Successful endovascular management of coral reef aortic occlusion.

Transaortic thromboendarterectomy and bypass have been the conventional treatment for coral reef aortic occlusions but are associated with significant mortality, morbidity and reintervention rate since these patients often present with heart failure, uncontrolled hypertension and renal dysfunction. Endovascular treatment has not become popular because of fear of aortic rupture and visceral ischemia. We present our experience with endovascular management of 10 patients with coral reef aorta. Uncontrolled hypertension, chronic renal disease, disabling claudication, and critical limb ischemia with tissue loss were the presenting symptoms. Seven patients had infrarenal aortic occlusion, and 3 had occlusion at renal and suprarenal aorta. Eight had involvement of the visceral vessels and 3 had renal artery stenosis. Common iliac, femoral and subclavian were the other arteries involved. All procedures were done under local anaesthesia. Aortic stenting was done in 7 and aortoiliac stent in 3. Two had covered stents and the rest had bare metal stents. Two had renal artery stenting. In 2 patients with suprarenal aortic occlusion, intravascular lithotripsy was used prior to aortic stenting. We achieved technical success in all patients with control of blood pressure and increase in Ankle Brachial Index (ABI). One patient died due to acute coronary event 2 months later.

Suprarenal Aortic Occlusion Due to Coral Reef Calcification: Successful Endovascular Management Assisted by Intravascular Lithotripsy and Visceral Protection.

PURPOSE: Suprarenal aortic occlusion due to coral reef calcification has been considered not suitable for endovascular therapy because of visceral artery involvement. Unfortunately, open surgical treatment also carries high morbidity and mortality. We describe here successful endovascular management of a case of suprarenal aortic occlusion due to coral reef calcification with the use of intravascular lithotripsy (IVL) and visceral protection. CASE REPORT: A 72-year-old women presented with uncontrolled hypertension, heart failure, and intermittent claudication. She was found to have occlusion of suprarenal aorta due to coral reef calcification at the level of the celiac artery. Celiac, superior mesenteric, and left renal arteries had stenosis. Right renal artery was normal. Intravascular lithotripsy-assisted balloon angioplasty and stenting of the aorta was done. Distal embolic protection of right renal artery and superior mesenteric artery was done during this procedure. Post procedure, there was no pressure gradient across the aortic stenosis, and all visceral arterial flow was maintained. Her cardiac function improved and hypertension could be managed with a single drug. Her pedal pulses became palpable. CONCLUSION: Coral reef calcification of suprarenal aorta can be safely managed by endovascular therapy using IVL and distal embolic protection of the visceral arteries.

Management of Acute Limb Ischaemia Due to COVID-19 Induced Arterial Thrombosis: A Multi-Centre Indian Experience.

Objective: To determine the outcomes following various surgical and medical treatments of Coronavirus disease 2019 (COVID-19) induced acute limb ischaemia. Methods: A retrospective study of patients presenting with COVID induced arterial ischaemia in three hospitals from Southern India during the months of May 2020 to August 2021 was undertaken. These patients were managed by either thrombectomy, primary bypass, thrombolysis, anticoagulation or primary amputation based on the stage of ischaemia and the severity of COVID. Results: A total of 67 limbs in 59 patients were analysed. The average time to intervention was 15 days. Upper limb involvement was seen in 16 and lower limb in 51 limbs. Of the 67 limbs, 39 (58.2%) were treated by open surgical revascularisation, 5 (7.4%) by catheter directed lysis, 17 (25.3%) were managed conservatively and 6 (8.9%) underwent primary amputation. Successful revascularisation could be carried out in 88.6% of patients. A limb salvage rate of 80.6% was achieved in these patients with a re-intervention rate of 13.6%. Major amputation rate was 14.92% and mortality was 13.56%. Conclusion: Limb ischaemia after COVID can be safely managed by open thrombectomy or bypass. Similar rates of limb salvage as in non-COVID acute limb ischaemia can be obtained.

Education in vascular surgery: Critical issues in India.

The first department of vascular surgery in India was established in 1978, and the first training course in peripheral vascular surgery was started in 1985. Despite this, vascular surgery has been slow to develop in India. The widespread misconception that vascular diseases are uncommon and that the result of vascular reconstruction is poor has resulted in vascular surgery not being popular among the medical students. Only 10 medical colleges have dedicated vascular surgical departments; hence, most students do not have enough knowledge about vascular diseases and the treatment options. This lack of awareness has resulted in a delay in diagnosis of vascular problems that results in poor outcome. At present there are only seven training centers for vascular surgery, training 12 students every year. Students receive adequate training in open surgical procedures, but endovascular training is still inadequate. Endovascular treatment has not picked up because of the expense and nonavailability of catheterization laboratories to vascular surgeons. The Vascular Society of India (VSI) has proposed to correct these problems by starting more training centers in private hospitals, starting vascular services in different parts of the country, conducting a nationwide awareness campaign, and conducting more continuing medical education programs and workshops for the general surgical trainees. VSI has been conducting endovascular workshops for the vascular trainees and has arranged for fellowships abroad in reputed vascular units. VSI is looking forward to having active interaction with World Federation of Vascular Societies to create more training opportunities for the young vascular surgeons.