In India, the adoption of orbital atherectomy (OA) for treating peripheral arterial disease (PAD) remains limited within routine clinical practice, despite increasing evidence supporting its effectiveness in optimizing the outcomes. To address this gap and promote wider integration of OA into endovascular practice, a position statement was developed to provide comprehensive and practical guidance on its appropriate use in peripheral interventions. A survey was conducted among 14 experienced peripheral vascular and interventional specialists across India to capture current clinical practices, first hand experience, and perceptions regarding the use of OA in managing PAD and identify barriers to its adoption. The aggregated survey responses were carefully analyzed alongside a detailed and systematic literature review, which compiled clinical evidence, procedural outcomes, safety profiles, and recent technological advancements related to OA in PAD. By combining real-world insights with the latest scientific data, the resulting position statement synthesizes evidence-based recommendations designed to enhance clinician understanding, encourage standardized use, and ultimately improve patient outcomes through optimized application of OA in PAD management.
Chronic venous insufficiency and varicose vein disease are common, progressive conditions associated with significant morbidity and impaired quality of life. Endovenous thermal ablation techniques have largely replaced surgical stripping; however, their reliance on tumescent anesthesia and thermal energy is associated with procedure-related discomfort and specific complications. Cyanoacrylate closure (CAC) has emerged as a nonthermal, nontumescent alternative that addresses several limitations of thermal techniques while eliminating the need for compression stockings postprocedure. While randomized controlled trials and real-world studies have demonstrated high vein closure rates and favorable safety profiles with CAC, data from India remain limited and largely observational. This manuscript summarizes the deliberations of a multidisciplinary Indian expert panel convened to integrate available evidence with real-world clinical experience and provide practical guidance for the safe and effective use of CAC in the management of varicose veins. Key areas addressed include optimal patient selection, procedural refinements, follow-up strategies, and the recognition and management of adverse reactions, particularly hypersensitivity reactions and phlebitis-like abnormal reactions. The panel emphasizes the importance of careful anatomical assessment, adherence to device instructions for use, and differentiation between immune-mediated reactions and inflammatory phlebitis to guide appropriate management. By contextualizing international evidence within Indian practice realities, these expert recommendations aim to support standardized adoption of CAC, optimize clinical outcomes, and enhance patient safety in the management of varicose veins.
Background: While several trials have established the superiority of intravascular ultrasound (IVUS) over traditional venography in cardiac interventions, evidence supporting its role in peripheral venous disease remains limited, particularly within the Indian population. This study aimed to evaluate the evolving role of IVUS in the assessment and management of nonthrombotic iliac venous obstruction in an Indian population. Materials and Methods: A prospective, investigator-initiated, single-center study was conducted at a tertiary-care center in Maharashtra, India, from February 2022 to May 2022. Symptomatic patients with a normal digital subtraction angiography venogram with deep venous refluxes and ineligible for endovenous ablation treatments were consecutively enrolled. Patients with CEAP C4-C6 disease demonstrating iliac vein narrowing and/or deep venous reflux on Valsalva on duplex ultrasound, suggestive of iliac venous outflow obstruction, were included. All patients underwent both venography and IVUS, and imaging findings were compared. Results: A total of 20 patients were studied. Minimal vessel diameter (venography: 7.04 +/- 2.52 mm vs. IVUS: 2.90 +/- 1.90 mm, P < 0.001) and reference vessel diameter (venography: 11.22 +/- 2.89 mm vs. IVUS: 9.80 +/- 2.59 mm, P < 0.001) were significantly higher on venography. Minimal vessel area and reference vessel area were also statistically higher on venography. In contrast, diameter stenosis (venography: 40.80% +/- 16.70% and IVUS: 71.21% +/- 15.96%, P < 0.001) and area stenosis (venography: 53.14% +/- 19.50% and IVUS: 66.37% +/- 11.09%) were lower on IVUS. The sensitivity of venography for correctly diagnosing significant stenosis was approximately 25%. Conclusion: Compared to traditional venography, IVUS is a valuable and effective imaging modality in the diagnosis and treatment of nonthrombotic iliac venous outflow obstructions in the Indian population.
The obturator bypass, described in the 1960s, offers an extra-anatomic bypass through the obturator foramen, avoiding the infected groin. This study analyzes a series of three obturator bypasses done in our institution between October 2024 and March 2025. Clinical data and operative details, conduit choice, and early outcomes - including adverse limb events - were reviewed. Two patients underwent aortopopliteal bypass; one underwent aortosuperficial femoral artery bypass. Dacron conduits were used. Two patients had limb salvage and graft patency at 1 month with palpable pedal pulses with no graft-related complications. Another patient died in the early postoperative period due to a cardiac event. One patient experienced an adverse limb outcome leading to mortality on postoperative day 57. Obturator bypass provides a useful extra-anatomic route for revascularization in patients with infected groin wounds, offering acceptable early outcomes. However, close postoperative surveillance is essential, as adverse limb outcomes can occur despite technically successful revascularization.
Dorsalis pedis artery (DPA) pseudoaneurysms following trauma in children are exceedingly rare. We present a case of an 8-year-old boy who developed a pulsatile swelling on his right foot 1 month after a trauma caused by a broken porcelain doll, which required suturing. Initially misdiagnosed and treated as a hematoma, the swelling progressively enlarged, leading to referral to our tertiary care center. This case highlights the importance of considering pseudoaneurysm in the differential diagnosis of persistent pulsatile swelling following foot trauma in children. Resection of the pseudoaneurysm with ligation of the DPA was performed. Given the rarity of this condition, further case reports are needed to establish dedicated management guidelines.
Background: Brachiobasilic fistula (BBF) is an established vascular access option in patients with end-stage renal disease when distal fistulas are not suitable. Superficialization of the basilic vein can be achieved using elevation or transposition techniques. Objective: To compare maturation, patency, and complication profiles of brachiobasilic arteriovenous fistulas (AVFs) created using the elevation and transposition techniques. Materials and Methods: This prospective observational study included 56 patients undergoing BBF creation at a tertiary care center, with 29 patients in the elevation group and 27 in the transposition group. Preoperative Doppler ultrasonography was performed for vascular assessment. Postoperative follow-up included clinical examination and duplex ultrasonography at 6 and 12 weeks. The outcomes assessed were fistula maturation, time to first cannulation, primary and secondary patency at 3 and 6 months, and procedure-related complications. Results: Baseline demographic, clinical, and preoperative Doppler parameters were comparable between the two groups. Overall fistula maturation rate was 98.2%, with no significant difference between the two techniques. Primary patency at 3 months was 79.3% in the elevation group and 81.5% in the transposition group, while primary patency at 6 months was 72.4% and 66.7%, respectively; the differences were statistically insignificant. Secondary patency at 3 and 6 months was 89.7% in the elevation group and 92.6% in the transposition group, with no significant difference. Wound-related complications were more frequent in the elevation group, whereas vascular complications were comparable between the two groups. Conclusion: Both elevation and transposition techniques provide satisfactory maturation and patency outcomes for brachiobasilic AVFs. The main differences between techniques were wound-related complications.
Aims:Pulmonary embolism (PE) remains underdiagnosed and inconsistently managed in the Indian healthcare setting due to specialty-driven silos, lack of standardized referral pathways, and limited access to advanced therapies. Recognizing these challenges, we pioneered the establishment of the multidisciplinary PE response team (PERT) in December 2023 to streamline and standardize the care of PE patients. This study aimed to quantify the impact of PERT on clinical outcomes of patients treated with acute PE.Subjects and Methods:Ambispective analysis of the patients diagnosed with acute PE before and after formation of PERT at Medanta - The Medicity, Gurugram. The referral patterns, time to diagnosis, time to intervention, changes in patient outcomes (30-day mortality, intensive care unit [ICU] length of stay [LOS], and total LOS), and use of advanced therapies between January 2022 and December 2023 (pre-PERT) and January 2024 and April 2025 (post-PERT) were compared.Results:Post-PERT formation, PE case referrals increased to 248% (from 75 to 186 cases per year). Post-PERT, there was a significant reduction in time to diagnosis (from 775 min to 252 min), ICU LOS (from 4 days to 2 days), total LOS (from 14 days to 9 days), and 30-day all-cause mortality (23.5% to 14.2%). A paradigm shift was observed with the increased adoption of mechanical thrombectomy, particularly in intermediate-risk PE cases.Conclusions:The implementation of the multidisciplinary PERT at our institution marks a significant advancement in the multidisciplinary management of PE. This scalable model warrants adoption across tertiary care centers nationwide to elevate PE care in India.
Introduction: The prevalence of diabetes and diabetic foot ulcers are rising world-wide. Diabetics are prone for wound infection and vulnerable for limb complications like amputation (major or minor) subsequently. Various grading or scoring systems have evolved over a period of time (e.g., Wagner’s Grading, University of Texas grading and PEDIS classification) to assess the severity of infection and disease among the diabetics and can predict the limb outcomes (ulcer healing/ minor or major amputations) as well. But the predictive abilities of these commonly used scoring systems are not consistent and varies in different studies. Patients and Methods: This was a cross-sectional, observational study conducted over one hundred patients and had compared the ability of various scoring systems (University of Texas, Wagner’s and PEDIS) in prediction of limb outcome (Ulcer healed/ minor amputation/ major amputation) among patients with diabetic foot ulcers. Results: It was observed that with increase in ulcer grades/ scores, chances of amputations were higher in all three scoring systems (P value < .0001). However, the increase in amputation rates were steadier and predicted earlier in PEDIS classification system as compared to other two grading systems. Conclusion: In our study, all three classification systems were found to be a good predictor of limb outcome. However, PEDIS was found better in detecting poor outcome earlier than other two classification systems.
Background:Randomized trials for treating chronic limb-threatening ischemia have highlighted the effectiveness of bare-metal stents in femoropopliteal disease, despite their low long-term patency rates. This article seeks to explore the optimal outcomes of high-dose drug-coated balloons (HD-DCB) as an alternative to metal stents, offering improved patency rates and reduced intimal hyperplasia.Methods:A retrospective observational study was done with 72 femoropopliteal lesions treated with HD-DCB to collect data over an average of 2 years. The endpoints evaluated included primary patency, late lumen loss (LLL) at 6 months, and all-cause mortality at 12 months.Results:Technical success was achieved in 100% of cases. The average lesion length was 107.1 +/- 42 mm. The overall primary patency rate was 75% at 1 year, with a statistically significant difference between de novo lesions (83.8%) and repeat lesions (65.7%), yielding a P = 0.029. The mean LLL was 0.45 mm, ranging from 0.07-0.51 mm. The ankle-brachial index improved from 0.343 +/- 0.106 to 0.873 +/- 0.073 (P < 0.0001). The survival rate was 94.8%.Conclusions:These findings suggest that HD-DCBs are both safe and effective, providing a metal-free alternative for treating femoropopliteal artery disease. Further research is needed to confirm these results.
Background: Complex abdominal aortic aneurysms (AAAs), including juxtarenal, pararenal, paravisceral, and thoracoabdominal aneurysms, present significant technical and perioperative challenges. In resource-limited public healthcare settings, open surgical repair continues to play a major role alongside endovascular techniques. Methods: We conducted a retrospective descriptive case series of six patients with complex aortic aneurysms managed at the Institute of Vascular Surgery, Madras Medical College, and Rajiv Gandhi Government General Hospital, Chennai, India. Four patients underwent open surgical repair with visceral debranching and endoaneurysmorrhaphy, while two underwent thoracic endovascular aneurysm repair (TEVAR). Operative techniques, renal protection strategies, complications, and short-term outcomes were analyzed. Results: Etiologies included atherosclerosis, Takayasu arteritis, and infective (tuberculous) aneurysm. Open repairs utilized supraceliac clamping, cold renal perfusion, carrel patch reimplantation, and multibranch graft reconstruction. One patient developed an enterocutaneous fistula managed successfully. No perioperative mortality was observed. Endovascular repairs demonstrated complete aneurysm exclusion without early endoleaks. Conclusion: Complex AAAs can be managed effectively in public-sector tertiary centers using tailored open and endovascular approaches. Open repair remains indispensable in inflammatory and infective aneurysms, while TEVAR provides excellent short-term outcomes in anatomically suitable patients.
Background:Antegrade ipsilateral superficial femoral artery (SFA) access is increasingly used as an alternative to common femoral artery (CFA) access for infrainguinal endovascular interventions. While it provides a direct approach to target vessels and avoids crossing the aortic bifurcation, concerns regarding access-site safety persist. This study compared outcomes of antegrade SFA and CFA access in patients undergoing infrainguinal revascularization for chronic limb-threatening ischemia (CLTI).Materials and Methods:In this retrospective, single-center study, 140 consecutive CFA access procedures and 140 consecutive SFA access procedures performed between January 2021 and June 2024 were analyzed. Baseline characteristics, technical success, stent utilization, additional access requirements, and access-site complications were evaluated. All procedures were ultrasound (US)-guided, with postoperative assessment using duplex US and ankle-brachial index.Results:Baseline characteristics were comparable between the groups. Technical success was achieved in 97.9% (95% confidence interval [CI]: 93.9%-99.6%) of CFA cases and 97.1% (95% CI: 92.8%-99.2%) of SFA cases (P = 0.687; difference 0.8%, 95% CI: 2.8%-4.4%). Stent deployment was required in 12.1% (95% CI: 7.2%-18.7%) of CFA and 15.7% (95% CI: 10.1%-22.8%) of SFA procedures (P = 0.49). Overall, access-site complications occurred in 3.6% (95% CI: 1.8%-6.6%), with no significant difference between SFA (4.3%) and CFA (2.9%) access (P = 0.519). Pseudoaneurysms occurred in 2.1% of patients and were managed conservatively.Conclusions:Antegrade SFA access is a safe and effective alternative to CFA access for infrainguinal interventions in CLTI, offering comparable technical success and low complication rates. With meticulous US guidance, SFA access can be reliably incorporated into routine clinical practice.
We presented a patient who was first diagnosed, 2 years ago, with left nutcracker syndrome, May–Thurner syndrome, and pelvic compression syndrome. The patient’s symptoms returned despite the corrective surgery. Further investigation revealed right nephroptosis, and the patient underwent another corrective surgery.
Objective: To evaluate limb-salvage outcomes, technical success, and clinical predictors of amputation in patients with chronic limb-threatening ischaemia (CLTI) undergoing below-the-knee (BTK) angioplasty in an Indian tertiary centre. Methods: A retrospective analysis of 251 patients with Rutherford class V and VI CLTI treated with percutaneous transluminal angioplasty (PTA) between January 2020 and January 2023 was performed. The primary outcome was limb salvage, defined as avoidance of major (above-ankle) amputation. Secondary outcomes included technical success, mortality, and factors associated with limb loss. Results: Technical success was achieved in 95.6 %. Limb salvage at 24 months was 92.5 % for Rutherford V and 92.2 % for Rutherford VI disease. Minor (toe/ray) amputations were required in 52.9 % during follow up . Diabetes (88.8 %) , Hypertension (70.9%) and Coronary artery disease (34.6%) Chronic kidney disease (16 %) were associated with higher rates of amputation. Post-procedural dual-pathway inhibition and statin therapy were commonly used and may have contributed to improved event-free survival. Conclusion: In this real-world Indian cohort with advanced CLTI, late presentation and heavy metabolic burden, isolated BTK angioplasty achieved acceptable limb salvage using plain balloon angioplasty alone. While outcomes compare favourably with published literature, absence of anatomical stratification and perfusion-based scoring limits broader generalisability. These results reflect pragmatic outcomes in a resource-constrained environment.
Ulnar artery pseudoaneurysm is an uncommon vascular condition, although trauma, infection, embolism, autoimmune disorders, and connective tissue diseases like Ehlers–Danlos Syndrome are more commonly associated with large vessel aneurysm and less frequently with medium or small vessel aneurysm. Prompt diagnosis and treatment are crucial, as these aneurysms may lead to distal ischemia and digital compromise. Imaging modalities such as Doppler ultrasound, computed tomography angiography, and clinical evaluation are essential for accurate diagnosis. Surgical resection and arterial reconstruction are the primary modes of treatment. We present a case of an ulnar artery pseudoaneurysm probably due connective tissue disorder managed with resection and autologous vein interposition graft.
Background:Enhanced recovery after surgery (ERAS) protocols have been increasingly adopted across various surgical specialties to optimize perioperative care, improve patient outcomes, and reduce hospital length of stay (LOS). However, their implementation in open aortic surgery remains limited due to the complexity and high-risk nature of these procedures.Objective:This study evaluates the implementation, outcomes, and evolving protocols of ERAS in open aortic surgeries at a tertiary care center, highlighting our institutional experience.Methods:A randomized controlled study was conducted on patients undergoing open aortic procedures from January 2024 to June 2025. Outcomes assessed included mean hospital LOS, postoperative pain, postoperative opioid consumption, mean time to first bowel movement, and mean time to return to liquid and regular diet.Results:A total of 30 patients were included - 15 in each group. Postoperative pain scores were similar between the groups at 12 and 24 h, but there was a statistically significant reduction in pain scores in the ERAS protocol group at 36 and 48 h (P < 0.05). A statistically significant reduction was also observed in the time taken for dietary advancement in the ERAS group (P < 0.05). These patients also experienced earlier bowel movement. Time to transition from IV to oral analgesics was observed to have exceeded than 72 h in both groups. Patients in the ERAS protocol group had a reduction in mean hospital LOS, although this was not statistically significant. Challenges in implementation included longer surgery duration as it is an academic center, extubation delay, adherence to early mobilization, and feeding goals. Patient-specific limitations such as chronic pain and baseline functional impairment also posed challenges to full protocol adherence.Conclusion:ERAS protocols can be safely and effectively applied to open aortic surgery with demonstrable benefits in pain control and gastrointestinal recovery. Continued refinement, multidisciplinary collaboration, and patient-specific tailoring are critical for sustained success.
Tuberculosis (TB), a chronic granulomatous infection, is associated with systemic inflammation that may unmask a hypercoagulable state. While venous thromboembolism (VTE) in TB has been sporadically reported, its occurrence in young, immunocompetent individuals without conventional risk factors remains underrecognized. We describe a 22-year-old male on treatment for extrapulmonary TB (pleural effusion) who presented with right lower limb swelling and breathlessness. Imaging revealed extensive iliofemoral and tibial deep vein thrombosis (DVT), along with bilateral pulmonary emboli. The patient responded well to anticoagulation with apixaban alongside continued antitubercular therapy. The coexistence of extensive iliofemoral DVT and bilateral pulmonary embolism (PE) in a young adult with extrapulmonary TB is exceedingly rare. Fewer than 50 cases of TB-associated VTE have been reported in the literature, with even fewer involving such proximal extensive DVT and PE in the absence of additional risk factors. This case underscores the need for heightened clinical suspicion and early imaging in TB patients presenting with thromboembolic symptoms, regardless of immune status or traditional risk factors.
