Faculty Bibliography

OBJECTIVE:Severe presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting. METHODS:The present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions. RESULTS:A total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]). CONCLUSIONS:For patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

INTRODUCTION/BACKGROUND:Antegrade superficial femoral artery (SFA) access for peripheral artery disease reduces the time, radiation and contrast required with contralateral common femoral access (CFA). Yet, this technique remains underutilized in the treatment of SFA, popliteal and tibial disease, and there remains limited data on the safety and effectiveness of antegrade SFA access in the outpatient setting. METHODS:A retrospective review of lower extremity peripheral arterial interventions in our office-based endovascular suite was conducted from 2013 to 2018. Interventions necessitating CFA access such as iliac, common femoral or deep femoral artery revascularization were excluded (n = 206). In addition, interventions potentially requiring large sheaths not amenable to SFA access (e.g. popliteal aneurysm) were excluded. Relevant demographic and treatment variables including postoperative complications were abstracted. RESULTS:We identified 718 patients, who underwent revascularization of the SFA, popliteal and tibial arteries. Antegrade SFA access was chosen in 448 patients (62.4%) with the remaining 270 patients having retrograde CFA access. Antegrade SFA access was achieved primarily with a 4 French sheath, while a majority of retrograde CFA interventions utilized a 6 French sheath for access (87.7% vs. 69.5%, p <0.001). Significantly less fluoroscopy (9.5 min vs 16.4 min, p <0.001) and contrast (25.4 mL vs. 38.5 mL, p <0.001) were used during SFA access compared with retrograde access. Technical success was achieved in 93.2% with antegrade SFA versus 94.8% retrograde CFA access (p 0.42). The overall rate of complications was low for both cohorts (2.7% vs. 3.7%, p 0.78) and there were no statistical differences in access-site complications (1.1% vs. 1.5%, p 0.94), hematoma (0.7% vs. 1.1%, p 0.84) and pseudoaneurysm (0.4% vs. 0%, p 0.98) between techniques. CONCLUSIONS:Percutaneous antegrade SFA access can be performed safely in the outpatient setting, and remains an effective alternative to retrograde CFA access with significantly less utilization of fluoroscopy and contrast.

Background: Severe presentations of chronic venous insufficiency may result from reflux or obstruction at the deep venous, perforator or superficial venous levels. Iliofemoral venous stenting may be used to address central venous obstruction, but its effect on deep venous reflux remains unclear. The purpose of this study was to evaluate the effect of iliac vein stenting on femoropopliteal deep vein reflux with the hypothesis that sonographic evidence of deep vein reflux would remain absent or improve following iliac vein stenting.
Method(s): This study was a retrospective review of patients undergoing iliofemoral venous stenting from 2013-2020. Patients were divided into two cohorts based on the preprocedural presence (Group A) or absence (Group B) of femoropopliteal reflux. Baseline patient variables were collected including age, gender, CEAP, presence of concomitant superficial or perforator reflux, DVT history, and additional venous intervention(s). The primary outcome evaluated was the persistent absence or the resolution of deep vein reflux on the latest venous duplex ultrasound follow-up. Other outcomes included follow-up CEAP classification as well as need for secondary deep venous interventions.
Result(s): There were 275 consecutive patients who underwent iliofemoral venous stenting. Of those, 58 presented with deep vein reflux (Group A), and the remaining did not (Group B). When comparing Group A and Group B, patients in Group A had a higher likelihood of prior DVT (P =.0001) as well as higher frequency of venous ablation (Table). The remaining demographics did not differ significantly between the two groups. In Group A, deep vein reflux resolved in follow-up in 17/51 patients (P =.0001). In Group B, deep vein reflux developed on follow-up in 6/217 patients. CEAP appeared to improve from preintervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; and C6, 24.5%) to latest follow-up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; and C6, 13.3%).
Conclusion(s): For patients who undergo iliofemoral vein stenting, deep vein reflux may improve if present initially, and is unlikely to develop if not present prior to intervention. A cohort of patients maintained persistent deep vein reflux, and these warrant further evaluation. Prospective studies are required to corroborate the safety, efficacy and durability of iliofemoral venous stenting in patients with deep vein reflux. [Formula presented]
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OBJECTIVE:Vascular surgery training and practice have been constantly evolving in the last two decades.The goal of this study is to report the changing trends in perspectives of vascular surgery trainees on current training program and issues that need redressal in vascular training and practice. METHODS:Vascular surgery trainees in the US who attended the Society of Clinical Vascular Surgery meeting from 2004-2015 were surveyed annually with an anonymous questionnaire during the meet. Questions pertaining to their endovascular and open surgical learning experience,independent performance of procedures, challenges of job search, starting an independent practice and their perception of issues in vascular surgery training were analyzed. Responses from the first half of the decade (2004-2009) were compared to the second half (2010-2015) to identify evolving trends in trainee perception. RESULTS:Among the 908 vascular surgery trainees who attended the annual meeting from 2004-2015, 670 (74%) trainees responded to the questionnaire. The mean age of vascular trainees was 32.5 years. In the latter half of the decade, there was a two-fold increase in female trainees, from 12.3% to 23.6% (p=0.002), and the integrated program trainees also increased from 0% to 12% of respondents (p=0.0023). Trainee satisfaction with endovascular training improved from 78% to 90% (p=0.0001) and satisfaction with open surgical experience was unchanged at 83% over the ten-year period (p=0.16) . The perception of vascular laboratory experience improved with only 35% vs. 27% (p=0.016) of respondents dissatisfied, despite only a third of respondents actually performing the non-invasive tests in both the former and the latter half of the decade respectively. CONCLUSION/CONCLUSIONS:Although the quality of vascular cases during training has improved, vascular trainees desire shorter training paradigms and vascular laboratory education is still viewed as deficient These findings can be used by training programs to reexamine their curricula and implement changes to improve the quality of training the next generation of vascular surgeons.

Objective In order to examine the academic productivity of US vascular surgery program directors, the number of vascular publications listed in PubMed from 2001 to 2015 for US vascular surgery program directors was reviewed. We suggest that this can be used as a benchmark for academic productivity. Methods The names of the program directors were taken from the Accreditation Council for Graduate Medical Education (ACGME) website at two time points: December 2009 (Independent Programs) and December 2015 (Independent + Integrated). This was used to query PubMed, which listed 5196 publications: 3284 from 2001 to 2009 and 1912 from 2010 to 2015. Results There were 104 program directors (2001-2009) and 114 program directors (2010-2015) with average number of publications in PubMed per program director as 3.68/year (SD ± 2.31) and 2.80/year (SD ± 2.73), respectively ( P = .01). From 2001 to 2009, 1215 (37%) and in 2010 to 2015, 860 (45%) of the publications were from Journal of vascular surgery. The top third produced 67% and 69% of publications in the two time-points. No statistical difference was ascertained regionally: northeast, southeast, midwest and west ( P = .46). The numbers of publications/year decreased by 17% compared to first 10 years. From 2001 to 2009, there were no programs with no publications which increased to five and three with no Journal of Vascular Surgery publications which increased to 21 in 2010-2015. The independent and integrated program directors published average of 2.85 (SD ± 2.69) and 3.47 (SD ± 3.1) total publications; 1.25 (SD ± 1.4) and 3.47 (SD ± 1.7) Journal of Vascular Surgery papers/year, respectively ( P = .28, P = .23). Changes in the study subject were noted by percentage of total publications: endovascular lower extremity arterial (4.7% to 8.9%), Thoracic Endovascular Aortic Repair (TEVAR) (4.5% to 9.9%), Arterio-Venous (AV) access (0.0% to 3.0%), basic science (14.7% to 6.8%), open thoracic (3.0% to 0.6%). Conclusion There seems to be a significant decline in the number of publications over the last 15 years. Yet, the subject of the publications has progressed from Open to TEVAR with an increase in endovascular publications. However, basic science publications reduced by half.

Objective The purpose of the study is to evaluate normal anatomical areas of infrarenal inferior vena cava, common iliac, external iliac and common femoral veins by intravascular ultrasound with the goal of assisting the development of venous-specific stents in the treatment of iliac vein stenosis. Method From February 2012 to December 2013, 656 office-based venograms were performed in our facility. Among them, 576 were stented and 80 were not. The measurements of veins were done intraoperatively using an intravascular ultrasound catheter to record areas of the inferior vena cava, proximal, middle and distal segments of common iliac vein, external iliac vein and common femoral vein. The data were compared between non-diseased segments of patients who were stented and those not stented. The stented diseased segments were excluded. Results The mean patient age was 67.33 years (range 22-96, SD ±13.99). Our data included 218 males, 438 females and 324 right lower extremities and 332 left lower extremities. The presenting symptoms of these patients based on CEAP were C1(0), C2 (185), C3(233), C4(107), C5(89) and C6(42). No correlation was found between area of veins and age, gender, laterality and CEAP score (P > .13). Comparison of the areas of non-diseased iliac vein segments between patients not stented and patients who underwent stenting showed a significant difference, with larger areas in non-stented patients in the distal common iliac vein (P = .039) and inferior vena cava (P = .012). Younger age (P = .03) and male gender (P < .0001) were associated with increased area of iliac vein segments. Conclusion Utilizing the intravascular ultrasound-guided technique, we were able to define normal anatomical areas of non-diseased inferior vena cava, iliac and femoral veins, which could be employed to guide the development of appropriate-sized stents and other tools needed for the treatment of venous insufficiency. There is specific variability in areas of normal vein segments with age and gender with/without stents.

BACKGROUND:Routine radiofrequency ablation (RFA) of an incompetent perforator vein (IPV) using the standard treatment protocol at 85°C has a treatment time of 6 minutes. To make treatment time more efficient, we sought to determine the effect of a shortened protocol for radiofrequency stylet (RFS) ablation by comparing the early success using three different temperatures: 85°C, 90°C, and 95°C. METHODS:A retrospective study examined 642 procedures of IPV closures in 255 patients with varying degrees of venous insufficiency treated with RFA from 2009 to 2015. The Covidien (Mansfield, Mass) RFA system allows the operator to regulate temperature and allows increments in temperature of the RFS to 85°C, 90°C, and 95°C. The RFS probe was angled at four 90-degree angles at the mentioned temperatures with a shorter treatment time at 6, 4, and 3 minutes, respectively. The three different treatment protocols were compared. All patients had comparative preoperative and postoperative duplex ultrasound scans. Postoperative duplex ultrasound scans were performed 3 to 7 days after the procedure. Successful obliteration was defined as lack of color flow on postoperative duplex ultrasound scanning. Clinical correlation with age, gender, laterality, presenting symptoms (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] classification), location, and vein diameter was also performed. RESULTS:Of the 255 patients who underwent RFS ablation, 138 were female, with a mean age of 65 years (standard deviation, ±14.6 years). These patients had CEAP presentations from C1 to C6 (0 C1, 1 C2, 57 C3, 118 C4, 4 C5, 75 C6). The location of the 642 IPVs was distributed as 472 in the calf and 170 in the ankle; 322 of these procedures were performed on the right leg. Use of a shortened protocol had no significant effect on the early obliteration rates with the 85°C, 90°C, and 95°C protocols, which were 66.1%, 61.8%, and 67.1%, respectively. Significant correlation was seen between location of targeted vein and successful obliteration (P < .001). There was a borderline inverse linear association between higher stylet temperature and successful obliteration in the proximal calf at 85°C. After accounting for within-patient correlation, the middle and distal calf continued to show higher nonobliteration compared with the ankle. No clinical correlation with age, gender, laterality, presenting symptoms of CEAP, or vein diameter was observed. CONCLUSIONS:The study showed that shortening the protocol time for RFA of the perforator did not make a significant difference in the early success rate, regardless of the temperature. The overall early success rate is still low (65.1%). RFA of perforator veins has a higher successful closure rate in proximal calf and ankle areas compared with the middle and distal calf.

Spontaneous renal artery dissection (SRAD) is a rare disease with approximately 200 cases reported in the literature. The severity of renal compromise, the anatomic location of the dissection, and the presence of uncontrollable hypertension are used to guide the initial management of SRAD. However, there are no reported guidelines for managing the progression of SRAD after acute failure of medical management. In this case, a 40-year-old man with a recently diagnosed SRAD was managed appropriately with therapeutic anticoagulation, yet presented with progression of his dissection and a new acute renal infarct. A covered endovascular stent was used to successfully control dissection progression and prevent further renal compromise.

Aortocaval fistula (ACF) is a lethal complication of aortic aneurysmal disease. Traditional treatment of ACF involves open surgical approaches to fistula ligation and repair of the great vessels, with a high mortality secondary to bleeding and cardiac compromise. We present the case of a 28-year-old man with a chronic ACF with concomitant aortic pseudoaneurysms secondary to penetrating trauma treated with a fenestrated endograft.