Leriche Syndrome- Treatment by thoraco bi-femoral grafting.

A 32 year old gentleman was referred to us with pain in calf and blackening of toes of his right foot for a week. He gave history of weakness in both lower limbs and erectile dysfunction for past 2 weeks. On examination he had absent femoral arterial pulses bilaterally. The pre-operative CT angiogram showed complete occlusion of juxta renal abdominal aorta with filling of iliac vessels via collaterals.(figure1). The symptoms and angiogram findings are classical features of Leriche syndrome. He had an absent right brachial pulse with occlusion of rt. axillary artery on angiogram. Since the patient was anon smoker the findings were suggestive of aorto arteritis as etiology.

Figure 1.-Pre-operative CT - complete occlusion of juxta reanl aorta (arrow)

 In view of his symptomatic status we decided to offer him surgery. A thoraco bifemoral graft was performed. Thoracic aorta was exposed via a lt thoracotomy(black arrow) and using a bifurcated aortic graft vascular supply was restored to both lower limbs (white arrows)relieving his pain and preventing gangrene.

Post-operative CT- thoraco bifemoral graft in place with restoration of blood supply.

Conclusion- Aorto iliac occlusive disease is a serious disease causing lot of morbidity and mortality. Amputation rates are very high in these patients. Atherosclerosis is the most common cause. Smoking is another major cause. Aorto arteritis is a cause in the young. In the symptomatic patients blood supply has to be restored either by surgery or percutaneous intervention to relieve symptoms and prevent amputation.

Case of The Month- Cabrols Procedure for Chronic Dissecting Aneurysm of Ascending Aorta

A54 year old gentleman was referred to me with progressive dyspnea and chest pain for one month. His echocardiography was suggestive of aortic dissection with aortic regurgitation. We diid a CECT of the chest which showed a chronic dissecting aneurysm of aorta measuring 8.5 cm. His echo also revealed a severe aortic regurgitation with dilated LV but normal EF.
A chronic aortic aneurysm may occur in patients who survive acute aortic dissection. In acute aortic dissection the layers of aorta split creating true and false lumens. In patients who survive or are not operated the weak aortic wall dilates with time and leads to aneurysm formation. The loss of support to aortic leaflets leads to development of aortic regurgitation. The tretment of this condition is surgery as rupture of aneurysm can cause sudden death.
The surgical procedure entails excising all diseased tissue i.e. aneurysmal aorta, aortic valve and replacing it with a prosthetic conduit and valve. The coronarie have to be reimplanted on to this conduit. This is the Bentalls operation. In this case however due to the large diameter of aneurysm and dense adhesions between aorta and pulmonary artery, coroary button fashionon for Bentall seemed impossible. I therfore chose to perform a Cabrols procedure. In this operation the aortic valved and aorta are replaced with a conduit the coronaries however are not implanted as buttons. They are connected with another graft which is then connected to aortic graft.

Cabrols Procedure

The procedure went well and the patient discharged in a weeks time.

Post op CT showing replace aorta and coronary graft

Patient Testimonials

First Anniversary at Ivy Hospital, Amritsar.

Completion of a successful and fulfilling year at Ivy, Amritsar. We are now the preferred care provider (adult cardio vascular surgery) in the region. Thanks to highly skilled and motivated team.

Launch of Heart Valve Repair Centre at Ivy Amritsar.

Chondrosarcoma of the Sternum- Radical Excision and Sternal Reconstruction using customised composite prosthesis.

Case Report- A 60 year old gentleman came with the history of gradually increasing swelling in the upper midline chest for last 6 months. He had been investigated elsewhere and a fine needle aspiration was done. The diagnosis was chondrosarcoma of the manubrium sterni. The CT scan images were also suggestive of the diagnosis. The tomor appeared to be locallu containe with no involvement of the mediastinal structures.

We advised the patient surgery and did a PET scan to rule out any secondaries. The PET scan was negative for tumor spread.

CT Image showing tumor with destruction of both tables of sternum (arrow)

PET Scan negative for any metastasis.

 Surgery- A wide excision with a 5cm margin was planned. This meant removing nearly half of sternum, 1-3 ribs and medial end of clavicles. This would result in a large defect requiring reconstuction.

                                                     

                                             Wide gap in the chest wall after radical excision.

Resected sternum with 1-3 ribsand clavicles (medial ends).

A median sternotomy incision was used and adequate resection carried out. The defect was repaired with a customised composite prosthesis made in the OR using double polypropylene mesh and acrylic bone cement. The prosthesis was covered with bilateral pec major flaps sutured in the midline.

Customised Composite prosthesis for sternal reconstruction using polypropylene mesh and acrylic bone cement

Composite prosthesis being sutured in place to fill defect

The patient was extubated on table and made an uneventful recovery and discharged on the 3rd postoperative day. 

Histopathology Report- Chondrosarcoma Grade II.

Comment-
Primary sternal tomors are rare and account for 1% of bone neoplasms. Chondrosarcoma is the commnest primart sternal tumor. It is resistant to chemotherapy and radiotherapy and curative resection is the only hope. Survival after curative resection is good if the tumor has not metastasised. Surgery involves radical resection with reconstruction of the anterior chest wall with various techniques.

Plication of Apical Left Ventricular Aneurysm on Beating Heart