Approximately 20 years ago, when I started my career as a vascular surgeon after fellowship training, I received an emergency call for a 52-year-old female with flu-like symptoms, fever, and painful swelling of her left neck and arm for 8 days. She had no history of trauma or central catheterization. Contrast-enhanced computed tomography revealed extensive acute thrombosis in the left internal jugular and subclavian veins. I had never seen such extensive venous thrombosis before. No one around me knew about this disease. I searched vascular textbooks; however, none were helpful. I proceeded to search the PubMed database using the search terms “thrombosis subclavian vein internal jugular vein.” It revealed more than 200 articles, the abstracts of which I read, concentrating on and searching for answers regarding diagnosis and treatment. Finally, I found an article dealing with Lemierre syndrome that exactly matched the clinical presentation of my patient. It took about 2 hours, and I left work with a happy heart after ordering antibiotics and anticoagulants. The following day, I attempted a more aggressive treatment approach via aspiration thrombectomy to obtain samples of infected thrombi for microbiological culture and to decrease the thrombus burden for earlier recanalization. However, the thrombi were thick and adhered to the vessel wall due to inflammation, and the retrieved thrombi revealed no microorganisms. After 6 weeks of antibiotics and 3 months of anticoagulant therapy, the veins completely recanalized, and her symptoms disappeared. Later, I realized that thrombolysis could be dangerous, causing multiple septic emboli, pneumonia, or systemic abscesses. After experiencing this rare case, I published a case report to share my knowledge [1]. This case report has been cited by at least 6 doctors and has helped more patients.

Herein, I would like to summarize why case reports of rare vascular diseases are needed, and how to write a good case report.

1) Report and share your experience to establish evidence-based practices

When a vascular case with a rare clinical presentation, unique imaging, novel treatment modality, or unexpected complications is encountered, it can be reported to a peer-reviewed journal such as Vasc Specialist Int (VSI). The current principles and ethics of modern medical practice are founded on evidence-based medicine, which means using the best available scientific evidence to inform clinical decision-making and improve patient outcomes. In the evidence pyramid, basic and fundamental evidence begins with case reports and case series. When encountering a rare vascular disease in practice, please report and share your experiences, especially in the VSI journal. Researchers can draw meaningful conclusions about rare diseases when enough cases are gathered. In addition, I recommend describing the case in detail, which may help in future collective analyses of the disease.

2) Be courageous to report a nightmare case

A famous quote by poet Alexander Pope states that “To err is human; to forgive, divine.” Sometimes, we learn more from failed cases than from successful ones. Complicated cases frequently provide critical lessons that were not expected preoperatively. Mistakes can be made based on human nature; continued medical education, training, and active surveillance of perioperative outcomes can help prevent or reduce mistakes.

Aleksic et al. [2] from Germany reported successful reconstruction of a stripped superficial femoral vein. The femoral vein was inadvertently stripped during varicose vein surgery, causing massive bleeding and shock. The stripped vein was rinsed with betadine and reimplanted, which remained patent for 11 months. van Nieuwenhuizen et al. [3] from the Netherlands reported a fatal case of small bowel perforation due to tunneling of a femorofemoral bypass. Their candid report revealed their mistakes in order to raise awareness of this rare fatal complication for educational purposes. Chung et al. [4] also reported a similar case for the same purpose. Reports of negative outcomes or complications are rare. Due to the reluctance of researchers to submit poor outcomes, resulting in publication bias, the potential harm of a procedure is usually underestimated or the treatment effects are overestimated, which can lead to flawed clinical guidelines or recommendations. To minimize the effect of publication bias, researchers should be encouraged to publish all research findings regardless of their results.

Oh et al. [5] reported 2 cases of meso-Rex shunt in children with extrahepatic portal vein occlusion. One case was successful, and the other failed; the reason for the different outcomes was obscure. The details of the 2 cases were reported for future analysis.

3) Publish or perish: make a record of historic novel treatments

In 2020, Ivancev and Vogelzang published an excellent editorial entitled “A 35 year history of stent grafting, and how EVAR conquered the world” [6]. However, their description of the world’s first fenestrated endovascular aneurysm repair (FEVAR) of the renal artery was not true. Therefore, I wrote an editorial in VSI [7], and a letter to the editor in the European Journal of Vascular and Endovascular Surgery [8]. The authors apologized for their omission. This correction was accepted because of a previous case report of 2 cases of the world’s first FEVAR performed in Seoul, Korea [9]. An old Korean proverb says that “Tigers leave their skins when they die, but humans leave their names.” Publish your scientific work or perish.

4) Report and remind readers of an unusual presentation of an exceptional case

In 2011, Kim et al. [10] reported an exceptional case of a wooden toothpick retrieved from an inferior vena cava (IVC) thrombus in a Caucasian woman with fever and abdominal pain. After successful endovascular removal and recovery without complications, the question remained as to how the toothpick traveled to the IVC. Speculations regarding the mysterious route of the toothpick into the IVC were investigated and discussed. A possible theory was that after ingesting a toothpick in street food, possibly under drug or alcohol intoxication, it penetrated the third portion of the duodenum and the nearby IVC, resulting in caval thrombophlebitis.

Kim et al. [11] reported a case of intravascular fasciitis in the femoral vein, mimicking a sarcoma with a happy ending. Park et al. [12] reported an intravascular epithelioid angiosarcoma in the abdominal aorta that mimicked an infected aneurysm. These cases are extremely rare to encounter, almost once in a lifetime, and reports from many researchers are important to define the clinical presentation and natural history of the disease.

5) Think rational, behave bravely: record innovative ideas and treatment of a rare vascular disease

Lee et al. [13] reported the first case of endovascular treatment for a celiomesenteric trunk (CMT) aneurysm. To commemorate the success of the first case of endovascular treatment of a CMT aneurysm, we reported the case using a cartoon of a giraffe, hoping for a good long-term prognosis (Fig. 1). After a comprehensive review of the literature, I created a table of 22 reported cases of CMT aneurysms for future researchers. This kind of work benefits not only surgeons and researchers encountering CMT aneurysms but also their patients.

Figure 1. Celiomesenteric trunk (CMT) aneurysm was treated by endovascular intervention, which appears like a giraffe’s head. Adapted from the article of Lee et al. (Vasc Specialist Int 2018;34:44-47) [13].

6) Make a collection of unique diseases in your country

In 2015, Choi et al. [14] reported 2 rare cases of IVC or aortic injury caused by acupuncture, a popular practice in Korea for treating back pain. Vascular surgeons should be aware that acupuncture can cause serious damage to the IVC or aorta, resulting in infection or chyle leakage. Case reports or case series comprise the most basic section of the evidence pyramid. Reporting rare vascular diseases is important for future patients and doctors.

VSI is a peer-reviewed, open-access international journal on vascular surgery, and any case reports, original articles, or review articles are welcome without any publication charges. In summary, there is a survival guide when a nobody-knows-disease is encountered:

• 1)

  Be courageous and remain positive.

• 2)

  Consult with experts and use available internet search engines or artificial intelligence-based platforms.

• 3)

  Find your rationale in treating the disease, and follow the Hippocratic Oath, “Do no harm.”

• 4)

  Report and share your experience for future patients and doctors.

The author has nothing to disclose.