Objective: To highlight the efficacy of temporary vascular shunts in saving life and limb. Study Design: Case series. Place and Duration of Study: Combined Military Hospital Rawalpindi, Lahore and Combined Military Hospital Quetta, from May 2006 to Jul 2014. Methodology: The data of those patients who had temporary intra vascular shunts were analyzed for the demography, location of hospital for shunt placement, material used as shunt, time of vascular repair after shunt placement, shunt patency and limb survival. Results: A total of 21 (All male, mean age 32 ± 17 years) patients of arterial trauma were included. 16 (76.1%) shunts were placed in peripheral hospitals for transportation while 5 (23.8%) were placed in tertiary care hospital, out of which 2 (9.5%) were for vascular damage control while 3 (14.2%) were for orthopedic surgery before definite vascular repair. Mean time to definite vascular intervention was 8 ± 6 hours. Prior to placing vascular shunt, distal embolectomy was done in 8 (38%) cases; while distal compression, back bleed and irrigation with heparinized saline were done in 13 (62%) cases. Nineteen (90%) shunts were patent at the time of definite vascular repair while 1 (5%) patient had amputation and 1 (5%) died before definite vascular repair. Conclusion: Temporary vascular shunt is an effective adjunct in the management of extremity vascular trauma for gaining time before definite vascular repair and in saving limb and life.

BACKGROUND To present a new modification of aneurysmectomy technique for the management of aneurysmal fistula vein. This cross-sectional study was carried out at Vascular Surgery department, Combined Military Hospital Rawalpindi from 1st October 2014 to 30th December 2018. METHODS This modified aneurysmectomy procedure was performed in 20 patients. Massive diffuse venous dilatation of vein, necrosis of overlying skin, reduction in the cannulation area and pain were the indications of surgery. Revision was performed by rotating the mobilized vein to 180°, excising redundant vein, reducing diameter, repairing venotomy posteriorly and placing the vein in a mobilized skin flap over the fascia of biceps muscle away from skin suture line, to facilitate subsequent cannulation and post puncture haemostasis. The rationale of this modification was to prevent damage to the usual anteriorly placed suture line during needle insertion for haemodialysis. The data were analysed by using SPSS version 25.0. RESULTS The mean age of patients was 45.45±14.75 years with a range of 12-65 years. Sixteen patients (80.0%) were having brachiocephalic fistula while 4 patients (20.0%) had radio cephalic fistula. The mean time of reuse of AVF after vein Aneurysmectomy was 24.55±5.3 days with half of the patients having reuse of AVF after 3 weeks. Three (15%) patients developed hematoma while 2 (10%) patients developed skin necrosis. Fifteen (75%) patients had no surgery related complications after procedure. CONCLUSIONS Posterior suturing and lateralization of aneurysmal vein under mobilized skin flap is a safe, effective and easy to learn modification of aneurysmectomy procedure for the management of aneurysmal dilatation of fistula vein.

Failing arteriovenous fistula can be salvaged by a variety of techniques provided that it is picked up in time..

BACKGROUND The aim of this study was to see the efficacy of different surgical procedures performed for the salvage of failing arteriovenous fistulas. Study design: Prospective observational study. Study was conducted at Department of Vascular surgery, CMH Rawalpindi from 1st August 2017 to 31st December 2018. METHODS Those surgical procedures were included which were done for the AVFs that failed to mature due to stealing veins or developed complications like thrombosis, hematoma, pseudo or true aneurysm, steal syndrome, stenosis and venous hypertension. The procedures like stealing vein ligation, hematoma evacuation, thrombectomies, redo-anastomosis, pseudo aneurysm excision, aneurysmorrhaphies, excision of stenotic segment, RUDI for steal syndrome and central veno venous bypasses for central vein occlusion were assessed for their efficacy. RESULTS Sixty-two patients were included. 21 stealing veins were ligated, 15 for fistula maturation and 6 for venous hypertension. Twelve out of these 15 non-maturing AVFs, matured after ligation of stealing vein (80%). In case of reverse vein ligation for venous hypertension all the 6 patients showed reduction in their limb swelling (100%). Nine thrombectomies were performed, 7 were successful (78%). Nine patients presented with stenosis. In 3 patients with stenosis near the anastomotic site, a proximal AVF was formed. In 2 patients the stenotic segment was excised and end to end anastomosis was done. In 1 patient an interposing vein graft was used. In 3 patients, the flow was redirected to basilic vein. All the patients had patent AVF on follow up (100%). In 8 non-infected pseudo aneurysms, excision and end to end anastomosis was done in 3, aneurysmorrhaphies in 2 and revision of the anastomosis in 3 cases. Seven out of 8 (87.5%) had good patency on follow up. In 7 patients with true aneurysm and 3 with bleeding from needle prick site sinus, aneurysmorrhaphies were performed. Two wound site hematomas were evacuated. Two patients presented with severe limb swelling due to central venous occlusion for whom a veno venous cross over bypass was done with good results. In 1 patient with steal syndrome, RUDI was done with acceptable results. CONCLUSIONS Failing arteriovenous fistula can be salvaged by a variety of techniques provided that it is picked up in time..

BACKGROUND:Ultrasound guided foam sclerotherapy is an outdoor, office based and minimally invasive procedure for the treatment of varicose veins. This study was carried out to highlight the potential of foam sclerotherapy as a first line treatment for varicose vein.METHODS:This prospective observational study was conducted at CMH Rawalpindi, form 1 Aug 2017 to 30 Aug 2018The demographic and outcome data of the patients, who underwent ultrasound guided foam sclerotherapy, were collected and analysed.RESULTS:A total of 662 patients and 752 legs were treated with foam sclerotherapy. Four hundred and ten (61.93%) were males and 252 (38.06%) were females. Their ages ranged from 17 to 68 years with the mean age of 43.21 years. Six hundred and sixty-eight (88.82%) legs were having Great Saphenous Vein while 84 (11.17%) legs were having short saphenous vein disease. Maximum legs 256 (34.04%) had C3 disease. single session of Foam sclerotherapy was enough in 511 (67.95%) legs, while 197 (26.19%) legs were treated with two and 44 (5.85%) legs were treated with three sessions of foam sclerotherapy. Percentages of main trunk occlusion were 98.01% at 1 month while 97.39% at 3 months follow up. Only 2 (0.30%) patients had Deep Venous Thrombosis while 3 (0.45%) patients had thrombophlebitis which required surgery.CONCLUSION:Ultrasound Guided Foam sclerotherapy is an OPD based, innovative, minimally invasive and safe method of treatment for varicose veins. In the context of prevalence of varicose vein disease in our community, it relieves the Burdon of operation theatre list and creates the theatre space for vascular surgeon for arterial Surgery.

Objective: To share five year experience and a half years with emphasis on some technical aspects which willhelp those managing such cases.Study Design: Descriptive case series.Place and Duration of Study: Combined Military Hospital Rawalpindi, from Jul 2010 to Dec 2015.Material and Methods: All cases of CBT presenting to our department from Jul 2010 to Dec 2015 were included inthe study and analyzed.Results: A total of 13 patients were treated at our institute in the last 5 and half years. Average age of patients was38.5 years with a range of 22-55 years. Male to female ratio was 1:6.5. Mean interval between symptoms onset andpresentation was 38.7 ± 16 months. None of the tumors were bilateral or malignant. Two patients had type Itumor (15%), seven patients had tumor of type II (54%) and four (31%) patients underwent resection for type IIItumor. Type I and Type II tumor was removed by simple excision. Three cases of type III tumor were managedby excision, use of temporary shunt and followed by reconstruction of internal carotid artery. One of the type IIItumor was excised with ligation of internal carotid artery. There was no mortality or stroke, three patients withtype III tumors had transient dysphagia; One of them had marginal mandibular nerve palsy as well. We usedbipolar diathermy in all cases, Harmonic TM Scalpel (Ethicon Endo-Surgery) in three cases and LigaSureTM(Covidien Ltd, Dublin Republic of Ireland) in three cases. Use of newer energy sources made dissection lessbloody, quick and easier.Conclusion: CBT are rare tumors. Surgical excision should be carefully planned and executed with the help ofmodern energy sources to avoid any serious complications.