This review aims to explore the HawkOne atherectomy (Medtronic), a single use directional atherectomy device, explaining in depth its indication, selection, preparation and application. It further provides techniques and tips to troubleshoot the device upon its use. Further, a review of the current evidence for directional atherectomy in the infra-inguinal arteries is conducted. Identifying that directional atherectomy in the infra-inguinal arteries allow for significant plaque modification and lumen gain without the use of barotrauma from balloon angioplasty. Highlighting that directional atherectomy had a lower incidence of flow limiting dissections and need for stenting after such treatment.

Aims: Extra-anatomical bypass (EAB) is still an important alternative treatment method in patients with aortoiliac occlusive disease (AIOD). Settings and Design: In this study, we assessed the results of EAB procedures, over a 22-year period, based on 30-day morbidity and mortality, 1^st month, 1^st, 3^rd, and 5^th year patient survival, primary patency, and limb salvage rates. Subjects and Methods: A retrospective review and analyze was performed on a single-center database of consecutive 46 patients who underwent femorofemoral or axillofemoral bypass grafting procedures from 1998 to 2020. All patients were called to followed up and were performed clinical examination and color duplex ultrasound (CDUS) evaluation for determination of graft patency. The surviving patients were followed-up for 5 years. Statistical Analysis Used: Five-year survival, graft patency, and limb salvage rates were calculated by the Kaplan–Meier method. Results: The 46 subjects included 25 (54.3%) femoral and 21 (45.7%) axillary bypass applications. The mean age was 64.2 ± 12.8 years (28–82) and 36 were male (78.3%). Critical limb ischemia was the most accounted indication for EAB surgery (25/54.4%). The cumulative mortality rate was 34.8% at 5 years' period. The graft patency and limb salvage rates for femoral and axillary applications were 59.2% versus 57.4% and 86.4% versus 80% at 5 years, respectively. Conclusions: Femorofemoral and axillofemoral bypasses are suitable for patients with AIOD requiring revascularization for relief of symptoms or limb salvage, who are not candidates for endovascular therapy or who are at high risk for direct anatomical revascularization.

Objective: Amount of time and number of procedures required in junior surgeon (JS) to achieve arteriovenous fistula (AVF) patency rate of surgeon with 20 years of experience. Methods: A single-center, retrospective, case–control study of AVF primary patency rate at 1 year postoperatively was observed among junior and experienced surgeon (ES) over a 4-year period. Fistula was created by terminolateral anastomosis in a fashion of continuous suture with nonabsorbable double-armed 7-0 monofilament. Maturation was grounded on the physical examination and fistula ultrasound 6 weeks postoperatively. Results: One hundred and twelve patients, 65% male and 35% female, were included in the study in 4 year period, 2015–2018. There were 51% radiocephalic and 49% brachiocephalic fistulas constructed by JS. Patency rate for JS was 66% overall, combining 64% for radiocephalic and 67% for brachiocephalic, compared to ESs 79%, performing only brachiocephalic fistulas. In the first 3 years, patency rate was 63%, 60%, and 66%, while significant improvement was accomplished in the the 4^th year with patency rate of 75%. Average time for hemodialysis initiation was 88 days postoperatively. Conclusions: Three years and approximately 60 procedures are required for JS to produce results comparable to ES in creation of AVF.

Context: In endovenous ablation under ultrasound guidance the saphenous vein is percutaneously accessed and the catheter is advanced cephalad toward the saphenofemoral junction. Tumescent anesthesia and thermal energy are used in concert to provide an effective means of eliminating great saphenous vein reflux. Aims and Objectives: Primary objective – (1) To study recanalization rate after light amplification stimulated by emission of radiation (LASER) in the varicose vein. Secondary Objectives are to Study – (1) Clinical effectiveness of LASER in varicose veins. (2) Quality of life (QoL). Materials and Methods: Single institute based prospective observational study of 81 patients undergoing LASER ablation for varicose veins was observed for 12 months post LASER ablation. Patients were assessed for residual varicosities, new varicosities, recurrence, complications, and QoL. Results: There was no recanalization of ablated veins at the end of 12 months. About 96.3% of patients remained free from developing new varicosities, whereas only 18.5% of patients had residual varicosities postprocedure at the initial follow-up which has been successfully treated with foam sclerotherapy. QoL postprocedure improved significantly with 69 patients (85.2%) had excellent QoL after 12 months postprocedure. Conclusion: (1) Least residual varicosities postprocedure treated by foam sclerotherapy. (2) Development of new varicosities occurs late in follow-up. (3) Zero recurrence rate of ablated veins through LASER. (4) Postopearative complication of pain and paraesthesia are minimal due to adequate tumescent anesthesia. (5) Dreaded complication of deep venous thrombosis is not recorded in any of the cases because of early ambulation. (6) There is a significant improvement in QoL of patients from the start to the end of the study.

Aim: The aim of this study was to emphasize the role of CO₂ angioplasty using dedicated automatic OptiMed CO₂ delivery system in patients with peripheral arterial disease (PAD) of high-risk group. Iodinated contrast media is harmful in all these patients of renal insufficiency with baseline creatinine >1.5 mg/dl. Methods: The present study is a retrospective analysis from a prospectively collected institutional review board-approved database. From April 2015 to June 2019, 44 patients (29 male patients and 15 female patients with a mean age of 68.5 years) underwent peripheral angioplasty using dedicated CO₂ delivery system (OptiMed). All the patients were known diabetic with renal insufficiency due to chronic kidney disease (CKD). Demographic factors, clinical characteristics, and atherosclerotic risk factors were documented. Lesions included proximal and distal superficial femoral artery, popliteal, and below-the-knee vessels. Patients with chronic obstructive pulmonary disease, ventricular septal defects, and pulmonary vascular malformations were excluded from the study. Preliminary diagnosis by duplex scan was done in all the patients. Technical success, periprocedural events, and clinical outcomes were documented in all the patients. Results: Technical success was achieved in 43 cases (97.7%) which is described as successful balloon angioplasty resulting in increased vascularity of the distal limb due to improved distal runoff. Adequate imaging and successful intervention was achieved using OptiMed CO₂ delivery system in majority of our patients. In one patient, the lesion could not be crossed and the patient had acute ST-elevation changes in electrocardiogram, and hence, the procedure was abandoned and the patient was shifted to cardiac care unit. Twenty-one patients complained of moderate pain which subsided with intra-arterial lidocaine. Four patients who complained of severe pain were given nerve block and sedation. There were no other intra- and postprocedural adverse events with stable renal parameters monitored up to 48 h. None of the patients required amputation after angioplasty in our study. Conclusion: With increasing burden of PAD in diabetic group, especially in CKD patients, angioplasty with dedicated CO₂ delivery system is safe and effective with satisfactory outcome and should be considered as standard choice in this group of patients for limb salvage.

Introduction: Pseudoaneurysm of the femoral artery or an infected graft in the femoral region is a very serious disease with devastating complication. The aim of this study is to describe a novel technique for its management in the form of an extra-anatomic bypass between external iliac artery (EIA) and the popliteal/distal superficial femoral artery (SFA). Methods: This is a single-center retrospective study and includes eight consecutive patients with infection of previous femoral grafts and large femoral pseudoaneurysms, in which extra-anatomic bypass between EIA and popliteal or distal SFA was done. Results: The mean age of patients in the study was 43 years. There was one 30-day postoperative mortality (12.5%) due to sepsis. The patency rate in rest of the seven patients at the end of 3 months was 100% with no major complications. Conclusion: Our technique of extra-anatomic bypass from external iliac to femoral or popliteal artery, just medial to anterior superior iliac spine beneath the inguinal ligament in the subcutaneous plane is a simple and quick approach with no major neurological or bleeding risk.

Objective: The term “large-vessel vasculitis” encompasses the spectrum of primary vasculitis that causes chronic granulomatous inflammation predominantly of the aorta and its major branches. The two major categories of large-vessel (LV) vasculitis are giant cell arteritis and Takayasu arteritis. LV vasculitis of unknown etiology presenting as mesenteric ischemia is presented here. Materials and Methods: This is a single-center retrospective analysis of 17 patients who presented with mesenteric ischemia over a period of 7 years. Their age ranged from 18 to 69 years. There were five females and the rest were male. The presenting symptoms were abdominal pain, nausea, malaise, and low-grade fever. Peripheral pulses were normal. Computed tomography (CT) aortogram showed typical wall edema and inflammatory tissue encasing the superior mesenteric artery, celiac artery, and the adjacent aorta in all the patients. Thrombosis and localized dissection in the superior mesenteric and celiac arteries was seen in some. Erythrocyte sedimentation rate and C-reactive protein were elevated, but other vasculitis markers were normal. Results: All of them were treated with glucocorticoids with immediate relief from the symptoms. Anticoagulation was given for those with thrombus, stenosis, and dissection. None had any intervention. At 1-year follow-up, there was no recurrence, and all were asymptomatic. Conclusion: Idiopathic LV vasculitis can present as mesenteric ischemia and acute abdomen. CT aortogram typically shows inflammatory tissue around the visceral artery and the aorta. The etiology is still uncertain. However, this condition has many similarities with LV giant cell arteritis (GCA-LV). Hence, all investigations should be done to rule out GCA. They respond very well to glucocorticoids. Correct diagnosis can avoid an unnecessary surgery. Long-term follow-up is required in order not to miss any late complications This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background and Objectives: Contrast-induced nephropathy (CIN) is an acute deterioration of renal function seen following the administration of iodinated contrast media for various diagnostic procedures. Although extensive study has been done in various fields, the data on CIN are lacking in peripheral endovascular procedures. This study was conducted to analyze the incidence, risk factors, and long-term renal morbidity of CIN after endovascular procedure for critical limb ischemia (CLI) of lower limbs. Methods: This was a prospective, observational study and the patients undergoing peripheral endovascular procedure for CLI in a referral center were included. The patients were followed up for the development of CIN with serum creatinine levels on the 5^th day postprocedure and till 6 months. Results: A total of 211 patients with various comorbidities were included. The incidence of CIN was found to be 7.5%. The risk factors and multiple comorbidities were compared between CIN and non CIN patients. The higher preprocedure creatinine (mean 1.03 mg/dl vs. 0.92 mg/dl, P < 0.045), higher contrast volume (mean 73.8 ml vs. 52.1 ml, P < 0.001), and lower hemoglobin (mean 10.5 g/dl vs. 11.8 g/dl, P < 0.008) were significantly associated with CIN. The follow-up at 6 months showed CIN patients had increased serum creatinine and reduced estimated glomerular filtration rate as compared to non-CIN patients. Conclusion: CIN is a substantial problem in peripheral endovascular procedures with long-term renal morbidity. The strategies to prevent CIN should be included in all patients undergoing endovascular procedures irrespective of risk profile and long-term renal function monitoring of CIN patients is warranted.

In complex endovascular interventions, there is often a need for multiple smaller sheaths to be placed parallelly inside a larger sheath to gain simultaneous access into different vessels. Here, we describe one such case of fenestrated repair of a juxtarenal aneurysm from our recent experience. This case required simultaneous cannulation with sheaths in both renal arteries and the superior mesenteric artery through the fenestration of a custom-made fenestrated stent graft. This paper aims to discuss, in simple terms, the mathematical basis behind calculating the diameters of smaller sheaths inside a larger sheath. Three different configurations are discussed – two, three, and four sheaths within a larger sheath. For simplicity, the inside sheaths are all of the same outer diameter and the diameter of all the sheaths is assumed to remain uniform throughout their lengths.

Objective: The purpose is to determine the incidence of erectile dysfunction (ED) in patients with aortoiliac occlusive disease and compare the change of ED after open surgery and endovascular repair. Materials and Methods: A prospective and comparative study in a single center from January 2013 to October 2015, 103 male patients admitted for extensive aortoiliac occlusive lesions. The erectile function (EF) was evaluated using a questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after 1 year. Results: This study enrolled two groups: 48 patients underwent endovascular treatment and 55 patients underwent open surgery (aortofemoral or aorto-iliac bypasses). Preoperatively, 45.8% of patients were functionally impotent; there was no difference EF depending on the stage of peripheral arterial disease or the severity of obstructive aortoiliac lesions. Postoperative impotence was twice as common in those with minor dysfunction preoperatively, deterioration of EF occurred in 16.2% in the surgical group, and 2.1% in the endovascular group, with a very significant difference (P = 0.0001). In multivariate analysis, adjusted to preoperative EF was significantly more impaired postoperatively after median laparotomy (heart rate: 24.80 confidence interval = 95% [3.17–51.80], P < 0.0001). Conclusion: Sexual dysfunction is a frequent and often missed comorbidity in vascular surgery patients, especially after aortoiliac surgery. Hence, it must be diagnosed and evaluated in preoperatively in the choice of the therapeutic approach. For that endovascular treatment offers a less invasive alternative to open surgery and allows patients to maintain its sexual function intact and improve the quality of life.

Since description of the first vascular anastomosis techniques pioneered by Alexis Carrel, vascular reconstructive techniques have undergone several advancements. The traditional three-point “Alexis” technique for and end-to-end anastomosis remains a textbook description of an ideal anastomosis, especially in microsurgery. In clinical practice, dissection extent, vessel mobility, and timing can limit the applicability for daily use. We describe a more intuitive procedure, using common vascular techniques of parachuting and growth factor inclusion to achieve a technically perfect end-to-end anastomosis. In particular, the usual limitations of the “Alexis” technique do not limit this procedure making it easily learnable and reproducible.

Hemodialysis access is not a common cause of femoral artery pseudoaneurysm (FAP) formation. FAP formation during dialysis access is due to inadvertent cannulation of the femoral artery instead of the femoral vein. The ruptured FAPs can lead to increased morbidity and mortality. We hereby share our experience of three cases of ruptured FAPs or with impending rupture after femoral hemodialysis access in patients of chronic kidney disease. Urgent intervention is usually required to prevent life-threatening complications in such patients.

Median nerve palsy is an uncommon complication of brachial artery catheterization. Compression from a pseudoaneurysm at the puncture site is rarely implicated as the cause for such median nerve dysfunction. Here, we report two patients who developed median nerve palsy secondary to compression from pseudoaneurysms after brachial catheterizations done for chronic lower limb ischemia. Both underwent operative repair of the culprit lesions. Despite months of aggressive physiotherapy, recovery of nerve function remains poor in both.

As the population ages, the average age of patients is expected to rise. Here, we describe a successful case of thoracic endovascular aneurysm repair (TEVAR) performed in a 106-year-old female. The patient had an impending rupture of 6 cm saccular aneurysm at the descending thoracic aorta. Although the patient was super senile, her activity of daily living was independent. After multiple multidisciplinary conference and informed consent, TEVAR using local and venous anesthesia was successfully performed. This case illustrates the importance of strict examination of each case for treatment indications, including risk/benefit balance, in a super aging world.

Mycotic aneurysms are uncommon, difficult to treat, and fatal. These aneurysms caused by Acinetobacter baumannii complex are not documented. We present the case of a 20-year-old female who presented with pain abdomen and vomiting with on and off episodes of fever. This woman had a history of postpartum cardiomyopathy for 12 months and chronic kidney disease for 2 months, on medical treatment. She was diagnosed with an infrarenal aortic aneurysm with iliac extension caused by A. baumannii complex and left hydronephrosis. She was successfully treated with surgery followed by long-term antibiotics. There is no documented evidence of this organism to cause mycotic aneurysm. We also discuss about the course, investigations, and management of this case.

Acute thrombosis of an abdominal aortic aneurysm with a horseshoe kidney (HSK) is a very rare phenomenon. This anatomical anomaly poses a challenge for the surgeon which requires prompt treatment. We present a case report of an elderly man who presented with a threatened acute left leg ischemia and a pulsatile abdominal mass. Computed tomography revealed a huge fusiform infrarenal aortic aneurysm extending to the left iliac artery with thrombotic occlusion and a HSK. He underwent emergency transabdominal laparotomy and aneurysectomy with inlay bifurcated graft repair. The renal isthmus was preserved and left accessory renal artery was reimplanted onto the graft. Postoperatively, bilateral lower limb was viable and kidney function was normal. He was discharged well. Open surgery remains the gold standard in treating such a complex case promptly.

Visceral venous aneurysms (VVAs) are rare, accounting for 3% of all venous aneurysms. We present a case of a 73-year-old man diagnosed with an incidental 3.3 cm superior mesenteric vein (SMV) aneurysm, which has been managed conservatively for over 2 years. A 73-year-old man presented to the emergency department with a 1-week history of abdominal pain, generalized fatigue, and multiple episodes of vomiting. A contrast-enhanced computed tomography scan of the abdomen and pelvis was performed. This demonstrated an incidental multilobulated SMV aneurysm at the level of the inferior aspect of the uncinate process of the pancreas, with a maximal diameter of 25 mm. We have successfully managed this conservatively with serial imaging for 2 years. There are only 17 reported cases of SMV aneurysms, most of which occur at the confluence of the splenic vein. Ours occurred in the distal SMV. Due to their rarity, there is no standardized management approach for VVAs. Treatment is only proposed for VVAs with increasing size or rupture, thrombosis, or compression of local structures. We provide our experience in successfully managing an uncomplicated SMV aneurysm conservatively.