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Fortis Hospitals Specialist EZine

Fortis Hospitals Specialist EZine

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Published by Fortis Hosp
Fortis Hospitals Specialist Ezines
Fortis Hospitals Specialist Ezines

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Published by: Fortis Hosp on Sep 12, 2011
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Email: enquiries@fortishospitals.inVisit us: www.fortishospitals.com
We look forward to hearing from you.Please send in your views and suggestions to enquiries@fortishospitals.in
Bannerghatta road
91 80 6621 4444 / 2254 4444/96633 67253
91 80 2301 4444 / 96633 67253
Cunningham road
91 80 4199 4444 / 96633 67253
91 80 2300 4444 / 96633 67253
91 80 4020 0000 / 96633 67253
Marathahalli clinic
91 80 6598 2915 / 6532 4444 / 96633 67253
The Specialist
Fortis Hospitals Bangalore: Bannerghatta road|Cunningham road|Sheshadripuram|Nagarbhavi|Rajajinagar|Marathahalli clinic
Vol 1, Issue1, September 2011
Dear Doctor,
Greetings rom Fortis Hospitals – Bangalore! Your continuous patronage and eedback have always helped us in providing quality healthcare services. In an efort to showcase some o our pioneering work in medical and surgical elds, I am pleased to share the current issue o ‘HE SPECIALIS’ with you. Tis issue ocuses on cases in Heart Care, Urology,Bone & Joint Care and Digestive Care. For more inormationon the cases shared, please do eel ree to get in touch with us.Your support has been a constant source o motivation that helped us in designing and developing medical programs across our network. All our 5 Hospitals in Bangalore ofer a range o services o the highest quality, with the widely acclaimed clinical talent and latest technology that they are equipped with. Both o these are attributes we value, and we constantly strive to add tothis talent as also to introduce technologies and techniques that are relevant to the population we serve.We have recently added HIFU (high intensity ocused ultrasound), the latest and the most advanced treatment or  prostate cancer, at Fortis Bannerghatta Road. Tis hospital is one o the ew in South India, and perhaps the rst inKarnataka, to have this technology. We would shortly be launching an IVF programme in Bangalore to cater to the increasing need or that service.I am also glad to inorm you that our upcoming Heart Hospital in Mysore (in association with Cauvery Hospital) is nearing completion and we are adding two more large acilities to our existing network in Bangalore City. Tese initiatives would  urther strengthen our ability to address the requirements o the region.I look orward to your valuable eedback and suggestions on “HE SPECIALIS” to make it even more useul and interesting or the readers.Seasons’ Greetings & Best Wishes,Dilip Jose  Zonal Director 
Aortic Dissection and Its Managementwith Frozen Elephant Trunk ProcedureComplication of Major Hip Fracturewith Head Injury and Its ManagementExstrophy-Epispadias Complex andits ManagementPancreatic Pseudocyst andits Management• Fortis Times
The Specialist
Case presentation
A 47-year-old lady presented to a hospital in Zimbabwewith crushing chest pain and was diagnosed to have anaortic dissection (when a tear in the inner wall of theaorta causes blood to
ow between the layers of the wallof the vessel, forcing the layers apart, see Fig. 1). Due tothe lack of quality healthcare facilities in Zimbabwe, thepatient visited Fortis Hospitals after two weeks.
Examination findings
The CT angiogram con
rmed the dissection
apextended from the base of the right coronary artery tothe right femoral artery (Type A dissection, see Fig. 2)and most of the visceral arteries except the left renalartery were being supplied by the true lumen. Thedescending thoracic aorta was also ballooned out withfeatures of impending rupture.
The patient was planned for
a Frozen Elephant trunkprocedure.
The procedure was performed by teamcomprising Dr. Mohammed Rehan Sayeed, SeniorConsultant Cardiovascular surgeon and Dr. A. GopiSenior Interventional Cardiologist.
Stage 1 Elephant trunk procedure
Replacement of the ascending aorta and aortic archreplacement with a dacron synthetic graft:
The patient had standard median sternotomy andwas placed on cardiopulmonary bypass (heart lungmachine). Through deep hypothermic circulatoryarrest technique, the body of the patient was cooled to18
C and the entire blood was drained out. The entireascending and arch of the aorta was then replaced witha Dacron synthetic graft. (See Fig. 3)
Aortic Dissection and Its Managementwith Frozen Elephant Trunk Procedure
Fig. 1: Aortic dissectionFig. 2: Type A dissection
The Specialist
The Specialist
Fig 2:
USGabdomen showed that stents were extracted fromthe patient.
Fig 1:
Fundus with cystogastrostomy stent insitu
Endoscopic ultrasound (EUS) showed pseudocystin closed opposition to fundus and body of stomachwith few prominent vessels. Options were to performlaparoscopic/open/EUS guided pseudocyst drainage.Pseudocyst was drained by puncturing with a 19 Gneedle away from collateral and about 800cc
uid wasdrained.Close follow-up on USG showed total collapse andstents were extracted 6 weeks later (see Fig 2). Poststent extraction USG’s over last 4 months did not revealany recurrence. Patient was asymptomatic.Conclusion: Post cystogastrostomy status stentextraction done
Endoscopic ultrasound offers excellent servicing for draining pseudocysts as it is minimally invasive, avoids vessels in thetrack. Unlike routine endoscopic drainage pseudocysts whichdo not indent stomach/duodenum can safely be drained withEUS. Liver abscess subphrenic abscesses and biliomos canalso be drained apart from
ne needle aspiration cytology (FNAC) of various lesions in GIT as well as organs in closejuxtaposition.
Pancreatic pseudocyst and Its Management
For further details you can contact: 
Dr. D Srinivasa91 80 4199 4444
The Specialist
The head vessels were reconnected and the circulationwas restarted and patient was re-warmed to 36
C.It is known as an elephant trunk procedure becausethe remaining part of the graft is left hanging in thedescending aorta to help in its replacement when thepatient comes back for the stage 2 procedure after3-4 months.
Stage 2 Frozen Elephant trunk procedure
Replacement of the descending thoracic aorta:
The replacement of the descending thoracic aorta startingfrom distal to the origin of the subclavian artery to the 10
 thoracic vertebral level was done. This was accomplishedwith a endovascular stent graft (see Fig. 4). The procedureis known as Frozen elephant trunk as it is accomplishedin a single sitting and is a hybrid approach to a problemwhich has high mortality and morbidity (see Fig. 5).
Post operative care
The patient was discharged from the hospital on day 7after her aorta was
xed. A repeat CT angiogram wasdone to document the position of the stent graft and tocon
rm that there are no leaks of any kind.
The treatment of complex aortic pathology representsa surgical challenge, with high post operativemorbidity and mortality rates.
Elephant trunk is atechnique which uses excess intravascular graft lengthto facilitate subsequent operations to facilitate the
Fig. 3:
Replacement of the ascending aorta and aortic arch
subsequent treatment of distal aortic aneurysms. Itgreatly facilitates and at the same time reduces the riskof multiple-stage aortic replacement.
It offers severaladvantages such as saves the proximal graft-to-aortaanastomosis, at the same time avoids dangerouscomplications at the previous anatomic site. Besides,it also reduces the time of aortic occlusion in simpleclamping to that needed for the distal anastomosis.
 This procedure has improved the results of complexreplacement of the ascending aorta, aortic arch anddistal aorta and has resulted in better survival ratesthan those of traditional approaches.
Aortic Dissection and Its Management with Frozen Elephant trunk procedure
1. Lus F, Hagl C, Haverich A,
et al
. Elephant trunk procedure 27 years after Borst: Whatremains and what is new?
Eur J Cardio-thoracic Surg
. 2011;40:1-12.2. Heinemann MK, Buehner B, Jurmann MJ,
et al
. Use of elephant trunk technique inaortic surgery.
 Ann Thorac Surg
. 1995;60(1):2-6.3. Svensson LG. Rationale and technique for replacement of the ascending aorta,arch, and distal aorta using a modi
ed elephant trunk procedure.
 J Card Surg
For further details you can contact: 
Dr. Mohammed Rehan Sayeed91 80 4199 4444/6621 4444
Fig. 4:
Endovascular stent
Fig. 5:
Frozen Elephant trunk procedure

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