Femoral Pseudoaneurysm in IV Drug Abusers: Single-center Study Experience.

BACKGROUND: Pseudoaneurysm of the femoral artery is the most common complication among IV drug abusers who inject drugs in groin. These are usually infective and potentially fatal so it requires astute clinical recognition and prompt treatment, possessing a significant challenge to vascular surgeons. METHODS: We present a retrospective descriptive study and the prevalent practice of their management covering the period from 2013 July- December 2019 at our center. Data regarding demography, presentation, surgical management, and the outcome was analyzed. RESULTS: Among 368 femoral pseudoaneurysm operated during the period, groin swelling with pulsatile mass was the most frequent presentation accounting 304 (82.61%) patients. About 67.12% (247 patients) of the pseudoaneurysm has purulent discharge and 60.07% (221 patients) had bleeding at presentation out of which 211patients had hepatitis C (HCV), hepatitis B (HBsAg) and/or Human Immunodeficiency virus (HIV) status positive.  Thirty six patients (9.78%) presented with femoral pseudoaneurysm in both groins. Ligation and excision of the pseudoaneurysm were done in all cases while delayed revascularization was done in eight patients with expanded Polytetrafluoroethylene (ePTFE) graft in one patient and venous bypass grafts in other 7 cases. All patients after bypass had no major limb loss and two patients had a patent graft at five years follow up. There were nine mortalities and thirty two patients underwent amputation.  Conclusions: Infected femoral pseudoaneurysm can be managed by ligation of the involved artery with delayed revascularization if required without major limb and life loss.

Outcome of Cuffed Tunneled Dialysis Catheters for Hemodialysis Patients at a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Arteriovenous fistula is the most common vascular access for patients requiring hemodialysis, but it is not always possible or practical hence cuffed tunneled dialysis catheter comes into play. The aim of the study was to determine the outcome of cuffed tunneled dialysis catheter used for hemodialysis at a teaching hospital. METHODS: A descriptive cross-sectional study was conducted between January 2014 and December 2019 on 103 chronic dialysis patients with end-stage renal disease presenting to a tertiary care hospital. Ethical approval was received from the institutional review board (2/(6-11) E2/076/77). Whole sampling was done. Data entry and analysis were done in Microsoft Excel 10. RESULTS: The study included 103 patients with 117 cuffed tunneled dialysis catheters placed for hemodialysis. On assessing the outcome of the catheters, the primary and secondary patency rates of the catheters were 5.85±4.87 and 1.21±3.77 months. Thirty-one (30.1%) patients required one intervention, and 11 (10.68%) catheters required 3 or more interventions to maintain patency. Eighteen (17.48%) patients presented with catheter dysfunction while in 11 (10.68%) cases, the catheter was kinked or malpositioned at the notch. In one patient, procedure was abandoned due to severe bleeding and in 2 (1.94%) patients dialysis catheters could not be negotiated into the right atrium and left in brachiocephalic junction. CONCLUSIONS: Cuffed tunneled dialysis catheter is effective for maintenance hemodialysis in patients with the end-stage renal disease if used with proper care during dialysis even in our setup. The results and outcomes of the procedure are at par with standards.

Thoracic aortic aneurysm causing aorto-esophageal fistula-our experience with a rare disease.

Aorto-esophageal fistula is a life-threatening condition, accounting for a small number of cases of upper gastrointestinal bleeding where patients present with one or more features of Chiari's triad. We present the case of a 43-year-old woman, referred to us with symptoms of central chest pain, sudden onset dysphagia followed by massive hemoptysis. She was diagnosed with an aorto-esophageal fistula due to a ruptured thoracic aortic aneurysm and rushed for an emergency endovascular thoracic aortic stent and feeding jejunostomy with intravenous antibiotics and supportive care. After 6 weeks of surgery, the patient was re-evaluated to plan for an esophageal stent if required. The purpose of this presentation is to make the surgical fraternity aware of the gravity of this disease and novel techniques to manage it.

Middle aortic syndrome with renal artery stenosis.

A 39-year lady referred to Vascular Surgery OPD from Cardiology with uncontrolled hypertension, non- functional left kidney and absent bilateral femoral pulses. Investigations revealed middle aortic syndrome with non-functional left kidney with bilateral renal artery stenosis. She successfully underwent bypass of stenotic segment with polyester graft from descending thoracic aorta to left common iliac artery with reverse saphenous vein graft interposed between polyester and right renal artery.

External Iliac Artery-Appendicular Fistula due to Antegrade Unusual Migration of K-Wire from Hip to Pelvis: An Unreported Complication.

Background. K-wires are thought to be extremely safe implants and complications as a result of direct insertion or migration are very rare. Complications may be life-threatening in some instances where migration results in injury to vital organs. We report one such case where antegrade migration of K-wire from the hip resulted in injury to external iliac artery and formation of external iliac artery-appendicular fistula. No such complication due to migration has ever been reported in the literature. Case Description. A 15-year-old boy presented with lower abdominal pain, right lower limb swelling and pain, inability to walk, and rectal bleeding for 1 month after 2 K-wires had been inserted in his right hip joint for treatment of slipped capital femoral epiphysis the previous year. On investigation, he was diagnosed to have external iliac artery-appendicular fistula for which he was surgically treated. Clinical Relevance. Antegrade migration of K-wire from hip joint may lead to life-threatening injuries which can be minimized by bending the end of the K-wire, keeping the tip protruding outside the skin wherever possible and by early removal of K-wire once its purpose has been achieved.

Femoral pseudoaneurysm rupturing into urinary bladder: A rare presentation.

Femoral pseudoaneurysm is a common occurrence in intravenous drug abuser due to repeated trauma to the femoral artery causing arterial leak contained by the surrounding tissue and does not contain all the layers of arterial wall. Rupture of these aneurysm to exterior is a common presentation while rupture into surrounding structure deemed an emergency surgical attention. Hence, we report an unusual case of rupture of femoral pseudoaneurysm into urinary bladder who presented us with history of hematuria and was successfully managed.

Intercostal muscle flap and intracostal suture to reduce post-thoracotomy pain.

BACKGROUND: Thoracotomy is considered to be the most painful surgical access, the main culprit being intercostal nerve injury. Despite the use of many techniques, this remains a major problem, pointing towards prevention as a better strategy. The effect of protecting both the upper and lower intercostal nerves during surgery has attracted many researchers. METHOD: A prospective study spanning 15 months was undertaken in 48 patients randomized to a conventional group (n = 25) and a study group (n = 23). Pericostal sutures in the former and intracostal sutures in the latter were used for closure. An intercostal muscle flap was harvested at the start of the operation in the study group only. The groups were comparable in terms of baseline characteristics. With a similar pain protocol, pain scores and analgesic consumption were recorded and analyzed. RESULTS: Times for pedicle harvest, intracostal suture, and pericostal suture were 5.2 ± 1.56, 3.65 ± 0.71, and 6.4 ± 1.20 min, respectively, in the study group. Total operative time was similar in both groups. Postoperative pain scores and the overall frequency of pain were consistently lower in the study group. CONCLUSION: these techniques lead to a reduction in the acute and chronic post-thoracotomy pain, without increasing complications.

Breast cancer in young women from a low risk population in Nepal.

BACKGROUND: The overall incidence of breast cancer in South Asian countries, including Nepal, is low compared to Western countries. However, the incidence of breast cancer among young women is relatively high. Breast cancer in such cases is characterized by a relatively unfavorable prognosis and unusual pathological features. The aim of this study was to investigate clinico-pathological and biological characteristics in younger breast cancer patients (<40 years) and compare these with their older counterparts. MATERIALS AND METHODS: Nine hundred and forty four consecutive female breast cancer patients, admitted to the Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal between November 1997 and October 2012, were retrospectively analyzed. RESULTS: Out of the 944 female breast cancer patients, 263 (27.9%) were <40 years. The mean age was 34.6 ± 5.0 years among younger patients compared to 54.1 ± 9.9 for those ≥ 40 years. The mean age at menarche was also significantly lower (13.5 ± 1.5 vs 14.2 ± 1.5 years p=0.001) while the mean duration of symptoms was significantly longer (7.6 vs 6.5 months p=0.004). Family history of breast cancer was evident in 3.0% of the young women versus 0.3% in the older one. Mammography was performed less frequently in younger patients (59.7%), compared to older (74.4%), and was of diagnostic benefit in only 20% of younger patients compared to 85% of older ones. At diagnosis, the mean tumor diameter was significantly larger in young women (5.0 ± 2.5 vs 4.5 ± 2.4 cm, p=0.005). Axillary lymph nodes were positive in 73% of younger patients and 59% of older patients. In the younger group, the proportion of stage III or IV disease was higher (55.1% vs 47.1%, p ≤ 0.05). The proportion of breast conserving surgery was higher in young patients (25.1% vs 8.7%) and a higher proportion of younger patients receive neoadjuvant chemotherapy (9.9% vs 2.8%). The most common histological type was ductal carcinoma (93.1% vs 86%). The proportion of histological grade II or III was higher in younger patients (55.9% vs 24.5%). Similarly, in the younger group, lymphatic and vascular invasion was more common (63.2% vs 34.3% and 39.8% vs 25.4%, respectively). Patients in the younger age group exhibited lower estrogen and/ or progesterone receptor positivity (34.7% vs 49.8%). Although statistically not significant, the proportion of triple negative tumors in younger age group was higher (22.4% vs 13.6%). CONCLUSIONS: Breast cancer in young Nepalese women represents over one quarter of all female breast cancers, many being diagnosed at an advanced stage. Tumors in young women exhibit more aggressive biological features. Hence, breast cancer in young women is worth special attention for earlier detection.