Dr Arvind Deshpande
CASE STUDIES FOR PATIENTS
1 Endovascular Treatment of Popliteal artery Aneurysm
An eighty year old patient presented with a large popliteal artery aneurysm. A covered stent was placed inside the weak dilated aneurysmal segment. A Viabahn flexible covered stent was used thus preventing further growth of the aneurysm which could have lead to rupture, pressure effects on adjacent nerves or trashing of calf and foot vessels due to clot within the aneurysm sac. Thus loss of Life and limb was prevented.
Angiogram showing a large dilated popliteal aneurysm with irregular contour due adherent clot
Final angiogram shows successfully stented popliteal artery
2 Carotid Stent
Patient is 70 year old, had a right carotid endarterectomy ten years ago and came back with a recurrent narrowing of the right carotid artery. A self expanding stent was placed in the tight area after placing a retrievable filter above to capture any potential trash minimising the risk of stroke. This entire procedure is performed with a small catheter barely 3mm in diameter placed in the the femoral artery in the groin
Carotid Duplex Scan Before Stent
Angiogram Before Stent
Angiogram After Stent
Duplex scan after Carotid Stent
3 PELVIC CONGESTION SYNDROME
A 40 year old female patient presented from a Gynaecologist with history of constant low back and pelvic pain on prolonged standing. She had irregular heavy menses and pain during and after intercourse. She was investigated by her Gynaecologist for pelvic inflammatory disease, fibroids, endometriosis and other pathologies. A CT scan showed large congested veins in the pelvis and duplex scan showed an incompetent left ovarian vein. The left ovarian vein was accessed through the right femoral vein and then multiple coils and Onyx glue was placed in the dilated veins through a small catheter. She experienced immediate relief from her symptoms.
CT scan shows dilated left ovarian vein
Duplex scan shows dilated incompetent left ovarian vein with reversed flow
Coils and glue placed in left ovarian and pelvic veins via the right groin
4 Endovenous laser for varicose veins
A sixty year old patient presented with large painful varicose veins in the right leg. An ultrasound was performed in a Vascular Lab and the worksheet shown below indicates incompetent veins and their distribution. An ultrasound guided endovenous laser ablation of varicose veins was scheduled.
The patient had veins marked while standing upright and then was kept awake with light sedation on the operating table while a high frequency laser fibre was inserted inside the main incompetent vein ( long saphenous) using lot of local anaesthetic at the puncture site under ultrasound guidance.
A mixture of Hartman solution, adrenaline, local anesthetic and Sodium bicarbonate was inlfitrated along the vein containing the laser fibre. This abolishes pain, creates a heat sink and presses the vein against the laser fibre.
The laser fibre tip was positioned very precisely 2 cms below the junction with the deep system. The laser was activated with the patient still awake to make sure there was no discomfort thus making sure the laser was not damaging any surrounding structures. Progress was followed with continous ultrasound imaging.
A Varixio device was used to create sterile foam from a medical grade detergent/ Sclerosant solution ( Fibrovein). This was injected into very fine varicose veins feeding the main vein. These veins very quickly thrombosed and were obliterated.
The patient was then administered a general anesthetic and the large venous prominences already marked with blue ink were carefully removed with very fine phlebectomy hooks. A clexane injection was given to minimise the risk of clots forming in the deep system. A three layer compression bandage was applied and the patient was transferred to recovery.
The patient was discharged with a compression stocking which replaced the original compression bandage at 24 hours. On discharge the patient was asked to return to rooms for checkup with a postoperative duplex scan at one week in order to make sure there was no deep venous thrombosis.
5 Management of Extensive Clot Affecting Left leg and Pelvic veins -May Thurner Syndrome in a young patient.
An 18 year old female patient presented with massive swelling of her left leg and clots in her lungs. She was started on a strong injectable blood thinner Clexane. She was advised to quit smoking. A duplex ultrasound confirmed extensive clots affecting the left thigh and extending into the pelvis through the left Common Iliac Vein and stopping just shy of the main large vein in the abdomen - The Inferior Vena Cava.
A CT scan with contrast in the venous phase confirmed compression of the left common iliac vein due to the lumbar spine at the back and the right Common Iliac Artery in the front. This is called May-Thurner Syndrome.
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​Prompt intervention is essential prevent a POST THROMBOTIC SYNDROME with venous ulcers, swelling , pigmentation and severe cramping and bursting pain in the leg on walking. This isa lifelong disability!
The yellow marker shows the site of constriction of the left common iliac vein by the spine at the back and the Right Common Iliac artery in the front.
The patient was shifted urgently to the Hybrid Lab and a retrievable filter was placed in the Inferior Vena Cava through the right groin to prevent any clots from escaping into the lungs during the removal process. From the lower left thigh a special collapsible metal mesh shaped like a witche's hat (INARI BASKET) was introduced and opened above the clot in the main left pelvic vein- the left common Iliac Vein and then pulled down under xray guidance to trawl and remove all of the clot.
INARI BASKET with Clot inside. Trawling was repeated until intravascular ultrasound and angiogram confirmed all clot had been cleared. On the right side the sheer volume of clot removed can be seen mounted on an actual size paper diagram with the left common iliac, external ilac and superficial femoral vein
ANGIOGRAM 1
ANGIOGRAM 2
Angiogram 1 shows a blocked left Common Iliac Vein and Angiogram 2 shows the left common Iliac Vein is widely open with a self expanding metal stent inside it.
The patient was discharged the following day on strong blood thinners taken orally. A postoperative Duplex Ultrasound Scan performed the following day confirmed the left sided venous stent was open. She has been advised a compression stocking, avoid smoking at all costs and report to rooms in three month with another ultrasound scan. A set of blood tests to look for THROMBOPHILIA ( clotting disorder) performed on admission will be available by then and this will be influence the duration for which this patient will be kept on strong blood thinners ( Eliquis).