Vascular Covid Diaries

Arunagiri Viruthagiri, Nedunchezhian Manjini

Consultant Vascular and Endovascular Surgeon, Department of Vascular and Endovascular Surgery, Kauvery Hospital, Trichy, Tamilnadu

Operative Procedure – Mar to Aug

Total number of procedures = 120
Open procedures = 85
Endovascular interventions = 35

Logbook

Procedures	No	Description	Mortality
Acute limb ischemia	14	Limb salvage – 10 Amputation – 4	Nil
Vascular Trauma	8	Limb Salvage – 8 Amputation – None	None
Peripheral arterial disease angioplasty/stenting	19	Limb Salvage – 18 Amputation – 1	None
Peripheral arterial disease-bypass	3	Aorobifemoral bypass – 2 Femoropopliteal bypass – 1	None
Varicose veins – endovenous Laser	10	Complete clinical success. Uneventful	Nil
AV fistula and interventions	16	AV fistula-11 Thrombolysis and Permcath insertion- 4	Nil Primary failure – 1. Graft thrombectomy – failed access
Interventions in DVT	2	IVC filter – 1 Iliac venous stenting – 1	Nil
Major amputations	10	Below knee – 8 Above knee – 2	Nil Primary wound healing achieved 9/10
Debridement and minor amputations	32	One proceeded to major amputation	Nil

Logbook

Miscellaneous	Procedure	No	Outcome
Brachial pseudo aneurysm repair	Bipolar ligation	1	Limb salvaged
Vascular malformations	Complete excision	3	No further bleeding
Renal cell carcinoma with suprahepatic IVC thrombosis	Left radical nephrectomy with IVC thrombectomy/splenectomy	1	Complete thrombus clearance. Discharged with no major complications
Acute mesenteric schema	Laparotomy with SMA embolectomy and bowel resection	1	Salvaged 120 cm of small bowel and discharged on anticoagulation

Interesting Cases

Case 1: Juxtarenal Aortic Occlusion With Renovascular Hypertension

Sixty-nine years old male was referred with episodes of recurrent flash pulmonary oedema
Past h/o CABG and TIA
BP 220/120. On five antihypertensives
Claudication distance of 200 m
On examination absent femoral pulses on both sides

On Evaluation

Diagnosed to have polycythemia rubra vera – JAK 2 positive.
DTPA scan – 25% function in left kidney and 15% in right kidney
CT Angio – Juxta renal Aortoiliac occlusion. Left renal artery stenosis. Rt contracted kidney
S. Creatinine – 1.5
Echo – Moderate LV dysfunction – 35%
Carotid doppler – < 50% stenosis

procedure: Aortobifemoral bypass with left renal artery endarterectomy

Epidural, central line, arterial line
Midline laparotomy
Aorto transected and thromboendarterectomy performed
Left kidney perfused with custodial solution
Aortobifem bypass with 14 × 7 bifurcated dacron

Postoperative Period

Had hypotension and drop in Hb requiring reexploration. No major bleeding noted.
Had complete heart block – requiring temporary pacing.
Nephrologist, cardiologist and anesthetist opinion obtained
Developed an AKI with serum creatinine 3.2
Gradually made a good recovery with serum creatinine back to 1.1
Three months follow up: BP – 130/90 on two antihypertensives. No further chest pain. Good urine output. Able to walk 500 m.

Case 2: Acute Mesenteric Ischemia

A 44-year-old male, diabetic and smoker presented with complaints of diffuse abdominal pain which was not responding to any analgesics over past 24 hrs.
On examination he had a grossly distended and tender abdomen. CECT abdomen showed a superior mesentric artery embolus with near total occlusion and ischemic bowel loops

Procedure Details

Emergency laparotomy, resection of gangrenous small bowel and SMA embolectomy with vein patch angioplasty was done by gastroenterology & vascular team
Abdomen was left open as laparostomy for reexploration after 48 h. During reexploration, the remaining small bowel was well vascularised and bowel continuity was restored by jejunocolic anastomosis.
Patient recovered well and was discharged on POD 12 with oral anticoagulants. He didn’t have features of short gut syndrome.

Case 3: Posterior dislocation knee with popliteal artery injury

45 year old male with H/o RTA presented with posterior dislocation left knee with tibial plateau fracture and absent pulses
CTA showed complete cut-off at midpopliteal artery with reformation of TP trunk

Imaging

External fixator with interposition graft for popliteal artery – prone position. Fasciotomy

Postop Period

Foot warm with palpable PTA pulse
RTPCR positive
Hence advised to transfer to Kauvery COVID center
Discharged AMA and admitted in GH
Followed up in GH and doing well

Case 4: Left renal cell CA with suprahepatic IVC thrombosis

Mr. Chellamuthu 39/M presented to Urology Department with upper abdominal pain, loss of appetite and loss of weight for three months duration

Procedure Details

Bilateral subcostal incision with median sternotomy (Benz/ Triradiate)
Left radical nephrectomy with splenectomy was done. Then mobilisation of infra hepatic IVC and mobilisation of liver was done. Right renal vein and artery were dissected out. On table it was decided to go for complete cardio pulmonary bypass
Control taken on the IVC and then it was opened to extract the tumour thrombus. The thrombus was milked down from intra thoracic IVC and was completely extracted in toto
Procedure and postoperative period were uneventful. He was discharged on anticoagulants and penicillin prophylaxis

Procedure: Urology, cardiac surgery and vascular team

Case 5: DM/critical limb threatening ischemia

62 year old male was admitted with foot sepsis and systemic sepsis
Underwent emergency debridement
Sepsis came under control
Postop wound was ischemic
MRA-Severe infrapopliteal arterial occlusive disease
Planned for Infrapopliteal angioplasty

Pre Angioplasty

Post Angioplasty

Postprocedure

Patient doing well
Palpable DP pulse and triphasic flow in peroneal artery
Discharged on dual antiplatelets
Wound managed with VAC
Wound healed after 6 weeks

Case 6: Acute left lower limb ischemia – Aorto iliac thrombosis in COVID 19 positive patient

History

43 year old farmer presented to the emergency room with sudden onset of pain left leg and inability to feel and move left leg for 48 h.
Recently detected DM. Non smoker. No other comorbidities.

Diagnosis

Acute left lower limb ischemia
Rutherford Class 3 ischemia
Left Iliac occlusion
Source – COVID related.

Imaging

Emergency bilateral transfemoral embolectomy with four compartment fasciotomy and left through knee amputation

Post OP Period

Uneventful
Therapeutic dose of LMWH.
Wound healthy.
Discharged on Day7.
2 week follow up- patient doing well.
Counselled for prosthesis.

Strategies with respect to COVID

PPE for all members of OT.
Minimally used bipolar diathermy.
Careful down bleed from iliac arteries to avoid splash
Through knee instead of above knee to avoid muscle and bone cutting thereby preventing aerosol generation.
Double operator to minimise time.
Total duration – 2 h 15 min

Vascular Interventions In Covid Positive Patients

Case No	Presentation	RT-PCR	CT Chest	Procedure	Outcome	Mortality
1	Acute bilateral lower limb ischemia. 4 day old.Class 3 ischemia left leg.	Positive	Positive CTSS	Bilteral transfemoral embolectom y with left through knee amputation	One limb salvaged.LIf e saved	Nil
2	Acute Rt lower limb ischemia – advanced	Positive	Positive	Conservative -Pancreatitis, CAD,AKI	Awaiting below knee amputation	Nil
3	Posterior dislocation knee with Popliteal artery injury	Positive	Negative	Ext fixator with Vascular repair	Limb salvaged. AMAGH.Doing well.	Nil
4	Acute Rt lower limb ischemiaClass 3 ischemia.	Positive	Negative	Right femoral embolectom y with Rt through knee amputation.	Doing well.AKi recovered.	Currently in hospital.
5	Acute bilateral lowerlimb ischemia- Aortic thrombosis	Positive	Indetermin ate	Bilateral Transfemoral embolectom y	Doing well. Normal foot pulses. Ambulating.	Currently in hospital.
6	Acute bilateral lowerlimb ischemiaClass2A.	Negative.Ig G antibody positive,	Positive	Conservative managemen t	Doing well. Claudicatio n.	Nil
7	Acute Rt upper limb ischemia Class 2B	Negative	Positive	Awaiting surgery	NA	NA
8	Acute Rt Upper limb ischemia Class 3.	Positive	Positive	AMA- Rt Above elbow amputation in Thanjavur.	NA	NA
9	Acute Rt lower limb ischemia.Class 2A	Positive	Positive	Conservative management. Patient deferred intervention	Discharged with claudicatio n.	Nil

Acknowledgements

Department of Anesthesiology and Cardiac Anesthesiology.
Departemnt of Radiology.
Department of Cardiology and Cardiac surgery.
Department of General Medicine and Diabetology.
Department of Hematology.
Department of Gastroenterology.
Department of Nephrology and Urology.
Department of Intensive Care and ER.
Department of Plastic Surgery.
Department of Orthopaedics.
Medical Administrator of 3 units
Nursing Superintendent of 3 units
Theatre team of 3 units. Cath team in Heartcity
Nursing and Paramedical staff
Billing and Management staff
Mr. Krishnamoorthy – Physician Assistant.
OPD staff – Mrs. Shanthasheela and Mrs. Kanaga

Vascular Covid Diaries