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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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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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Introduction: Obturator artery is the branch of anterior division of internal iliac artery. Variations in its origin are quite common and are very important from surgical point of view. Methods: To study the variations in the origin of the obturator artery 35 dissected vessels were studied. Results: Commonest variation of its origin from the posterior division of internal iliac artery was found in five cases. Other variations like its origin from internal pudendal artery or from inferior gluteal artery were also found, which are also discussed along with its embryological basis and clinical significance. Conclusions: Knowledge of anomalous origin of obturator artery from posterior division is helpful to vascular surgeons while planning endovascular treatment.

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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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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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Ascending pharyngeal artery (APA) is a branch of the external carotid artery. Extracranial internal carotid artery (ICA) usually does not have any branches. We present here a rare case of anomalous origin of the APA from the extracranial ICA and discuss the clinical importance of this rare anatomical variant.

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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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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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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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Background: The success of hemodialysis depends on a functioning vascular access. The most important factor limiting the arteriovenous fistula (AVF) growth and patency is the availability of a good caliber venous segment: Cephalic veins smaller than 2.5 mm have been reported to have increased failure rates. Unfortunately, in the Indian population, we frequently come across patients with a poor cephalic vein diameter ≤2 mm. The present study was done to evaluate if primary balloon angioplasty (PBA) of these small cephalic veins could improve the primary patency rates and maturation time of autogenous AVFs, and also to compare this technique with the standard hydrostatic dilatation technique. Materials and Methods: Sixty patients requiring arteriovenous access surgery (but having small cephalic veins (≤2 mm) were randomized into two groups of thirty patients each. All patients underwent a thorough preoperative evaluation, after which they were subjected to AVF surgery. Thirty of these patients underwent standard hydrostatic dilatation (HD) whereas the remaining thirty were offered PBA of the vein before creating the fistula. These patients were followed up for 6 months and primary patency, reintervention rates, and maturation times were recorded. Results: Immediate technical success was 100% in the PBA group, with 6-month primary patency of 93.3%, whereas HD group had 73.3% immediate success and a 6-month primary patency of 63.3%. In HD group, 36.7% patients underwent re-intervention over a follow-up of 6 months, as compared to only 6.7% in PBA group. The average maturation time for PBA group was 32.83 days, whereas in HD group, it was 52.53 days. Conclusions: PBA of very small cephalic veins (≤2 mm) is a safe and feasible procedure. The technique is associated with excellent primary patency rates and decreased maturation time, significantly decreases the need for re-intervention, and is superior to the standard hydrostatic dilatation technique. It has the potential to maximize the number of patients with autogenous AVF by including those patients who have been rejected due to small cephalic veins.

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Objectives of this Trial: The objectives of this trial were to compare the treatment of lymphedema by creating artificial pathways along with standard compressive therapy versus standard therapy alone in Stage 2 and 3 lymphedema. Materials and Methods: A total of 18 patients were randomized into two groups. Silicone group (n = 8) received the placement of fenestrated silicone tubes subcutaneously from the hand to scapular region along with standard compression therapy, and the control group (n = 10) received standard compression therapy only. Follow-up was for 6 months. Results: A mean reduction of limb volume in the silicone group was 887 ml (25%), whereas in the control group, it was 250 ml (8%) (P = 0.01). All patients, 8 (100%) of silicone group and only 4 (40%) of control group, had ≥10% limb volume reduction at the end of 24 weeks with P = 0.013. More number of patients in the silicone group had a mean reduction in limb circumference of ≥2 cm as compared to the control group at almost all points of measurements along the limb with P < 0.05. There was a significant improvement in the quality of life, especially the functional domain in the silicone group with a P = 0.01. Improvement in pain-free range of motion in all major joints was observed in both the groups. No serious complications were reported. Postoperative ultrasonography and lymphoscintigraphy have shown patency of tubes, lymphatic fluid flow in silicone tubes. Postoperative indocyanine green lymphography showed decreased dermal backflow compared to preoperative. Conclusion: Combination of artificial lymphatics in the form of silicone tubes and standard care leads to a more significant reduction in the limb volume and limb circumference with improved quality of life with no serious complications.

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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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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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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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Accidental impaction of small fish bone in upper gastro intestinal tract is relatively common. Most of the time people ignore such small fish bone impaction as they become asymptomatic with subsequent swallowing of food. Rarely, it may perforate esophagus and cause serious complications and may even be fatal. A 28-year-old male was referred to us with a 4 day history of painful swallowing, and rapidly enlarging right sided neck swelling for last 3 days. He had a history of a fish bone impaction 2 weeks ago on the same side which he felt had resolved with subsequent dry rice swallow. Radiological investigation showed a pseudoaneurysm of the right common carotid artery (CCA) with impacted fish bone in the neck outside gastro intestinal tract impinging on the wall of CCA. The neck was explored; the CCA repaired, and patient was discharged in good health. This is an unusual complication of fish bone impaction. Urgent surgical intervention, rapid resuscitation and multidisciplinary approach are necessary for a good patient outcome.

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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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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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Objectives: To determine whether delayed vascular repair is feasible or has good results in delayed presented cases of vascular trauma, even after >48 h with ischemic changes in some cases. General literature said that <6 h is appropriate for limbs salvage but our study said that this time limitation can be extended to a greater extent. We have chosen this study because our adverse geographical conditions-desert, hilly and tribal, and roads conditions are not so apt that patients get accessible to surgical intervention in the time limit as stated in the literature. Hence, we consider these patients for surgery even after delayed presentation as limb loss is emotionally/psychological deterrent as well as economic hardship to the patient. To the best of our knowledge, this is the first report on delayed vascular trauma repair from our region of India. Materials and Methods: Prospective analyses of 100 patients operated for peripheral vascular injuries between August 2011 and April 2014 were done. Diagnosis tools included physical examination, pulse oximeter and handheld Doppler alone or in combination with computed tomography angiography. Primary end-to-end vascular repairs or embolectomies were carried out where possible; if not possible, interposition vein graft was placed. Patients with injury > 48 h, with obviously unsalvageable lower extremity injury requiring primary amputation, severe other body organ injury, on ventilator support, vascular injury below trifurcation of popliteal artery, and having ischemic line of demarcation were excluded from the study. Results: Of the 100 patients, 86 were males (86%) and 14 (14%) were females (14%), and their age ranging from 5 to 80 years. Mean duration of the presentation of our study cases was 56 hours after the injury. The most common etiological reason was road traffic accidents; nearly 67% of the patients in penetrating trauma group and 58% among blunt traumas. The incidence of concomitant orthopedic injuries was 74%. The most common injured artery was brachial artery 36%, followed by popliteal artery 30% and femoral artery 22%. Surgical intervention included primary repair with end-to-end anastomosis in 45%, and embolectomy in 15%, whereas interposition of vein graft were placed in 40% cases. Final outcome was – 77% had viable and functional limbs and 15% had viable, but nonfunctional limbs and amputation after repair was 8%. Conclusions: Delayed surgery in vascular injuries has a prognostic value for salvaging the extremity/limb and life of the patient as well as vascular injuries require immediate surgical intervention, regardless of localization but the extent of time limitation for vascular intervention can be widened. Patients suffering from vascular injuries to the extremities should be transferred to vascular surgery centers as soon as possible and consider the patient for surgery even after the delayed presentation.

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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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