Klippel-Trenaunay syndrome is rare. It is diagnosed in childhood and the gender distribution is almost equal. A challenge arises in pregnancy, as several risks are significantly elevated, such as hemorrhage, bleeding of the varicosities, and life-threatening thromboembolic events. Due to the rarity of the condition, there is limited literature and guidelines regarding management of pregnancy for these patients. This report describes a successful pregnancy outcome in a 34-year-old primigravida with Klippel-Trenaunay syndrome. The aim is to contribute to the limited literature pertaining to this condition and emphasize the role of meticulous planning of antenatal care and birth, to help formulate clinical guidelines in the management of pregnancy in Klippel-Trenaunay syndrome. Multidisciplinary comprehensive clinical evaluation, involving obstetricians, vascular surgeons, a thrombosis team, anesthesiologists, intensivists, radiologists and intervention radiologists, along with the use of ultrasound and magnetic resonance imaging, aids in identifying the extent of disease and to individualize management.

In 2023, the VAS international working group on Buerger’s Disease (BD) recommended two diagnostic criteria based on a prior Delphi study: “definitive” and “suspected”. The “definitive” criteria are history of smoking, typical angiography, and typical histopathological features. All three features are mandatory to confirm a “definitive” diagnosis of BD. The conundrum is—what features should be considered typical of BD angiography? According to this review, segmental occlusion of infrapopliteal arteries, corkscrew collaterals that appear to continue the occluded arterial segment (Martorell’s sign) or bypass the segmental occlusion, absence of atherosclerotic plaque or aneurysm could differentiate BD from ASO. Hence, for “typical” BD angiography, these manifestations should certainly be considered. However, data for differentiating angiography patterns of BD from the small- and medium-sized vasculitis including Behcet’s disease, scleroderma, hepatitis associated vasculitis, and anti-phospholipid syndrome are limited. Further studies for investigating the angiography pattern in BD patients in early and late presentation of BD, particularly in the patients with long-term follow up, are highly recommended.

Background:Arteriovenous fistula (AVF) creation for hemodialysis requires arterial inflow but carries a risk of ischemia. Preoperative assessment of collateral circulation is crucial. The modified Allen test (MAT) is commonly used, whereas the Barbeau test (BT) is less so. Both lack standardization and strong predictive validity.Methods:This prospective observational study was conducted at an academic center in Oman (July-August 2024) and included 27 patients undergoing AVF creation. MAT and BT were performed preoperatively and on postoperative day 1 by a single trained investigator. The MAT involved elevating the patient's hand above heart level, occluding both the radial and ulnar arteries while the patient made a fist, then releasing the ulnar artery and observing for hand flushing within 5-15 s. BT waveforms were classified (Types A-D), with A-C considered adequate. ROC curve analysis assessed BT's predictive utility.Results:Among the 27 patients, 63.0% underwent brachiocephalic AVF, 33.3% brachio-basilic, and 3.7% radiocephalic. Preoperatively, MAT was positive in all cases. The BT showed Type A waveforms in all 27 patients (100%) preoperatively. By postoperative day 1, 23 (85.2%) retained Type A. Two (7.4%) had Type B (one BB and one radiocephalic fistula), and two (7.4%) had Type D, both with BB fistulas. ROC analysis showed poor diagnostic performance (area under the curve = 0.086, P = 0.166), with limited ability to discriminate ischemic risk.Conclusion:MAT and BT showed poor predictive value for postoperative ischemia in AVF patients. The BT, though more objective, failed to meaningfully stratify risk in this pilot cohort.

Thoracic outlet syndrome (TOS) remains a clinical enigma, with its management often being complex. The majority of the patients are managed with nonsurgical measures, including physiotherapy, analgesics, muscle relaxants, and Botox injections, with surgery being offered to those in whom symptoms persist or recur despite conservative management. In patients with symptomatic, nonarterial TOS, trans-axillary first (with or without cervical) rib resection is an excellent approach for thoracic outlet decompression. Although popularized by Roos, this approach is less commonly practiced today due to limited anatomic visibility and reduced familiarity among vascular surgeons. This paper outlines the surgical steps and provides practical insights for performing transaxillary first and/or cervical rib resection.

Background: Carotid body tumor is a paraganglioma originating in chemoreceptor cells at the carotid bifurcation. Surgical resection is the gold standard treatment but is challenging due to its vascularity and relation to the carotid arteries and cranial nerves, with risk of bleeding permanent nerve injury and stroke. Radiotherapy is reserved for unresectable tumors. Shamblin, in 1971, described a classification that has been correlated to operative bleeding, the possibility of vascular injury, and the requirement for arterial reconstruction. Clinical palpation evaluating the texture, size, and proximal extension in relation to the mandible, combined with computed tomography angiography or magnetic resonance angiography, provides an important preoperative evaluation of the tumor size, volume, extension, distance to the base of the skull, encasement, and infiltration of the carotid arteries and neck structures. Preoperative embolization is used in decreasing complications such as the risk of blood loss. A balloon occlusion test of the internal carotid artery can evaluate the cerebral ischemic tolerance, in case ligation of the internal carotid artery is required. Methods: We report the case of a patient with a submandibular mass, pain, progressive growth, dysphagia, and occasional dyspnea. Results: Diagnosis of a carotid body tumor was made based on history and clinical and radiological examinations, with complete 360-degree rotation around the carotid arteries, demonstrating infiltration of the wall of these vessels, and extension to the base of the skull and parapharyngeal space. The extent of the disease required mandible osteotomy and carotid resection. Surgery has been the gold standard for treatment, but the procedure is challenging when there is tumor encasement of the carotid arteries, involvement of cranial nerves, and the possibility of recurrence and malignancy. Conclusions: The importance of considering not only the Shamblin classification but other relevant variables for preoperative planning is mandatory. We review this rare disease and propose the need for updated reporting standards on carotid body tumor.

BACKGROUND: Fibroadipose vascular anomaly (FAVA), is a recently described entity in the nomenclature of vascular malformations. It is described as an atypical venous malformation which has a significant component of pain and frequently involve the extremities, especially lower limbs. Ultrasonography and MRI play an important role in the diagnosis. Treatment modalities include sclerotherapy, intralesional steroids and alcohol injection, cryo-ablation, and open surgical resection. The aim of this study was to understand the clinical, radiological and histopathology features of the FAVA and to assess the outcome. METHODS: A retrospective study of patients diagnosed with FAVA from August 2016 to December 2023 were included in our study. The clinical, radiological, pathological data, procedures performed, and the outcomes were analyzed. Patients were followed up for minimum of 6 months clinically and with ultrasound if recurrence was suspected. RESULTS: A total of 40 patients biopsy proven were included. The gender distribution was almost equal in number and the age was ranging from 6 years to 63 years. All patients presented with pain and swelling. The lower limbs were involved in 33/40 cases, and upper limb involvement was seen in 7 cases. In the lower limbs, the posterior compartment muscles were predominantly involved (10/40). The overlying skin was involved in two cases. Sclerotherapy was given in 13/40 cases, of these 10 patients subsequently underwent surgical resection as symptoms were persistent. A total of 23 patients underwent surgical resection. No recurrence was noted in the cohort. CONCLUSIONS: FAVA, though recently diagnosed has evolved rapidly and is no longer a rare entity. To our knowledge this is the largest case series reported in English literature. It is best managed in a multi-disciplinary approach involving vascular surgery, diagnostic radiology, interventional radiology, pathology and occupational therapy. Surgical excision appears to be the best form of treatment. In summary, a proper diagnosis based on clinical findings and imaging is crucial which must be followed by appropriate management will improve the outcome. Recent advances like targeting mTOR pathways seem worth exploring.

Abstract True arterial aneurysms involving the peripheral arteries are rare in childhood and are usually associated with inflammatory or connective tissue disorders. We present a case of idiopathic true aneurysm in an 8-year-old girl involving the distal superficial femoral artery, popliteal and proximal anterior tibial arteries which were successfully managed by open surgical repair with ligation of the aneurysmal segments, and an interposition graft using a reversed saphenous vein.

Introduction: Pediatric acute limb ischemia (PALI) is a consequence of sudden loss of blood flow to an extremity that can progress to irreversible ischemia if not promptly treated. This may unfortunately result in life-changing consequences which include limb loss, limb length discrepancy, emotional trauma, and or financial stress. Due to the rarity of this condition, and the lack of high-quality evidence, treatment strategies have largely been anecdotal or extrapolated from treatment of the adult patient. The article is a guide to improve overall functional outcomes and reduce morbidity of PALI. Methods: The authors retrospectively analysed patient data on the electronic patient record of the hospital between January 2021 and December 2023. The patients with PALI were divided into three broad categories: iatrogenic arterial injury managed with the best medical management, managed surgically; iatrogenic deep vein injury/thrombosis, and trauma. Results: A total of 13 patients were referred during the study period. 9 were male. 8 cases were line related, 2 trauma and 3 acute deep vein thrombosis [DVT]. Two patients succumbed prior to intervention. Eight patients were managed with best medical therapy, two surgically and one by endovascular means. Conclusion: Since experience worldwide is limited with PALI, we decided to share our experience and a propose comprehensive algorithm for the management of PALI emphasizing a multi-disciplinary team approach that we follow at our hospital. Early and decisive involvement of vascular surgeons, hematologists, intervention radiologists, and pediatric intensive care physicians is necessary to achieve the most favorable outcomes.

Background: Blunt cerebrovascular injury (BCVI) is an injury to the carotid or vertebral artery that is nonpenetrating and results from stretching or impingement of the vessel walls due to sudden head movement. Recent studies showed that the incidence of BCVI is around 1%-9%, with stroke being the most dreaded complication. Methodology: This retrospective study was conducted after approval by the medical research ethics committee at our tertiary care center, including all consecutive neck computed tomography angiography scans for blunt trauma patients from January 2017 to December 2020. The patient demographics, symptoms, and signs at presentation and imaging were reviewed through the electronic patient records for the presence of BCVI using the modified Denver scoring and Biffl criteria. Patients younger than 18 years, those with penetrating trauma, and patients with no head-and-neck scans were excluded from the study. The treatment and outcome of the positive cases were studied. Results: There were 871 patients with blunt trauma during the study. Of this number, 16 patients were identified with BCVI (1.83%). Most of the patients were male (75%), and the mean age of the cohort was 31 years (18-45 years). Among those with BCVI, five had carotid artery injuries (31%), and 11 had vertebral artery injuries (68.8%). BCVI Grades 2 and 4 were the most prevalent injuries. Ischemic infarction was seen in three patients (18%). Five patients (31.3%) with BCVI received antiplatelet therapy. None of the patients underwent endovascular or surgical treatment. Moreover, there was no BCVI-related mortality. There was a statistically significant between the Biffl grading, type of artery injury, and the presence of neurological deficit at the time of initial presentation, which both turned to be significant with a P = 0.017 and P = 0.049, respectively. Conclusion: BCVI is a serious injury with the potential for neurological complications. The artery involved and Biffl grading influence the presentation. Initiation of therapy with antithrombotic medications for stroke prevention is essential in all patients. The patients with positive findings need follow-up imaging, and an internationally recognized guideline is essential to manage this cohort.

The integration of WhatsApp (WhatsApp Inc., Mountain View, CA, USA) into the health-care sector is transforming the dynamics of medical communication. Launched in 2009 and incorporated into the Facebook suite of companies in 2014, WhatsApp has become a pivotal platform for health-care professionals. It allows for quick, personal, and group messaging, which is increasingly used to exchange patient information, discuss cases, and make timely decisions. The app’s end-to-end encryption is critical for maintaining patient confidentiality, ensuring that sensitive data are only accessible to the intended recipients. This security feature and the group sharing format enable health-care teams to communicate confidentially and efficiently, bolstering the oversight capabilities of attending senior consultants or physicians over their junior peers. The real-time exchange of information is crucial in providing continuous supervision and facilitating immediate feedback, which is indispensable in clinical training and patient care. However, the widespread adoption of WhatsApp also comes with challenges and potential drawbacks, which have been the focus of past research. These studies assessed the impact of WhatsApp on health-care delivery, considering both the enhancement of communication it offers and the issues it may present, such as data security beyond encryption and the blurring of professional and personal boundaries. In this “medical opinion” from an academic tertiary care center in Muscat, we explored how emergency medicine physicians can effectively use WhatsApp to expedite or bypass referral processes for emergency cases, particularly those involving vascular and other surgical emergencies.

Objectives: This study aimed to determine the risk factors associated with the failure of arteriovenous fistulae (AVF) maturation. Methods: This retrospective cohort study was conducted from January 2014 to December 2018 in Sultan Qaboos University Hospital, Muscat, Oman. Patients were followed-up 3 months after surgery, and their electronic medical records were accessed for demographic and clinical data. Univariate analysis was used to determine the risk factors associated with early AVF maturation and multivariant analysis was used to determine the predictive factors for AVF failure. Results: A total of 269 patients were included. Female gender was a significant factor affecting AVF maturity (P = 0.049), while age (P = 0.626), diabetes (P = 0.954), hypertension (P = 0.378), dyslipidaemia (P = 0.907), coronary artery disease (P = 0.576), cerebrovascular accident (P = 0.864), congestive heart failure (P = 0.685), previous central venous catheterisation (P = 0.05), fistula type (P = 0.863) and fistula site (P = 0.861) did not affect AVF maturation. Binary logistic regression showed that all the risk factors were insignificant. Failure of early AVF maturation affected 11.5% in the cohort. Conclusion: This study found that the proportion of early AVF maturation at our hospital is at par with that in the international literature. Failure of AVF maturation was significantly associated with the female gender. These findings can help nephrologists and vascular surgeons prognosticate AVF maturation rates. However, a larger study is needed for definitive conclusions. Keywords: End Stage Renal Disease; Arteriovenous Fistula; Dialysis; Outcome.

INTRODUCTION Contrast-associated acute kidney injury (CA-AKI) poses a significant concern and unnerves surgeons who require imaging that uses contrast to make/exclude a diagnosis or treat a patient, especially in patients with preexisting renal conditions. CA-AKI and contrast-induced acute kidney injury (CI-AKI) are used interchangeably, leading to confusion in clinical discussions, however, it is crucial to distinguish between these two entities. While CI-AKI traditionally implied a direct link between contrast agents and AKI, recent literature favors the term CA-AKI.[1-4] It acknowledges the multifactorial nature of renal impairment following contrast exposure. We aim to unravel the differences between these terms, offering insights into diagnostic nuances, optimal timing for repeat creatinine assessments, the onset of nephropathy, and guidelines for nephrologist intervention. GETTING TERMINOLOGY RIGHT CA-AKI versus CI-AKI: CA-AKI and CI-AKI both pose concerns for patients, but they have distinct characteristics that merit exploration. CI-AKI is primarily associated with the direct nephrotoxic effects of contrast agents, leading to a decline in renal function, particularly in patients with chronic kidney disease (CKD).[3,4] On the other hand, CA-AKI takes a broader view, considering additional factors such as the patient's comorbidities, hemodynamic changes, and procedural variables.[5,6] While CI-AKI is a subset of CA-AKI, the latter term better captures the intricate web of influences contributing to renal dysfunction after contrast exposure.[2,4,6] Recognizing this difference is vital for tailoring diagnostic and management strategies. Certain patient profiles are more prone to either CA-AKI or CI-AKI, depending on their prior or preexisting health conditions. Patients with atherosclerotic disease, coronary artery disease, and peripheral vascular disease may face an increased risk of CI-AKI due to compromised renal perfusion.[4] In contrast, CA-AKI is often observed in individuals with CKD, diabetes mellitus, or congestive heart failure, where the multifactorial nature of renal dysfunction comes into play.[3,5] When it comes to medical imaging, the risks associated with CA-AKI and CI-AKI are nuanced. Choosing a low or iso-osmolar contrast agent can mitigate the risk of renal injury. Risk factors for contrast-associated nephropathy[2,5] Diabetes mellitus increases vulnerability due to nephropathy and microvascular complications Congestive heart failure amplifies the risk CKD heightens susceptibility Age plays a role, advancing age potentially intensifying the impact. Risk factors for contrast-induced nephropathy[1,6] Atherosclerotic disease is a notable risk, compromising renal blood flow Advanced age makes individuals more susceptible to contrast agents Volume depletion, from conditions such as dehydration or heart failure CKD, even if mild, heightens vulnerability. Clinical scenarios If the patient's urine output drops within 48–72 h after using contrast and the patient has risk factors of atherosclerotic disease, it is more likely CI-AKI If kidney impairment happens later, beyond the usual postprocedure timeframe, and is linked to existing kidney conditions, diabetes, or heart failure, CA-AKI becomes a significant possibility. Kidney Disease: Improving Global Outcomes (KIDIGOs) for diagnosing how serious AKI is, along with the scoring system from Sgura etal. (Mehran contrast-induced nephropathy risk score), are important for understanding risks. KIDIGO breaks it down into three stages, looking at serum creatinine, percentage increase, and urine output to get a detailed picture of the risk.[7,8] The KIDIGO AKI Staging, by the 2022 guidelines, is presented in Table 1.[7] Mehran CI-AKI risk scoring system was initially made for cardiac procedures, but, can be used for both CA-AKI and CI-AKI. The Mehran risk scoring system is detailed in Table 2.[8] A recent study conducted by Samir etal. found that among patients experiencing contrast-induced nephropathy following primary percutaneous coronary intervention, Mehran's score exhibited remarkable sensitivity at 100%, high specificity at 96.77%, a positive predictive value of 70%, and a negative predictive value of 100%.[9]Table 1: Kidney disease: Improving global outcomes kidney injury staging 2022[ 7 ]Table 2: The Mehran risk scoring system for contrast-associated acute kidney injury and contrast-induced acute kidney injury, along with the categorization of risk factors[ 8 ]By considering variables such as age, existing kidney issues, and diabetes in the overall score, this system helps spot people at a higher risk of CI-AKI. Utilizing imaging studies such as Doppler ultrasound to examine renal blood flow and kidney size can be valuable in distinguishing between CI-AKI and CA-AKI.[3,6] Furthermore, monitoring biomarkers beyond creatinine, such as Cystatin C or innovative urinary markers, may offer a more sensitive indication of early renal dysfunction associated with CA-AKI.[2,3,5] Diagnosing CA-AKI and CI-AKI comes with its challenges, especially concerning the timing of creatinine assessments. Typically, creatinine levels are checked 48–72 h after using contrast, but recent study findings suggest that deterioration in renal function may show up later, especially in those at higher risk.[4,6] Vigilant monitoring is essential, with an emphasis on recognizing early signs such as subtle creatinine elevations or diminished urine output. Understanding the role of predisposing factors, including diabetes, hypertension, and heart failure, aids in risk stratification and timely detection.[7,8] Protocol-guided management strategies play an important role, before seeking advice from a nephrologist. This involves timely assessment of risks, following hydration protocols, and stopping nephrotoxic medications as initial steps. Remembering "DAAMN" (Diuretics, ACE inhibitors/ARBs, Aminoglycosides, Metformin, NSAIDs) can help recall the medications that should be stopped before contrast procedures.[10,11] Maintaining renal blood flow through intravascular volume expansion is crucial by following an intravenous fluid protocol as outlined in Table 3.[10,11] In some patients, pharmacological agents such as sodium bicarbonate, N-acetylcysteine, statins, ascorbic acid, theophylline, and aminophylline can be used.[10,12] Depending on the severity of renal impairment, using vasodilators, forced diuresis, or renal replacement therapy may be considered.[10-12] When a conservative approach falls short or signs of worsening renal function persist, a nephrologist's opinion is recommended. Indicators for this step include a significant rise in serum creatinine, ongoing low urine output, or the need for renal replacement therapy. Ensuring timely communication and collaboration between the primary care team and nephrologists becomes essential when navigating critical stages of renal impairment postcontrast exposure.Table 3: Intravenous fluid protocol to prevent contrast-associated acute kidney injury and contrast-induced acute kidney injury[ 9 , 11 ]To conclude, understanding CA-AKI and CI-AKI is like putting together puzzle pieces – knowing the terms, numbers, and how things work. Surgeons and physicians should first consider the use of noncontrast modalities of imaging in the elderly and those with multiple comorbidities, weighing the risks versus benefits of using contrast. In those where contrast has to be used the abovementioned measures should be put in place to reduce the risk of CI-AKI/CA-AKI. The adage "prevention is better than cure" holds in this real-life scenario.

Varicose veins are not uncommon among Omani women. As currently there are no female vascular surgeons, it has been noticed in our outpatient clinic that a number of them are reluctant to be examined by a male vascular surgeon, have a duplex ultrasound done and therefore a management plan cannot be made in this subset. This study is a first of its kind in Oman, looking at the impact of a patient information booklet about varicose veins etiology, symptoms, signs, assessment and management, on the attitude of a female patient’s acceptance towards examination by a male surgeon in the presence of a chaperone.

An elderly woman presented a year after undergoing endovascular repair of her infrarenal aortic aneurysm (IRAA) with abdominal pain and hypotension. Imaging revealed a ruptured IRAA, and this was managed with banding of the aorta to correct the Type-1a endoleak and tranexamic acid postoperative. We share details and a brief review of the literature.

16 Objectives: An arteriovenous fistula is ideal for vascular access, the maturation of which is 17 vital for hemodialysis. Our aim was to determine the risk factors associated with failure of 18 maturation of arteriovenous fistulae. Methods: This retrospective cohort study, from January 19 2014 to December 2018 was conducted in a tertiary care hospital in Oman, Patients were 20 followed up for three months after surgery. Electronic medical records were accessed for 21 demographics and clinical data. Data was analyzed using SPSS package. Univariant analysis 22 was used to determine the risk factors associated with early maturation of AVF and multi 23 variant analysis used to determine the predictive risk factors. Results: There were a total of 269 24 patients in the study. Female gender was a significant factor affecting maturity (P= 0.027). 25 While factors not affecting maturation were age (P= 0.320), diabetes (P= 0.858), hypertension 26 (P= 0.215), dyslipidemia (P= 0.215), coronary artery disease (P= 0.433), cerebrovascular 27 accident (P= 0.864), congestive heart failure (P= 0.509), previous central venous catheter

Data spanning the first two waves of COVID from May 2020 to June 2021, from 268 patients with COVID-19 related acute limb ischaemia from 22 centres across India were collected after ethics clearance. The inclusion criterion was all COVID positive patients who presented with signs and symptoms of acute limb ischaemia (ALI) or acute on chronic limb ischaemia. The severity of limb ischaemia was classified using Rutherford’s classification for ALI, while disease severity was documented using the World Health Organisation classification of COVID infection. Data were collected retrospectively and underwent logistic regression analysis for three outcomes: immediate, 14 day, and overall limb salvage.