Treating upper limb claudication in a patient with Takayasu's arteritis with carotid-to-subclavian bypass: A case report.

INTRODUCTION AND IMPORTANCE: Takayasu's Arteritis (TA) is a rare form of large vessel vasculitis often being apparent late in its progression with features of artery occlusion. Studies comparing endovascular approach with bypass surgeries reveal surgery to be a better option with lesser rates of postoperative restenosis. CLINICAL PRESENTATION: A 25-year-old female patient presented with dizziness, headache, claudication and paresthesias in the right arm. Her right radial pulse couldn't be appreciated and BP on the right brachial artery was unrecordable. BP on her left brachial artery was 160/110 mmHg. CT angiogram demonstrated stenosis in the right subclavian, coeliac and left renal artery. After adequate control of hypertension and ruling out the active phase of TA, she underwent right carotid to subclavian bypass with Polytetrafluoroethylene(PTFE) graft. At 1 year follow up there was significant improvement in her right arm claudication. DISCUSSION: Symptomatic cases of TA need either endovascular angioplasty or surgical intervention to establish reperfusion. Surgery must be done only in the inactive phase of the disease because of the risk of reocclusion. The remission of TA is difficult to predict with clinical findings and ESR values. Oftentimes biopsies taken from the arteries of patients who underwent surgery showed features of active inflammation. CONCLUSION: We recommend all cases of TA to be treated with a course of steroids before planning for surgery irrespective of symptomatology and ESR values. Bypass surgeries with PTFE graft along with preoperative or postoperative steroid therapy result in resolution of ischemic symptoms.

Ewing's sarcoma arising from the right sided chest wall: a case report.

Ewing sarcoma (ES) is a malignant tumour prevalent in young adults with a reported 5-year survival ranging between 40 and 60% in most studies. Majority of the patients with ES are usually diagnosed late with significant chest wall mass, chest pain or respiratory distress. Case presentation: Here, the authors present a case of a 21-year-old female with a diagnosis of right sided chest wall ES treated with neoadjuvant chemotherapy followed by surgical resection of the mass. Clinical findings and investigations: The patient presented to the Surgical OPD with shortness of breath for 6 months associated with chest pain on the right side. Radiological investigations including chest X-ray and multi-detector row computed tomography chest was done. Additionally, diagnosis of ES was confirmed with histopathological examination of the mass obtained from fine needle aspiration cytology. Interventions and outcome: She was planned for safe maximal resection of tumour with chest wall reconstruction using double prolene mesh with bone cement and the defect was sutured with adjacent ribs. Good outcome was noted on postoperative period with resolution of symptoms. Relevance and impact: This procedure is now commonly used and is considered as an effective treatment for chest wall tumours, which was also noted in our case and the procedure is also well tolerated.

Accidental gunshot injury with left-sided lung injury and D11 burst fracture: a case report.

Penetrating chest injuries are mainly caused by gunshot trauma and stab injuries. These lead to damage to the vital structures, which requires a multidisciplinary approach for management. Case presentation: We present a case of an accidental gunshot injury (GSI) to the chest resulting in left-sided hemopneumothorax, left lung contusion, and D11 burst fracture with spinal cord injury. The patient underwent thoracotomy to remove the bullet along with instrumentation and fixation of the D11 burst fracture. Clinical discussion: Penetrating trauma to the chest requires prompt resuscitation and stabilization with eventual definitive care. Most GSIs to the chest require chest tube insertion, which helps to create negative pressure in the chest cavity, allowing adequate time for the expansion of the lungs. Conclusion: GSIs to the chest could give rise to life-threatening conditions. However, the patient must be stabilized for at least 48 h before performing any surgical repair to ensure that there are fewer complications following surgery.

Supraventricular tachycardia and deep vein thrombosis following Moderna vaccination: A case series.

There have been reports of deep vein thrombosis and supraventricular tachycardia following the Moderna vaccination. The timing of SVT and DVT just after vaccination in our case series could suggest possible temporal relationships to the vaccination. But further studies are needed to establish such evidence.

Anticoagulation failure in pulmonary thromboembolism in COVID-19 pneumonia despite prolonged anticoagulation: A case series.

Introduction: Moderate to severely ill patients diagnosed with Coronavirus disease 2019 (COVID-19) pneumonia develop a series of complications and less frequently, we might witness cases of Pulmonary Thromboembolism (PE)-refractory to the standard treatment with Low Molecular Weight Heparin (LMWH). The aim of this case series is to report the presentation and management of pulmonary thromboembolism secondary to COVID-19 pneumonia. Method: We report a case series of seven cases aged 40-70 who were presented in Dhulikhel Hospital with COVID-19 symptoms in different stages. The case details were extracted from their medical reports of the hospital. The written informed ethical consents were obtained from all the cases and their voluntary participation was assured. Outcome: The cases in the case series admitted with COVID-19 pneumonia, after diagnostic investigation (Chest x-ray, HRCT, CTPA) were suggestive of COVID-19 Pneumonia with ARDS and pulmonary thromboembolism. The cases received rivaroxaban, a newer anticoagulant-15 mg twice daily for 21 days and after discharge, they were asked to continue once daily doses for 9 weeks. Significant improvement was witnessed, with the presence of additional intervention including rehabilitative chest exercises. Conclusion: Pulmonary thromboembolism secondary to COVID-19 pneumonia is a life-threatening condition. Rivaroxaban is seen to be very effective in the management of this condition when an anticoagulation failure occurs even after the therapeutic dose of low molecular weight heparin. Future studies may require more scientific investigations to prevent complications even in the early stages of COVID-19.

Klippel Trenaunay syndrome in a 3-year-old: A case report.

INTRODUCTION AND IMPORTANCE: Klippel-Trenaunay syndrome (KTS) is characterized by a triad of port-wine stain, varicose veins and soft tissue or bony hypertrophy of lower limb. Varicose veins in Klippel Trenaunay syndrome are mostly distributed in the lateral aspect of the lower limb. The exact etiology of KTS is not known, and the treatment usually starts with conservative management- limb elevation, compression stockings and physiotherapy. However, some cases are severe enough to warrant surgical management. CASE PRESENTATION: Here we present a case of a 3-year-old male child with clinical features suggestive of Klippel Trenaunay Syndrome managed successfully with sclerotherapy of persistent lateral marginal vein of servelle. At one month follow-up the vein was sclerosed and there was a significant reduction in varicosities of leg. CLINICAL DISCUSSION: Starting treatment of varicose veins in Klippel Trenaunay Syndrome in children is effective in preventing long-term complications in adults. Thus, treating venous malformation with sclerotherapy is warranted in early childhood to prevent venous hypertension and chronic venous insufficiency. CONCLUSION: Varicose veins in KT syndrome can be managed successfully by sclerotherapy of lateral marginal vein of servelle resulting in significant reduction in varicosities of leg.

Traumatic gastric laceration with injury of splenic and celiac vessel following intentional self-harm by crashing of motor vehicle: A case report.

Intra-abdominal injury due to blunt trauma accounts for 5-10% of all traumatic cases. It usually occurs secondary to motor vehicle collision, pedestrian injury, and falls. Typically these result in injury to solid abdominal organs-liver and spleen, hollow visceral organs, and rarely the abdominal vasculature. Blunt abdominal trauma causing concurrent injury to the hepatic branch of the celiac artery and the associated vein along with gastric laceration is a rare presentation and has a high mortality rate, thereby warranting prompt evaluation. While the initial stabilization should follow Advanced Trauma Life Support guidelines, the adherence to nonoperative management or operative care depends upon the severity of the injury and the patient's clinical status. Here, we present an unusual case of gastric and splenic laceration with damage to the hepatic branch of celiac artery, splenic artery, and the associated vein following blunt abdominal trauma in a 12-year-old child following intentional self-harm by crashing a self-inflicted motor vehicle. Despite the negative preoperative radiological finding, the case was managed successfully with the laparotomic correction of the damaged stomach segment, splenectomy, and repair of the damaged artery, and ligation of the transected vein to control hemorrhage.

Spontaneous Common Femoral Artery Pseudoaneurysm: A Case Report.

Spontaneous femoral artery pseudoaneurysm in a young person with no comorbidity is a rare occurrence. A 30 years old gentleman presented to our hospital with complaints of painful swelling of spontaneous onset in the right inguinal region for 15 days. He had undergone incision and drainage of the contents of the swelling five days back but he suffered from a recurrence of the painful right inguinal swelling and persistent bleeding from the incision site for four days. Computed tomography showed a pseudoaneurysm of the right common femoral artery. It was treated surgically by emergency exploration, hematoma evacuation, removal of pseudoaneurysm, and repair of the defect in the right common femoral artery. In this case, we were fortunate that inadvertent incision of the pseudoaneurysm didn't result in a massive haemorrhage. This serves as a reminder that the possibility of a femoral artery pseudoaneurysm should be considered when evaluating a swelling of the inguinal region. Keywords: case report; common femoral artery; misdiagnosis; pseudoaneurysm; vascular surgery.

Klippel-Trenaunay Syndrome: Case series from a university hospital of Nepal.

Introduction: Klippel Trenaunay Syndrome (KTS) is a rare congenital malformation with capillary and venous malformations and soft tissue/bony overgrowth with or without lymphatic malformation. Cutaneous vascular stain, varicosities and tissue hypertrophy represent its main clinical features. Besides, the patient can develop thromboembolic pathologies, recurrent bouts of infection, stasis eczema, limb length discrepancy and intolerable pain typical of intraosseous involvement. Methods: Here, we report a case series of seven patients aged 10-45 who presented to our centre with clinical features suggestive of KTS. Out of them, six patients had involvement of unilateral lower limb, while only one had involvement of bilateral lower limb. They all had typical cutaneous vascular stains and underlying venous malformation, while one patient had developed complications with multiple ulcer formation. Outcomes: An interdisciplinary team of vascular surgeons, dermatologists, interventional radiologists, orthopaedics, and physiotherapists managed the cases. We performed an individualized treatment as per the patient's presentation, which included a combination of supportive, medical, interventional radiologic, and surgical interventions. The follow-up outcomes of all the patients revealed significant resolution of symptoms. Conclusion: Patients with KTS can have diverse presentations. Therefore, clinicians should ensure an individualized treatment with the involvement of a multidisciplinary team for proper management and prevention of complications.

Combined vascular malformation of neck: A case report.

Vascular malformations are developmental anomalies occurring due to defective vasculogenesis. Depending on the number of vessels involved, they are subgrouped into simple or combined types. Combined vascular malformations are a rare clinical entity with two or more vascular malformations (capillary, venous, arteriovenous, lymphatic) present in one lesion. Due to the complexity of these lesions, clinicians should employ an interdisciplinary approach with multi-staged treatment for the proper management. Here, we report a case of a lady with a combined vascular malformation in the right side of the neck who presented to our department with a complaint of progressively increasing swelling for three months. A multidisciplinary team of vascular surgeons, interventional radiologists and physiotherapists were involved in its treatment. Initially, Doppler ultrasonography was performed, which revealed a vascular lesion with arterial and venous components and a flow void region suggestive of lymphatic malformation, further confirmed by magnetic resonance imaging (MRI). A multistage treatment modality was employed where intralesional steroid was initially administered in the lesion area to shrink the vessel's size. Next, venous malformation targeted sclerotherapy was performed preoperatively, followed by intraoperative ligation of the feeding vessel and excision of remaining malformation. Postoperatively the patient had no wound site complication and was discharged on the fourth postoperative day with advice to follow rehabilitative neck exercises. One month follow-up revealed complete resolution of the malformation. Thus, in the case of combined vascular malformation, multistage treatment modalities with a multidisciplinary team should be employed for proper treatment.

Placement of cuffed tunnelled permanent hemodialysis catheter in patients with end stage renal disease: A cross sectional study.

Background: End-Stage Renal Disease (ESRD) is a significantly increasing condition warranting renal replacement therapy. Gaining vascular access for catheter placement for this procedure is of paramount importance. These can be done by temporary and permanent cuffed tunnelled catheters. The present study aims to analyze the outcome of permanent hemodialysis catheters and their efficacy in the case of patients suffering from end-stage renal disease. Materials and methods: A cross-sectional study was conducted on 32 patients who underwent permanent tunnelled catheter intervention along with details of follow-up from January 1st, 2021 till December 31st, 2021. Results: Among 32 patients, the mean age of the patient was 50.25 ± 18.10 years with 62.5% females. The site of insertion was right 27(84.37%) and left internal jugular vein in 4 (12.50%) and 1 patient (3.12%) in the left common femoral vein. Bleeding the peri-catheter site was observed in 4 (12.5%), infection was found among 2 patients (6.25%), thrombosis in the catheter in 7 (21.87%) patients. Indication for the procedure was due to failure of arteriovenous fistula in 21 (65.62%), lack of maturation of the AVF in 9 (28.12%) and patients awaiting transplantation in 2 (6.25%). The mean months of follow-up of the patients were 5.9 months (SD 4.4 months, range 1 month-12 months). Total 25 (78.1%) of the catheters were patent till the time of follow-up. Seven (21.9%) of the patients required manipulation once after which they also had functioning permanent catheters. The mean month on which manipulation was required was 4.1 months (SD 2.3months, range one month to seven months). Conclusion: Permanent cuffed tunnelled catheter has good patency and can be an alternative to an arteriovenous fistula.

Vascular Injury to the Neck by a Bamboo Stick: A Case Report.

Penetrating neck injuries causing rupture of sternocleidomastoid muscle along with transection of major vessels of the neck have significant morbidity and mortality due to the risk of severe hemorrhage and cerebral infarction. However, there are no universal guidelines for the management of penetrating neck injuries. Here, we report a case of a 67-year-old female with a lacerated wound on the left side of the neck with a complete transection of the left sternocleidomastoid muscle along with transection of internal jugular vein and two superficial branches of internal carotid artery following penetrating injury to the neck by a bamboo stick. It was managed by emergency wound exploration with ligation of the injured vessels with repair of sternocleidomastoid muscle. Post-operatively the hemorrhage was controlled and the patient was discharged on the fourth postoperative day. Thus, in a case of penetrating injury to the neck, prompt surgical wound exploration is beneficial.

Peripheral Vascular Trauma among Vascular Surgery Cases Operated in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Peripheral vascular trauma can result in limb or life-threatening injuries. Early surgical intervention leads to a better outcome. Diagnosis is made clinically, by non-invasive and invasive imaging modalities. Our aim in this study is to find out the prevalence of peripheral vascular trauma among vascular surgery cases operated in a tertiary care centre of Nepal. METHODS: This is a descriptive cross-sectional study of peripheral vascular injuries that underwent operative management in a tertiary care hospital of Nepal from January 2018 to May 2020. Ethical approval was taken from the Institutional Review Committee of Kathmandu University School of Medical Sciences (Registration Number 79/20). Convenience sampling technique was used. Data for the study was retrieved from operation records of the patients along with their treatment summaries and entered and analyzed in the Statistical Package for Social Sciences version 20.0. All cases with complete records were included. Conservatively managed cases and cases that underwent primary amputation were not included in the study. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Among 624 vascular surgery patients, 40 (6.41%) (4.48-8.33 at 95% Confidence Interval) patients had presented with peripheral vascular trauma during the study period. There were 26 (65%) cases where the upper limb was involved. CONCLUSIONS: The prevalence of vascular surgery for peripheral vascular trauma among vascular surgeries operated in our study was similar to other studies done in similar settings. Vascular injury needs urgent intervention and appropriate management will result in a high chance of limb salvage and survival.

Circumferential intimal tear with thrombosis of right superficial femoral artery due to penetrating injury by bull horn: A case report.

In agrarian countries where bulls are used for farming and stock breeding, bull horn injuries are common. Bull horn injuries range from blunt trauma to penetrating injuries, which can cause massive hemorrhage. Vascular injuries to the limbs by goring bull horn injury usually involve transection of vessels but rarely cause intimal tear with thrombus formation. Here, we report an unusual case of a 33-year-old male with circumferential intimal tear with thrombosis in the subintimal region of the right superficial femoral artery without transection of the vessel following penetrating injury to the right thigh caused by a bull's horn. There was a pulse deficit above the popliteal artery, and Doppler ultrasonography revealed decreased flow indicative of underlying femoral vessel injury for which the wound was surgically explored. It was followed by right superficial femoral arteriotomy at the site of the thrombus with the evacuation of a 6 cm long clot, revealing a 6 cm long endothelial injury in the same vessel. Next, an interposition reversed saphenous graft was placed in the same location. Following this, Doppler ultrasonography was done that revealed restoration of blood flow to the site of thrombosis. Thus, in a case of bull horn injury, thrombosis should be ruled out with prompt surgical wound exploration despite the presence of an intact vessel.

Cervical rib, case series from a university hospital of Nepal.

Cervical rib is a rare anatomical anomaly with an incidence of 0.2%-1% and is an important cause of thoracic outlet syndrome. We present a case series of five female patients with a mean age of 20.6 (15-26) years, symptoms present were neck pain, neck mass, tingling sensation and weakness in the affected side. Symptoms develop in adolescence probably due to sagging of the shoulders and a disproportion between chest and neck growth at this age. X-rays of cervical spine was a common mode of diagnosis and showed bilateral cervical rib in three cases and unilateral in two cases. They were managed by performing surgeries under supraclavicular approach with resection of cervical rib of affected side. There was improvement of symptoms with restoration of limb function with a mean time of recovery of 9 weeks. Early diagnosis is important as differential diagnosis of such symptoms may be cervical stenosis and myelopathy which differ in management and have a greater risk of morbidity. In absence of intervention, cervical ribs can lead to compression of neurovascular structures leading to worsening of symptoms, thrombosis of subclavian artery or cerebral emboli.

Quantification of Superficial Venous Reflux by Duplex Ultrasound - Role of Peak Reflux Velocity and Reflux Time in the Assessment of Varicose Vein.

BACKGROUND: The study compared the peak reflux velocity and reflux time in cases of varicose veins and non-varicose veins with a focus on quantifying the reflux parameters. METHODS: This is a hospital based observational comparative study. The limbs with CEAP Clinical classification of C2 or more were taken as diseased limbs and contra-lateral limbs with no symptoms or disease were taken as control limbs. RESULTS: Altogether 792 limbs (452 diseased limbs and 340 control limbs) were evaluated with color duplex. Mean Great Saphenous Vein diameter was 5.68 ± 2.07 mm and 4.00 ± 1.34mmin diseased limbs and control limbs respectively (p=0.0001). Mean sapheno-femoral junction diameter was 8.23 ± 2.64 mm and 6.16 ± 1.93 mm in diseased limbs and control limbs respectively (p=0.0001). Mean peak reflux velocity in diseased limbs was significantly higher than control limbs (77.38 cm/sec vs 7.95 cm/sec; p=0.0001).  Similarly mean reflux time was significantly longer in diseased limbs than non-diseased limb (406.58ms and 67.28 ms respectively; p=0.0001). An optimal cut-off point of 27.4 cm/s for peak reflux velocity and 250 ms for the reflux time at Sapheno-Femoral junction had a discriminatory power between the two groups. CONCLUSION: The quantification of peak reflux velocity seems to be more consistent than reflux time in determining the superficial venous reflux. An optimal peak reflux velocity cut off point of 27.4 cm/sec has the discriminatory power between diseased and non-diseased limb.

Study of Arteriovenous Fistula Cases in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Arteriovenous fistulas are a preferred choice for hemodialysis access in chronic kidney disease patients. There is increased adoption of arteriovenous fistula creation in Nepal. Our objective is to study various arteriovenous fistulas that have been created in our center. METHODS: This is a descriptive cross-sectional study conducted in a tertiary care hospital including all cases of arteriovenous fistula creation from January 2018 to December 2019. We obtained the ethical clearance from the institutional review committee of Kathmandu University School of Medical sciences. Convenient sampling method was used. Detailed vascular mapping and color doppler ultrasonography was done in the bilateral upper limb as preoperative preparation and to choose a site for arteriovenous fistula creation. Data were entered into the Statistical Package for the Social Sciences version 20 for analysis. RESULTS: Among 50 patients, the most common location was brachiobasilic 20 (40%) patients followed by brachiocephalic 18 (36%), radiocephalic 11 (22%), and arteriovenous graft between the brachial artery and axillary vein 1 (2%). The mean duration of hospital stay was 1.44 days. Three (6%) patients required re-intervention, all within 24 hours. Two (4%) patients had a failure of arteriovenous fistula requiring the creation of a new arteriovenous fistula. CONCLUSIONS: Brachiobasilic was the most common location for arteriovenous fistula creation. Reintervention was not common.

One-, two-, and three-class resistance among HIV-infected patients on antiretroviral therapy in private care clinics: Mumbai, India.

HIV-infected patients receiving antiretroviral (ARV) therapy (ART) in India are not all adequately virally suppressed. We analyzed ARV drug resistance in adults receiving ART in three private clinics in Mumbai, India. HIV viral load was measured in 200 patients with the Roche AMPLICOR HIV-1 Monitor Test, v1.5. HIV genotyping was performed with the ViroSeq HIV-1 Genotyping System for 61 participants who had HIV-1 RNA >1000 copies/ml. Genotyping results were obtained for 51 samples. The participants with resistance results were on ART for a median of 24 months and were on their current regimen for a median of 12 months (median CD4 cell count: 217 cells/mm(3); median HIV viral load: 28,200 copies/ml). ARV regimens included nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens (n = 27), dual nucleoside reverse transcriptase inhibitors (NRTIs, n = 19), protease inhibitor (PI)-based regimens (n = 3), and other regimens (n = 2). Twenty-six participants (51.0%) were on their first ARV regimen and 24 (47%) reported >95% adherence. Forty-nine participants (96.1%) had resistance to at least one ARV drug; 47 (92.2%) had NRTI resistance, 32 (62.7%) had NNRTI resistance, and four (7.8%) had PI resistance. Thirty (58.8%) had two-class resistance and three (5.9%) had three-class resistance. Four (8%) had three or more resistance mutations associated with etravirine resistance and two (4%) had two mutations associated with reduced darunavir susceptibility. Almost all patients with HIV-1 RNA >1000 copies/ml had NRTI resistance and nearly two-thirds had NNRTI resistance; PI resistance was uncommon. Nearly 60% and 6% had two- and three-class resistance, respectively. This emphasizes the need for greater viral load and resistance monitoring, use of optimal ART combinations, and increased availability of second- and third-line agents for patients with ARV resistance.

Knowledge, attitudes, and practices of antiretroviral therapy among HIV-infected adults attending private and public clinics in India.

India has approximately 5.2 million persons infected with HIV. Although antiretroviral therapy (ART) is being widely introduced in public clinics, many HIV-infected persons still seek care via the private sector. A cross-sectional survey was conducted in 2004 at six public and private sites to characterize the knowledge, attitudes, and practices (KAP) of ART among patients with HIV receiving care in India. Of 1667 persons surveyed, 609 (36%) had heard of ART and 19% of these persons reported that ART could cure HIV. Twenty-four percent reported that they were currently taking ART, with 18% of these patients not actually on ART according to their provider. Major barriers to taking ART were cost (33%), lack of knowledge of ART (41%), and deferral by physician (30%). More than half of all public and private patients had not heard of CD4 (57%) or viral load testing (80%), and even fewer had received these tests (32% and 11%, respectively). Private clinic attendees were almost 4 times more likely to be on ART (35% versus 9%, p < 0.0001), more likely to be male, have a higher education, be partnered, have a higher income, and have had a CD4 or viral load (p < 0.0001). Overall, low levels of ART knowledge and access were observed among HIV infected patients, with access to ART being particularly low among patients attending public clinics. In order to make widespread dissemination of ART effective in India, further educational and programmatic efforts are likely needed to optimize access, treatment awareness, and compliance among patients with HIV.