Faculty Bibliography

BACKGROUND:The goal of this study is to evaluate the efficacy of a smoking cessation intervention performed by a vascular surgery provider compared with current smoking cessation practices. METHODS:Patients with peripheral arterial and aneurysmal disease who presented to the vascular surgery service at a tertiary care center over a 9-month period were randomized to either control or intervention group. Both control and intervention groups received 2 weeks of free nicotine patches and referral to an outpatient smoking-cessation program. The intervention group additionally received a brief presentation by a vascular surgeon regarding the benefits of smoking cessation, with a focus on vascular complications. At enrollment and at follow-up, patients underwent carbon monoxide breath testing and completed a survey. The primary outcome was smoking cessation or reduction among control and intervention groups in patients who underwent medical management, endovascular procedures, or open surgical procedures. Fisher's exact test was used to assess the primary outcome among groups. RESULTS:Fifty-nine patients were enrolled in the trial initially, but 55 had 1-month follow-up (control n = 28, intervention n = 27) and 52 had long-term follow-up (control n = 28, intervention n = 24). By long-term follow-up, 40 patients (77%) had reduced smoking by at least 50% and 16 patients (31%) had quit completely. At long-term follow-up, 88% of patients in the intervention group and 68% of patients in the control group reduced smoking (P = 0.1). CONCLUSIONS:A large proportion of vascular patients who received 2 weeks of nicotine replacement with or without the addition of brief smoking cessation counseling delivered by a vascular surgery provider were able to reduce smoking and maintain reduction after 6 months. Delivery of a brief standardized smoking cessation counseling session by a vascular surgery provider is safe and feasible. Additional randomized controlled trials with large enrollment periods and long follow-up are needed to determine the efficacy of this intervention in comparison to standard care.

OBJECTIVE:Iliac vein stenting of nonthrombotic iliac vein lesions is an evolving treatment course for management of chronic venous insufficiency. To characterize these lesions, we examined our experience treating these lesions with balloon venoplasty before stenting. METHODS:A retrospective analysis was performed to study all patients who underwent venograms with venoplasty and stenting of iliac veins from February 2013 to July 2016. All patients included in the study were treated with a trial conservative management for 3 consecutive months before venogram and, if indicated, venoplasty was performed. If a greater than 50% reduction in cross-sectional area or diameter was observed on intravascular ultrasound examination, the stenotic area was treated with balloon angioplasty, sized to nonstenotic distal vein segment (range, 10 × 40 mm to 16 × 60 mm). Intravascular ultrasound examination was also used to measure the area of stenotic iliofemoral veins before and after balloon angioplasty. RESULTS:). There were 227 patients (22.2%) who had the same area before and after venoplasty. Left-sided lesions had a greater increase in area than right-sided lesions (51.3% vs 46.2%, respectively; P = .048). No significant correlation of stenotic area response with age, presenting symptoms of Clinical, Etiology, Anatomy, and Pathophysiology (C2-C6), gender, or location of targeted lesion was observed. CONCLUSIONS:Our data show there is a highly variable response after venoplasty of stenotic area of nonthrombotic iliac vein lesions. Balloon venoplasty showed greater improvement in improving the area of stenotic left-sided lesions. However, stenting of the lesions should be performed routinely owing to recoil and spasm in lesions.

Vascular complications secondary to acute pancreatitis carry a high morbidity and mortality, often because of their hemorrhagic or thrombotic effects. When thrombosis presents, it is typically localized to the splanchnic venous system. In this report, we present a case of acute superior mesenteric artery thrombosis secondary to necrotizing pancreatitis after a laparoscopic cholecystectomy. The patient was successfully treated with catheter-directed thrombolysis and mechanical thrombectomy.

OBJECTIVE:Iliac vein stenting is an evolving treatment option for chronic venous insufficiency and management of nonthrombotic iliac vein lesions (NIVLs). Currently described protocols recommend deployed stents to be dilated with balloon venoplasty before completion of the procedure, based on previous literature established from management of arterial lesions. The objective of the study was to investigate the role of balloon venoplasty after stent deployment in the management of NIVLs. METHODS:During the course of 6 months, 71 balloon venoplasties with stenting of iliac veins (34 right and 37 left limbs) were performed. Intraoperatively, we used intravascular ultrasound to measure and to record area of iliofemoral veins. The measurement of stenosis was compared with adjacent nonstenotic iliofemoral veins. If >50% cross-sectional area or diameter reduction was found, it was treated with an appropriate balloon size (range, 10 × 40 mm to 16 × 60 mm) and Wallstent (Boston Scientific, Natick, Mass; 12-24 mm in diameter by 40-90 in mm length). All stents were dilated with a balloon after deployment. Intravascular ultrasound was used to measure the preoperative area of stenotic lesion, area of lesion after stenting, and area after balloon dilation of the stent. RESULTS:; P = .22). No statistically significant correlation was found between difference in areas and age of the patient, clinical class (C2-C6), sex, lesion, laterality, and location of targeted lesion. One patient developed an intraluminal partial thrombus within 30 days of intervention. CONCLUSIONS:Our preliminary data show no significant clinical or technical benefit with use of balloon venoplasty to dilate stents after deployment in NIVLs. Postdilation should thus be limited to only those with suboptimal self-expansion of stent after initial deployment on fluoroscopic imaging.

OBJECTIVE:Iliac vein stenting has been an evolving treatment option in the management of CVI secondary to iliac vein obstruction. Historically, treatment of CVI has been focused on the elimination of saphenous vein disease; however, the effect of reduction of iliac vein obstruction on superficial venous reflux remains largely unknown. This study aimed to identify the effect of iliac vein stenting on saphenous vein reflux. METHODS:In this retrospective study spanning course of five years, we performed 2681 venograms with venoplasties and stenting of the iliac veins. Pre-operative and post-operative venous mapping was performed via duplex ultrasonography. Patients who received any lower extremity vascular intervention between "pre-" and "post-stenting" duplex ultrasonography examination, other than iliac vein stenting, were excluded from analysis. RESULTS:(18%). Bilateral iliac vein stenting significantly reduced reflux in the bilateral great saphenous and small saphenous veins by 363.8 ms ( p < 0.0001) and 345.4 ms ( p < 0.0002), respectively, but had no effect on ASV reflux. Unilateral stenting did not produce significant reductions in reflux, besides an average reduction of 573.2 ms ( p = 0.004) in the left great saphenous vein. CONCLUSION/CONCLUSIONS:Bilateral iliac vein stenting decreased great saphenous vein and small saphenous vein reflux. Unilateral stenting did not demonstrate a significant reduction in saphenous reflux. Bilateral reduction in stenosis of the iliac veins may influence superficial venous reflux.

OBJECTIVE/UNASSIGNED:The Society for Vascular Surgery (SVS) is a not-for-profit medical society, whose goal is to further advance in vascular health on a global scale. With its 10th anniversary in sight, we were interested in analyzing the impact of a specific scholarship given under the SVS, the International Scholars Program. Our goal was to examine the awardees' characteristics and academic productivity. MATERIALS AND METHODS/UNASSIGNED:We measured the number of peer-reviewed articles, before and after the program, using PubMed® and Google Scholar® (2008-2018) of the scholarship recipients. Editorials, book chapters, letter to editor, and oral/poster presentations were excluded. A survey was sent out to assess the awardees' current status. RESULTS/UNASSIGNED:The average number of applicants/year was 15.4 (standard deviation ± 6.69), with 17.5% females and a mean age of 37 ± 3.37 years, with 5.6 ± 2.30 years status post vascular fellowship. Brazil had the highest number of recipients (n = 5; 18.5%) followed by China (n = 4; 14.8%). No significant difference was noted between each country in terms of publications ( P = .45), nor with after the SVS scholarship program compared to before ( P = .14, 1.84 vs 2.76). The survey concluded 33% had attended a subsequent SVS meeting after the program, with 27% having presented their research (n = 15). The recipients noted the program helped adopt new practices in clinical management (n = 13, 87%), learn new procedures (n = 10, 67%), gain local/regional leadership (n = 9, 60%), and improve technical skills (n = 8, 53%). The most visited clinical sites were Massachusetts General Hospital and Mayo Clinic (n = 4, 27%). The program was given a 9.1/10 rating. CONCLUSION/UNASSIGNED:The program was successful in maintaining academic productivity by continuing to publish research even after the scholarship, while teaching recipients skills to further improve their career goals. The award remains a competitive process that selects highly skilled recipients and still has much growth and progress to look forward to over the next decade.

OBJECTIVE:Fluoroscopic-guided interventions have become a major part of the modern vascular surgeon's practice. Imaging is typically required to safely and effectively perform both simple and complex endovascular interventions. With an ever-increasing volume of fluoroscopic-guided interventions being performed each year, the minimization of harmful radiation exposure has become of paramount concern for both patients and providers. The purpose of this study was to identify the extent of radiation exposure associated with venography and iliac vein stenting, an intervention utilized in the management of chronic venous insufficiency. METHODS:This was a single-center, retrospective analysis of 40 venograms performed on 29 unique patients over a three-month period. Patients with signs and symptoms of chronic venous insufficiency who failed conservative therapy underwent evaluation of the vena cava and iliofemoral veins with venography and intravascular ultrasound. Stent placement was performed if a >50% cross-sectional area or diameter reduction was identified via intravascular ultrasound. All patients were found to have non-thrombotic iliac vein lesions. All patients wore two individual film badge dosimeters - one on their chest and the other on the abdomen. The same mobile C-arm system was used for all interventions. RESULTS:. Sixteen limbs had C6 disease, 10 had C4 disease, and 14 had C3 disease. Thirty-eight of the 40 procedures resulted in stent placement, with an average of 1.13 stents placed per intervention. The average fluoroscopy time was 76.5 s (SD ± 36.9; range 7.8-209.5), and the mean cumulative air kerma was 1.08 mGy (SD ± 0.55; range 0.362-2.24). Average cumulative air kerma was higher in procedures resulting >1 stent placement compared to those with placement of ≤1 stent (1.44 vs. 1.02 mGy; p = 0.04). Fluoroscopy time was also higher in procedures with >1 stent placed (120.1 vs. 68.8 s; p = 0.0004). The mean deep dose equivalent per procedure from the patient-worn abdominal badge was 0.221 mSv. CONCLUSION/CONCLUSIONS:With the adjunctive use of intravascular ultrasound, iliac vein stenting can be safely and effectively performed with very low utilization of fluoroscopy, and therefore radiation exposure can be minimized for both patients and surgeons. Placement of >1 iliac vein stent resulted in higher cumulative air kerma and fluoroscopy time.

Isolated celiac artery vasculitis is an uncommon disease rarely reported in the Western literature. In this case report, we describe a 52-year-old Chinese male presenting with abdominal pain who was diagnosed with nonspecific celiac artery vasculitis and was successfully treated with a short course of oral corticosteroids.

OBJECTIVE:Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive "back-up plan." METHODS:(range 16.8-35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2). RESULTS:The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3-6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3-166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support. CONCLUSION/CONCLUSIONS:These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.

OBJECTIVE:Little is known about the natural history and management of aneurysmal aortic arch branch vessels (AABVs). The objectives of this study were to assess the natural history of aneurysmal AABVs and to examine the outcomes of operative intervention. METHODS:A retrospective review of the Yale radiologic database from 1999 to 2016 was performed. Only those patients with an aneurysmal AABV and a computed tomography scan were selected for review. Patients' demographics, aneurysm characteristics, management, and follow-up information were collected. RESULTS:There were 105 patients with 147 aneurysmal AABVs; 76 were male (72%), with a mean age of 70 years (range, 17-93 years). We identified 63 innominate, 50 left subclavian, 30 right subclavian, and 4 common carotid artery aneurysms. On computed tomography, 65 (62%) had aortic aneurysms and six (6%) had suffered an aortic dissection. Most were asymptomatic (104 [99%]); one had chest pain and an enlarging swollen mass. Twelve (11%) patients underwent operative repair (OR) for 12 aneurysmal AABVs because of symptoms, growth, or concomitant aortic operations; 93 (89%) were observed in the no operative repair (NOR) group with cross-sectional imaging. The overall mean vessel diameter was 2.08 ± 0.68 cm. The mean diameters in the OR and NOR groups were 3.32 ± 1.24 cm and 1.97 ± 0.46 cm, respectively (P = .002). OR included nine bypasses with resection, two stent grafts, and one resection without reconstruction. Two patients developed postoperative hemorrhage requiring re-exploration, one patient developed stent thrombosis, and one patient required pseudoaneurysm repair 20 years after index operation. Mean follow-up was 52 ± 51 months for the NOR group, with no ruptures or emboli. The growth rate was 0.04 ± 0.10 cm/y. On multivariable regression analysis, a descending aortic aneurysm (P = .041) and a left subclavian artery aneurysm (P = .016) were associated with higher growth rates, whereas height was associated with a lower growth rate (P = .001). CONCLUSIONS:Aneurysmal AABVs tend to have a benign natural history with slow growth rates and low rates of complications, including rupture and embolization. We recommend expectant observational management for small, incidentally detected aneurysms.