Venous aneurysms (VAs) are uncommon vascular abnormalities characterized by a focal dilation of a vein, wherein the vessel is markedly enlarged compared to its original size. VAs can be classified as either superficial or deep. A 60-year-old female patient presented with a 25-year history of a spontaneous VA on her wrist. Throughout this duration, the patient experienced no pain, only mild discomfort. The aneurysm was superficial, subcutaneous, and diagnosed through clinical examination. Surgical ligation and excision were performed under local anesthesia. Swellings at this site on the wrist can be due to a ganglion, arteriovenous (A-V) fistula, implantation dermoid, or sebaceous cyst; however, this uncommon VA had distinctive clinical features. VAs are often diagnosed using duplex ultrasound, magnetic resonance venography, and blood tests. Definitive treatment involves surgical ligation and excision of the aneurysm.

Leiomyomas are benign mesenchymal stromal tumors of smooth muscle; while these are more traditionally found in the uterus, in rare cases, they can also be found in the breast, particularly in the subareolar region. Clinically and radiographically, these tumors are very similar to fibroadenomas but can be definitively distinguished based on distinctive histopathological features. Surgical management for breast leiomyomas has previously included procedures ranging from lumpectomy to mastectomy; however, resection of the tumor with free margins is the most well-recognized treatment for breast leiomyomas.

Urgent carotid endarterectomy (CEA) is beneficial in patients with non-disabling stroke or transient ischemic attack and significant ipsilateral carotid artery stenosis. It is recommended to be performed within 2-4 weeks of the event; however, its safety when done within 48 hours is still under investigation with potential risks of recurrent ipsilateral stroke and death being reported. This case highlights that urgent CEA done within 48 hours can result in significant neurological improvement. NICE advises within 48 hours of diagnosis and <7 days of radiological imaging while some large studies- especially a Swedish study of >2000 patients concluded an increased risk of stroke and death when performed within 48 hours. Evidence is still developing. In selected cases, this timely intervention can be the standard of care in the Caribbean setting in keeping with international best practice.

Introduction This study aimed to examine the characteristics and clinical outcomes of coronavirus (COVID-19) positive patients presenting with acute limb ischemia (ALI) during the coronavirus pandemic. Design and Methods A multi-center, observational study was undertaken. It included patients from three tertiary parallel healthcare facilities in Trinidad and Tobago who were COVID-19 positive and had an acute thromboembolic event between August 2020 and April 2022. The data was collected in a prospectively maintained database. Results Over the 21 months, 24 patients with ALI infected with COVID-19 were evaluated, analyzing 25 consecutive limbs. The cohort's median age was 62.2 years (42-88 years), of which 62.5% were male. The most common comorbidities were diabetes (45.8%) and hypertension (33.3%). 12.5% (3/24) of patients’ initial manifestation was acute arterial ischemia, with the remaining patients (87.5%) developing signs of ALI during their hospitalization for their COVID-19 infection. Additionally, 12.5% (3/24) of patients were found to have had extremity thrombosis at multiple levels. Treatment arms were categorized as medical (N= 16), surgical (open surgery 7, and endovascular 2) management. There were no major adverse limb events in patients treated surgically. Non-surgical management was more prevalent in severe cases of Covid-19 disease in 37.5%. The in-hospital mortality was 41.7% (the leading cause of death being acute respiratory distress syndrome and multiorgan failure), all of whom were managed medically. Conclusion COVID-19 posed unique challenges in the management of ALI, with increased mortality and primary amputation rates. However, in patients who underwent surgical revascularization, there was a 100% major amputation-free survival at 24 months.

Smooth muscle is a normal component of the inferior vena cava (IVC) wall. Although uncommon, the smooth muscle component may undergo neoplastic change. Benign neoplasms are termed leiomyomas, and when there is a malignant change, the nomenclature is changed to an IVC leiomyosarcoma. Leiomyosarcomas of the IVC are rare, with less than 150 cases reported in medical literature. Unfortunately, the majority of IVC leiomyosarcomas are diagnosed at advanced disease stages. Surgical resection of locally advanced lesions is technically challenging, but complete resection is the mainstay of treatment as leiomyosarcomas respond poorly to chemo-radiotherapy. Due to the advanced disease stage at diagnosis and the technical complexity of IVC resection and reconstruction, most patients are transferred to high-volume centers in developed nations. We report a case of a patient with a locally advanced leiomyosarcoma masquerading as a pancreatic head tumor. This patient could not access care in a high-volume center and required aggressive maneuvers to resect the IVC leiomyosarcoma in a resource-poor, low-volume center. We present this case to highlight the steps in operative management and also to show that these procedures can be carried out in resource-poor environments once there is meticulous planning, appropriate equipment, and multidisciplinary care.

This retrospective study investigated major adverse limb events (MALE) and mortality outcomes in critical limb-threatening ischemia (CLTI) patients with tissue loss after an endovascular revascularization-first (EVR-1st) strategy. MALE and mortality were assessed in 157 consecutive patients with CLTI and tissue loss from June 2019 to June 2022 at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. 157 patients underwent the EVR-1st strategy, of whom 20 were pivoted to immediate surgical revascularization (SR). Of the remaining 137 patients, successful EVR was achieved in 112, giving a procedural success of 82

Acute penetration of a total hip arthroplasty into the pelvic cavity is a grave and potentially catastrophic scenario. Fortunately, this complication is uncommon and rarely encountered during a surgical career. Currently, a two-stage procedure is favoured by most surgeons, but the evidence for this is unconvincing and may expose the patient to unnecessary risks. Furthermore, a two-stage approach may be more suitable for the more common chronic migration of a loose acetabular shell, which fundamentally differs from acute pelvic penetration. We present the case of a 76-year-old man referred to our institution for reconstructive surgery following acute pelvic penetration of the acetabular shell during total hip arthroplasty. We used a single-stage Hardinge approach to retrieve the shell and successfully reconstruct the acetabulum. Specific indications for using this method are proposed. In carefully selected cases of intrapelvic implants, a single-stage method can improve patient outcomes while minimising unnecessary risks associated with the conventional two-stage approach.

Female patients with abdominal aortic aneurysms (AAAs) are usually less common and older than their male counterparts. We report on AAA disease in a Caribbean nation with respect to gender and review their outcomes relative to the male population. Data were collected prospectively and analyzed retrospectively for patients with AAAs who underwent surgery from 2001 to 2018. Sixty patients were diagnosed with AAA with 44 going on to have surgical repair of which 35 were males, aged 61 to 89 (mean age 73.4 years). Nine women ages 44 to 74 years (mean age 60.8 years) had surgical intervention, three being between 40 and 49 years. The size of aneurysms in these patients ranged from 4.3 to 11.0 cm in diameter (average 6.95 cm), female patients having an average diameter of 6.7 cm. Of the 44 patients, 43 underwent open and one endovascular repair. Thirty-three were elective cases and 11 were ruptured with 32 aorto-aortic and 13 aorto-iliac repairs. There were nine fatalities, three elective and six ruptured, with only one being female. Women had similar outcomes to men in all age groups with young patients having good results. Female AAA patients are usually older, undergo less surgical procedures especially if endovascular, and have worse outcomes than their male counterparts. Our study showed that the females were younger but had similar outcomes to the male patients. The female Caribbean patients may present at much younger ages than in continental populations and this may be due to genetic, ethnic, or lifestyle factors.

Necrotizing fasciitis, commonly known as “flesh-eating disease,” is an aggressive soft tissue infection that destroys the fascia, subcutaneous tissue, and skin. Specific clinical features (crepitus or radiologic features of gas in tissues) either appear late or are of poor sensitivity. Thus, a high index of clinical suspicion is required for early diagnosis and prompt treatment, which are the best methods of minimizing its high associated morbidity and mortality. We present 3 cases to demonstrate diagnostic difficulties and challenges in management and highlight the feature of pain on muscular activity.

The Klippel-Trénaunay syndrome is an unusual syndrome of vascular and dermatologic manifestation in which patients demonstrate hemihypertrophy of the soft tissue and bones of one limb, cutaneous haemangiomas and varicosities in anatomically abnormal positions. Described in 1900 by two French physicians, the etiology remained unclear until recently, when evidence emerged that there was a genetic basis for this sporadic disorder. Genes that encoded pathological angiogenic factors and caused vascular dysmorphogenesis, explaining the molecular bases of this syndrome, were identified. Several angiogenic genes were identified but one gene, the AGGF1 (formerly VG5Q) gene, was seen in mutations involving patients diagnosed with Klippel-Trénaunay syndrome. Furthermore, this syndrome was also noted to have overlapping clinical features linked with the “overgrowth syndromes,” in which genetic mutations along somatic lines were identified. These involved The PI3K enzyme which forms part of the phosphoinositide 3– kinase pathway which is encoded by the PIK3CA-gene. This enzyme mediates embryonic cellular growth in-utero and diseases involved in this pathway are classified as members of the PIK3CA-related overgrowth syndrome. This paper reviews the status of what is now known about the molecular genetics of this unusual, but clinically challenging disorder and its differentiation from similar diseases, linked with the PIK3CA-gene and the related overgrowth syndromes.

The median arcuate ligament compression syndrome is a rare entity that occurs in 2 per 100,000 unselected individuals. We present a case where the median arcuate ligament compression syndrome was associated with an equally uncommon anatomic variation-a celiac-mesenteric trunk, which occurs in 0.42-2.7% of unselected individuals. We could find no prior report of a celiac-mesenteric trunk being associated with the median arcuate ligament compression syndrome. This report also adds to the literature to show that a laparoscopic approach to median arcuate ligament release is feasible.

The prevalence of non-healing diabetic foot ulcers in increasing and its management continues to be a challenge with high rates of progression and recurrence. The Achilles tendon in diabetics undergoes microscopic reorganization leading to its shortening. The resulting equinus deformity, combined with neuropathy and arthropathy, may cause pressure ulcers to form on the plantar aspect of the forefoot. Without ofoading the pressure at these points, the lesions remain open. Lengthening of the Achilles tendon restores normal range of motion of the ankle and decreases pressure facilitating ulcer healing. This short, same day procedure, done under local anaesthesia allows immediate extension of the tendon. Fourteen patients with non-healing ulcers had tenotomies. Ankle dorsiexion before and after was documented and time taken for the ulcers to heal post operatively recorded. All patients showed immediate improvement in the amount of ankle extension postoperatively; ulcer healing was achieved on average by 8 weeks. One patient has recurrence of ulceration at 15 months postoperatively. Follow up time was 18 months. Achilles tendon lengthening is an easy, safe, same day procedure for diabetic patients and should be considered as an option for non-healing pressure ulcers to the soles of their feet.

The Klippel-Trenaunay syndrome is an unusual syndrome of vascular and dermatologic manifestation in which patients demonstrate hemihypertrophy of the soft tissue and bones of one limb, cutaneous haemangiomas and varicosities in anatomically abnormal positions. Described in 1900 by two French physicians, the etiology remained unclear until recently, when evidence emerged that there was a genetic basis for this sporadic disorder. Genes that encoded pathological angiogenic factors and caused vascular dysmorphogenesis, explaining the molecular bases of this syndrome, were identified. Several angiogenic genes were identified but one gene, the AGGF1 (formerly VG5Q) gene, was seen in mutations involving patients diagnosed with Klippel-Trenaunay syndrome. Furthermore, this syndrome was also noted to have overlapping clinical features linked with the "overgrowth syndromes," in which genetic mutations along somatic lines were identified. These involved The PI3K enzyme which forms part of the phosphoinositide 3-kinase pathway which is encoded by the PIK3CA-gene. This enzyme mediates embryonic cellular growth in-utero and diseases involved in this pathway are classified as members of the PIK3CA-related overgrowth syndrome. This paper reviews the status of what is now known about the molecular genetics of this unusual, but clinically challenging disorder and its differentiation from similar diseases, linked with the PIK3CA-gene and the related overgrowth syndromes.

A deep vein thrombosis (DVT) is a blood clot that forms in the deep veins of the leg. A deep vein thrombosis in the thigh carries a risk of pulmonary embolism (PE). This occurs when the clot loses its attachment to the inside of the vein, leaves the leg and lodges in the pulmonary artery, the main blood vessel to the lungs. If the clot is large enough, it can completely block that artery and cause death.

When Henri Hartmann invented his operation in 1921, his intent was not for use in benign disease but as an alternative for Miles’ abdominoperineal resection which, at that period, had a high mortality rate. With advancements in medicine, Hartmann’s procedure was replaced by abdominoperineal resection which had a significant drop in mortality. In the 1980s to the 1990s, however, there was a renewed interest in Hartmann’s procedure as an alternative management for perforated diverticular disease leading to the formation of guidelines that advocated its use. Since then, resection with primary anastomosis has replaced Hartmann’s as the standard of care and with the alternative operations available for colorectal cancers, the place for Hartmann’s operation in medicine should be clearly defined.

Objective: We report a case of systemic arterial air embolism (SAAE), complicating the open repair of a ruptured descending thoracic aneurysm and aorto-bronchial fistula, while on cardiopulmonary bypass. Method: A 55-year-old patient was placed on beating heart cardiac bypass, for the open repair of a ruptured type C descending thoracic aneurysm, complicated by an aorto-bronchial fistula. After an uncomplicated graft replacement and primary repair of the bronchial fistula, weaning off bypass was complicated by a significant amount of air within the left heart, associated with ST elevations and poor cardiac ejection. Results: Despite multiple attempts at de-airing, positive pressure ventilation consistently resulted in re-accumulation of air within the cardiac chambers and its sequelae. The patient was unable to be weaned off cardiac bypass, and the consequence of SAAE worsened her condition and she subsequently expired. Conclusion: Broncho-venous fistula (BVF) is a rare complication that has occurred in patients following CPB, and usually presents as a significant, continuous flow of air into the left heart, related to positive pressure ventilation and refractory to usual de-airing techniques. We advise that these clinical criteria along with blood entering the endotracheal tube be used to promptly identify BVF, so that urgent, life-saving treatment can be initiated. To our knowledge this is the fourth such case reported in the literature.

The Klippel-Trénaunay syndrome is an unusual syndrome of vascular and dermatologic manifestation in which patients demonstrate hemihypertrophy of the soft tissue and bones of one limb, cutaneous haemangiomas and varicosities in anatomically abnormal positions. Described in 1900 by two French physicians, the etiology remained unclear until recently, when evidence emerged that there was a genetic basis for this sporadic disorder. Genes that encoded pathological angiogenic factors and caused vascular dysmorphogenesis, explaining the molecular bases of this syndrome, were identified. Several angiogenic genes were identified but one gene, the AGGF1 (formerly VG5Q) gene, was seen in mutations involving patients diagnosed with Klippel-Trénaunay syndrome. Furthermore, this syndrome was also noted to have overlapping clinical features linked with the "overgrowth syndromes," in which genetic mutations along somatic lines were identified. These involved The PI3K enzyme which forms part of the phosphoinositide 3-kinase pathway which is encoded by the PIK3CA-gene. This enzyme mediates embryonic cellular growth in-utero and diseases involved in this pathway are classified as members of the PIK3CA-related overgrowth syndrome. This paper reviews the status of what is now known about the molecular genetics of this unusual, but clinically challenging disorder and its differentiation from similar diseases, linked with the PIK3CA-gene and the related overgrowth syndromes.

Skin tethering (ST) is regarded as a classical clinical feature of breast cancer. In many cases, ST is not evident on inspection, with the arm raised and skin pinching over the lump. We have observed that pushing the lump in one or another direction may elicit skin dimpling that was not otherwise evident. In these cases, there is normal fat, grossly and histologically, between the tumor and the skin. Thus, the dimpling is not due to cutaneous infiltration. We believe that it is caused by tumor involvement of the ligaments of Cooper and present suggestions as to why it might be so. It may be that this is very early involvement of these ligaments, long before ST becomes very obvious. We report our experience with six such cases.

Background: Major lower extremity amputation is defined as any amputation of the limb performed above the level of the ankle. Indications often include severe infection, ischemia, trauma and tumours. Total amputation rate in Trinidad and Tobago (T&T) is not yet known. Data is only available from a single center in Trinidad and Tobago over a two year period and not from the entire country and the number of total amputation was based on simple speculation and general estimate. The aim of this study is to first time document the exact annual amputation rate in T&T with their demographic characteristics and also to find out whether the existing methods of health education are effective in reducing amputations. Methods: A retrospective review of all lower limb amputations was performed in all 5 public hospitals in Trinidad and Tobago from January 2012 to December 2018. Annual major lower limb amputations in the 10 private hospitals were also documented. Data collected on patients demographics included patient’s age, sex, race, and amputation type. Results: A total of 3586 (85.87%) major lower limb amputations were performed in the public and 590 (14.13%) in the private hospitals over our 7 year study period. The average annual major lower limb amputation rate in T&T is about 600 (596.5) with an average daily rate of 1.63. The mean age of our study group was 65.7 (23-103) years with a male to female ratio of 1.2:1. Afro Trinidadian accounted for 1962 (47%), Indo Trinidadian 1899 (42%) and other 11%. The predominant type of amputations was above knee 55.06% (n=2299) compared to below knee 44.94% (n=1877). Diabetic foot complications accounted for the majority of amputations in this study. The amputation rate has not declined over the years; rather there has been an annual increase over the study. Conclusions: The annual major lower limb amputation rate in T&T is significantly higher than previous estimates. This is very costly in the context of our limited resources and alarming on our already exhausted economy. This study shows that diabetes and peripheral vascular disease continue to be major risk factors for lower limb amputations: this negatively impacts the overall health of our society. Current methods have failed to reduce amputations. We recommend an integrated multidisciplinary approach involving doctors, diabetic nurse counselors, dieticians, podiatrists, physiotherapists, social welfare officers, politicians, religious leaders and social scientists. Continued education on diabetes, its complications and foot care as well as modifications of current methods are essential to minimize limb loss.

Carotid arterial injuries occur in 5-6% of persons with penetrating trauma. Complete transection is rare in civilian practice and is most often due to penetrating injuries. Complete transection as an iatrogenic complication is rare. We present a case where we were required to repair a complete transection of the carotid artery with segmental loss which occurred as an iatrogenic complication during thyroidectomy. We could find no previous reports of this type of iatrogenic complication. The lessons learned during the management of this case were the following: (1) surgeons should call for help early, (2) a multidisciplinary approach ensures that all options are considered, (3) adhere to surgical principles of proximal and distal control, (4) always use atraumatic clamps to control vessels, and (5) flow restoration should be attempted, leaving carotid ligation as the last resort.