Severe leg swelling following removal of a temporary femoral venous hemodialysis catheter.

Temporary central venous catheters are commonly used for patients who require emergency hemodialysis (HD). An arteriovenous fistula (AVF) is a rare complication of this procedure. In this case report, we present a patient who was diagnosed with an iatrogenic femoral AVF after cannulation of the right femoral vein with a temporary HD catheter.

An epithelioid haemangioma of the ulnar artery masquerading as an aneurysm.

Epithelioid haemangiomas are rare benign vascular tumors that usually present as subcutaneous nodules in the head and neck area. Occasionally these tumors can arise in a peripheral artery. When it does so, it is often confused with an aneurysmal dilatation of the respective vessel. In these circumstances, surgical resection with vascular reconstruction is the preferred treatment option.

Mycotic aortic aneurysm in a debilitated patient with compromised immunity; beware of Candida!

Candida is a rare cause of infected aortic aneurysms. We report the case of a diabetic patient with end stage kidney disease who underwent repair of a leaking abdominal aortic aneurysm. He was on long-term antibiotic treatment for malignant otitis externa. Candida albicans was isolated from the culture of the excised aneurysm wall. An infected aortic aneurysm due to Candida has not been previously reported in a patient with malignant otitis externa. This case report aims to highlight that Candida should be suspected as a cause of infected aortic aneurysms in patients with debilitation and chronic immunosuppression. Management of such cases can be extremely challenging, especially in resource-poor settings, and we will be touching upon the advantages and disadvantages of various treatment options.

A cândida é uma causa rara de aneurismas da aorta infecciosos. Relatamos o caso de um paciente diabético com doença renal terminal, que foi submetido a reparo de aneurisma da aorta abdominal com vazamento. Ele estava em tratamento de longo prazo com antibióticos para otite externa maligna. A Candida albicans foi isolada da cultura da parede do aneurisma que sofreu a excisão. Não há relatos prévios de aneurisma da aorta infeccioso causado por cândida em pacientes com otite externa maligna. Este relato de caso visa reforçar que a cândida deve ser uma das suspeitas de causa de aneurisma da aorta infeccioso em pacientes debilitados e com imunossupressão crônica. O manejo desses casos pode ser extremamente desafiador, principalmente em contextos em que os recursos são escassos, e mencionaremos as vantagens e desvantagens das diversas opções de tratamento.

Pulsatile varicose veins: an uncommon presentation of a common condition.

Varicose veins of the lower limbs are common. However, pulsatile varicose veins are unusual. They could be an indicator of a sinister underlying pathology, such as severe cardiac dysfunction. It is easy to miss these rare cases during clinical workup, which can result in futile treatment with potentially dangerous consequences. In this report, we describe 2 cases of pulsatile varicose veins that highlight different etiologies and management strategies for this condition.

Varizes dos membros inferiores são comuns. Entretanto, varizes pulsáteis são raras, podendo ser indicadoras de uma patologia subjacente sombria como disfunção cardíaca grave. É fácil deixar passar esses casos raros durante exames clínicos, o que pode resultar em tratamento fútil com consequências potencialmente perigosas. Neste relato, descrevemos dois casos de varizes pulsáteis que evidenciam as diferentes etiologias e estratégias de manejo para essa condição.

Clinical Outcomes Following Lower Extremity Vein Bypass for Chronic Limb Threatening Ischaemia (CLTI) at the University of Colombo, Sri Lanka.

OBJECTIVE: Although high quality epidemiological data are lacking, the global increase in chronic limb threatening ischaemia may be disproportionately affecting low and LMICs. All available data for outcomes from bypass for limb salvage are from high income countries, with none from LMIC settings where the challenge is greatest. This study aimed to assess the clinical outcomes following vein lower extremity bypass for chronic limb threatening ischaemia at the University of Colombo, Sri Lanka, and to compare patients and outcomes with those described in the Society for Vascular Surgery (SVS) Objective Performance Goals (OPG) and United States National Surgical Quality Improvement Program (NSQIP). METHODS: Consecutive patients (n = 367) undergoing SVS-OPG eligible lower extremity bypass between 2015 and 2017 were studied. Thirty day major adverse cardiovascular events (MACE), major adverse limb events (MALE), deaths, and amputations are reported, along with one year overall survival, limb salvage, and amputation free survival. RESULTS: Patients at University of Colombo had more diabetes mellitus (80% vs. SVS 57% vs. NSQIP 50%, p < .001) and tissue loss (100% vs. SVS 74% vs. NSQIP 59%, p < .001). The 30 day MALE was 7.6%, which is not a statistically significant difference from the SVS (6.1%) or NSQIP (9%). The 30 day MACE was 8.2%, statistically significantly higher than NSQIP (4.2%, p < .001) but not SVS (6.2%, p = .20). At 12 months, the overall survival (82%) was within the OPG threshold, but limb salvage (81.8%) and amputation free survival (64.5%) were just outside. CONCLUSION: Outcomes following vein bypass for ischaemic necrosis at the University of Colombo, Sri Lanka, are acceptable and similar to those reported from high income countries despite greater limb threat severity and resource limitations. Further real world data from similar settings on outcomes following revascularisation are required. These data suggest that a vein bypass first strategy for advanced ischaemic necrosis is feasible and effective even in resource limited settings.

A cross-sectional study on peripheral arterial disease in a district of Sri Lanka: prevalence and associated factors.

BACKGROUND: Peripheral arterial disease (PAD), a slowly progressive atherosclerotic disease affecting vital organs of the body, is increasingly recognized as a health burden worldwide. Epidemiological information on peripheral arterial disease is scarce in Sri Lanka. The present study intended to estimate the prevalence and associated factors of PAD among adults aged 40-74 years in Gampaha district, Sri Lanka. METHODS: A cross-sectional study was carried out to estimate the prevalence of PAD among adults aged 40-74 years in four randomly selected divisional secretariat areas in Gampaha district in 2012-2013. The sample size of 2912 adults was obtained from 104 clusters using multistage probability proportionate to size sampling. The number of individuals to be included in the 5-year age groups between 40 and 74 years was determined based on the population proportion of the respective age groups in the district. Cluster size was 28, and equal numbers of males and females were selected for each age group per cluster. PAD was defined as having an ankle-brachial pressure index ≤ 0.89. RESULTS: The age-and sex-standardized prevalence of PAD, adjusted for the sensitivity of the ankle-brachial pressure index was 3.6% (95% CI 2.9-4.3%), and no significant difference was found between males (3.7%) and females (3.6%) (p = 0.08). Eighty-eight individuals were newly identified as having PAD, and a significant trend of prevalence with increasing age was observed (p < 0.001). Histories of diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, cerebrovascular accident, smoking, and erectile dysfunction among males were significantly associated with PAD (p < 0.001). Only one third of those with PAD experienced claudication symptoms. CONCLUSIONS: PAD was found to be a hidden disease in the Gampaha district population. Although there is minimal attention on PAD at present, the disease is likely to become a problematic public health concern in Sri Lanka, particularly with its aging population. Primary prevention measures to modify risk factors of PAD, including screening activities for early identification, should be a priority.

The undergraduate virtual grand teaching ward round: Perceptions from the subcontinent.

Background Grand ward rounds are an integral component of undergraduate medical education. Covid-19 prevented the conduct of conventional grand ward rounds (CWRs) prompting a 'virtual' grand ward round (VWR). With restrictions lifted should future grand ward rounds remain virtual? Undergraduate perceptions on the two formats were sought to explore the feasibility of the VWR as a teaching ward round for medical students. Methods Our study was done during April 2021 to April 2022. The weekly grand ward round was converted to a VWR during April-November 2021. Following lifting of restrictions, it was reverted to a CWR. All patients provided informed consent. A Zoom-based, secure, online platform was created with the use of smartphones to share audiovisuals and patient discussions. An online anonymised feedback survey was conducted for undergraduates during both VWR and CWR phases. Results The response rate was 71% (182/258). VWR was considered more advantageous than the CWR in terms of time efficiency (p=0.03), space restrictions (p=0.01), improved audibility (p=0.02) and better opportunity to engage in discussions (p=0.1). Most students (80%) felt that the VWR provides a more 'ideal' grand ward. Overall preference was towards VWR across safety (92%), efficacy (72%), communication (85%), information availability (84%) and training opportunity (73%). Again 80% of students preferred future ward rounds to be virtual. Conclusions VWR is an innovative approach. While not a substitute for bedside teaching it appears safer, efficient, thought/discussion-provoking and more satisfactory. Successful elements of the VWR can be adopted in future, to develop a more ideal undergraduate grand ward round.

Major Lower Limb Amputation for Chronic Limb-Threatening Ischemia Is Associated with Poor Long-Term Survival: 4-Year Follow-Up of a Single-Center Experience.

Objective: Despite advances in medicine, 30% of patients with chronic limb-threatening ischemia (CLTI) require major lower limb amputation (MLLA). The long-term outcome of this cohort is poorly described. Methods: In all, 154 patients undergoing MLLA for CLTI during 2018-2020 were analyzed for short-term and long-term outcomes and prosthesis use. Results: In total, 106 below-knee amputations and 48 above-knee amputations were followed up for a mean duration of 50 months (37-78). The mean age of the cohort was 63 years. The majority were male (60%) with multiple comorbidities, including diabetes (83.8%), hypertension (49.4%), ischemic heart disease (20%), and smoking (32.5%). An equal proportion underwent MLLA as primary (45%) or secondary (55%). 30-day mortality was 6%. The mean length of in-hospital stay was 18 days (3-56). Overall survival rates at 1st, 2nd, and 4th year were 73%, 64%, and 35%, respectively. On a multivariate regression analysis, a higher level of amputation had a significant impact on mortality (p = 0.015). 54% of amputees had a prosthetic limb. However, the primary use of prosthesis was for cosmesis, with only 12% mobile independently. Conclusions: MLLA for CLTI is associated with poor early and long-term survival. Prosthesis use and mobility are extremely poor in the Sri Lankan context.

A Case of Common Carotid Artery Occlusion: A Unique Pattern of Occlusion and Lessons Learned.

Common carotid artery occlusion (CCAO) is a rare cause of cerebrovascular events. For patients with neurological deficits due to emboli from an occluded common carotid artery, ligation of the ipsilateral internal carotid may appear as a simple therapeutic option, provided there is adequate collateral circulation. Here, we describe a patient with an unusual pattern of CCAO, who underwent ligation of the internal carotid artery after a successful test occlusion with a hypotensive challenge. He suffered a delayed stroke. This case report aims to highlight the unique pattern of CCAO in this patient and our experience with his management.

Iatrogenic Deep Femoral Artery Pseudoaneurysm Causing Quadriceps Paralysis: An Indication for Open Surgery in an Endovascular Era.

Contemporary management of iatrogenic pseudoaneurysms is mostly performed using non-surgical techniques. Herein, we present a rare case of deep femoral artery (DFA) pseudoaneurysm with compression neuropathy, which required open repair. A 67-year-old female patient presented with increasing pain in the right groin, sensory neuropathy of the anteromedial thigh and upper leg, and quadriceps paralysis 4 days after coronary angiography via femoral puncture. Computed tomography angiography revealed a pseudoaneurysm of the DFA. The disabling compressive neuropathy warranted urgent open decompression rather than thrombin injection or endovascular therapy. Timely open evacuation of the hematoma, release of compression on the femoral nerve, and postoperative physiotherapy resulted in complete recovery of quadriceps power. The patient was pain free within 12 weeks and able to ambulate independently. This case report highlights the role of prompt open surgery for pseudoaneurysms with compression neuropathy.

Infected Aortic Aneurysm with Infective Spondylitis in a Patient with Pre-Aortic Confluence of the Iliac Veins: An Unusual Triple Combination.

It is uncommon for infective spondylitis to coexist with an infected aneurysm of the adjacent abdominal aorta. Also, pre-aortic confluence of the iliac veins or marsupial vena cava is a rare anatomical variant, which increases the potential for venous injury and hemorrhage during an emergency operation. Herein, we report the case of a 57-year-old male with these three pathologies, who was successfully treated with emergency open surgery. During surgery, we noted this anomaly and extensive destruction of the lumbar vertebral bodies. We discuss options to treat these rare pathologies with literature review.

Spontaneous Transection of the Superficial Femoral Artery with Devastating Outcomes: A Case Report.

Non-traumatic, simultaneous pseudoaneurysms of the bilateral superficial femoral arteries (SFAs) are extremely rare. Spontaneous transection of the SFA is another unique pathology. Here, we present a patient with end stage kidney disease who was diagnosed with bilateral, simultaneous SFA pseudoaneurysms. He had a recent history of methicillin-sensitive Staphylococcus aureus septicemia; therefore, infection was suspected to be the main cause. Complete transection of the SFA was noted during the operative exploration of the symptomatic left side. Wide debridement and autologous vein bypass were performed via a clean route. Unfortunately, two months later, recurrent surgical site infection caused distal anastomotic rupture and fatal sepsis.

Aortoenteric Fistula after Endovascular Aneurysm Repair.

Aortoenteric fistula is a rare complication following endovascular abdominal aortic aneurysm repair. However, there is a significant morbidity and mortality associated with this complication. Patients can present with gastrointestinal hemorrhage, fever, or nonspecific features of chronic infection. Extra anatomic bypass with complete graft explanation is the standard management.

Pulsatile varicose veins: an uncommon presentation of a common condition / Varizes pulsáteis: uma apresentação incomum de uma condição comum

Abstract Varicose veins of the lower limbs are common. However, pulsatile varicose veins are unusual. They could be an indicator of a sinister underlying pathology, such as severe cardiac dysfunction. It is easy to miss these rare cases during clinical workup, which can result in futile treatment with potentially dangerous consequences. In this report, we describe 2 cases of pulsatile varicose veins that highlight different etiologies and management strategies for this condition.

Resumo Varizes dos membros inferiores são comuns. Entretanto, varizes pulsáteis são raras, podendo ser indicadoras de uma patologia subjacente sombria como disfunção cardíaca grave. É fácil deixar passar esses casos raros durante exames clínicos, o que pode resultar em tratamento fútil com consequências potencialmente perigosas. Neste relato, descrevemos dois casos de varizes pulsáteis que evidenciam as diferentes etiologias e estratégias de manejo para essa condição.

Mycotic aortic aneurysm in a debilitated patient with compromised immunity; beware of Candida! / Aneurisma micótico da aorta em paciente debilitado com imunidade comprometida - um alerta para Cândida

Abstract Candida is a rare cause of infected aortic aneurysms. We report the case of a diabetic patient with end stage kidney disease who underwent repair of a leaking abdominal aortic aneurysm. He was on long-term antibiotic treatment for malignant otitis externa. Candida albicans was isolated from the culture of the excised aneurysm wall. An infected aortic aneurysm due to Candida has not been previously reported in a patient with malignant otitis externa. This case report aims to highlight that Candida should be suspected as a cause of infected aortic aneurysms in patients with debilitation and chronic immunosuppression. Management of such cases can be extremely challenging, especially in resource-poor settings, and we will be touching upon the advantages and disadvantages of various treatment options.

Resumo A cândida é uma causa rara de aneurismas da aorta infecciosos. Relatamos o caso de um paciente diabético com doença renal terminal, que foi submetido a reparo de aneurisma da aorta abdominal com vazamento. Ele estava em tratamento de longo prazo com antibióticos para otite externa maligna. A Candida albicans foi isolada da cultura da parede do aneurisma que sofreu a excisão. Não há relatos prévios de aneurisma da aorta infeccioso causado por cândida em pacientes com otite externa maligna. Este relato de caso visa reforçar que a cândida deve ser uma das suspeitas de causa de aneurisma da aorta infeccioso em pacientes debilitados e com imunossupressão crônica. O manejo desses casos pode ser extremamente desafiador, principalmente em contextos em que os recursos são escassos, e mencionaremos as vantagens e desvantagens das diversas opções de tratamento.

Open repair of infra renal abdominal aortic aneurysms: a single center experience from the developing world.

INTRODUCTION: In the absence of endovascular aneurysm repair due to financial constraints, Abdominal Aortic Aneurysm (AAA) in Sri Lanka is managed exclusively by open surgery. We report our experience with open AAA repair with emphasis on peri-operative morbidity and mortality. METHODS: Seventy nine consecutive open AAA repairs were carried out between April 2004 and March 2010. A multiple regression model was used to identify predictors of significant peri-operative morbidity and mortality. RESULTS: Mean age of the study cohort was 68 years. There were 63 (80%) males and 16 (20%) females. Mean aneurysm diameter was 6.4 (3.5-9.70) cm. Twenty seven (34%) underwent emergency surgical repair (group-1) while 52 (66%) had elective repair (group-2). The peri-operative mortality was 10/27 (37%) in group-1, 4/52 (7.6%) in group-2, (p = 0.0035). Significant post-operative morbidity was seen in 5/17 (29%) in group-1 and 7/48 (15%) in group-2, (p = 0.27). Aneurysm diameter >7 cm (p = 0.001), emergency repair (p = 0.004), history of smoking (p = 0.002), aortic cross-clamp time >60 minutes (p = 0.044), and need for post-operative ventilwation >24 hours (p = 0.024) were found to be independent predictors of peri-operative mortality or significant morbidity. CONCLUSION: Open aneurysm repair still has a strong place especially in the limited resource setting, with acceptable outcomes.

A case of a mycotic aneurysm of the superficial femoral artery infected by mixed bacterial species.

A 65-year-old woman, recently diagnosed with diabetes, presented with fever and a warm, pulsatile, tender mass over the medial aspect of her left thigh. She gave a history of diarrhea two weeks earlier. All lower limb pulses were present. CRP was 18.3 mg/l with evidence of neutrophil leukocytosis. Contrast angiography demonstrated a saccular aneurysm in her left superficial femoral artery (SFA). The aneurysm and surrounding infected, necrotic muscle was excised, and the limb was re-vascularized in-situ. Cultures from the aneurysmal wall grew both coliform bacilli and staphylococcus aureus. A mycotic aneurysm of the SFA, following a previous gastroenteritis, harbouring both staphylococcal and coliforms, makes this case unique.