This study is one of the first more extensive patient series from a lower-middle income country (LMIC) to report outcomes following lower extremity vein bypass for chronic limb threatening ischaemia. Despite the high prevalence of diabetes mellitus, limb threat severity, and many economic and resource constraints, overall outcomes exceed expectations, are within international benchmarks, and are similar to those reported from high income countries. These outcomes point to the feasibility and efficacy of a "vein bypass first strategy" for amputation prevention in lower-middle income resource limited countries.Objective: Although high quality epidemiological data are lacking, the global increase in chronic limb threatening ischaemia may be disproportionately affecting low and LMICs. All available data for outcomes from bypass for limb salvage are from high income countries, with none from LMIC settings where the challenge is greatest. This study aimed to assess the clinical outcomes following vein lower extremity bypass for chronic limb threatening ischaemia at the University of Colombo, Sri Lanka, and to compare patients and outcomes with those described in the Society for Vascular Surgery (SVS) Objective Performance Goals (OPG) and United States National Surgical Quality Improvement Program (NSQIP). Methods: Consecutive patients (n ¼ 367) undergoing SVS-OPG eligible lower extremity bypass between 2015 and 2017 were studied. Thirty day major adverse cardiovascular events (MACE), major adverse limb events (MALE), deaths, and amputations are reported, along with one year overall survival, limb salvage, and amputation free survival.Results: Patients at University of Colombo had more diabetes mellitus (80% vs. SVS 57% vs. NSQIP 50%, p < .001) and tissue loss (100% vs. SVS 74% vs. NSQIP 59%, p < .001). The 30 day MALE was 7.6%, which is not a statistically significant difference from the SVS (6.1%) or NSQIP (9%). The 30 day MACE was 8.2%, statistically significantly higher than NSQIP (4.2%, p < .001) but not SVS (6.2%, p ¼ .20). At 12 months, the overall survival (82%) was within the OPG threshold, but limb salvage (81.8%) and amputation free survival (64.5%) were just outside. Conclusion: Outcomes following vein bypass for ischaemic necrosis at the University of Colombo, Sri Lanka, are acceptable and similar to those reported from high income countries despite greater limb threat severity and resource limitations. Further real world data from similar settings on outcomes following revascularisation are required. These data suggest that a vein bypass first strategy for advanced ischaemic necrosis is feasible and effective even in resource limited settings.

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

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

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

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precipitation (mm) and wind velocity (m/s). Readings from these meteorological conditions were obtained for the day of the event, the previous day, and mean results for 3 days, 1 week and 1 month prior to the event. The moon phase for every day and seasonality were also determined. 75 controls per case were randomly selected in a one-year period before and after every event, in the same meteorological station, for every rupture, and compared. Comparisons of all these variables between ruptures and controls were performed. Results: A total of 717 with rAAA were identified, and 53775 controls were randomly selected. There were significant low temperatures, low solar global irradiation and higher mean humidity levels in all analyzed time periods (from the same day to one month before) when rAAA occurred (P< 0.001, < 0.001 and < 0.05, respectively). Variability of atmospheric pressure 7 days and 1 month before the event also showed an increment on AAA rupture risk (P¼0.01 and P¼0.005). According to seasonality, the majority of rAAAs occurred during fall and winter (56.9%, P< 0.001). All the prognostic variables were more frequent in fall-winter, but logistic regression did not identify a clear independent prognostic factor. In regard to lunar phases, the frequency of AAA rupture was significantly higher during the waning moon period (27.9%) versus the other periods (P¼0.035). Conclusion: This study shows that the incidence of rAAA is higher during fall and winter. Meteorological factors such as temperature, global solar irradiation, humidity and variability of atmospheric pressure on previous days (up to one month before rupture), increase the risk of AAA rupture. Finally, we observed that rAAAs occur more frequently on periods of waning moon, although the pathophysiologic mechanisms are still unknown.