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Endovascular Interventions for Varicose Veins in Ultrasound Rooms

Sep 22 | 1:30 PM

IRIA, Kerala has organized one interesting talk on 'Endovascular Interventions for Varicose Veins in Ultrasound Rooms'. There is lot more to radiological procedures than just interpreting scans. Interventional radiology is the burning dimension. Let's take a look at it from a different perspective.

[Music] good evening and welcome everyone for for ira kerala turf expansion program on netflix platform and the speaker himself is the chairman of turf expansion team coming back to this evening session for the opening remarks we have dr rajesh kumar in inna gala sir is the consultant radiologist and chairman of maven medical center hyderabad an award winner of vaidya ratna award 2019 and first to launch echo microwave ablation of varicose veins in india may i welcome dr rajesh kumar sir for the opening remarks over to you sir yeah thank you thank you all for inviting me for the opening remarks especially thanks to dr ramesh sir i mentioned sir and thank you judy so today's topic is a very interesting topic actually so earlier varicose veins was supposed to be a very painful experience for the patients so lot of patients used to postpone their treatment and come at a very late stage when they had answers and different in walking and dvds and other things so now the treatment has become so simple that you can do it in in the a group on a decade procedure so any radiologist who can do minimal interventions can also practice this so and you do not need very expensive setup also all what you need is an ultrasound equipment and then a laser equipment so initially you need not buy an um laser also a lot of companies are there who give it on rent also so this is one of the things for turf expansion we talk always about radiologists talk about turf erosion perforation and all so now we have taken this treatment from the vascular surgeons so now because this treatment is ultrasound guided doppler guided so we are more qualified than the vascular surgeons to do interventional radiology work like endovenous laser treatment so i i request i think all the young audience who are there they should take up this treatment of varicose veins or a daycare procedure so now this treatment can be done under local anesthesia or even you can do under sedation the patient is anxious some patients might need spinal anesthesia but overall very safe procedure and even success rates compared to previous stripping and ligation is much more because i say when they were doing stripping and ligation they used to pull out the weeds so while pulling out the veins lot of beans used to break and then the success it was only hardly about 60 to 70 percent now we are doing this treatment under doppler guidance and success rate is very more than 97 if you are doing properly especially if you are taking care of the perforators and the reflex part of the varicose veins so very simple uh technology very easy to learn this technique i request all the youngsters especially to take up this procedure and also not only this thermal treatments like endovascular laser treatment now we have got non-thermal treatments also so that is hardly patient can walk in and walk out we do not even need to give any diminished anesthesia also and no need for local anesthesia also so walk-in workout techniques have come like super glue and mocha so these are other advancements in the treatment of varicose veins which all can be done under doppler guidance so uh for further i think uh i think dr joe's corullah is going to enumerate on the treatment part of endovascular laser operations but remember intervention radiologists are doing many more work than the uh just the awareness laser treatments so if you are just a radiologist also simple common radiologist you can practice this learning this technique is very easy and please do learn this technique and take up this treatment so now over to i think dr jose i think he will be able to emulate much more the any questions even i can take up other questions at the end of the session i will be willing to answer uh dr jose and dr judy will hand over to dr josh thank you sir thank you sir i welcome dr jose corowella consultant radiologist at marian medical center kerala he has been the ima pala branch president and i am a junior doctors network vice chairman he is also kerala iria turf expansion team chairman i invite dr joe scarola for his talk on endovascular interventions for varicose veins in ultrasound rooms over to you sir jose judy for the directory words i especially thank dr rajetsar for the inspirational words let me uh start with my topic so i'll be dealing with the radio uh which i have been doing for last 11 years uh actually no varicose veins are elongated superficial veins that are usually seen in the legs and before starting session we should know the anatomy leg veins the venous systems are basic specified into three groups which is in relation the muscular fascia which drains into the deep system and the deep system means like okay the deep brains that are uh start from starting from the leg veins to the antenatal veins and the into the positive vein the anger table and the positive when joined from the tibia peroneal trunk and that drains into the populative vein which finally supervillain cell veins are the great surname which starts medial uh medially in the as a marginal vein of dose motherboard it ascends through the middle aspect leg and suffin a femoral junction it has this and uh namely accessory greater finish speed circumflex wheel now we have the positive we have the small stuffiness the dorsal pedal arch and essence ascends postor laterally behind the lateral manuals joining the population vein at the safety network junction now variations are there swordsmen scan when can extend cranially to joint which connect the great surface wave with the positive build when they start off that's a pocket then we have a proximal parity pill perfect voids and the lava type perfecting veins of ml canal dot and the proximal type hunter in perforator incompetence of these perforators can cause medial tie and carb varies even without the sf junction incompetence now this is a normal venous drainage of leg you can see the deep system and the superficial system and they are connected through the perfecter veins and you can see the arrows the venous flow is always unidirectional usually it is from the superficial to the deep and upwards so what happens in varicose veins is this when there is incompetence of this junction veins valve junction valves and the perforators the blood start flowing in the opposite direction that is from the deep system to the supervision system now the etiology of varicose veins there are primary and secondary causes uh primary are a continental weakness of vessel wall continental absence of valves congenital incompetence and familial secondary causes are the deep thrombosis av fistula obstruction to flow which may be due to the pregnancy or pelvic tumors or any reproductive fibrosis now the basic pathophysiology of varicose veins it's a venus this is results from the valve reflex when the venous blood flow from the superficial to the deep and the lower extremity we have one one-way valve located at interval cell intervals along the main means the risk factors are heredity the more common in women obesity menopause and aging long-standing leg injury abdominis training now about the ceap classification of venous disease venous disease of leg can be classified according to the following elements using the ceap classification c stands for the clinical severity etiology of course a anatomy and p pathophysiology now with the grading of c c 0 to c 6 c 0 is an ordinance of venous disease c 1 superficial spider veins that reticular veins only c2 is simple varicose veins only c3 is ankle edema of venous origin c4 is skin pigmentation that is lipodimetrosclerosis and c5 is a healed venous ulcer c66 non non healing venus also this is a classification link classification with examples given for each c1 c2 c3 c4 and c6 you can you can see in c1 there are all the reticular veins then the symbol you can see in c2 large varicose veins c3 is uh edema then color changes in c4 and healed ulcer in c5 and with an active ulcer in c6 now the signs and symptoms of varicose veins aching legs and cramps appearance of spider veins in the affected leg ankle swelling redness venous eczema lipid amateur sclerosis white and irregular scar-like patches can appear at the angles now the complications of varicose vein the main complications pain tenderness heaviness in the leg inability to walk or stand for long hours dermatitis skin ulcers especially near the angle development of carcinoma or sarcoma and long-standing venous cells severe bleeding from minor trauma superstitious thrombophlegia phlebitis and dvd acute fat necrosis now the diagnosis is clinical and using imaging modalities imaging modalities uh doppler ultrasound is a mainstream of imaging ct winogram mr vinogram and direct contrast phenography can be done now venus doppler is the main main imaging modality for varicose veins will be commonly reduced use this venus is easy easily available and economical for the patient also so it's a done using high frequency linear probe we use five hertz or more uh frequency linear probes venus doppler basically is done for the to roll out dvt and to look for the deep weight reflex to see for the superficial veining competence and the extent of the reflex and the size of the great saphenous vein and the short stuff in a swing the perforator size and incompetence any continental and anatomical variants of superficial veins and we should do a routine arterial workup to see severe occlusive artery disease now the mapping of the veins and prophetess we can use a key technique can be used with a long limb of the t which indicates a supervision vein and the junction of the two limbs indicate the perforator entry point you can mark the perforators before the procedure and even you can mention the depth from the skin surface which will help in the treatment in the doing the procedure now the grading of the saphina femoral junction incompetence a grade one incompetence only or or while cell or only incompetence only on wall silver in standing and supine position and grade 3 is incompetent spontaneous on standing even without valsalva and grade 4 is incompetent spontaneous on standing and supine now the treatment modalities initially surgical treatment dialysis this were suffering femoral junction ligation and slipping then came the sclerotherapy microphobectomy radioablation radiofrequency ablation endovascular laser ablation glue microwave uh ablation mocha as a diet circle these are the new new additions to the treatment in of in varicose veins now i'm dealing with the endovenous laser therapy in this session the endomes laser trap is thermal ablation technique that uses a laser fiber placed inside the incompetent vein usually we follow the celtic over the wire technique where we place a long catheter along the length of the triangle bearings which is should be ablated now about the venus intervention the endovascular laser regulation here the incompetent great saphenous vein or the shorts are venous vein accessory superficial veins and large diameter straight various and supervision tributaries are ablated using this endovascular laser ablation now we use microphobictomy for torches viruses and incompetent perforators and sclerotherapy for very small dimension vein viruses and and for the tiling tactic veins now the advantages of endo venous laser ablation it's a minimally invasive procedure and the patients are from the patient side is very comfortable less mobility and fast recovery for the after procedure and the cosmetic results are much better compared to the uh compared to the other procedures patient satisfaction is better than the older treatment options and the complications also very low no major complications for this treatment in the hospital elaboration and the recurrence rate is also less compared very less compared to the surgical and other treatment options which we which were being conventionally used now about the patient selection now we are before uh going with the procedure we have to select the patient so for that the some criteria we have to follow before doing the procedure for the patient selection and you should look for the incompetence of rates happiness or shorts up in a strain and look for the uh ceap score usually is c2 to c6 core patients can be taken up for uh endow is endovascular venous ablation now you have to rule out the uh your ruler dvd first then look for the deep venous insufficiency and even in post-robotic syndrome varicose vein which develop after the dvt we can do this procedure for such patients rule out vasculitis and other systemic causes of venous ulcers where the role of roll out severe arterial insufficiency arterial mapping should be done and we have to roll out associated lymphatic obstruction so in such patients the edema may be persist and patient satisfaction may not be that good in cases of patients with lymphatic obstruction so you have to while selecting the patients for this procedure you have to keep these points in mind now about the pre-op workup routine bread examination should be done and we have to look for the bleeding time and clotting time the syringe creatine and the sugar levels should be monitored because patients with high sugar if you take up the procedure they can go to complications of cellulitis and the ulcer may get worsened and the basic serology should be done to look for the hiv hbcg and all and you should do an ultrasound abdomen and pelvis ultrasound abdominal pelvis to roll out any pelvic tumors or mass and any obstructive and proper concern should be taken from the patient before the procedure now the contraindications to this treatment are any coagulation defects uh patients in in with chronic liver disease or or other continental coagulation defects if we should not take this patient so because the bleeding the patient may bleed and uh we may not be able to stop the bleeding because this usually this procedures are done in small setup ultrasound rooms so you should take care of that uh keep in mind patients with correlation defects you should keep a caution and inability to ambulate because inability to ambulate the patients may develop dvt post procedure so it's a contraindication any arterial venous malformations patients such patients should not be taken for the endovascular linguistic operation acute dvt acute dvt the virus return is through the maybe we can the complication if you knock your dvd if we regulate the supervision veins uh symptoms my worst impression penis return may be completely blocked so it should not take patience with acutivity severe rdd insufficiency the the ulcer healing may not be that good and complications and cellulitis can occur in such cases then pregnancy then allergy to local anesthetis and very apparently large vein so that appellation may not happen to the venous walls so these are the contrastigations of the treatment of erythritol now the procedure uh you can uh give sedation iv fentanyl or metasolum can be given they used to give the fentanyl but once in a while patient may go into a respiratory depression so when you don't have an anesthetist nearby so it's better to avoid a fentanyl and a metasolum can be given with fentanyl may have a very very rare possibility of uh respiratory depression then local anesthesia using lipnoxy in one person and then tumors and anaesthesia where we mix 20 ml of five percent sodium bicarbonate and 25 ml of one percent liquid which is diluted in finite amount of saline and it's used for the domestic anesthesia and spinal anesthesia can be used female and or nerve block can be used for anesthesia or anesthesia now lesser generators usually use is a 600 nanometer lesser fiber to deliver the energy the lesser energy generates high energy bonded light that is monochromatic one wavelength and collimated a thermal reaction obvious after the laser forces in the is a suspected mechanism the produced heat may reach up to 800 degree celsius at the tip of the layers of fiber and the result is a formation of steam bubbles these bubbles force the blood to boil and induce thermal injuries to the venous endothelium the intravascular heat decreases to 90 degree at the foramen from the laser steam bubbles that form at the tip of the laser dissipate just dissipate quickly and oppose no systemic risk of tissue burn around the vein and to avoid this tissue burns around the vein histological studies show that the endovascular estrogen damages the endothelial and the intimate layers the elastic internal elastic lamina and the media to some degree without affecting the advantage and the most important thing is delivering adequate energy is crucial in achieving a successful ablation of the treated way we the the most important parameter is the joules that's the amount of amount of delivery amount of energy we deliver for ablation the amount of energy is in joules depends on the power and the duration of exposure of the laser beam to the area it depends on uh we select the energy dosing depending on the diameter of the vein use of high energy levels for large diameter veins and low energy levels for small diameter veins and we use all voltages from 100 to 30 watt which will uh which will be sufficient to achieve an adequate abrasion the primary mechanism which is responsible for delivering the less energy to the main wall is same for all wavelengths the this is the generation general of the steam bubbles using the pulse mode or continuous mod usually does not influence you can use two mods are the pulse mode or continuous board both can be successfully used much different no there is no major difference in the effectiveness of using pulse mode or harmless mode major advantage of the pulse mode is a continuous mode is that duration of treatment is shorter but pulse mode is considered to have a higher risk of address effects such as micro perforation so continuous mode is safe compared to the pulse mode of the technique endovascular acceleration can be performed under local chromosome anaesthesia in an outpatient setting the larger vein is identified using ultrasound from the angle to the subuniform junction the saphenous nerve is you have to keep in mind about the safeness nerve which is uh distal from the great surface when you're above the knee compared to bologna knee it will be close to the great saphenous rate so the puncture can be done it should be done just below the knee or above the knee because once you come down the safeness nerve will be close to the laser constraint so the chance for venous injury is high we can cannulate any but you can candidate the greatest amino spin even from even from below from the lower third aspect before the maldives because some patients will have venous reflux till the lower third of the leg in such cases we have to cannulate the gsp even down even down taking care of the surfiness now we can give thomas and anastasia and [Music] which may get lived in due course now the venous success is obtained by a needle puncture which is under the ultrasound guidance a 21 gauge needle is preferred as venous trauma and spasm will be less likely in that case once you are puncturing the needle if the venous passion occurs you can try entering the vein a guidewar is preferably a hydrophilic hardware is used uh the if the varicose veins torches uh you can use small diameter advancing very torches and as a very small diameter this wire advance may be difficult so if severe tortoisity or obsession of the vein cannot be multiple punctures can be performed at higher levels and ablation can be completed in segment by segment and once the guidewar is placed the needle is removed a small incision is made at the skin and an introducer sheath with dilator is inserted the lesser fiber is inserted through the sheet and positioned about a one to two centimeter distal to the surface junction uh local thomas anasa is then injected along the entire course of the subgenus vein to be ablated uh from the cannulation side to the suffering femoral junction which is also done on the ultrasound variants guidance using a syringe or an automated pump and you keep the needle tip very close to the vane wall as possible so we will get the eye of the [Music] [Music] tissues and one for one like we usually require about 250 to 500 ml of solution which depends on the on the patient's physical characteristics now the tumescent anesthesia protocols uh the perivenous tissue from from the it's it it protects the perimenos tissues from the effects of laser energy like a cooling effect it removes the another advantage of the tombstones is it removes the blood from the lumen by collapsing the vein which will increase the effectiveness of left vibration because uh the vein when the vein comes come together they collapse the laser fiber will adequately coagulate the vessel wall and it increases surface the act of forcing the blood from the vein prior to the ablation is important for ablation of the vein wall and this is done for both in two advantages it prevents thrombosis within the loop and it allows a good ablation of the green wall if the penis lumen cannot be completely collapsed we can elevate the leg and collapse the veins so that we will get a good thrombosis of the good ablation of the vein wall now before activation of the laser each person in the room should wear a protective googles and now this is a picture victoria depiction of the this is what you this is a through the sheet and slowly correctly using continuous or false more while we draw the laser fiber [Music] down depending on the correlation now that was about the endovascular laser ablation now as i mentioned for the small viruses we can use clear authority it's a most widely used medical procedure for population and of the varicose veins the most commonly used glycosyntheair polytonal and sds a sclerosing substance is injected into the abnormal vessels to produce an endothelial restriction and which eventually forms a fibrotic core and the how to make it we should usually we use forms clear acid the sclerosis is mixed with air to form a form uh by desiree method and the ratio is three is to two is to one uh whether three a portion will be air two portion will be normal saline and one portion will be the sclerosin solution which is mixed to form a uh form which is injected into the small viruses and this this forms clever sin cause endothelial destruction and thereby the weight becomes fibrotic and that's how small varies are being coagulated now about this clear center this uh the sclerosis are used because of law incidence of allergic reactions and there will be less staining on the skin surface and uh even if it is extra messages there is a less problem no major complications with extravasation of this clear ascent so so that is preferred uh just so we are preferring this sclerosing agents now about the microphobic as i mentioned we have to mark the patient's various incompetent perforators in the standing position and [Music] on the table we'll through this marking at the at the point of this marking will put a series of small cuts which is usually usually two to three millimeters we use uh venus laboratory hooks are used to actually externalize these veins our tree clamps are then used to slowly extract the wing and this process is completely within the small incision along the full extent of the wing and until we remove all the perforators and forces viruses and this will be no need of any sutures because we we are putting very small incisions which will heal without any switches and at the end of the surgical procedure we give venus compression uh is applied for 24 hours by compression panties patients are instructed to walk immediately after procedure and to continue their normal daily activities the patients are asked to wear full time class 2 compression stockings during the day time now patients generally report a discomfort for five to eight days after the endovascular sublimation which is related to the inflammation resulting from successful indo-venous ablation there is a there will be wall thickening along the along the way now the treatment or outcome a success rate of 100 percent can be attained evla after one week and a success rate of greater than 90 on one year and three year follow-up now freedom from recurrent varicose veins are achieved in seven nine percent patient after a five-year fallout uh there are a few studies comparing endovascular cell relation with other feedback mobilities mainly uh surgeries but this endovascular sufficient as far more successfully compared to the other treatment or the conventional treatment modalities now the recurrence following varicose veins surgery now recurrence after endovascular laser revolution are uh usually short-term uh which may indicate inadequate initial treatment rather than true recurrences usually the recanalyzation after endovascular reservation mostly within the past six months and all reconorizations occur within the first 12 months now the recurrence forms of this fungal mostly occur within the first six months and all break analyzation occur within the first 12 months now the recurrent form of functional vein insufficiency in a short segment of all all along the vein can be effectively treated by repeat endowers usually minor and transient complications and transit ruin bruising soreness tenderness and integrations along the treated way segment operatively and then gradually usually these complications will be there for the two weeks for operating and you and they gradually subside completely the post procedural complications can be reduced by by using the compression stockings and anti-inflammatory medications a pulling cot sensation along the course of the gsp is a sign of developing vein fibrosis this will be for a short period of time after the procedure which will finally resolve now skin pigmentation can occur which is more common with the sclerotherapy than endovascular separation but it can happen with endoscopic separation also when the uh subcutaneous tissue is uh less in pain with in patients with uh in patients there can be pigmentation of the skin uh even up even along the grains of venezuelan after endovascular less vibration but it's more common with sclerotherapy now superficial thrombophlebitis can there is another complication which can occur which requires simple symptomatic treatment with compression and inflammatory medications now paresthesia that's what usually they it can happen especially when you puncture the breed surface weight below knee this can this is a usual complaint from patient side you can uh that they usually this viruses results in two to three months and uh you can ask the patient to wait for two to three months so that uh it will be completely dissolved now sapphine's nerve injury also resolves spontaneously but it takes weeks or months to achieve complete recovery now pain and restlessness in the leg is another another complication cellulitis can occur contrary to the incisions and rarely due to the at the site of the needle puncture when then uh diffuse like menos with pass formation can occur these are all very rare complications most of the patients will walk through without any complications now some of the rare very rare complications which come across as skin burns which can be prevented with the good thomas analysis as i've mentioned especially in areas where the vein is varies vein is superficial now dvt uh one person called chance of dvd but uh till now i haven't come across any patients with dvt uh six this years but as a textbooks or the literature says one percent chance of dbt and we should do a follow-up doppler after uh interval s operation to exclude dvds now anticoagulation can be considered for patients with a history of dvt uh into the post or period pulmonary embolism is a very very rare complication which can occur uh in patients who develop dvt then after aneurysms and arterial venous fisla can occur uh because of the micro profession which happens uh in some cases a very rare complication now about the device related complications the retained fiber in the vein can occur because of the significant painting retained guide wear or retained introducer shaped segment can occur now the laser tip may melt and disconnect the plastic sheet fragment which may maybe dislodged into within the vein most common complications are usually self-limited and spontaneously uh most complications is resolved major complications are very rare in endoscopy regulation now about what about the prevention of varicose vein uh wearing 30 to 40 millimeters mercury in compression talkings whenever standing especially in pregnant ladies and familial cases and constant use of compression stockings can prevent the worsening of the existing varicose vein which cannot who are some uh contraindications can do some compression stockings uh to prevent worsening of as a combination for with intervals laser therapy for a better outcome of varicose treatment now why radiologists should take up this procedure now intravascular laser application is a very safe and effective treatment of venous insufficiency the radiologists are the best ever for doing this intervention as its success depends largely on the opera guidance so it's an easiest intervention for radio is very minimum setup doppler machine is the most expensive tool for the procedure it's a simple but beautiful intervention to become a clinical radiologist it has high immediate technical success a short recovery time good cosmetic results minor complications are taken but usually temporary and self-limited major complications complication surveyor high level of patient satisfaction appreciation now about case files i have a companion dr bobby worker from pushpadi medical group these are the case files compiled by dr boby these are the few cases which he done [Music] the old case file of 2014 the patient came with the ulcers and completely also completely healed without any complications in two to three weeks time most of the patients come come to us with with leg ulcers after treatment at many centers including ayurveda homeo and all usually they will fed up with this issue and come to us for a chance but they'll they'll have a good patient satisfaction with we'll have good good present satisfaction with the healed ursus you can see big ulcers even without any skin graft will be able to heal the surfaces these are some of the sclerotherapy cases and the microphone and these is long torches veins and after the post procedure you can see this leg and you can see the uh [Music] this is how we mark very torches various landing orbiters this is another case of laboratory now though about the post-op complications i already mentioned my discoverization of the skin thermal damage to the skin infection super chromophobic cellulite edema itching and the major complications as we already mentioned are recurrent dvt and probably emotion now recurrence they now damage skin necrosis that's all thank you thank you sir that was a wonderful presentation which included endovascular laser ablation microphlebectomy and sclerotherapy and and your own case files there's one query sir regarding uh the treatment for superficial spider like varicose veins what do you have to say sir yeah that's what i already mentioned in my presentations the superficial spider veins and mainly the telecacti beans we can do sclerotherapy can uh we can coagulate these small veins using form sclerotherapy where we use clearest and air and saline which is mixed in a ratio 3 is to 2 is to 1 and it's injected into the vein uh this glycerin will cause endothelial damage to this small superficial variances that's how we treat these superficial venouses spider veins okay sir and regarding the puncture for shorts short surface vein ablation sir see same thing with the we look for the short circuit when we same thing we look for the incompetence or the reflex we'll go to the level of reflex and will puncture the vein of the short stiffness swing till from the place we we can till where we can demonstrate the reflex then we will uh puncture the vein and we'll get into the same thing we will give thomason insatia procedure is same for both okay so uh i assume no more query sir uh uh thank you sir and uh that was dr joe's corolla cell consultant radiologist from marian medical center palette on the topic endovascular interventions for varicose veins in ultrasound rooms thank you sir

BEING ATTENDED BY

Dr. Sasikanth Reddy & 381 others

SPEAKERS

dr. Praveen  R

Dr. Praveen R

Orchid hospital Malappuram

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. M.C.J. Prakash

Dr. M.C.J. Prakash

Consultant Radiologist | President - IRIA, Kerala

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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dr. Praveen  R

Dr. Praveen R

Orchid hospital Malappuram

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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dr. M.C.J. Prakash

Dr. M.C.J. Prakash

Consultant Radiologist | President - IRIA, Ke...

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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Dr. Rijo Mathew

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