Pseudoaneurysm of head and neck vessels has been frequently observed in road side bomb blast victims.

BACKGROUND: Due to recent war situation in neighboring country we have witnessed large number of victims with post-traumatic false (pseudo) aneurysms of head and neck in roadside bomb blast victims in Pakistan. Thus through this observational retrospective study we aim to share our experience of managing these patients. METHOD: 5 years patients' case records, from June 2008-June 2013, were reviewed from the hospital's records. 14 cases of roadside bomb blast victims, developing false aneurysms of major or minor vessels of head and neck, were studied. We excluded the post-traumatic pseudoaneurysms involving other sites and vessels of the body. We observed the mechanism, the duration of presentation, symptoms/signs, vessels involved, complications and the management done. RESULTS: All 14 cases presented with a localized pulsatile swelling with tenderness in the course of a known artery and with an overlying entry site wound from bomb blast sharp nails. Men were affected more as compared to women. All (14) cases had 2-12 weeks of duration between the injury and presentation. Temporal artery (4) was involved in most cases followed by common carotid artery (3). Open surgery was treatment of choice in 12 (85.7%) of cases; however 2 (14.3%) patients had endovascular intervention to correct the pathology. Post-operatively all patients recovered completely, without any major or minor complications. CONCLUSION: Surgical intervention remains the management of choice for post-traumatic false aneurysms of head and neck in Pakistan. Despite the benefits of endovascular procedures, improvements must be weighed against the added costs on the patients.

Vascular injuries of the extremities are a major challenge in a third world country.

BACKGROUND: Traumatic vascular injuries of the extremities are a major challenge especially in the third world countries. These injuries are mostly due to poor traffic laws, street crimes, firearms and blast associated injuries. We therefore would like to share our 10 years of experience in dealing with vascular injuries in Pakistan. METHODS: This was a retrospective observational study conducted in the department of vascular surgery of Liaquat National Hospital, Karachi, Pakistan. Patients' records were retrieved from the department and were reviewed. Cases with vascular injuries of upper and lower limb that presented with signs of salvageable limb and presented within 12 hours of injury were included in the study. Patients with more than 12 hours of presentation and in whom primary amputation was done, were excluded from the study. RESULTS: There were 328 patients who presented with vascular injuries of the extremities that fell in the inclusion criteria. Limb salvage rate was 41 %, whereas 30-days perioperative mortality was 5.48 %. The major cause of limb loss was delay in presentation of more than 8 h of injury. Major vessels involved were popliteal artery (41.76 %), followed by femoral artery (27.43 %). CONCLUSION: Vascular injuries are becoming a major contributor of limb loss in third world countries due to violence, terrorism and unavailability of vascular facilities. This morbidity can be reduced by improving law and order situation, evolving an effective emergency ambulatory system and with better training and provision of vascular services in remote areas so that the delay factor can be reduced.

EARLY EXPERIENCE OF ENDOVASCULAR TREATMENT OF PERIPHERAL VASCULAR DISEASE.

BACKGROUND: Atherosclerotic peripheral arterial disease (PAD) is prevalent affecting up to 16% of the population aged 55 years or older. Endovascular intervention for the treatment of limb ischemia has become the first line therapy but in Pakistan it is in embryonic stage due to dearth of trained persons and dedicated centres. This study was conducted to evaluate procedural success and early outcome of endovascular treatment of peripheral vascular disease. METHODS: A prospective single arm multicentre study was conducted at the National Institute of Cardiovascular Disease and National Medical Centre, Karachi, Pakistan from January 2013 to June 2014. A total of 25 patients were enrolled in the study that underwent endovascular treatment. Out of 25 patients 23 (92%) had critical limb ischemia (CLI) as per TASC II classification (A to D) and 2 (8%) had carotid lesion with history of TIA. Patients of acute limb ischemia and stroke were excluded. Ankle brachial index (ABI) was classified as normal (0.9-1.3), mild (0.7-0.9), moderate (0.4-0.69), severe. (<0.4). Outcome was taken as immediate success and symptoms, amputation of limb among CLI patients and incidence of stroke in patients with carotid artery lesion at end of six months. RESULTS: Among aortoiliac, femoropopliteal and tibioperoneal lesions, tibioperoneal lesions at six months were found to be more symptomatic 6 (86%) and amputation 4 (57%). Two carotid lesions at follow up were asymptomatic without stroke. CONCLUSION: Endovascular treatment of peripheral vascular lesions, i.e., aortoiliac, femoropopliteal tibioperoneal and carotid lesions were satisfactory in immediate outcome. Tibioperoneal lesions were more symptomatic and limb amputation at six months.

Endovascular treatment of a post catheterization pseudoaneurysm: A stitch in time saves nine.

External iliac artery (EIA) pseudoaneurysms are a well-known complication after arterial catheterization procedures. Most develop as a result of high femoral puncture. Small asymptomatic pseudoaneurysms are usually of no consequence but large symptomatic pseudoaneurysm carries a significant risk of rupture with serious life-threatening consequences and needs to be treated. We report here a case of EIA pseudoaneurysm in a 60 year old male patient after a cardiac catheterization procedure. CT angiography demonstrated a large pseudoaneurysm arising from the EIA and compressing the urinary bladder. Patient complained of abdominal pain and felt dizzy and required transfusions due to rapidly developing anaemia secondary to blood loss. Conventional angiography revealed free extravasation of contrast from the EIA. Percutaneous intervention through femoral access was performed by deploying a covered stent which effectively sealed off the perforation site with no evidence of contrast extravasation.

Giant iliac vein aneurysm secondary to long standing traumatic popliteal arteriovenous fistula.

A 48-year-old man presented with a traumatic arteriovenous fistula (AVF) in the left popliteal space, due to a bullet injury 20 years back. A computed tomographic (CT) angiography revealed an AVF in the left popliteal space with an associated large iliac vein aneurysm (9.2 x 9.0 cms). Primary repair of the AVF was done. A Doppler scan showed marked reduction in the size of the aneurysm, 4 months after surgery. Cases associated with a venous aneurysm distant from the site of AVF are rare and there are only 7 cases reported in the international literature.