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Background: Long saphenous vein (LSV) is used usually as the graft of the choice in the treatment of critical limb ischemia (CLI). LSV graft in femoropopliteal and femrodistal bypasses is more durable and also associated with reduced surgical mortality ratios and good success rates in preserving the ischemic limb. Synthetic graft, i.e. Dacron /Polytetrafluoroethylene (PTFE) is a good alternative if the saphenous vein is not available. PTFE has been the most popular choice. However, the preference for PTFE over Dacron is not evidence-based. The optimum graft configuration for the above-knee femoropopliteal bypass, whether PTFE or Dacron, remains a subject of controversy. Objective: To outcome whether Dacron versus PTFE Grafts as optimum in supragenicular femoropopliteal revascularization. Patients and Methods: Fifty patients with critical limb ischemia referred to Vascular Surgery Department, Al-Azhar University, Sednawy and El-Araby Hospitals were included during the period from July 2018 to April 2020. They had foot lesions as ulcer, wound or tissue loss associated with non-palpable distal pulses, and long occlusion of superficial femoral artery (SFA) defined as TransAtlantic Inter-Society Consensus (TASC) II C or D lesions. End points were healed, healing, nonhealing wounds or amputation. Patients were divided into two groups: group A included 25 patients who underwent Dacron graft bypass “DB”, and group B included 25 patients who underwent PTFE bypass “PB”. Results: Twenty- two patients (44%) reached the end point of complete healing (10 patients did “DB” and 12 did “PB”), whereas twenty-six patients (52%) had no or inadequate healing lesions. The limb salvage after one year was 40 patients (80%): 21 of them with ‘DB’ technique, and 19 with ‘PB’ technique. The remaining 8 patients (16%) underwent major amputation (5 with ‘DB’ technique and 3 with ‘PB’ technique) and two patients (4%) died. The early patency rate at 1 and 3 months was 92.43 % in the group with ‘DB’, and 94.39% in the group with ‘PB’. The late patency rate at one year post-operatively was 63.63 % in the ‘DB’ group and 68.63 % in the ‘PB’ group. Conclusion: Both Dacron and PTFE grafts were effective regarding wound healing and limb salvage as well as patency rate in supragenicular femoropopliteal revascularization.

Introduction: Varicose veins are part of the spectrum of chronic venous diseases and include dilated, tortuous veins of lower limbs, spider telangiectasia and reticular veins. Varicose vein disease is a very common problem of the western world and mostly their patients come for treatment because of cosmetic reasons. Indian scenario is different as mostly patients from lower socioeconomic strata of the society come for complications like ulceration, dermatitis etc. of varicose veins come for treatment. This problem sometimes results in chronic absenteeism from work, economic losses and change of occupation in many individuals. Methods: This observational study was carried out from 1st January 2017 to 30th June 2018 in Sri Aurobindo Medical College and Postgraduate Institute, Indore. Clinical profile of 52 patients of varicose vein disease was studied. All the patients were thoroughly examined and the pertaining data recorded. This data was tabulated and compared with the available literature on this subject. Results: Fifty two cases of varicose vein disease were studied. The commonest age group affected with the disease was between 41 to 50 years. Male patients were more and comprised of 84.6% of total number. Sapheno femoral junction valve was incompetent in 73.1 % cases as compared to saphenopopliteal junction[34.6%].Obesity was an important factor in causation of varicose vein disease. Flush ligation at SFJ with stripping was the commonest surgical procedure carried out our center. Conclusion: It is found that varicose vein disease with its associated sequelae brings the patient for treatment in our scenario. Long saphenous vein is the commonly affected part of the superficial venous system because of incompetency of the valve at SFJ. Although various etiological factors can be attributed to varicose vein disease but occupation and obesity remain the main factors. Accurate assessment of problem and adequate surgery will prevent recurrence. Key words: Varicose veins, venous ulcers, recurrent varicose veins.

Objective The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts amongst multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort amongst these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arterial-venous loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with arteriovenous (AV) loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to follow to guide mangled limb salvage. Methods Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which twenty-one received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All ten patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores (MESS) were tabulated. Patients age ranged from 21-44 with 8 males and 2 females. Repeated debridements until successful sterilization of the wounds was accomplished. Ten long saphenous vein arteriovenous loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post AV loop creation for vascular complications and wound assessments. Results All ten patients had sterilization of the wounds with repair of the fracture site prior to vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (Range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi and 1 anterior thigh graft within 10 days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The nine patients with successful procedures reached pre-operative ambulatory status within 3 months after their final surgery. At 24 months follow-up, 90% amputation free survival is still maintained. Conclusion Although a small patient cohort, utilization of long saphenous vein arterio-venous loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long term data needs to be complied to assess patency of the free flap transfer and quality of life outcomes.

The lower limbs’ venous system has the pressure of posture, and blood has to be pushed against gravity into the heart cavity. This issue is generally approached either by a cautious approach or by surgical interference, all of which are constrained. Attempts to study different clinical manifestations of varicose veins are being made in the present study. The overall number of 50 varicose vein patients was analysed and the study results were reported. Varicosity veins of the lower limb is a fairly normal pathological entity. In the 20-50 age range, the condition is more common. The main modality of the procedure is surgery. The most common technique performed is Saphenofemoral flush ligation with stripping.

Background: Contrary to traditional long saphenous vein (LSV) surgeries, stripping and endovenous laser ablation, using heat coagulation, ambulatory conservative hemodynamic correction of venous insufficiency (CHIVA) is LSV sparing technique. Aim: Based on the lack of studies discussing success and recurrence rate, this study was designed to assess the immediate and one-year follow-up of this technique, as well as its efficacy and safety. Patients and Methods: Thirty-three patients with primary LSV varicosities were included in this uncontrolled clinical trial. Patients with LSV diameter of ≥ 9.5mm or pregnancy were excluded. Results: The mean age of our patients was 33.36±8.865 years, and 54.5% of them were males. According to Hobb's score, 25 patients (75.7%) were completely cured, 6 patients (18.1%) were improved, while 2 patients (6.2%) were considered as failure. Most (87.9%) of the patients showed absent or no visible recurrence. The rest showed visible recurrence by duplex ultrasound. All patients had significant improvement of their symptoms (no pain, or edema) at the immediate follow-up after operation. No complication including hematomas, ecchymosis, hemorrhage, saphenous nerve neuralgia, phlebitis, infection, deep or LSV thrombosis was detected. Conclusion: CHIVA is a successful and effective option in managing patients with primary long Saphenous varicosities, with minimal recurrence rate, after one-year of follow-up.

The long saphenous vein (LSV) is commonly used as a conduit in coronary artery bypass grafting. However, long term patency remains limited by the development of vascular inflammation, intimal hyperplasia and accelerated atherosclerosis. The impact of acute exposure of venous endothelial cells (ECs) to acute arterial wall shear stress (WSS) in the arterial circulation, and the subsequent activation of inflammatory pathways, remain poorly defined. Here, we tested the hypothesis that acute exposure of venous ECs to high shear stress is associated with inflammatory responses that are regulated by NF-κB both in-vitro and ex-vivo. Analysis of the LSV endothelium revealed that activation of NF-κB occurred within 30 min after exposure to arterial rates of shear stress. Activation of NF-κB was associated with increased levels of CCL2 production and enhanced binding of monocytes in LSVECs exposed to 6 h acute arterial WSS. Consistent with this, ex vivo exposure of LSVs to acute arterial WSS promoted monocyte interactions with the vessel lumen. Inhibition of the NF-κB pathway prevented acute arterial WSS-induced CCL2 production and reduced monocyte adhesion, both in vitro and in human LSV ex vivo, demonstrating that this pathway is necessary for the induction of the acute arterial WSS-induced pro-inflammatory response. We have identified NF-κB as a critical regulator of acute endothelial inflammation in saphenous vein in response to acute arterial WSS. Localised endothelial-specific inhibition of the NF-κB pathway may be beneficial to prevent vein graft inflammation and consequent failure.

Background: In a developing country like India, study encompassing the clinical evaluation and management of lower limb varicose veins on the conventional lines seem a necessity to improve the quality care with the available resources. Aims and Objectives 1. To analyse the age and sex incidence of lower limb varicose veins. 2. To study the correlation between occupation and lower limb varicose veins, the clinical manifestations of lower limb varicose veins, the different treatment modalities like sapheno-femoral flush ligation, multiple subfascial perforator ligations, stripping and sclerotherapy and the respective clinical outcomes at the end of three months of follow up.Methods: A total 60 number of patients with primary lower limb varicose veins were admitted, investigated, operated and followed up from June 2019 to January 2020. Final outcome was evaluated. Results: It was noted that the varicose veins affected the younger adult and middle age population. A greater portion (48.3) of the patients had combined valvular incompetence (sapheno-femoral and sapheno-popliteal incompetence) Sapheno-femoral flush ligation withstripping appeared to be the best method of surgical management for incompetence in the long saphenous vein territory. Subfascial perforator ligation in patients with no junctional incompetence showed no recurrence Sclerotherapy was found to be an effective procedure especially for early varicosities. Conclusions: Majority 0f the patients presented with complications of varicose vein with combined valvular incompetence and Sapheno-femoral flush ligation with stripping appeared to be the best method of surgical management for incompetence in the great saphenous vein territory. When no junctional incompetence is present, performing sub facial perforator ligation alone for isolated perforator incompetence showed no recurrence in this study.

Uncertainty exists around the optimal method of leg wound closure following open long saphenous vein harvesting in adults undergoing coronary artery bypass graft surgery (CABG). Such is evident from the variety observed in the closure approach utilised. Consequently, a best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘following open long saphenous vein harvesting in adults undergoing CABG, is single-layer leg wound closure superior to multiple-layer closure in terms of post-operative complications encountered? ‘. Altogether 382 papers on Ovid Embase and Ovid Medline, 301 papers on PubMed and 11 papers on the Cochrane database were found using the reported search. From the screened articles, 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the best method of leg closure following open saphenous vein harvesting for CABG is single-layer cutaneous closure. The use of a suction drain to eliminate the dead space should be considered on a case-to-case basis by the lead operating surgeon with the patient's characteristics and their own expertise in mind., Highlights • Uncertainty exists around the best closure method after open harvesting of the long saphenous vein for CABG in adults. • Various options include single-layer and multiple-layer closure. • Therefore, we conducted a literature review to identify the best closure technique. • We conclude that the best method is single-layer cutaneous closure. • The use of a suction drain to eliminate the dead space should be considered.

Background: Utilisation of the Endoscopic Vein Harvesting (EVH) technique has been increasing for coronary artery bypass grafting (CABG) for the last two decades. Some surgeons remain concerned about the long-term patency of the long saphenous vein harvested endoscopically compared to traditional Open Vein Harvesting (OVH). The aim of this study was to perform a retrospective analysis of the outcomes between EVH and OVH from three UK centres with 10 years follow-up. Methods: 27,024 patients underwent CABG with long saphenous vein harvested by EVH (n=13,794) or OVH (n=13,230) in three UK centres between 2007 and 2019. Propensity modelling was used to calculate the Inverse Probability of Treatment Weights (IPTW). The primary endpoint was mortality from all causes and secondary endpoints were length of hospital stay, postoperative complications, and incidence of repeat coronary re-vascularisation for symptomatic patients. IPTW was used to balance the two intervention groups for baseline and preoperative co-morbidities. Results: Median follow-up time was 4.54 years for EVH and 6.00 years for OVH. Death from any cause occurred in 13.8% of the EVH group versus 20.8% in the OVH group over the follow-up period. The hazard ratio of death (EVH to OVH) was 0.823 (95% CI: 0.767, 0.884). Length of hospital stay was similar between the groups (p=0.86). Post-operative pulmonary complications were more common in EVH vs OVH (14.7% vs. 12.8%, p Conclusion: This large retrospective multicentre analysis indicates that EVH has a lower risk of mortality compared with OVH during the follow-up period of the study. The observed benefits of EVH may outweigh the risks but should be considered on a case-by-case basis. We hope this review gives confidence to other cardiac centres that offering an EVH approach to conduit harvesting does not affect long term patient outcomes.

Popliteal artery entrapment syndrome (PAES) is a rare cause of limb-threatening vascular disease. Usually, it arises from aberrant embryological development or acquired dysfunctionality of the popliteal artery and its surrounding musculotendinous structures in the popliteal fossa. Here, we present a case report of a young woman with relatively sudden-onset short-distance claudication and paraesthesia affecting her right leg primarily. She had no recent traumatic history and no atherosclerotic risk factors and was otherwise previously very active. She had a feeble right popliteal artery pulse and no foot pulses. Nerve conduction studies demonstrated no electrophysiological abnormalities. Following computed tomography angiography and magnetic resonance imaging, it was determined she had type 2 PAES. Subsequently, the patient underwent surgical division of a lateralised head of her medial gastrocnemius, resection of her fibrosed popliteal artery, and repair with a reversed long saphenous vein interposition graft. Following surgery, her symptoms resolved, and she remains on aspirin and ultrasound surveillance.

We describe a possible systemic vasculitis involving electively large veins. The patient presented with severe febrile lower limb pain. Diagnosis was made by color Doppler ultrasound (CDU) and confirmed by anatomopathological examination of the long saphenous vein, but not by examination of the temporal artery which was normal. CDU found a unilateral halo sign of one temporal artery and a major wall swelling of the lower limb proximal deep veins. The etiology of this possible vasculitis is still unknown. It could be an unusual clinical presentation of giant cell arteritis with vein involvement but without proven arterial involvement. To confirm this hypothesis, it would be interesting to look systematically for lower limb vein thickening with CDU in patients newly diagnosed with giant cell arteritis who have lower limb pain.

Background: Varicose vein are abnormally dilated, tortuous, elongated veins of lower limbs which have permanently lost their valvular efficiency. The main objectives of our study was to study etiological profile (Age, sex, occupation and site pathology) and different modalities utilized in our institute and to assess and study final outcome in patients included in our study. Methodology: It was a prospective study; fifty cases of varicose veins were attending outpatient Department and admitted in the Surgical Department of Deccan Medical College & Hospital from October 2018 to September 2019. Results: In the present study, fifty cases of varicose veins treated in our institute form the basis of this study. The average age of the patients was 41.86 years. The youngest patient was of 19 years and the oldest was 65 years of age. Varicose veins were common in males; the male to female ratio was 3.1:1. The number of patients who were involved in occupations requiring prolonged hours of standing was 35 (70%). A positive family history of varicose veins was present in only 4 cases (8%). Deep vein thrombosis was present in 7 patients (12.72%). The commonest presentation was dilated veins. The common associated symptoms were itching and pigmentation in 27 patients (54%) and ulceration in 13 patients (26%). 5 patients had bilateral varicose veins and the remaining 45 had only one limb affected. The limb commonly affected was right lower extremity in 29 cases (52.7%). Long saphenous vein was involved in 42 limbs (76.36%) and both long and short saphenous vein were affected only in 3 limbs (5.4%). Conclusion: The database of our retrospective study regarding age & sex incidence, clinicopathological features and therapeutic outcome was comparable to other studies in various literatures.

Coronary artery bypass grafting is a key cardiac surgery procedure and is the main treatment for patients with multivessel coronary artery disease. The most frequently used conduit for this procedure is the long saphenous vein (LSV). The technique of harvesting the LSV has evolved over the last 30 years from total open harvesting to endoscopic with minimal access technique. The most important determining factor for success in coronary artery surgery is the graft patency rate. The literature evidence behind each technique has been reported at different levels and there is an ongoing debate about which technique can provide optimum vein patency over the long term. This literature review aims to summarize the current evidence, the implications involved with the use of each technique for harvesting LSV and the patency rate at variable follow-up intervals.

Coronary artery bypass grafting is the most common cardiac surgical procedure performed worldwide and the long saphenous vein the most common conduit for this. When performed as an open vein harvest (OVH), the incision on each leg can be up to 85cm long, making it the longest incision of any routine procedure. This confers a high degree of morbidity to the procedure. Endoscopic vein harvest (EVH) methods were popularised over two decades ago, demonstrating significant benefits over OVH in terms of leg wound complications including surgical site infections. They also appeared to hasten return to usual activities and wound healing and became popular particularly in North America. Subgroup analyses of two trials designed for other purposes created a period of uncertainty between 2009-2013 while the impact of endoscopic vein harvesting on vein graft patency and major adverse cardiac events was scrutinised. Large observational studies debunked the findings of increased mortality in the short-term, allowing practitioners and governing bodies to regain some confidence in the procedure. A well designed, adequately powered, randomised controlled trial published in 2019 also definitively demonstrated that there was no increase in death, myocardial infarction or repeat revascularisation with endoscopic vein harvest. Endoscopic vein harvest is a Class IIa indication in European Association of Cardio-Thoracic Surgery (EACTS) and a Class I indication in International Society of Minimally Invasive Cardiac Surgery (ISMICS) guidelines.

Introduction: Varicosity is the common problem of various etiology having simple limb aching to worst complications like oedema, ulcer, and skin changes. Minimal invasive endovenous laser therapy is a noble procedure. The aim of the study is to find out the recurrence of the varicose vein after laser therapy in a tertiary care center. Methods: This descriptive cross-sectional study was done in 38 patients with varicosity of the lower limb in a tertiary care hospital, from January 2019 to June 2019 after taking ethical clearance from Institutional Review Committee. Convenience sampling was done. Data was collected and entry was done in Statistical Package for the Social Science software version 22, point estimate at 90% Confidence Interval was calculated along with frequency and proportion for binary data. Results: We recorded 38 patients with ablated limb out of which none of the ablated veins showed recanalization in six months follow up. Twenty two (58%) patients were male and 16 (42%) patients were female with a mean age of 40.26 years. Major bulk, 23 (60.5%) resumed activity in second postoperative day and only 1 (2.6%) patient waited for 5 days for normal activity with mean of 2.58 days postoperatively. Sixteen (42.1%) patients developed erythema or ecchymosis, 12 (31.6%) patients had induration along the long saphenous vein course, 7 (18.4%) patients had paresthesia, 2 (5.3%) patients had limb swelling and 1 (2.6%) patient had skin burn. Conclusions: Endovenous laser ablation has very low rate of recurrence of varicosity and has minorcomplications.

Objectives: Groin node dissection for recurrent vulval cancer in a previously irradiated field presents many surgical challenges - risk of vascular involvement, ill-defined planes and poor tissue quality for closure and healing. Our case demonstrates the feasibility of surgical management and value of flap reconstruction in managing disease relapse in such patients. Methods: We present the surgical approach to recurrent squamous cell carcinoma (SCC) vulva in a patient who has undergone previous radical radiotherapy to the site of relapse. Download : Download high-res image (268KB) Download : Download full-size image Results: In 2019 - a 70 year old lady underwent radical vulvectomy and left gluteal fold flap reconstruction, followed by radical radiotherapy and concomitant cisplatin for stage IIIc SCC vulva. A total of 12 months later, the patient presented with a clinically palpable, fixed left groin swelling. Imaging confirmed an FDG-avid 2.6 x 4.2 centimetre (cm) partially necrotic left inguinal lymph node, engulfing the femoral vessels. The patient was counselled pre-operatively by both gynae-oncology and plastic surgery – offering surgical excision of this single site recurrence, anticipating the need for further flap reconstruction for wound closure. Additional challenges included body mass index (BMI) of over 40 kilograms/metre2 and chronic candida of the abdominal pannus. Joint examination under anaesthetic by gynae-oncology and plastic surgery confirmed no vulval recurrence and no palpable right groin nodes. Left thigh perforator vessels were identified and marked using doppler. An 8.6 x 3.1cm elliptical incision was made around the fixed underlying node; and systematic inguino-femoral lymph node dissection performed using both bipolar scissors and an advanced energy device. An en-bloc specimen measuring 6.6 x 3.1 x 6.1cm was obtained. The femoral artery and vein were identified; and long saphenous vein preserved. Wound closure was achieved by raising an 18 x 8cm tensor fasciae latae (TFL) islanded flap, rotating and anchoring into place. Postoperatively, the patient was managed jointly under gynae-oncology and plastic surgery. Intravenous antibiotics, anti-fungals and thromboprophylaxis were given. The patient was advised to avoid sitting for 2 weeks. Drain outputs were monitored; and drains removed day 14. A small area of wound dehiscence occurred along the inferior border of the groin flap – which was healing well by secondary intention at the time of 4 week post-operative review, without need for further management. Final histopathology confirmed excised metastatic SCC, with a plan for ongoing surveillance arranged. Conclusions: In patients having undergone previous radiotherapy - surgery remains the main therapeutic option for recurrence. Undertaking such surgery, however, in a previously irradiated field - with altered anatomy and compromised perfusion - significantly increases the risk of inadvertent vessel or nerve injury and wound breakdown. We have demonstrated an approach, however, in an obese patient that achieved disease clearance through meticulous dissection, achieving wound closure and healing by incorporating TFL flap reconstruction.

A 58-year-old man on azathioprine with a history of ulcerative colitis underwent urgent coronary artery bypass grafting following a myocardial infarction, via a median sternotomy and open harvesting of the long saphenous vein. On postoperative day 5, he developed severe and progressive sternal and leg wound ulceration and necrosis, unresponsive to intravenous antibiotics and requiring surgical debridement. He developed septic shock requiring intensive therapy unit admission. Microbiology was negative and histology supported a diagnosis of pyoderma gangrenosum. Unresponsive to azathioprine and steroid therapy, he underwent a successful skin graft to the leg wound and pectoral reconstruction of the sternal wound.

Since its first introduction coronary artery bypass grafting (CABG) has become one of the mainstays in the treatment of ischemic heart disease. Both arterial and venous conduits as well as a variety of their combinations can be used. Long saphenous vein is the predominantly used venous conduit. Left internal thoracic artery (LITA), right internal thoracic artery (RITA), radial artery (RA), and right gastroepiploic artery (RGEA) are currently in use as arterial grafts. Pedicled or skeletonized harvesting techniques have been described for arterial conduits with the latter being recommended for ITAs. Minimally invasive endoscopic harvesting techniques can be applied to radial artery and long saphenous vein. The latter can also be harvested preserving the tissue surrounding the vessel (no-touch technique) as it is thought to improve patency rate. Biological augmentation or physical reinforcement of saphenous vein grafts (SVG) is also being proposed to improve patency. As far the grafting strategy is concerned, there is an established consensus on the use of arterial conduit on the left anterior descending coronary due to the well-established prognostic benefit. The choice of the second and further conduits for the remaining targets is still an area of debate due to the discrepancy in outcomes observed among randomized and large retrospective studies published in the literature. However, recent meta-analyses are pointing at the superiority of an arterial strategy in terms of long-term patency and outcomes. On the basis of the evidence currently available and on the basis of the long-term results of previous and new randomized controlled trials (RCTs), a multiple arterial grafting strategy should be the preferred approach in the majority of the patients and an ad hoc decisional algorithm has been recently suggested in this chapter.

Introduction The case of an idiopathic thrombosed popliteal aneurysm is described in an otherwise healthy 6 year old child. This is the fourth reported case and the second youngest patient to present with an idiopathic isolated popliteal aneurysm. Report A 6 year old boy presented with an acutely ischaemic right foot. Computed tomography angiography confirmed a thrombosed popliteal aneurysm. A femoropopliteal bypass was performed with reversed long saphenous vein and ligation of the aneurysm. Yearly follow up is ongoing with ultrasound surveillance; the child's growth and development is unaffected, and the graft is patent. There was a readmission over six years later with claudication on the right side. There was evidence of thrombus in the graft with associated distal embolisation, which was managed conservatively with anticoagulation. Discussion Given the rarity of such presentations in the paediatric population, there is minimal good quality data to guide treatment. There have been three previous cases of idiopathic popliteal aneurysms all managed with a reversed long saphenous vein femoropopliteal bypass with resection of the aneurysm. Management should be guided based on the clinical picture and should be undertaken in specialised tertiary centres if possible. Surgical intervention is the treatment of choice in patients with an ischaemic limb., Highlights • In children, idiopathic, true popliteal aneurysms are a rare clinical entity, with only three cases reported previously. • Surgical options are limited; femoral popliteal bypass was performed with reversed long saphenous vein. • There is minimal good quality data to guide treatment of these presentations in children; management should be undertaken in specialised centres.

Despite the apparent superiority of arterial conduits for coronary artery bypass grafting (CABG), the long saphenous vein remains the most commonly used graft. The high failure rate of long saphenous vein grafts (SVGs) over time is therefore an important limiting factor for the long-term outcomes of CABG. Various methods to improve SVG patency have been proposed, although few have had a significant impact on clinical practice. External SVG supports have been a focus of research over the past 50 years, with their use intended to minimize well-documented pathophysiological changes that occur in the SVG following implantation into the coronary circulation. These devices have been trialled extensively in animal models to assess their impact on both the morphology and the function of vascular conduits. Recently, a number of studies have been conducted in patients, leading to a substantial development in their design and the accumulation of a large body of evidence attesting to their potential benefit in CABG. In this review, we briefly discuss the proposed mechanism of action of external SVG supports and then evaluate the results from animal studies and more recent research assessing their use in CABG patients. Finally, we conclude that newer models of external stents have the potential to improve long-term outcomes in SVG.

Aims And Objectives: To compare the effectiveness, incidence of complications and recurrence after Trendelenburg operation and Trendelenburg operation combined with stripping of the thigh segment of long saphenous vein in the treatment of primary varicose veins of lower limb. Study is based on analysis Material & Methods: of 100 cases of primary varicose veins of long saphenous vein with or without perforator incompetence who got treated by either simple ligation or ligation with stripping of long saphenous vein from at Department of General Surgery, Osmania General Hospital, Hyderabad Telangana. After surgery residual long Results: saphenous vein reux was present in 22% cases in the group in which ligation alone was done and residual thigh perforators were identied in 11% of cases whereas in the group which underwent ligation combined with stripping of the thigh segment of long saphenous vein residual reux was present in 6% cases and no residual thigh perforators were identied. The i Conclusion: ncidence of Residual long saphenous vein reex and residual perforator in the thigh is less after ligation and stripping of long saphenous vein compared to Ligation of Saphenofemoral junction alone. The incidence of Nerve palsy and bleeding and hematoma is also not more in the ligation + stripping group compared to ligation alone.

The long saphenous vein is the most commonly used conduit in coronary artery bypass graft (CABG) surgery when bypassing multiple diseased arteries; however, its use is complicated by the development of vascular inflammation, intimal hyperplasia and accelerated atherosclerosis leading to compromised graft efficacy. Despite refinement of surgical techniques to improve graft patency, late vein graft failure remains a significant problem. Moreover, there is a lack of pharmacological interventions proven to be effective in the treatment of late vein graft failure. A greater understanding of the molecular nature of the disease and the interactions between endothelial and smooth muscle cells as a result of alterations in local haemodynamics may assist with designing future beneficial pharmacological interventions. Venous endothelial cells (ECs) are physiologically adapted to chronic low shear stress; however, once the graft is implanted into the arterial circulation, they become suddenly exposed to acute high levels of shear stress. A small number of in vitro and ex vivo studies have demonstrated that acute high shear stress is associated with the activation of a pro-inflammatory profile in saphenous vein ECs, which may be mediated by mitogen-activated protein kinase (MAPK) and nuclear factor-κB (NF-κB) signalling pathways. The impact of acute changes in shear stress on venous ECs and the role of ECs in the development of intimal hyperplasia remains incomplete and is the subject of this review.

A best evidence topic was written according to a structured protocol. The question addressed was whether endoscopic vein harvesting (EVH) is equivalent to open vein harvesting in terms of graft patency for patients undergoing coronary artery bypass surgery. A total of 417 articles were found using the reported search, of which 4 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these articles are tabulated. Reported outcomes were vein graft failure or patency on coronary angiography or computed tomography angiography at early, mid and long-term follow-up. Of the non-randomized studies reviewed, those with greater patient numbers and longer follow-up periods showed reduced patency rates in the EVH group. Two small early randomized controlled trials demonstrated equivalent patency rates at up to 6 months follow-up. However, a more recent randomized controlled trial showed reduced patency with EVH in 63 patients at a median follow-up of 6.3 years. We conclude that high-quality evidence for the effects of harvesting method on vein graft patency is lacking, with no large randomized trials performed to date. The current evidence suggests that although rates of vein graft failure seem to be similar within the first 6 months following surgery, EVH is associated with reduced graft patency from 12 months onwards.

Background Complex lower extremity trauma still poses a formidable challenge for micro vascular reconstruction. The extensive surrounding zone of trauma can make it difficult to find a suitable recipient pedicle for anastomosis. A need was felt for exploration of newer recipient vessels in lower extremity which could be harnessed for reliable and tension free micro anastomosis. The purpose of the present report is to highlight the possibility of using medial sural artery for safe micro vascular anastomosis in selected scenarios like vessel depleted extremity. Methods Between 2008 and 2013, we used the medial sural vessels for micro anastomosis in 10 cases of lower extremity trauma. All the cases had severe soft tissue trauma with or without a bony defect. A computed tomography angiogram (CTA) of the involved extremity revealed either severe perivascular scarring around the standard recipient vessels or patency of just a single vessel. However, in all cases a patent medial sural pedicle was identified on CTA. Interposition vein grafts (IVGs) were used in most cases to ensure a tension free anastomosis. Results In all cases, unscarred medial sural vessels were identified with average dissected length and diameter being 6.2 cm (range 4 to 7.5 cm) and 2 mm (range 1.5 to 2.5 mm) respectively. Vein graft [average length 5.6 cm (range 4 to 15 cm)] was interposed in seven cases, while in remaining three, long saphenous vein was used for vein anastomosis. All the flaps survived after the surgery. There was one re-exploration for evacuation of peri-anastomotic hematoma with no adverse effect on flap survival. The mean follow up period was 27.6 months. In the four cases with bone reconstruction, bony union was seen between 5 and 8 months. They were able to walk without aids and resume work after 10–14 months, following a structured rehabilitation program. The patients with soft tissue reconstruction (6 cases) could carry out aid free locomotion and resume their routine after 4–6 weeks. There were no long term complications in any of the flap. Conclusions Medial sural artery may prove to be a reliable recipient pedicle for use in complex lower extremity trauma cases and could possibly provide a safer alternative in cases with severe perivascular scarring or in a “single vessel” extremity.

Introduction Despite multiple randomized trials, coronary artery bypass grafting (CABG) remains the gold standard revascularisation technique for severe coronary artery disease. The long saphenous vein (LSV) is the most common conduit used due to its abundant length and ease of harvest. Traditionally, LSV is harvested using an open technique. However, the open technique is associated with severe wound complications and poor cosmesis. Endoscopic vein harvesting (EVH) is a new minimally invasive vein harvesting technique with significant advantages. This technique was introduced in UHG on February 2017. Here we report our early experience of adopting this technique. Aim To assess the impact of EVH during our early experience. Method Data was obtained retrospectively from a prospectively maintained electronic database of all CABG patients from February 2017 to February 2019. Data analysis was performed using MS Excel. Results From February 2017 to February 2019, 207 patients underwent CABG procedure that required at least one LSV graft. 118 patients (57%) underwent EVH. During our early experience, the average harvesting time per vein graft length was 35 minutes for the first 10 cases. This improved significantly with experience with the average harvesting time per vein graft length now being 15 minutes. There was negligible blood loss in all cases. There were 5 conversions (4%) to open LSV harvesting, due to bleeding. There was no conversion in last 58 cases. Post operatively, average pain score was 1/10. 5 patients (4.2%) developed haematoma at the LSV harvest site, which did not require intervention. There were no late wound complications. In contrast, during the same period, 5 patients who had open LSV harvest, developed severe surgical site infection. Conclusion EVH, although challenging, could be introduced safely with appropriate mentoring. The adoption of EVH has significantly improved wound infection rate in patients undergoing CABG in our experience.

The talonavicular joint is defined as a ball-and-socket joint. It allows multiaxial movements as it is a component of the talocalcaneonavicular joint, also called the anterior subtalar joint, and a component of the transverse midtarsal joints. It is supported by the dorsal talonavicular, deltoid, and plantar calcaneonavicular (spring) ligaments. There are important neurovascular structures and tendons around the talonavicular joint including the long saphenous vein and nerve dorsomedially; the dorsalis pedis artery and deep peroneal nerve dorsolaterally; the tibialis anterior, extensor hallucis longus, and extensor digitorum longus tendons dorsally; and the tibialis posterior tendon plantarmedially.

Vulvar varicosities in nonpregnant females, either isolated or as a part of the pelvic congestion syndrome, are rare. We present a case of an adolescent girl with morbid obesity with bilateral bluish protrusions on the labia minora, as an incidental finding, that coincided with her excessive weight gain. The adolescent underwent thorough clinical examination, doppler ultrasound, contrast venography and varicography, and magnetic resonance angiography to rule out alternative diagnoses. Imaging results confirmed the presence of large venous lakes. Venous drainage to the internal iliac vein and connections with the long saphenous vein were delineated. Incompetence, dilatation, or reflux of ovarian or internal iliac veins, or their main tributaries, were not noted. Since the adolescent was asymptomatic and other pathologies, such as vascular malformations or hemangiomas were excluded, she was managed conservatively with counseling about lifestyle modification and weight reduction. This is only the third reported case of vulvar venous varicosities in adolescents. Female sex, along with obesity, are known risk factors for varicose vein formation; however, the pathogenesis is not fully understood. Additional research is needed to elucidate the role of excess adipose tissue in the pathophysiology of vulvar varicose veins and to optimize diagnostic workup and management in adolescence.

background and objectives: varicose vein are abnormally dilated, tortuous, elongated veins of lower limbs which have permanently lost their valvular efficiency. objectives of our study was to study clinical profile, complications and different modalities utilized in our institute and to assess and study final outcome in patients included in our study. methods: this study was a prospective observational and analytical study of 100 patients. Patients within age group of 10 to 70 years and patients with varicose vein complications were included in our study whereas patients with age less than 10 years and more than 70 years, patients with deep vein thrombosis, chronic debilitated and immune-compromised patients were excluded. results: 100 patients were treated for varicose veins of lower limb in our institute. Average age of the patients was 36 years. The youngest patient was of 15 years and oldest patient was 65 years old. Commonest presentation was dilated veins with itching and pigmentation in 65% of patients. Long saphenous vein was involved in 96% of limbs. Most common valve involved was SFJ. 25 patients were treated by sclerotherapy, residual varicosity seen in 4 patients. only 5 patients (20%) developed residual varicosity after operative procedure.

Purpose Peripherally inserted central catheters (PICC) are used extensively in neonates. However, insertion of these thinnest catheters is a very delicate procedure. We developed an easy and safe insertion technique for 2-French (F) PICCs with a new fine-tipped introducer cannula created without modifying commercial products by advancing a 24-gauge peripheral venous cannula through a half-peeled (20-gauge) introducer cannula. We evaluated neonates treated with our new PICC insertion technique. Methods Information was collected retrospectively on all 32 2-F PICCs inserted during the 4-year period from November 2010 to November 2014. We monitored neonates, recording the success rate of placement, number of insertion attempts, reasons for removal, and complications. Results In total, 32 2-F PICCs were placed in 31 patients (19 (61%) males and 12 (39%) females; median age 7 (range: 1–36) days, median weight 2200 (range: 800–4100) g) using the new technique. The vein accessed most commonly was the long saphenous vein (87%). The duration of catheterization was 10.3±4.2days. Almost all PICCs were inserted successfully (32/33, success rate 97%) and in the first venipuncture (28/32, 88%). Of the PICCs, 81% were removed after completion of therapy or upon death. Two minor bleeding complications were noted at the insertion site. Conclusions This novel technique is an easy and safe way of inserting a 2-F PICC in neonates. It can be used by anyone in a neonatal unit who can insert a 24-gauge peripheral venous access.

Vascular ultrasonography has an important role in the diagnosis and management of venous disease. The venous system, however, is more complex and variable compared to the arterial system due to its frequent anatomical variations. This often becomes quite challenging for sonographers. This paper discusses the anatomy of the long saphenous vein and its anatomical variations accompanied by sonograms and illustrations.

Background: Varicose veins defined as dilated, tortuous, subcutaneous veins ≥3 mm in diameter, measured in the upright position with demonstrable reflux. Though the history of varicose veins dates prehistorically, the advances in diagnosis and new management modalities gained attention recently. The aim of the present study was to study the clinical profile, risk factors and their association, different types of surgical procedures employed and complications associated with varicose veins.Methods: A one year observational after ethical committee approval was conducted by department of general surgery at ACSR Medical College. Cases fulfilling the inclusion criteria were clinically examined and duplex ultrasound colour Doppler was performed for diagnosing the varicose veins and findings of site of incompetence was noted. All the cases were operated and followed up for six months period. The results were tabulated and analyzed in Microsoft Excel for any corrections.Results: Eighty cases with 66.25% males and 33.75% females with mean age of 40.24 years and majority (40%) were in 41 to 50 years group. 60% of cases had varices in right limb and long saphenous vein was involved in 52.5% of cases.85% had dilated veins, perforator incompetence was noted below the knee in 30% of cases. 41.25% of cases saphenofemoral flush ligation with stripping of long saphenous vein. Wound infection was the common postoperative complication.Conclusions: Operative line of management should be the first line of treatment even though conservative management relieves the symptoms but always requires a definitive management.