Context: Chronic total occlusions (CTOs) sometimes are a challenge for endovascular intervention, especially in developing countries where new devices used to cross CTOs are either unavailable or too expensive. Using basic endovascular tools remains the only solution in such cases when patients were at high risk for open surgical intervention. We present our experience of using double balloon technique to cross CTO lesions in the femoropopliteal segment after failure of known traditional techniques, i.e. intraluminal, subintimal angioplasty, and subintimal arterial flossing with antegrade–retrograde intervention (SAFARI technique). We looked for technical success of double balloon technique in such difficult CTO. Aims: To assess the safety and applicability of double balloon technique in crossing long and complex CTOs lesions, where new crossing re-entry devices are unavailable. Subjects and Methods: This is a retrospective study to look into cases between November 2013 and October 2015, in Kasr Ani Hospital, Cairo University, Egypt. Results: The success rate of the technique was 100%. Conventional Methods: Intraluminal, subintimal angioplasty, and SAFARI technique for crossing CTOs in the femoropopliteal territory were used in 350 lesions, but it failed in 30 where double balloon technique was used. The technical success rate of the technique was 100%. Conclusions: Double balloon technique was safe and cheap. It should replace the use of new re-entry devices keeping them only in bail-out cases after the failure of this technique.

Objective: Intrinsic esophageal pathologies constitute prime cause for dysphagia clinically. However, thoracic esophageal domain is prone to extrinsic compression by various vascular afflictions including aneurysms with attendant therapeutic challenges. Herein, we present a case series of dysphagia aortica with emphasis on its appropriate management option based on grade of dysphagia. Methods: Patients who presented to the vascular division of our tertiary care referral institute between January 2014 and October 2015 with dysphagia due to extrinsic esophageal compression by aneurysmal thoracic aorta form the basis for this report. Prior to referral, all patients were evaluated elsewhere to rule out intrinsic causes and computed tomography angiogram performed delineating aortic aneurysm in four patients and penetrating aortic ulcer in one. Patient cohort included one female and four male patients whose age ranged from 40 to 68 years, with a median of 62 years. Left posterolateral thoracotomy provided access to an aneurysm which was repaired using interposition polyester graft in four patients. Due to severe comorbidities which precluded open surgery, one patient who presented with mild dysphagia was managed by endovascular stent graft repair. Results: Degree of dysphagia was assessed between grades 0 and 4 as in literature. All patients, including four open conventional and one endovascular, recovered well and left hospital totally symptom free. Conclusion: Dysphagia due to vascular diseases in the thoracic domain is an uncommon clinical entity. Patients with thoracic aortic aneurysm presenting with severe dysphagia deserve open surgical repair to provide optimal symptomatic relief in addition to saving life. The state-of-the-art endovascular stent grafting may be considered in very elderly patient having severe comorbidities presenting with mild dysphagia.

Purpose: An option for patients who are unsuitable for radiocephalic fistula is brachiocephalic (BC) fistula. In such patients, we exploited the venous interconnections in the cubital fossa for median antecubital vein (MAV)-BC arteriovenous fistula (AVF) creation. In this article, we describe our experience in the creation of such technical variant of the BC fistula AVF, its success, and associated complications. Materials and Methods: A retrospective review of such AVF created between September 2014 and August 2015 was done. The data collected included demographics, comorbidities, basic disease, operative details, patency, complications, and mortality. Results: A total of 68 vascular access surgeries were done which included 26 (38.2%) BC AVF using the MAV. The mean cephalic vein diameter and mean flow rate were 7.18 mm and 1415 ml/min, respectively, 2 months after fistula creation. The primary and secondary failure rates were 3.87% and 7.69%, respectively. Complications included aneurysm (7.69%), edema (19.23%), hematoma (11.53%), and wound infection (2.5%). Conclusion: Using reverse flow in the MAV is a safe and simple way to perform BC AVF before brachiobasilic AVF and grafts.

Background: Peripheral vascular disease of lower limbs is a debilitating condition with a significant proportion of patients having diffuse, long segment atherosclerosis. This study emphasizes the role of surgery in this group of patients. Materials and Methods: Eighty patients (95 legs) met the inclusion criteria for this study and were followed prospectively. Patients with Rutherford Class IV–VI were taken. Operative findings (type of operation, number of patches, total length of patches, etc.) were recorded. Subsequently, in postoperative period, they were evaluated for improvement in clinical (Rutherford) class, appearance of distal pulsations, ulcer healing, primary patency rates, freedom from amputation, and associated complications at 1, 3, 6, 12, 18, and 24 months. Results: Sustained clinical treatment efficacy according to Rutherford was 82% at 12 months and 59% at 24 months. Amputation-free survival rate was 86% at 12 months and 74% at 24 months. Until 24 months, 17 legs were amputated (18%) and 10 (10.5%) target limbs were revascularized through femoral embolectomy. At 2 years, cumulative femoral artery patency was 88%, whereas cumulative popliteal artery patency was 71%. Conclusion: The present series evaluated patients with the most advanced form of critical leg ischemia with a high rate of leg salvage with this procedure. Multiple atherectomy with patch plasty does offers hope to such patients and can become part of armamentarium of a vascular surgeon.

The application of robotics to Vascular surgery has not progressed as rapidly as of endovascular technology, but this is changing with the amalgamation of these two fields. The advent of Endovascular robotics is an exciting field which overcomes many of the limitations of endovascular therapy like vessel tortuosity and operator fatigue. This has much clinical appeal for the surgeon and hold significant promise of better patient outcomes. As with most newer technological advances, it is still limited by cost and availability. However, this field has seen some rapid progress in the last decade with the technology moving into the clinical realm. This review details the development of robotics, applications, outcomes, advantages, disadvantages and current advances focussing on Vascular and Endovascular robotics

Posttraumatic pseudoaneurysm of hepatic artery is an uncommon complication. However, when diagnosed, they need early treatment to prevent rupture. Currently, the treatment of choice for hepatic artery pseudoaneurysm is endovascular embolization depending on the location. We present a series of 4 cases of posttraumatic intrahepatic pseudoaneurysm in branches of hepatic artery who were successfully treated with n-butyl cyanoacrylate embolization.

Primary aortoenteric fistula (AEF) is a rare clinical entity which is life-threatening. Early diagnosis and prompt treatment play a crucial role in the management. Minimally invasive approaches such as endovascular treatment are newer options in treatment. We describe three patients with primary AEF successfully managed with endovascular treatment. The presentation of primary AEF may be acute, with an exsanguinating unstable patient who would be unfit to undergo a major laparotomy. In such instances, endovascular treatment can be used as the initial option to control the bleeding. Endovascular treatment is a valuable treatment option to control bleeding when the morbidity of open repair is high.

Leiomyosarcomas of the inferior vena cava (IVC) are rare tumors that occur commonly in women of middle age group and usually present with nonspecific symptoms. Treatment consists of surgical excision with or without IVC reconstruction, combined with chemotherapy and radiotherapy. We present a case of leiomyosarcoma of infrarenal IVC extending into both iliac veins, which was resected with reconstruction of IVC and both iliacs with bifurcated Dacron graft. Although IVC reconstruction is mentioned in literature, reconstruction with bifurcated graft is rare.

A 59-year-old Chinese patient was diagnosed with fibromuscular dysplasia (FMD) which is a rare genetic disorder among Asians. Neck vessels angiography showed a classic ''string of bead appearance'' affecting vertebral and internal carotid arteries. Carotid artery surgical reconstruction and vertebral intervention were proposed by vascular surgeon to prevent future strokes, but patient's family refused for intervention/surgery. However, on optimal medical management his health improved during follow-up of over 8 months. This case shows unique multivessel FMD involving bilateral vertebral and one internal carotid artery which was managed successfully with medical management.

Vascular cysts of the adrenal gland are rare heterogeneous group of lesions with an autopsy incidence of 0.06%. They have female preponderance with most common presentation being pain abdomen. Cysts of the adrenal glands are classified as (a) parasitic cysts (b) epithelial cyst (c) pseudocyst and (d) endothelial cysts. Out of these endothelial cysts constitute about 84% of the cases. As the clinical features and radiological findings of these lesions are nonspecific, a proper histological examination along with immunohistochemistry are necessary for a definitive diagnosis. Here, we report two cases of vascular endothelial cyst of the adrenal gland to emphasize the histomorphological and immunohistochemical features of these lesions.