Deep-vein thrombosis (DVT) is encountered commonly in clinical practice. Recently, the European Society of Cardiology released guidelines on the diagnosis and management of venous thromboembolism. In this article, the authors reviewed the important aspects of DVT and advised on the clinical diagnosis and management of the same. Further, assessment of bleeding risk, risk of recurrences of DVT, and management of DVT in special situations is reviewed briefly. This will help physicians effectively diagnose and manage DVT in routine practice. Some of the essential clinical pearls include the following. Clinical risk prediction scores such as modified Wells score and Padua prediction score are effective tools used for screening DVT. Along with D-dimer assessment, venous ultrasound is helpful in confirming the DVT in “likely DVT” patients. Anticoagulation should be offered to all the patients diagnosed with DVT. Newer direct oral anticoagulants (DOACs) should be preferred. Among four commonly used DOACs, dabigatran and edoxaban use should be preceded by parenteral anticoagulants for at least 10 days without any drug overlap, whereas rivaroxaban and apixaban should be used as single-drug approach. Treatment duration should be 3–6 months and extended treatment should be based on the assessment of risk of bleeding and recurrences. Special situations such as DVT in upper extremity and in the elderly should be managed as recommended otherwise. For DVT pregnancy, low-molecular-weight heparin should be the anticoagulant of choice.

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Truly isolated aneurysms of the superficial femoral artery (SFA) are uncommon. The treatment options come from small case series and case reports. In the absence of definitive management guidelines, a revision of the available literature was carried out. True SFA aneurysms are more common in elderly male patients and tend to present late and can grow to significant sizes. Both open and endovascular options are available, which will depend on many factors highlighted in this review. Open repair should be offered to fit patients.

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Temporary central venous catheters are frequently used for vascular access in patients who require renal replacement therapy. The right internal jugular vein is the preferred central vein in such occasions. Accidental cannulation of the carotid artery is a potential complication of catheter placement in the internal jugular vein. This can lead to serious consequences such as stroke, life threatening hemorrhage and airway obstruction. Surgical removal is the management option of choice if a catheter is inadvertently placed in the carotid artery.

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Background: We conducted a physician-based survey to understand the management and clinical practicing patterns of venous thromboembolism (VTE) by physicians in India. Methods: This was an observational, physician-based clinical survey. A set of 22 questions on diagnosis, prophylaxis, duration of treatment, and risk factors of VTE was formulated along with nine patient case-studies. Seventy-six consulting physicians across India responded to the survey questionnaire. An expert panel comprising vascular surgeon, cardiac surgeon, and senior physicians provided recommendations on the recorded survey responses. Results: About 63.16% of physicians considered clinical examination of VTE based on signs and symptoms, whereas 23.68% used deep-vein thrombosis (DVT) scores (Wells score) to assess patients' risk. Recent surgery was considered a risk factor for developing DVT or pulmonary embolism by 86.84% of physicians; 82.89% preferred performing duplex ultrasonography test, and on positive results, treated patients for DVT. Dabigatran was the preferred choice of treatment by the participants. VTE prophylaxis with oral anticoagulants was considered by 80.3% of physicians during major orthopedic surgery. Direct oral anticoagulant (DOAC) with bridging therapy was preferred by 44.74% of physicians and 77.63% felt that DOACs will lead to a better quality of life for VTE patients. For patients with permanent risk factors of DVT, 76.32% of physicians preferred the indefinite duration of anticoagulation therapy. Conclusions: VTE remains a growing area of concern that needs to be managed in line with the clinical guidelines. These insights may aid in developing strategies for diagnostic accuracy and treatment of DVT.

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Background: Varicose vein is prominent dilated veins of lower limbs. Incomplete treatment and local recurrence are still the clinical challenge among the vascular surgeons. We aim to evaluate the range of imaging on color duplex describing the anatomy of veins, their variants, valve competencies, territories of defective venous system, demographic data, and the factors contributing among the patients referred to Vascular Outpatient Department of Kathmandu University Hospital. Objective: The aim was to know the ultrasound (US) color duplex parameters of superficial venous system in varicose vein. Materials and Methods: We included 299 patients during the study of 6 months with varicose veins for detailed US Doppler analysis. Gray-scale US was done to study the anatomy of veins followed by color duplex and color duplex spectrometry to determine the reflux of the superficial venous system. Quantification of reflux was determined by the use of Valsalva maneuver. Association of great saphenous vein (GSV) cross-sectional diameter and saphenofemoral junction incompetence was also studied. Results: Of 299 varicose vein cases, 52.50% were female. Among involved cases, the mean of GSV diameter was 5.43 mm in the right and 5.68 mm in the left. Saphenofemoral junction diameter was 7.89 mm in the right and 8.17 mm in the left. Receiver operative characteristics curve showed GSV diameter at femoral condyl of 4.5 mm as best cutoff value for the diagnosis saphenofemoral junction reflux. Conclusions: US color duplex is investigation of choice for varicose vein as a preoperative analysis tool, quantifying the superficial valve incompetency, studying and mapping the venous anatomy, and planning the surgery.

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Introduction: Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the lower limb veins are not functioning effectively, making it difficult for the blood to return to the heart from the lower limb. Over time, it can lead to pain, swelling, skin changes over the lower limb, and ulcers around the ankles. Some common etiological factors of CVI include obesity, more than 50 years of age, family history of CVI, smoking, and pregnancy. The combination of obesity and other genetic and environmental factors creates a higher risk for the development of CVI. Objective: The objective was to study the relation between body mass index (BMI) and CVI at its various stages using the clinical, etiological, anatomical, and pathophysiologic (CEAP) classification of CVI. In addition, it was to study whether there was a notable increase of diameter seen in saphenofemoral junction and great saphenous vein (GSV) as the BMI increases and in patients of CVI. Materials and Methods: It was a study conducted on 100 consecutive patients; data were collected from the vascular surgery outpatient department where patients presented with venous disease. The grade of the venous disease was recorded using the CEAP criteria. BMI was calculated for each patient. Based on the BMI, the patients were classified into underweight, normal, overweight, and obese. The mean, standard deviation, P value, and percentage of each stage of venous disease in each group were calculated accordingly and studied. Results: A total of 100 patients were undertaken for the study, out of which 78 were male and 22 were female. The clinical stage according to the CEAP criteria, BMI, diameter of the saphenofemoral junction, and diameter of the GSV was recorded for each patient. Clinical stage (CEAP criteria) was discovered to become more advanced as the BMI increased. According to the data, 50% of underweight patients reported of CVI, 53% of normal weight patients reported of CVI, 72% of overweight patients reported of CVI, and 87% of obese patients reported of CVI. Furthermore, it was noted that there was an increase in the diameter of the GSV as the BMI increased, although no change was seen in the diameter of the saphenofemoral junction. Conclusion: Lower limb venous flow parameters differ significantly among normal, overweight, and obese individuals. The CEAP clinical stage of venous disease is more advanced in obese patients than in nonobese patients with comparable anatomical patterns of venous incompetence. This could possibly be a result of raised intra-abdominal pressure leading to greater reflux, increased vein diameter, and venous pressures. In addition, an increase in diameter was noted in the GSV, however no change in diameter was observed at the saphenofemoral junction, as the BMI of the patients increased. Hence, the findings support the mechanical role of abdominal adipose tissue, which may potentially lead to elevated risk for both, venous thromboembolism and CVI.

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Limb ischemia is acute, chronic, or acute on chronic, and the prevalence of the latter is rising with the presence of an increasing aging population. When occlusion to the flow of blood is sudden, it results in acute limb ischemia, the early diagnosis of which is vital for the salvage of the limb. In chronic ischemia, the occlusion is progressive, and diagnosis can alter the quality of life for a patient, besides limb salvage. Dark skin tones are more common in Africa, India, Asia, and the Middle East. Diagnosis of limb ischemia is missed in this subset because the classical “pallor” described in Caucasians is not seen. It is seen as shades of duskiness, like the purplish hue on an aubergine – also known as Badinjal, Eggplant, or Brinjal. This article explains why there is a color discrepancy and a need for healthcare professionals to be aware, hence improving limb salvage.

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Venous aneurysms of the external jugular veins are rare. In this case report, we describe the case of a 49-year-old gentleman who presented to us with a painless neck swelling and underwent surgical resection.

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Introduction: Deep-vein thrombosis (DVT) is one of the precarious complications of spinal cord injury (SCI). The present study was aimed to determine the incidence of DVT in acute traumatic SCI in the Indian population, factors associated with DVT, and to evaluate the role of D-dimer and color Doppler in establishing the diagnosis. Patients and Methods: Fifty patients with acute SCI presenting to a tertiary care center within 48 h of injury were clinically evaluated for the level, extent, and severity of SCI according to the ASIA standards. The local examination for the assessment of DVT was conducted. D-dimer test and color Doppler for DVT were performed at initial presentation, on day 7 and 14, 1 month, 3 months, and 6 months. Results: Three patients developed DVT between 14 days to 1 month. Overall DVT incidence was found to be 6%. Neurological level (P < 0.05) and the severity of the deficit (P < 0.001) were found to be associated with DVT. Patients with DVT had significantly more thigh and calf circumference at 1 month. Significantly higher levels of D-dimer were observed right from initial presentations to 6 months. Color Doppler was positive in all the three cases of DVT. Conclusions: The incidence of DVT is low in SCI patients in India, but it is not a rare complication. The occurrence of DVT has a significant correlation with factors such as the level and severity of injury. Frequent clinical examinations including the thigh and calf circumference along with D-dimer level estimation are good screening indicators, and color Doppler is an effective tool for establishing a definitive diagnosis of DVT in SCI patients.

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Introduction: Chronic total occlusions (CTO) of the superficial femoral artery (SFA) are generally managed by an endovascular retrograde contralateral “crossover” or ipsilateral antegrade common femoral artery (CFA) approach. In cases with flush occlusion or a very short SFA stump at common CFA bifurcation, antegrade recanalization frequently fails due to an inability to engage the true ostium of the SFA. The purpose of this study was to evaluate the efficacy and safety of retrograde popliteal approach for endovascular revascularization of flush SFA CTO. Materials and Methods: We retrospectively investigated 18 patients (14 males and 4 females, mean age 61 ± 14 years) with flush SFA CTO undergoing retrograde popliteal artery (PA) revascularization at two endovascular centers in North India between January 2017 and December 2018. All the patients had critical limb ischemia (CLI) and flush SFA CTO with ostial involvement. Hemostasis was achieved by the manual compression only. Study endpoints were technical success rate, puncture site complications, and limb salvage. Results: CLI with Rutherford category 5 dominated the clinical presentation (56%) with most of the patients presenting late after disease onset. Majority were Trans-Atlantic Inter-Society Consensus-C (72%) chronic SFA occlusions (mean lesion length 185 ± 52 mm). Doppler-guided popliteal puncture and sheath placement were successful in 100%. Technical success rate of retrograde revascularization was 83%. Intraluminal recanalization was possible in 56% from the popliteal access, and subintimal recanalization was done in 28%. There was no major access site-related complication or mortality in the follow-up period. The primary patency rates at 6 months and 1 year postintervention were 93% and 80%, respectively. Conclusions: Retrograde PA approach under Doppler guidance was effective in terms of technical success rate of popliteal puncture as well as retrograde revascularization of flush SFA CTO. The approach was safe with no major access site complications.

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Masson hemangioma is a rare benign vascular tumor characterized by intravascular papillary endothelial hyperplasia (IPEH). Numerous case reports have described lesions in the digits, neck, oral cavity, and intracranially. IPEH involving primary brachial artery aneurysm is extremely rare, with only a handful of reported cases. We present a 43-year-old female with a true distal brachial artery aneurysm who presented with a painful pulsatile mass in the antecubital region. She underwent aneurysm resection and end-to-end repair with a saphenous vein graft. Histology confirmed the diagnosis of IPEH with characteristic features of papillary hyperplasia within the intravascular thrombus.

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Context: Acute limb ischemia (ALI) is an emergency. The diagnosis of ALI can be missed. However, little is known about predisposing factors. Objective: The objective of the study was to determine the factors leading to misdiagnosis of lower limb ALI based on our experience and to suggest steps in overcoming the shortcomings. Materials and Methods: It is a single-center prospective observational study done from June 2016 to May 2019. All nontraumatic lower limb ALIs were included. Those with prior arterial interventions and thrombophilia were excluded from the study. Referral notes were scrutinized. Chronology of symptoms, time delay by a patient, category of first-contact health-care provider, initial diagnosis, and time lapse by clinician were noted. Patients were quizzed regarding ALI awareness. Statistical Analysis: Not applicable. Results: Twenty-six cases of lower limb ALI were included. Most common presentation was sudden onset claudication (n = 11), followed by pain (n = 9) and sudden onset weakness (n = 6). None were aware of ALI. A clinician was the first contact in 19 and local healer in 7. Eighteen presented late with an average delay of 18 days. Clinician misdiagnosed in 19 with an initial diagnosis of musculoskeletal pain (n = 9), arthritis of hip/knee (n = 4), neurological weakness (n = 2), sciatica (n = 2), and backache (n = 2). Lower limb pulse examination was missed in all 19. Thrombectomy with or without additional procedure was successful in 12 and bypass in one. The limb was salvaged in 20. There were six amputations and two deaths. Conclusion: Lower limb ALI is missed due to its variable presentation and failure to consider its possibility. Poor awareness among the public leads to late presentation. Better awareness needs be created by the education of both common public and the physicians to salvage the limbs in time.

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In superior vena cava syndrome, relieving the obstruction by stenting is the treatment of choice to alleviate the symptoms. We present cases of two patients with superior vena cava obstruction who underwent successful revascularization with the placement of a self-expanding metallic stent using the upper limb venous approach.

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Purpose and Objective: Central vein stenosis is not uncommon in renal patients who are on dialysis. Performing new arterio-venous fistula (AVF) in patients with central vein stenosis can lead to significant problems, ultimately leading to loss of AVF. The aim of this study was to assess the role of central venogram before the creation of a new AVF. Materials and Methods: All patients who underwent central venogram before AVF surgery between September 2017 and June 2019 were included in the study. The medical records and central venogram images were reviewed. Data regarding demographics, indication, findings of venogram, arterio-venous access performed, were collected using an online database. Results: A total of 143 patients met the inclusion criteria. The mean age was 52.25 (range 23–86 years) and 85 were men (59.44%). One hundred and thirty-nine out of 143 (97.2%) patients were on dialysis and had a history of ipsilateral and/or contralateral central vein catheterization. However, only 18 of 143 (12.58%) had central vein symptoms. The most common indication was being a precious fistula or last access option (64 patients; 44.75%). Central venogram identified ipsilateral abnormality in 52 patients (36.36%) and contralateral abnormality in 46 patients. Preoperative plan was changed in 24 patients (16.78%) due to venogram findings. Conclusions: This study highlights that central vein stenosis/occlusion can exist in renal dialysis patients even without obvious clinical signs and symptoms. Routine use of diagnostic central venogram in such high-risk patients can identify central vein problems preoperatively and prevent postoperative complications.

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Acute brain infarction due to carotid artery occlusion has been associated with poor outcome in the absence of cerebral collaterals. The incipient development of collaterals does not guarantee their persistence while available data are strongly indicative that good collateral flow is key in cerebral perfusion, and in reducing infarct size, this knowledge has resulted in only limited therapeutic applications.

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True aneurysm is dilatation of an artery which consists of all layers of the arterial wall. True radial artery aneurysms are very rare. The most common cause of radial artery aneurysm is iatrogenic trauma. Here, we report a case of iatrogenic true radial artery aneurysm. A 38-year-old male with a history of right radial artery cannulation for anticoagulant therapy to treat right leg deep venous thrombosis presented to our outpatient department with a complaint of swelling on the radial side of the volar aspect of the right arm. He was treated conservatively with steroids, but symptoms did not subside. Doppler ultrasound and computed tomography scan suggested true radial artery aneurysm. In view of pseudoaneurysm, surgical plan was made. During surgery, the aneurysm seemed to be involved in all the vessel layers. The aneurysm was excised, and ligation of both the ends was done. Anastomosis was not done owing to good flow in the distal part from the ulnar artery and damage to a long segment of the radial artery. Patients on anticoagulants are at a risk of aneurysm formation than patients who are not. It can be diagnosed clinically and radiologically.

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Introduction: The immediate postoperative hemodynamic alterations occurring after carotid endarterectomy (CEA) is called postendarterectomy hypertension (PEH). PEH results in prolonged hospital admission, increased peri-operative morbidity, and mortality. The exact causes of the PEH whether it is due to carotid sinus denervation or due to the increased norepinephrine production in cerebral and peripheral circulation remain unclear. Materials and Methods: A prospective analysis of 62 patients who underwent CEA from 2018 to 2019 were carried out by dividing into two groups based on the technique of surgery (conventional CEA [c-CEA], n = 31; eversion CEA [e-CEA], n = 31), and the effect of four class of drugs mainly beta blockers (βBs), calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), and alpha blockers (αBs) were studied for the prevention of PEH. Results: 72.6% of patients developed PEH irrespective of the technique of surgery (e-CEA n = 25 c-CEA n = 20; P = 0.15). The mean postoperative dose of antihypertensive drugs (M_{postoperative}) were found significantly increased compared to mean preoperative dose (M_preoperative) in all PEH patients among βB? group (M_preoperative 18.95 mg vs. M_{postoperative} 45.76 mg; P = 0.00); CCB group (preoperative M_preoperative 6.21 mg vs. M_{postoperative} 9.79 mg; P = 0.01); ARB group (M_preoperative 14.03 mg vs. M_{postoperative} 38.23 mg; P = 0.01); but those patients with preoperative αBs have well controlled BP in the postoperative period without significant change in mean dosage; αB (M_preoperative 0.16 mg vs. M_{postoperative} 3.74 mg: P = 0.27). Conclusions: This study indirectly showed that fluctuations of sympathetic system are happening in both e- and c-CEA irrespective of the technique of surgery. These fluctuations were better controlled in patients who had adequate sympathetic blockade preoperatively. In other words, αB can be considered a drug of choice for PEH.

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Objectives: The aim of this study is to detect the anatomical variations of the saphenous fascia (SF) around the great saphenous vein (GSV) in the Omani population and compare it to published studies in other populations. The extent of the SF has been documented to vary between certain populations. There are no such studies from the Arabian Gulf population. Methods: Following ethical approval, bilateral lower limbs of 100 consecutive consenting volunteers at our tertiary care university hospital were scanned using an ultrasound scan. The GSV was traced from the groin to ankle, and the point of exit from the SF was noted. Results: The results showed that the majority of the Omani population had a SF ending at the upper thigh (39.5%). The next most common location was at the mid-thigh (26.5%). Conclusions: This study found that the course of the GSV within the SF can differ between populations. This has important implications in the pathophysiology and endovenous treatment options offered to Omani patients seeking treatment for varicose veins.

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Most superficial temporal artery (STA) aneurysms are pseudoaneurysms that occur following a trivial trauma to the temporal region. True aneurysms of the STA are very rare. They occur usually due to congenital defects in vessel wall or atherosclerotic degeneration. We report a case of true aneurysm of the STA following trauma which is exceedingly rare. A 23-year-old male presented with painless swelling in front of the right ear for 4 months with a history of trauma to the right temporal region. Examination revealed a painless pulsatile mass of 4 cm × 3 cm size, and the diagnosis was supported by Doppler ultrasound and magnetic resonance imaging. Surgical excision was done. Histological examination showed all the three layers of the arterial wall to be intact, confirming a diagnosis of true aneurysm of the STA.

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Background: High triglycerides (TG) and low High density Lipoproteins (HDL) are established coronary risk predctors (ratio of 3:1 being associated with definite increase in coronary risk). The TG/HDL ratio has also been established as a predictor of major cardio vascular events, insulin resistance and metabolic syndrome. However, the utility of the same in predicting worsening of peripheral vascular disease remains under-researched. Aims and Objectives: We aim at establishing TG/HDL ratio as a predictor of peripheral arterial disease in diabetic patients and to also explore the role of triglycerides and lipid lowering agents, in general, in modifying this risk. Materials and Methods: We carried out a cross sectional study enrolling Diabetes Mellitus patients with symptoms suggestive of peripheral vascular disease. We included 304 patients and analyzed their TG levels and TG/HDL ratios stratified as per age, gender and medical history. Relevant statistical analysis was carried out. Results: There was a difference in TG levels in men and women who developed serious peripheral vascular events with women having significantly elevated TG levels in comparison to men. The TG/HDL ratio was also found to be 8.06 in women and 7.88 in men. This was statistically significant in comparison to the control group. Conclusion: TG/HDL-C ratio, also known as atherogenic index, which is easily obtained by routine biochemical evaluation can be used to prognosticate incidence of peripheral arterial disease in addition to cardiovascular risk. This would serve as an easy Outpatient prognosticating and predictive factor for further assessment and patient education.

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Objective: Does systematic surveillance help improve arteriovenous fistula (AVF) patency and health economics in renal failure patients? Materials and Methods: As part of a quality initiative project, prospective data were maintained in the electronic medical records at the Sultan Qaboos University Hospital by our clinical nurse specialist, of AVFs created for patients requiring renal replacement therapy from December 2015. Beginning in January 2018, a surveillance program of patients undergoing intervention to improve patency of AVF was started. The records of these patients up to December 31, 2019, were accessed to see if the program helped improve patency, thereby reducing the number of emergency admissions and improving health economics. The minimum follow-up period was 8 weeks. Results: A total of 143 patients had AVFs created during the study period. Fifty-one patients required fistulogram with or without fistuloplasty. Thirty-six out of 51 (70%) fistulas remain patent, whereas 9 (18%) thrombosed and 6 (12%) were either lost to follow-up or deceased. The number presenting to the emergency department reduced by 50%. In addition, we observed a noticeable reduction in the number of emergency procedures required to sustain the fistula. Both duration of in-hospital stay and repetitive investigations were reduced. Conclusion: A surveillance program requires liaising with the patient, their relatives, local health center, regional dialysis unit, interventional radiology, nephrology, and vascular surgery team. We have seen a significant reduction in emergency interventions, increase in overall patency rate of AVFs, shorter in-patient hospital stays, and a decrease in number of laboratory investigations repeated.

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Introduction: In chronic kidney disease patients, arteriovenous fistula (AVF) is now increasingly and widely accepted as a vascular access for long-term hemodialysis, so their surveillance and maintenance is of paramount importance. In endovascular procedures, fistulogram and fistuloplasty are being most commonly used for the treatment of malfunctioning AVFs, however, Ultrasound-guided fistuloplasty also now has been established, so here we had evaluated its utility in our institute. Materials and Methods: A prospective, observational study of 67 patients who underwent? USG (ultrasound)-guided fistuloplasty in failing AVF was conducted from April 2019 to April 2020. The outcome of USG-guided fistuloplasty was assessed in terms of technical success rate using Doppler-derived volume flow (VF) criteria, complications, and primary patency at the end of 6 months. Observation and Results: Post fistuloplasty, all our cases showed a 100% procedural and clinical success rate with a significant increase in VF. Mean preprocedure volume flow (VF) was 160 ml / min +/- 47 standard deviation (SD) increased to mean post procedue VF of 399 ml/min +/- 102 SD. The most common complication noted was fistuloplasty site hematoma. Complications were fewer and managed using ultrasound. The primary patency at the end of 1, 3, and 6 months was 100%, 88.1%, and 77.6%, respectively. Conclusion: Ultrasound-guided fistuloplasty is a safe and effective treatment option with low morbidity rates for the treatment of failing AVF. This technique is safe, feasible, and reliable as it facilitates to reduce intervention time and achieve better results so should be used more frequently and effectively. Doppler-derived VF is a very useful and remarkable criterion to assess technical outcome.

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Arteriovenous fistula (AVF) is defined as an anomalous communication between an artery and a vein. Iatrogenic AVFs are a rare clinical finding compared to the congenital type. They are most commonly secondary to penetrating and blunt trauma, iatrogenic complications of invasive procedures, and operations. Although still rare, iatrogenic AVFs are more commonly reported now due to the increased use of percutaneous diagnostic and interventional endovascular procedures. Here, we present the case report of a 22-year-old female, who had undergone intravenous (IV) cannulation in the right forearm volar aspect, for IV antibiotics, as a treatment of typhoid fever. Five years after the procedure, she developed an aneurysmal swelling in the volar aspect of the right forearm, which on computed tomography revealed two aneurysms lying next to each other with a communication akin to a fistula. The dual aneurysms were completely resected.

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It is becoming increasingly commonplace to find patients with their third or fourth revascularization procedure. We present one such patient with thrice-failed infra-inguinal bypass, which was successfully revascularized. A 63-year-old diabetic, hypertensive with three failed infra-inguinal bypasses presented with forefoot gangrene. Computed tomography angiogram revealed a long-segment occlusion from the external iliac to the middle posterior tibial artery (PT). Hybrid approach was used to stent the proximal anastomotic site and open surgical bypass was carried out for the distal site. The forefoot healed after amputation with skin grafting. Failed infra-inguinal procedures usually present as long-segment, complex lesion, which require a hybrid approach for revascularization. Preoperative planning and reintervention are paramount in achieving suitable patency in this group of patients.

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