending below knee in the management of Peripheral Vascular Disease(PVD), though ilio-femoral bypass[2] has been reported more frequently. Common procedures done in cases of PVD are femoro-popliteal bypass in above knee or below knee positions using saphenous vein or prosthetic grafts, femoro-femoral bypass, aorto-bifemoral bypass and axillo-bifemoral bypass. Use of composite graft comprising of Polytetrafluoroethylene (PTFE) and great saphenous vein is also not common. Most of the literature is either on use of prosthetic grafts, Dacron or PTFE [3–5] and autologous saphenous vein. There are lot of studies comparing the use of prosthetic grafts with autologous vein grafts[6,7]however there are few studies on the use of composite grafts[8,9]. Results of bypass grafting are better in the above knee positions as compared to below knee positions and that using saphenous vein are better than that of PTFE. Endovascular stenting is increasingly being used in the management of peripheral vascular diseases because of shorter hospital stay, less invasive approach, cosmetically better results and comparable early to midterm patency rates compared to conventional procedures[10]. Case report

Axillo-popliteal bypass with sequential graft to femoral artery in a case of aorto-iliac occlusive disease with calcified abdominal aorta and iliac vessels

Management of aorto-iliac disease includes procedures like aorto-bifemoral bypass, axillo-bifemoral bypass [1], thoracic aorta to femoral artery bypass [2], and in recent times endovascular stent grafting is playing a major role. Presence of significant disease in femoral arteries in addition to the aorto-iliac disease requires either aorto-femoral bypass with femoro-popliteal bypass or rarely aorto-popliteal bypass or even rarely axillopopliteal bypass. Extra-anatomic procedures like axillo-femoral bypass [3] are usually done when anatomic or aorto-femoral bypass is either contraindicated or too risky (previous abdominal surgery, morbid obesity, infection). Axillo-femoral bypass [4] is one of the common extra-anatomic procedures but axillopopliteal bypass is rarely required and performed. Axillo-popliteal bypass are rarely performed procedures with limited literature available. Endovascular interventions in recent times have further decreased their use. There are certain situations like calcified aorta (as in this case) and infected previously placed aorto-femoral grafts [5, 6] where their use is advantageous or necessary. Axillo-popliteal bypass can be done with sequential graft to femoral artery or directly to popliteal arteries. Another very similar option can be axillo-femoral bypass with femoro-popliteal bypass which requires an extra anastomosis in the femoral region as compared to axillo-popliteal bypass with sequential graft to the femoral artery. Sequential anastomoses, although common in coronary artery bypass grafting, are rather rarely performed in peripheral vascular surgeries with few series and reports available in literature.

New technique for tunneling of reversed saphenous vein graft to prevent kinking and twisting during vascular bypass procedures

We describe a new, simple technique for tunneling of reversed saphenous vein graft to prevent its kinking and twisting thereby avoiding early graft failure during peripheral vascular bypass procedures. The technique is based on the principle of a temporary rigid tube outside acting as tunnel for the delicate, compressible reversed saphenous vein grafts in getting the proper lie without twists and kinks.

Sapheno-femoral crossover venous bypass in a case of deep vein thrombosis: an uncommonly done procedure for a very common disease

Vascular bypass procedures using saphenous vein graft are commonly done in cases of peripheral vascular disease, however in cases of venous disease the use of vascular bypass is limited , even though reports in literature show good results with resolution of symptoms in majority of patients. A review of the results of deep vein reconstruction for obstructive disease reveals the clear ability to perform these procedures with the minimum of risk, and the results in the successful cases demonstrate the improvement that follows correction of the physiologic abnormalities of obstruction [1]. Management of venous obstruction seems to be a bit neglected as far as surgical management is concerned with anticoagulants playing the major role. The procedures used in management of unilateral iliofemoral thrombosis are Palma’s procedure (cross-over femoro-femoral venous bypass using saphenous vein from contralateral thigh), use of prosthetic conduits and endovascular interventions. Deep Vein Thrombosis (DVT) is a very common disease with acute presentation of sudden onset edema, difficulty in walking and severe pain in the leg. Initial management is usually with anticoagulants and thrombolysis, with very few patients undergoing embolectomy. Medical management in the acute phase mostly leads to partial recannalization. After resolution of symptoms partially, the chronic phase sets in where patients continue to have edema, develop pigmentation, varicose veins and decreased work performance. Virchow’s triad of stasis, hypercoagulability and injury to vessel wall are important in the pathogenesis and management of the disease. Cross-over femoral venous bypass is suitable for persistent isolated unilateral iliac or common femoral vein occlusions in young and middle aged patients with severe chronic deep venous insufficiency unresponsive to conservative measures [2]. This case is reported to highlight the benefit and good results of vascular bypass in venous obstructions where facility for endovascular procedures is not available.