Background Steal syndrome is one of the complications of dialysis arterio-venous fistula (AVF) characterized by decrease digital arterial pressure from preferential blood flow through the low pressure venous outflow. It has clinical importance when leading to hand ischaemia, heart overload, or both. High flow steal has the distal upper limb arteries intact. Treatment options include ligation, change fistula inflow, and banding procedures. Partial fistula excision and reclosure is a technique that tries to limit the AVF hyperfunction to improve hand ischaemia. Aim of the work To assess feasibility, outcome, and complications of partial shunt excision to treat hyperfunctioning steal. Patients and methods The study included 20 patients, 12 women and 8 men, with high flow steal hand ischaemia from September 2018 to December 2020. Preoperative duplex assessment of fistula outflow volume and wrist arteries was performed. All patients had partial fistula body and outflow excision, resizing, and suture closure in 3-month follow-up for clinical and duplex outcome. Results Significant decrease of fistula outflow volume after the procedure from 1847.50 +/- 656.04 to 1258.50 +/- 413.93 and increase in wrist arterial peak systolic velocity from 23.50 +/- 8.64 to 56.80 +/- 15.03 (P=0.002 and P<0.002), respectively, were found. Complete relief of hand ischaemic symptoms in 75% of patients, partial improvement in 25% with minimal postoperative complications, no reintervention, and no limb loss during follow-up with 3-month 100% patency was noted. Conclusion Partial shunt excision is a feasible flow limiting procedure that can treat high flow AVF effectively with minimal complication.

Background: Subclavian artery aneurysms (SAAs) are uncommon aneurysms.SAA is potentially serious disease due to complications. Objective: to evaluate the surgical treatment of SAAs and its complications. Methods: Fifteen patients with SAAs: 13 patients (86.67%) had extrathoracic (ET) aneurysms and two patients (13.33%) had intrathoracic (IT) aneurysms. Thoracic outlet syndrome (TOS) was presented in 8 patients (53.33%), while, atherosclerosis was presented in 7patients (46.67%). Laboratory & radiological studies were done. All patients were treated surgically. Results: In 13 patients with extrathoracic aneurysms, a supraclavicular approach to the subclavian artery was used in (6/13, 46.15%), supraclavicular and infraclavicular approach was used in (7/13, 53.85%) cases. After excision of the aneurysm, graft interposition using (PTFE) and saphenous vein graft bypass were done in (6/13, 46.15% & 5/13 , 38.46 %) patients respectively. In two patients (2/13, 15.38 %), aneurysmal excision and end to end anastomosis were done. While in two patients with intrathoracic aneurysms, a combined left thoracotomy and supraclavicular approach was used. Common carotid-subclavian bypass using Dacron graft was done. In (6/8, 75 %) of patients with TOS, decompression was performed before arterial reconstruction. In three (37.50 %) patients with cervical rib, the cervical rib was resected. In three patients (37.50 %) with scalene syndrome, scalenectomy of the scalenus anterior muscle was done. In two patients (2/8, 25 %) with brachial artery embolism, embolectomy was done. Conclusions: Early intervention was needed, especially in distal SAAs, because of the risk of thrombo-embolic complications. Open repair is sill the gold standard intervention for SAA.

Introduction Chronic limb-threatening ischemia (CLTI) is commonly produced by multilevel arterial tree affection. To correct its effect, multisegment revascularization was adopted. The use of hybrid revascularization includes the use of an open access to accomplish the endovascular part of the procedure. Sometimes, for technical issues, open access is used for only angioplasty. In thrombectomy, for acute ischemia, residual chronic lesion angioplasty is done. This, also, entails the use of open access for angioplasty. Aim To report and evaluate three-center work in open access endovascular therapy for lower limb CLTI and acute thrombotic ischemia. Patients and methods This prospective study included patients admitted to Vascular Surgery Unit, Faculty of Medicine, Alexandria University, Department of Vascular Surgery, Faculty of Medicine, Tanta University, and Department of Experimental and Clinical Surgery, Medical Research Institute, Alexandria University, from June 1, 2018, to May 31, 2019, treated by different endovascular modalities done through open surgical access and followed for 1 year. Results A total of 116 patients were included, comprising 86.2% men and 13.8%women. The mean±SD age was 59.74±7.82 years. A total of 98 (84.5%) patients had CLTI and 18 (15.5%) had acute thrombotic ischemia. All acute patients had hybrid thrombectomy and completion angioplasty with excellent outcome. For patients with CLTI, 30 (25.9%) had open access angioplasty only and the rest 86 (74.1%) patients had hybrid endosurgical revascularization. Technical success was 94.8% for all cases. The primary and secondary patency rates were 67.6 and 76.5%, respectively, at 6 months and 52.7 and 62.6%, respectively, at 1 year, with an acceptable limb salvage rate of 91.2% at 1 year. Conclusion Open access endovascular procedures are feasible maneuvers allowing multisegment arterial disease treatment in both chronic and acute occlusions, offering good tools for the surgeon to minimize invasive approaches with acceptable patency and good limb salvage but should be reserved for critical ischemia owing to their complex nature.

Background: Few data were documented about risk factors for lower limb varicose veins (LLVV) among Egyptian population. Identifying modifiable risk factors is crucial to plan for prevention. The current research aims to study the epidemiological, life style, and occupational factors associated with LLVV in a sample of Egyptian population. Methods: A case control study was adopted. Cases with LLVV (n = 150) were compared with controls (n = 150). Data was collected using an interview questionnaire and clinical assessment. Data was analyzed using the univariate and multivariate logistic regression analyses. Results: According to multivariate analysis among all participants (n = 300), the odds of LLVV was 59.8 times greater for those who frequently lift heavy objects (95% CI = 6.01, 584.36) and 6.95 times higher for those who drink < 5 cups of water/day (95% CI = 2.78, 17.33). Moreover, it was 4.27 times greater for those who infrequently/never consume fiber-rich foods (95% CI = 1.95, 9.37) and 3.65 times greater for those who stand > 4 h/day (95% CI = 1.63, 8.17). Additionally, odds of LLVV was 3.34 times greater for those who report irregular defecation habit (95% CI = 1.68, 6.60), and 2.86 times higher for those who sleep < 8 h/day (95% CI = 1.14, 7.16), and 2.53 times higher for smokers compared with ex-smokers/non-smokers (95% CI = 1.15, 5.58). In addition, a standing posture at work was an independent predictor of LLVV among ever employed participants (n = 234) in the current study (OR = 3.10; 95% CI = 1.02, 9.38). Conclusions: This study highlighted seven modifiable independent predictors of LLVV mostly related to the life style, namely, frequent lifting of heavy objects, drinking < 5 cups of water/day, infrequent/no consumption of fiber-rich food, standing more than 4 h/day, irregular defecation habit, sleeping less than 8 h/day, and smoking. These findings provide a basis to design an evidence-based low-cost strategy for prevention of LLVV among Egyptian population.

1 Assistant Prof. of Vascular Surgery, Department of Experimental and Clinical Surgery, Medical Research Institute, Alexandria University, Egypt 2 Prof. of Vascular Surgery, Vascular Surgery Unit, Department of Surgery, Faculty of Medicine, Alexandria University, Egypt 3 Lecturer of Neurosurgery, Department of Neurosurgery, Faculty of Medicine, Alexandria University, Egypt 4 Assistant Prof. of Vascular Surgery, Vascular Surgery Unit, Department of Surgery, Faculty of Medicine, Alexandria University, Egypt

Background: Renovascular hypertension is the commonest form of secondary hypertension. It occurs in less than 5 % of all hypertensive population. There are two forms of renovascular hypertension: Atherosclerotic and fibromuscular dysplasia. The aim was to evaluate the indications of surgical treatment of “renovascular hypertension”.Methods: Twenty cases with renovascular hypertension were included. The main investigations were: Laboratory studies, Duplex ultrasound, Intravenous pyelogram, CT angiography, aortography and selective renal angiography. Indications for surgery were : complex disease of the renal artery, aneurysm, accessory renal arteries, fibromuscular dysplasia and partial damaged of one kidney, atherosclerotic stenosis of the renal arteries and complete kidney damage. Results : The patients were divided into two groups : (Fibromuscular dysplasia group)which included 14 patients, (100.0%) were females, their age ranged from 18 to55 to 68 years with the mean±SD( 62 ±4.1), 5(83.3%)were males and 1(16.7%) was female. Renal artery bypass graft was done for 15 cases, endarterectomy in 2 cases, endarterectomy with patch graft in two cases and nephrectomy in one case. Control of hypertension was successful in 17 cases, partial control of 2 cases, while the blood pressure still high in case of nephrectomy. No mortality in both groups within 6 months follow up period. Conclusions : Surgical treatment for renovascular hypertension is mandatory for complex disease of the renal artery, aneurysms and failure of endovascular procedures. Nephrectomy is the treatment of choice for damaged kidney

Background Infragenicular arterial total occlusion is a major cause of critical ischemia of the lower limbs (CLTI) treated by endovascular intervention. Retrograde pedal artery access is an alternative method to cross total occlusion from below when antegrade passage fails. The aim of this study was to evaluate the short-term outcome in terms of patency, limb salvage, redoangioplasty rate, and complications. Patients and methods From June 2018 to July 2019, adult patients who had critical lower limb ischemia (Rutherford 4 and 5) were admitted to the vascular surgery unit of Alexandria main university hospital and department of CLTI clinical and experimental surgery at Alexandria medical research institute. They all were planned to be treated by infragenicular angioplasty. After failure of antegrade lesion crossing, angioplasty was done via retrograde access. Patients were followed for outcome and complications for 6 months. Results A total of 20 patients were included, comprising 14 (70%) males and six (30%) females. Mean age±SD was 71±13.5 years. Overall, 85% were diabetic, 75% hypertensive, 30% coronary heart disease, and 80% were smokers. CLTI clinical presentation was ischemic rest pain (20%) and tissue loss and gangrene (80%). Technical success was 85%. There were no procedural mortalities or complications except one case of limited leg hematoma (5%). The 6-month mortality was 5.8%, and major amputation was 5.8%. The 6-month primary and secondary patency rates were 62.5 and 87.5%, respectively, whereas the 6-month limb salvage rate was 93.75%. Conclusions Retrograde pedal access angioplasty to treat below-knee CLTI is a safe and feasible alternative to antegrade tibial angioplasty when it fails, with similar limb salvage and acceptable complications, but with possible higher reintervention rate, which needs to be studied further on a larger scale.

Background: We aimed to study variables affecting limb outcome following ligation of infected femoral pseudoaneurysms in intravenous drug abusers (IVDA)in the emergency setting and to propose an algorithm for management. Design: Prospective study. Methods: We studied short-term outcomes of 26 IVDA presenting with infected femoral pseudoaneurysms who underwent arterial ligation, hematoma evacuation, and debridement. Long-term results pertaining to limb functionality were unfeasible, as all patients were lost to follow-up. We aimed to study the potential predictors that might impact limb outcome in the emergency setting, namely: 1) mode of presentation (impending versus ruptured), 2) site of arterial ligation (above versus below inguinal ligament), 3) presence or absence of pedal Doppler flow post-ligation, and 4) ankle brachial pressure index (ABI) pre- and post-ligation. Results: Arterial ligation without revascularization was done in 19 (73.1%) of our patients, requiring no further intervention for limb salvage during their hospital stay. Four patients (15.4%) required iliopopliteal bypass, and 3 patients (11.5%) required major amputations (2 hip disarticulations and one above-knee amputation). In total, 23 limbs (88.5%) were salvaged. Proximal arterial ligation was done below the inguinal ligament (common femoral artery) in 21 patients (80.8%), while in the remaining 5 patients (19.2%), higher ligation was done above the inguinal ligament (external iliac artery). All 19 patients who were compensated had pedal Doppler flow post-ligation, and 18 of them had arterial ligation done below the inguinal ligament. The mean preoperative ABI (+/- SD) was 0.87 +/- 0.34, and the mean postoperative ABI (+/- SD) was 0.37 +/- 0.27. The mean change in ABI (+/- SD) was 0.50 +/- 0.32. Conclusions: Arterial ligation with local debridement alone is a safe procedure and would have salvaged 73.1% of limbs in this study. However, implementing a selective approach for postligation revascularization and our proposed algorithm increased limb salvage rate to 88.5%. The detection of pedal Doppler flow after ligation can stratify patients in whom urgent revascularization might not be required for limb salvage. Additionally, all efforts should be made to ligate the femoral artery below the inguinal ligament to preserve important juxta-inguinal collateral branches.

Background: Arteriovenous malformations (AVMs) are congenital high flow vascular malformations (VMFs) composed of anomalous capillary beds shunting blood from the arterial system to the venous system. They are infiltrative causing destruction of the local tissue and often severe bleeding. Objectives: The aim of this study was to review the clinical results of surgical treatment for AVMs, with preoperative scleratherpy. Patients and methods: 24 patients with AVMs and AVFs were treated in a period from October 2012 to March 2015. All patients were subjected to history taking, clinical examination, laboratory investigations and imaging studies which included: colored Duplex ultrasound, CTA, arteriography and direct haemangiography. All patients were treated by surgical excision after preoperative injections of sclerotherapy. Results: Age incidence of the patients ranged between 1-35 years, 70.8% of them were below the age of 5 years and 80% of the patients were females. The common site for AVMs was the head and neck in 66.67%. Symptoms and sings included: cosmetic 83.33%, thrill and pulsating mass 75%, sensation of heat 66.67%, while pain, tissue necrosis, bleeding, port-win stain and cardiomegaly were the least symptoms and sings. All patients were treated by surgical excision after preoperative sclerotherapy. Conclusions: Surgical treatment of AVM is a challenging issue for vascular surgeons. To minimize the complications related with surgery, a multidisciplinary team approach should be considered.

Purpose: Was to study the results of open surgical reconstruction of huge abdominal aortic aneurysms (HAAAs) & their complications. Patients and methods: Twenty eight patients with huge abdominal aortic aneurysms were studied in the period from October 2012- March 2015. The diagnosis was done by: history, clinical examination, various imaging which included: Duplex Ultrasound, CTA, MRA, DSA & Mid-stream aortography. Open aortic reconstruction was done by using Bifurcated graft (Collagen coated or PTFE ) or aneurysmorrhaphy in two cases of mycotic saccular aneurysms. Results: The age incidence ranged from 45-78 years with a mean of 64 years. Male sex was predominant than female sex with M:F ratio 6:1. There was a history of Diabetes mellitus, smoking, hypertension, hypercholesterolaemia, obesity, myocardial infarction (seven cases) & renal impairment (two cases). The most common presentation of AAAs were abdominal pain, back pain, pulsating abdominal mass & acute abdomen (in two leaking AAAs). The size of the aneurysm (diameter) ranged between 12-22 cm with a mean of 16 cm, the size was measured by Duplex Ultrasound & CTA. Postoperative Morbidity: lower limb ischemia due to arterial thrombosis was present in two cases & distal embolization in two cases, thrombectomy & embolectomy were done respectively & successfully except one big toe amputated after embolectomy. Myocardial infarction occurred in four cases, two of them died. Another two cases developed uraemia, one of them died. Leaking abdominal aortic aneurysms occurred in two cases, one of them died. The overall all mortality rate within thirty postoperative days was four cases (14.3%), no intraoperative mortality. Conclusion: The morbidity & mortality rates were proportional with increase in size of the aneurysm & increase with the presence of preoperative cardiac, renal dysfunction & risk factors.

Background: As a result of rapidly growing population with increased incidence of DM, chronic kidney disease (CKD) and end-stage renal disease (ESRD) increased markedly worldwide.This led to increased importance of haemodialysis access creation and the care for its possible complications.In Egypt, hypertension and diabetes mellitus are important causes of ESRD with their impact on the incidence of dialysis access complications.Late complications encountered during access use in dialysis may include late thrombosis, late infection at puncture sites, aneurysm and pseudoaneurysm formation, venous hypertension and steal syndrome.Cardiopulmonary and neurologic complications may be encountered also but they were not delt with in this study. Aim of work: To report and assess different types of complications of functioning haemodialysis access done at Alexandria main university hospital and medical research institute in one year follow up (from January 2013 to January 2014) for late complications and their management.Patients and methods: 160 patients with dialysis access done in the year 2012 and used for regular dialysis were included in this study.They were followed for one year, from January 2013 to January 2014 for late complications and their management aiming primarily for access salvage.Early access failure before dialysis and early infection cases were excluded from the study as well as mild neuropathy and subclinical steal.They were all subjected to clinical examination, laboratory investigations, imaging studies.Different management tools were used according to the type of complication encountered aiming primarily to life saving as well as limb and access salvage.Results: 160 patients were included in this study.They had ESRD with haemodialysis access constructed during the year 2012 at the main Alexandria university hospital and medical research institute.They all used their access for regular dialysis and were followed for late complications during the period from January 2013 to January 2014.They were 95 males (60%) and 65 females (40%).80 patients (50%) had radiocephalic arterio-venous fistula (AVF) , 40(25%) brachi-basilic AVF, 28(17.5%)brachio-cephalic AVF, and 12(7.5%)brachioaxillary shunt PTFE grafts.43 (26.8%)patients developed complications during the follow up period.27 of the complicated cases (62.7%) were infective in the form of 24(55.8%)infected puncture site pseudoaneurysm of native fistula and 3(6.9%) cases of infected shunt graft.They, all, resulted in access loss.The remaining complications were 9 cases of thrombosis managed by thrombectomy , 3 cases of aneurysm formation repaired, 3 cases of venous hypertension treated by ligation and by angioplasty, and one case of clinically significant steal syndrome treated by distal revascularization interval ligation operation.The non infective complications management showed a good access salvage rate (75%) while salvage rate went down to (27.9%) when infected cases were included. Conclusion:The majority of complications reported in this study were infective and the limited use of prosthetic grafts minimizes this type of complications.Except for infectious complications, most of dialysis access complications can be treated and controlled or corrected with good access salvage rates.More attention and care should be given to infection control measures in dialysis units , health education and patients' hygiene and immune status as well.