Faculty Bibliography

INTRODUCTION/BACKGROUND:This study highlights the presentation of inframalleolar ulcers in venous disease not classically described their wound healing factors, recurrence rate, and response to Unna boot treatment with adjunct endovenous and/or iliac vein stenting treatments. METHODS:This retrospective single-center study included 71 office-based patients with inframalleolar venous ulcers treated between May 2012 and May 2023. Of the 71 patients evaluated, 12 presented with bilateral ulcers, resulting in a total of 83 limbs. Patient demographics including age, sex, ulcer etiology, ulcer location, diabetes status, and treatment modality were evaluated. All patients presented with bilateral leg swelling and venous reflux greater than 500ms suggestive of venous insufficiency. Initially, patients were required to have palpable pedal pulses and a normal ankle-brachial index (ABI) for inclusion. Over time, inclusion criteria were broadened to accept patients with mixed arterial-venous disease, provided their ABI was greater than 0.6. Patients with isolated arterial pathology and an ABI < 0.6 and diabetic neuropathic ulcer etiology were excluded from this study. Patients received compression therapy that included an elastic ACE wrap and an inelastic Unna boot formulated with calamine, zinc oxide, and glycerin, both applied by trained medical assistants. Sixty-five patients received additional endovenous and/or iliac vein stenting treatments. RESULTS:The mean patient age was 67 years +/-14 years (range 25-96 years). Of the 71 patients treated, 12 (mean 16.9%, SE 4.45%) presented with ulcers on both of their limbs resulting in a total of 83 limbs treated. All ulcers were treated with weekly Unna boots with an average treatment duration of 12 weeks +/- 23 weeks (range 1-181 weeks), and median treatment duration of 5 weeks. After wound healing patients were followed for a mean duration of 16 +/- 28 months. The rate of success of > 90% healing for inframalleolar ulcers was 51.8%. Factors associated with wound healing were ulcers that were primarily venous in nature as opposed to mixed (p=0.01). Heel ulcers were not associated with inferior wound healing (p=0.10) as compared to other locations but were associated with higher rates of recurrence (p=0.002). 26.76% of patients had recurring ulcers while 45.13% did not, 8.4% of ulcers were still actively being treated with Unna boots and 19.71% were lost to follow-up. Improved healing of inframalleolar ulcers was significantly associated with the presence of a concomitant supramalleolar ulcer on the same limb (p=0.02). CONCLUSIONS:This study brings attention to the uncommon presentation of inframalleolar ulcers in venous stasis disease and is driven by the observation that bilateral leg swelling can lead to poor wound healing. Compression therapy using Unna boots is easily accessible, cost-effective, and should be considered as it offers significant therapeutic benefit in this patient population.

OBJECTIVE:Topical Oxygen therapy (tOT) is a novel treatment method capable of expediting granulation tissue formation in patients with non-healing lower extremity venous leg ulcers (VLUs). tOT provides cyclic oxygen with compression and is able to be administered at home, unlike chamber-based oxygen therapy. Although previous randomized prospective trials have demonstrated effectiveness of tOT in treating ulcers of diabetic etiology, its ability to promote healing in refractory venous ulcers requires additional exploration. Thus, we investigated preliminary outcomes of tOT administration in treatment-resistant VLUs. METHODS:We conducted a single-center retrospective review of treatment outcomes among 31 patients with 32 total extremities with VLUs following longitudinal administration of tOT. All patients received managed Medicaid approval for tOT after each ulcer failed to resolve following multiple alternative therapies, including Unnaboot compression, sclerotherapy, thermal ablation, iliac vein stenting, and debridement. Patient response to tOT was determined by assessing mid-treatment progression of ulcer length and width, in addition to final ulceration status at the conclusion of therapy. Mean treatment length, total ulcer duration, peak ulcer length, and peak ulcer width were determined for each patient and compared between healed and unhealed VLUs. RESULTS:Average age across all individuals was 73±19 years (range 27-99). 14 (45%) patients were male, with a racial breakdown of 18 (58%) White, 5 (16%) Hispanic, 6 (19%) Black, and 2 (6%) Asian patients. Comorbid conditions included hypertension in 31 (100%) patients, hyperlipidemia in 15 (48%), and diabetes in 12 (39%). 4 (13%) patients demonstrated a former history of smoking while 3 (10%) patients were currently using tobacco products during the study period. Total duration across all VLUs was 1075±1004 days. Average duration of tOT was 265±233 days, while average pre-treatment ulcer duration was 718±842 days. Mean ulcer length was 7.6±6.8 cm and mean ulcer width was 5.7±5.0 cm (range 2-24 cm for both). Following tOT administration, 11 (34%) VLUs healed entirely, 9 (28%) ulcers improved but did not completely heal, 8 (25%) remained unchanged, and 4 (13%) worsened despite treatment. Median time to healing among the 11 VLUs which healed completely was 121 days. For ulcers that did not heal, the mean duration of tOT was 333±261 days. No differences were observed in the pretreatment VLU duration (p=0.54), maximum length (p=0.50) or maximum width (p=0.80) of healed versus unhealed VLUs. CONCLUSIONS:20 (62.5%) of the 32 refractory VLUs treated with tOT either decreased in size or healed entirely after failing multiple previous therapies. 3 (27.3%) of the 11 ulcers which healed completely recurred following topical oxygen therapy.

Background Physicians from underrepresented groups in medicine have historically been less likely to enter surgical specialties. This project sought to evaluate changes in the demographics of surgical society leadership from 1980 to 2025. Methodology In total, 31 societies were included in this retrospective analysis, and data on age, sex, and ethnicity were gathered and analyzed using SPSS. Results There was a significant increase in the number of female presidents and non-White presidents in the 2010-2025 period compared to 1980-1995. The Association for Academic Surgery (AAS), American Society of Breast Surgeons, and the Association for Surgical Education all had more female presidents than average, while the American Urological Association had fewer. AAS and the Surgical Society of the Alimentary Tract both had more non-White presidents than other societies. The American Pediatric Surgical Association and Western Surgical Association presidents were significantly older, while the AAS, American Society of Colon and Rectal Surgeons, EAST Trauma Society, Midwestern Surgical Society, and Society for University Surgeons presidents were significantly younger than the overall median age. Conclusions Many surgical societies have improved their representation of women and non-White surgeons. These significant changes in representation signify an appreciation for the demographic changes in the United States within the past 45 years.

BACKGROUND:Perivenous tumescence with saline or a dilute lidocaine solution is routinely used for thermal ablation of refluxing superficial lower extremity veins to displace sensitive structures away from the thermal probe and provide better contact with the treated venous endothelium. In this study we introduce an adjunctive technique of tumescence infiltration at the most efferent segment of refluxing saphenous veins treated with 1% polidocanol endovenous microfoam (PEM). We hypothesize that by reducing the vein diameter, Proximal Tumescence (PT) prolongs apposition time of PEM to the endothelium by delaying venous outflow and microfoam propagation speed. We evaluated PT effects on vein closure, volume of PEM used as well as the incidence of superficial venous thrombosis (SVT) and ablation related thrombus extension (ARTE). METHODS:A single institution retrospective study was performed with PEM ablations for the above knee great saphenous vein (AK-GSV), below knee GSV (BK-GSV), and small saphenous vein (SSV) by two operators over a 12-month period. Duplex ultrasonography (DUS) within 3-to-7 days after ablation followed by a serial surveillance DUS schedule were used to evaluate for vein closure, VT, and ARTE per institutional protocol. Any treated vein segment found to be completely or partially patent with reflux after treatment was deemed an ablation failure. Demographics and outcomes of tumescent PEM ablations (T-PEM) were compared with non-tumescent PEM (NT-PEM) through univariate and generalized estimating equation modeling. RESULTS:Between June 2023 and May 2024, 183 adult patients (64 male, 119 female) treated with 1% PEM in 246 lower extremities (113 right, 133 left) met study criteria. Nineteen patients without documented follow up DUS were excluded from this study. Overall, 293 ablations (23 AK-GSV, 199 BK-GSV, 71 SSV) were performed with a mean PEM volume of 2.8cc (SD=0.6cc) per ablation with a combined closure rate of 91.8% (269 of 293). One hundred and nineteen (40.6%) ablations were augmented with PT (mean tumescence volume = 6cc, SD=2.4cc, range=3cc to 16cc). Veins treated with T-PEM were significantly larger (mean vein diameter=4.8mm, SD=1.3mm) than veins treated with NT-PEM (mean vein diameter=4.0mm, SD=0.9mm, p<.001). There were no significant differences in patient age (p=.37), sex (p=.06), laterality (p=.29), preoperative CEAP clinical severity scores (p=.34), PEM volume used (p=.09), VT (p=.65), ARTE (p=.41), or rate of treatment success (p=.16) on univariate comparison of T-PEM and NT-PEM ablations. Generalized estimating equation regression predicts lower microfoam volume use with PT (B=-0.4, p=.003) and similar treatment success rates when correcting for inter-operator variability. CONCLUSION/CONCLUSIONS:Proximal tumescence is a safe and effective adjunct to PEM ablation that provides high short and mid-term closure rates with low ARTE incidence for large and small saphenous veins. PT is associated with reduced microfoam volume use.

INTRODUCTION/BACKGROUND:Risk index calculator models are widely used to estimate perioperative risk of surgical procedures, directly impacting surgical planning and patient outcomes. This study assessed the accuracy of the National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC), Revised Cardiac Risk Index (RCRI) calculator, and Vascular Quality Initiative Cardiac Risk Index (VQI-CRI) calculators in predicting adverse event rates for common vascular procedures. METHODS:A retrospective cohort of all carotid endarterectomy (CEA), endovascular abdominal aortic aneurysm repair (EVAR), infrainguinal bypass, open abdominal aortic aneurysm (AAA) repair, and suprainguinal bypass procedures completed in a single hospital system between January 2020 - January 2023 was assembled. Preoperative demographics, medical history, and postoperative adverse events were collected through chart review. Preoperative data was entered into each calculator to produce a predicted risk of adverse events. These predicted adverse event rates were compared to the actual adverse event rates observed; comparison was conducted via χ2 goodness-of-fit tests. RESULTS:952 procedures were included, comprising 348 CEA, 33 open AAA repair, 218 EVAR, 258 infrainguinal bypass, and 95 suprainguinal bypass procedures. In conglomerate, the RCRI significantly overestimated 30-day postoperative cardiac arrest or myocardial infarction (p<0.0001); the VQI-CRI also significantly overestimated in-hospital postoperative myocardial infarction (p=0.0035). The NSQIP-SRC significantly underestimated severe complications (p<0.0001), any complications (p<0.0001), UTI (p<0.0001), renal failure (p=0.0344), and return to the OR (p<0.0001), while significantly overestimating SSI (p=0.0027) and discharge to nursing/rehabilitation (p<0.0001). By procedure, the RCRI significantly overestimated risk for CEA (p<0.0001) and EVAR (p=0.0014), while significantly underestimating risk for open AAA repairs (p=0.0259). The VQI-CRI significantly overestimated risk for infrainguinal bypass (p=0.0038). The NSQIP-SRC significantly underestimated severe complications for EVAR (p=0.0002), infrainguinal bypass (p<0.0001), and suprainguinal bypass (p<0.0001). The NSQIP-SRC significantly underestimated any complications for EVAR (p=0.0091), infrainguinal bypass (p=0.0015), and suprainguinal bypass (p=0.0049). CONCLUSIONS:Significant variability in the accuracy of the NSQIP-SRC, RCRI, and VQI-CRI calculators was found for prediction of adverse events for common vascular procedures. The degree of inaccuracy per calculator varied significantly based on the indexed procedure. Updated calculators inclusive of modern vascular surgery procedural data may better capture accurate predictions of adverse events to best inform vascular surgical planning.

OBJECTIVES/OBJECTIVE:Patients presenting with iliofemoral deep venous thrombosis (DVT) often undergo percutaneous thrombectomy intending to prevent post-thrombotic syndrome (PTS). However, the relationship between the extent of DVT and outcomes after thrombectomy has not been explored. The objective of this study was to compare rates of post-thrombectomy DVT recurrence between patients with isolated iliofemoral DVT and patients with iliofemoral DVT and extension more peripherally. METHODS:We conducted a single-center, retrospective analysis of all patients who underwent thrombectomy for iliofemoral DVT from 2014-2023. Patients were stratified into two cohorts: (1) iliofemoral DVT without popliteal/tibial extension or (2) iliofemoral DVT with popliteal/tibial extension. The primary outcome was acute DVT recurrence and multivariable analysis was performed to identify risk factors for recurrence. Chi-squared and t-tests were calculated for categorical and continuous data, respectively. Kaplan-Meier analysis was used to compare rates of acute DVT and chronic venous changes postoperatively. A P-value <0.05 was considered statistically significant. RESULTS:222 patients were identified during the study period (76 isolated iliofemoral DVT vs. 146 iliofemoral DVT with peripheral extension) with a median follow-up of 19 months. Patients who presented with iliofemoral DVT with peripheral extension were more likely to be older (57 vs. 50 years, p=0.004), have hypertension (64% vs. 41%, p=0.001) or hyperlipidemia (58% vs. 40%, p=0.01), and to have had surgery within the prior 6-months (29% vs. 17%, p=0.04). Amongst female patients, those on hormone therapy were more likely to have isolated iliofemoral DVT (17% vs. 3%, p<0.001). Patients with iliofemoral DVT with peripheral extension had a greater chance of developing recurrent acute DVT (48% vs. 20%, p<0.001) and chronic venous changes (51% vs. 30%, p=0.004) during follow-up. Multivariable analysis showed a significant correlation between iliofemoral DVT with peripheral extension (Odds ratio 3.8 [95% confidence interval 1.7-8.7], p=0.001) and acute DVT recurrence. There were no differences in the rates of reintervention or death. CONCLUSION/CONCLUSIONS:More extensive peripheral thrombus burden was associated with higher rates of follow-up DVT recurrence in patients undergoing thrombectomy for iliofemoral DVT. These findings suggest that such patients may require closer follow-up and more aggressive anticoagulation therapy postoperatively. Moreover, our results provide a framework for further studies to specifically study the role peripheral thrombus may play in venous hemodynamics and the development of recurrent DVT and, ultimately, PTS.

BACKGROUND:To determine the structural changes of Wallstents (Boston Scientific, Natick, MA) in vivo following deployment in iliac veins. METHODS:This retrospective single-center study was performed from September 2012 to April 2013 and included 100 office-based patients who underwent initial stent placement for nonthrombotic iliac vein lesions with Wallstent as well as a second procedure for stenting of the contralateral iliac vein. Measurements were obtained with marker balloons and the diameters of the stents were compared at the time of the index procedure to the secondary procedure. RESULTS:The average time between the 2 procedures was 28 days (range 3-237, SD ± 39.89). The overall average stent diameter after the index procedure was 16.38 mm (range 10.95-21.45, SD ± 2.24). The overall average stent diameter of the index stent when remeasured during the second intervention was 17.58 mm (range 12.84-24.11, SD ± 2.38, P = 0.0003), which was significantly different from the initial measurements. There was no difference when comparing changes in stent diameter by gender or laterality of procedure. However, there was a significant difference in expansion of stents when placed in the common iliac vein versus the external iliac or common femoral veins. CONCLUSIONS:This study shows that self-expanding Wallstents can continue to expand days to weeks in vivo following initial deployment. Additionally, we found that the change in diameter from initial placement to follow-up was more significant in stents placed in the proximal and middle segments of the common iliac vein. CLINICAL RELEVANCE/CONCLUSIONS:Wallstents are durable implants designed to last within a patient for the rest of their life, it is important to understand the structural changes occurring after their placement. This study allows for a better understanding of Wallstent dynamics in vivo.

OBJECTIVE:Previous randomized prospective trials have demonstrated the effectiveness of transcatheter tissue plasminogen activator (tPA) thrombolysis in treating acute limb ischemia (ALI) compared to conventional surgery. These pivotal trials have also highlighted contraindications for these procedures. Given recent advancements in techniques and technology, our aim is to reassess the relevance of these contraindications in contemporary practice. METHODS:A retrospective chart analysis was performed utilizing the inpatient medical records of consecutive individuals who underwent tPA treatment for acute limb ischemia (ALI) from September 2016 to April 2022. Inclusion criteria encompassed patients aged 18 and above displaying clinical symptoms and imaging evidence of ALI within 14 days. All patients received tPA with suction thrombectomy following the fast-track thrombolysis protocol. In cases where a persistent thrombus or stenosis was detected, catheter-directed thrombolysis was considered overnight, and patients underwent angiography and reassessment in the operating room subsequently. RESULTS:= .771). Additionally, no amputations were observed within our population. CONCLUSIONS:In light of our study results and advancements in endovascular therapies, we can now safely and efficiently treat patients who were previously considered contraindicated for such treatments. It is essential to individualize treatments and carefully balance the risks and benefits of endovascular versus open surgical revascularization for these patients. Additionally, we believe that the nearly 30-year-old guidelines for endovascular therapies need to be revisited and updated to align with modern technology.

BACKGROUND:The minimally invasive procedures of venous ablation and iliac vein stenting are evolving treatment options for venous insufficiency. Yet, there are no studies directly comparing the outcome of these procedures. We performed a survey on patients who had both procedures, to determine if either procedure helped more and if there is any other clinical factor related to the outcome. METHOD/METHODS:We collected data between Jan 2012 and Feb 2019 from 726 patients who failed to improve swelling after conservative management. The patients underwent iliac vein stenting and vein ablations. We recorded patient assessment of the leg immediately after completion of both procedures. Follow-up was performed using in-person questionnaires by asking if improvement in lower extremity swelling occurred and if so, which procedure helped more. RESULTS:= 0.095). CONCLUSION/CONCLUSIONS:In this qualitative assessment, preliminary data suggest that the comparative role of iliac vein stent versus endovenous ablation warrants further study. The data were broadly distributed, and neither procedure was superior. In addition, 16% of the patients stated that neither procedure helped. The age of patients may also play a role in their procedure preferences and their subjective assessment for improvement.

A dramatic increase in the number of vascular procedures performed in the office-based laboratory setting has been observed since 2008, when the Centers for Medicare and Medicaid Services increased reimbursement for procedures performed in the ambulatory setting. We sought to evaluate the appropriateness of arterial intervention in the office-based laboratory and patient selection. This systematic review was conducted with a search of Google Scholar and PubMed using the following search terms: office-based lab, outpatient, angioplasty, patient selection, arterial, and appropriateness. More than 500 publications were screened and 14 publications related to the topic were selected. The existing literature that examined patient selection for intervention in the outpatient setting, rates of complications after outpatient procedures, and short-term data on the safety and efficacy of these procedures is discussed. Gaps were identified in current knowledge about the long-term outcomes of peripheral arterial interventions performed in the office-based laboratory setting, as well as existing guidelines for the management of patients with peripheral arterial disease.