Spontaneous vascular thrombosis may occur after a short climb or prolonged stay at high altitude (HA). Both venous and arterial thrombosis has been reported in the literature and cause significant morbidity and mortality. Diagnosis is often difficult; treatment delayed and postthrombotic sequelae disabling. Experimental evidence is limited and trials to prove thrombogenecity of HA are technically challenging to conduct. A greater understanding and awareness of its varied presentations and management is required by all those engaged in treating such patients.

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Congenital vascular malformations are one of the most challenging subgroup of diseases treated by vascular surgeons and interventionalists. Currently, there exists a lot of misunderstandings and controversies in terminology, diagnosis, and management of patients with these problems. This review article helps doctors with a concise and current understanding of classification, clinical features, complications as well as diagnostic and therapeutic guidelines.

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The lateral marginal vein is one form of truncular venous malformation seen commonly in Klippel–Trenaunay syndrome. It is characterized by avalvulosis and presents with features of chronic venous insufficiency. As there can be associated intravascular thrombosis, there is an increased risk of venous thromboembolism and pulmonary embolism. In children, it can cause vascular bone syndrome. Surgical excision is indicated when possible to prevent complications.

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Posttraumatic pseudoaneurysm of hepatic artery is an uncommon complication. However, when diagnosed, they need early treatment to prevent rupture. Currently, the treatment of choice for hepatic artery pseudoaneurysm is endovascular embolization depending on the location. We present a series of 4 cases of posttraumatic intrahepatic pseudoaneurysm in branches of hepatic artery who were successfully treated with n-butyl cyanoacrylate embolization.

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Patients with connective tissue disorders have benefitted from refinements in surgical technique and progress in molecular biology research. As many patients with connective tissue disorders now enjoy a longer life expectancy, non aortic root manifestations of their conditions are becoming more commonplace and vascular surgeons are tooled to address them. In this review, we will elucidate the triage and diagnosis of patients with connective tissue disorders and advance practical treatment strategies for these challenging vascular surgery patients.

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Hemangiomas are one of the commonest benign soft tissue tumors of vascular origin affecting females more than males. Deep soft tissue hemangiomas are uncommon and usually involve skeletal muscles. Intramuscular hemangiomas commonly involve muscles of the lower extremity and rarely the upper extremity. Clinical diagnosis is often missed/delayed as chronic pain and/or swelling are often the only symptoms. We present a case of intramuscular cavernous hemangioma of the triceps muscle in a young male with brief review of literature.

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Mycotic aneurysms as a result of salmonella arteritis are rare in the era of broad spectrum antibiotics. However, few cases have been reported in cases of immunosuppression, presence of cardiovascular prosthetic materials or intravenous drug addiction. Though Salmonella infections cause aortitis and aortic aneurysms in elderly patients with atherosclerosis, it is rare to have common iliac artery aneurysms in young adults. High index of suspicion and aggressive investigation is required to detect these cases as the clinical presentation may be vague. Management of mycotic aneurysms is challenging, requiring emergency surgery. We hereby present a successful management of salmonella mycotic aneurysm of iliac artery in a young adult with no atherosclerotic risk factors.

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Mycotic aneurysms are rare and usually occur secondary to embolization of septic foci. Early diagnosis is the crucial. They have high risk of rupture/complications and can pose a difficult management challenge especially in an acute setting. We describe the management of four patients with mycotic aneurysms in our case series.

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Pseudoaneurysms of brachial artery are rare cause of upper limb mass. Their diagnosis is straightforward in the setting of a rapidly growing pulsatile soft tissue mass with bruit or distal limb ischemia. We hereby present a case of hard nonpulsatile left upper limb soft tissue mass in a 50-year-old female. Mass of 5-year duration was misdiagnosed clinically as soft tissue neoplasm and underwent trucut biopsy. The case came out to be a large pseudoaneurysm of brachial artery and was successfully excised.

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Upper extremity aneurysms are quite uncommon when compared to other peripheral arterial aneurysms. Among them, giant (>5 cm) subclavian artery aneurysms (SCAAs) are extremely rare. We report a case of giant SCAA measuring 8.8 cm in its maximal diameter with an updated review of literature. Our case is unique in view of surgical exposure method used (modified trapdoor thoracotomy with claviculectomy).

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Carotid body tumors (CBTs) are rare benign tumors, but they do have a chance of turning into malignant tumors. Hence, the earliest mode of treatment is surgical resection. The high vascularity of the tumors poses a surgical and anesthetic challenge. Hereby, we present a successfully resected case of large CBT measuring 7 cm × 6 cm. In contrast-computed tomography angiogram of the neck, the hyperdense mass was noted in the left carotid space splaying the left internal carotid artery and external carotid artery. Conventional general anesthesia with controlled ventilation technique was used in the resection of this tumor. The final histopathology report was paraganglioma. She had an uneventful perioperative period and was doing well after 18 months of follow-up.

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A 24 year old female presented with recurrent hemoptysis and the work up revealed a large right pulmonary artery aneurysm for which she underwent endovascular intervention with relief of symptoms. Her symptoms recurred after one month and now she had left pulmonary artery aneurysm, again treated with endovascular intervention. With systemic symptoms and absence of signs of Behcets syndrome led to diagnosis of Hughes-Stovin Syndrome. She symptom free at 18 months with immunosuppression.

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We report three cases of primary leiomyosarcoma (LMS) of inferior vena cava (IVC). Vascular LMSs are rare tumors, arising most frequently from IVC. These tumors have a female predominance. Their diagnosis is often challenging, as patients may present with nonspecific complaints such as dyspnea, malaise, weight loss, abdominal pain, or back pain, preceding the diagnosis by several years. LMS of the IVC most frequently occurs in the middle segment. The final diagnosis can be made by an ultrasound or computed tomography-guided biopsy. Due to limited experience with this disease, optimal management of IVC LMS is unknown. Curative surgical resection remains the current treatment of choice for primary LMS of IVC. Neoadjuvant therapy may be given to downsize the tumor and increase resectability rates. Nonetheless, there is no proven role for adjuvant therapy, and recurrence is common. We, hereby, report three cases of this rare entity with emphasis on management.

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The Indian COVID-19 situation is and will demand more and more hospital bed capacity to manage. With diabetic foot disease (DFD) being a leading cause of hospital bed occupancy, managing these patients based on evidence-based guidelines can significantly reduce the rates of hospitalization. Every hospital bed that is not needed for a patient with DFD , gives room for occupancy by a patient suffering from COVID-19. The goal of doctors treating diabetic foot is aimed at early successful treatment of infections and preventing amputations, decreasing the hospital stay of inpatients, and effective cost reduction. Hence, changing our way of approach to managing a patient with diabetic foot and implementing new and unique ways is the need of the hour at this time of crisis. This guidance also has a section on managing diabetes in people with diabetic foot during the COVID19 pandemic.

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Objective: Intrinsic esophageal pathologies constitute prime cause for dysphagia clinically. However, thoracic esophageal domain is prone to extrinsic compression by various vascular afflictions including aneurysms with attendant therapeutic challenges. Herein, we present a case series of dysphagia aortica with emphasis on its appropriate management option based on grade of dysphagia. Methods: Patients who presented to the vascular division of our tertiary care referral institute between January 2014 and October 2015 with dysphagia due to extrinsic esophageal compression by aneurysmal thoracic aorta form the basis for this report. Prior to referral, all patients were evaluated elsewhere to rule out intrinsic causes and computed tomography angiogram performed delineating aortic aneurysm in four patients and penetrating aortic ulcer in one. Patient cohort included one female and four male patients whose age ranged from 40 to 68 years, with a median of 62 years. Left posterolateral thoracotomy provided access to an aneurysm which was repaired using interposition polyester graft in four patients. Due to severe comorbidities which precluded open surgery, one patient who presented with mild dysphagia was managed by endovascular stent graft repair. Results: Degree of dysphagia was assessed between grades 0 and 4 as in literature. All patients, including four open conventional and one endovascular, recovered well and left hospital totally symptom free. Conclusion: Dysphagia due to vascular diseases in the thoracic domain is an uncommon clinical entity. Patients with thoracic aortic aneurysm presenting with severe dysphagia deserve open surgical repair to provide optimal symptomatic relief in addition to saving life. The state-of-the-art endovascular stent grafting may be considered in very elderly patient having severe comorbidities presenting with mild dysphagia.

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Background: Carotid endarterectomy (CEA) using eversion technique has been used by vascular surgeons across the world. A simpler technique, modified eversion endarterectomy (MEE) is emerging as a promising option. Advantages are shorter clamping time, less neurological complications, and avoidance of prosthetic patch plasty. Selective shunting can be done whenever required. In the climate of carotid artery stenting versus CEA debate, one would consider this method to reduce the morbidity of CEA. Materials and Methods: This is a retrospective analysis of patients undergoing CEA at a single institution by four vascular surgeons over a period of 2½ years (January 2012–June 2014). Data were collected from computerized medical records and various parameters analyzed. Forty patients underwent MEE during the given period. The majority were symptomatic 34 (85%). Results: One patient (2.5%) required conversion to conventional endarterectomy with patch plasty because of the long length of the plaque. One patient (2.5%) had lateralizing transient ischemic attack (TIA) in the postoperative period. Two patients had hematoma of which one was returned to operating theater for evacuation. Seven patients underwent MEE along with coronary artery bypass grafting with uneventful recovery. Selective shunting was done for four patients (10%) who had a contralateral occlusive disease or poor back bleed from an internal carotid artery (ICA) on table. Average ICA cross-clamping time was 13 min. None of the patients had cerebrovascular accident/TIA in the follow-up period. Conclusions: MEE is a simpler and easier technique to perform with comparable results when compared with other conventional techniques. MEE, in our assumption, will be the technique of choice in the future for open CEA; however, larger studies with longer follow-up are required before final validation of this technique.

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Objective: To study the outcomes of the ultrasound guided foam sclerotherapy (UGFS) treatment for superficial venous insufficiency. Materials and Methods: Selected patients with varicose veins were treated with UGFS using sodium tetradecyl sulfate as sclerosant and followed up to 1-year. Total 148 legs in 123 patients, 98 unilateral limbs, and 25 bilateral limbs were treated by this method. Results: Out of 148 legs saphenofemoral junction (SFJ) incompetence was found in 42 and sapheno-popliteal junction (SPJ) incompetence in 49, perforator's incompetence in 11, while combination of SFJ and perforators and SPJ and perforators in 16 and 7, respectively. Great saphenous vein varicosity was found in 58, short saphenous vein in 56 and others 34. Twenty-four limbs had recurrent varicose veins previously treated by other modalities, and 124 limbs had primary varicose veins. Fifty-two limbs were treated for complicated varicose veins (CEAP 4-6) and 96 limbs for uncomplicated varicose veins (CEAP 2-3). Early outcome was 100% success rate. No recurrences were noted at 1-year follow-up. Early complications were: Superficial skin necrosis in 4 legs (2.70%), pain at injection sites in 21 legs (14.18%), superficial thrombophlebitis in injected vein in 21 legs (14.18%), bruising in 18 legs (12.16%), superficial vein thrombosis in 10 legs (6.75%), and skin staining around injected veins in 13 legs (8.78%). Conclusion: UGFS is a safe, good, and effective treatment modality of treatment for patients with varicose veins and found to be associated with significantly less bruising and pain.

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Objective: Venous ulcers play a major burden on the patient and health-care system in terms of morbidity and medical expenditure. The objective of the study was to evaluate the efficacy of prostaglandin E1 (PGE1) administered via intravenous infusion in the healing time of venous leg ulcer and to evaluate the safety of prostaglandin intravenous infusion. Materials and Methods: This was a prospective observational study at a single tertiary care center. Patients who had proven venous ulcers of the legs which are not healing for more than 3 months with conventional therapy were included. About 500 μg PGE1 was given in equally divided doses over 5 days as intravenous infusion along with regular compression therapy. Ulcers were followed up every 3 weeks for 18 weeks and measurement of ulcer area done. Results: A total of 47 patients with 50 ulcers were included in the study with a mean age of 55.9 years. About 50% of ulcers healed 9 weeks after PGE1 administration and 92% healed after 18 weeks of treatment. The estimated healing time of 25%, 50%, and 75% of the patients treated with PGE1 was 40, 63, and 86 days, respectively, which was statistically significant compared to the previous studies with compression therapy alone. The only factor to independently affect healing time was found to be the initial ulcer size. There were no major adversities with PGE1 administration, 2 patients developed minor symptoms, in the form of hypotension and tachycardia, which were managed with stoppage of infusion for short duration. Conclusion: The study shows the effectiveness of PGE1 in reducing the healing time of VLUs, thereby allowing patients for lesser hospitalization and quicker return to work and life producing improvement in the quality of life. The adverse effects were also very minor with PGE1 treatment, overall, acceptable and were well tolerated by the patients.

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Background: Title and keywords are the two most important parts of a manuscript. The words or phrases used in the title or keywords should be selected wisely for a wider dissemination of the article. Medical Subject Headings (MeSH) terms are used to index article in MEDLINE/PubMed. Hence, choosing the title and keywords according to MeSH would be a better choice for authors. Aim: The aim of this article was to provide a technical guide for selecting words and phrases for title and keywords of an article according to MeSH terms. Methods: The most frequently used words in a manuscript can be identified by the help of word cloud technique. We showed an example of making a word cloud from the text of a manuscript. The method of searching MeSH terms in a manuscript text was shown with an example. Writing title and keywords with amalgamation of these two methods was described. Conclusion: This tutorial showed the use of two freely available tools on the World Wide Web (word cloud and MeSH on demand) for choosing title and keywords for a manuscript. This brief description would help authors in wider dissemination of research knowledge to the targeted audience.

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India with a population of about 1.3 billion and diverse cultures holds within its large land mass an encyclopedia of medical cases, several un/underdiagnosed. Klippel-Trenaunay syndrome (KTS) is one such condition. Over the years, as the understanding of our team increased about the condition, we were able to share the same with our colleagues across the institution and publish the brief article. This resulted in an increased referral pattern from within the institution and across the country. At our institution, we managed 127 cases of KTS between October 2009 and December 2017. In this article, we share our experience about managing the cases, lessons learnt, and the challenges we face.

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Acute mesenteric ischemia (AMI) is a complex clinical problem with a high mortality. The mortality associated with AMI has declined steadily over the last three decades. This is due to higher index of suspicion among clinicians, advances in radiographic diagnostic modalities, aggressive surgical approach, endovascular intervention, nutritional supplementation, and better perioperative care. Early diagnosis and prompt, effective treatment are essential to improve the clinical outcome. This article reviews the etiopathogenesis, clinical features, management, and outcomes of AMI.

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Introduction: In the era of endovascular repair, open repair for abdominal aortic aneurysm (AAA) is still needed in the patients who had anatomical difficulties with the endovascular repair. Open repair for internal iliac artery aneurysm (IIAA) is a challenge because of the deep operating field, which is associated with high morbidity. Therefore, we performed preceding coil embolization for IIAA before open repair to control the bleeding from gluteal arteries. Materials and Methods: The present study is a retrospective case series study. Ten patients underwent preceding coil embolization for IIAA before open repair between January 2010 and August 2015. Three patients had two-stage coil embolization for bilateral IIAA. Six patients also had infrarenal AAAs. After preceding coil embolization, open repair consisting of vascular graft replacement with aneurysmectomy and closure of IIAA was undertaken. Results: The mean age was 72.5 ± 10.7 years. There were nine men and one woman. Operative time and intraoperative bleeding were 270 ± 50 min and 817 ± 671 mL, respectively. There was no postoperative mortality. Three patients developed morbidity, which consisted of paralytic ileus, pneumonia, and shower embolization caused by shaggy aorta. No recurrent IIAA, buttock claudication, and intestinal ischemia after the open repair were observed. Conclusion: Preceding coil embolization for IIAA before open repair may be an effective procedure to control the bleeding from gluteal arteries and prevent recurrent IIAA.

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