Faculty Bibliography

BACKGROUND:Polidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost one decade with specific advantages for below knee (BK) truncal veins where thermal ablation poses a risk of injury to adjacent nerves. The current literature of the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients. METHODS:We performed a retrospective study of a prospectively maintained database of patients from a single institution who underwent 1% PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasound (DU) within 7 days after injection, every 3 to 6 months for 1 year, and every 6 to 12 months thereafter. Patients with symptomatic recanalization underwent reintervention. The 26 patients lost to follow-up without DU after ablation were excluded. The factors associated with recanalization and reintervention were examined by multivariate and nonparametric analyses. RESULTS:Between March 2018 and July 2023, 411 patients (166 male, 245 female) with 573 treated limbs (284 right, 289 left) met the study criteria. Of the 573 included limbs, 457 (79.8%) had undergone prior above knee saphenous ablations. A total of 554 BK GSV and 42 SSV ablations were performed. The most recent DU was performed at a mean of 231 ± 329 days. The overall recanalization rate was 10.6% (55 GSVs and 8 SSVs) at a mean follow-up of 104 ± 180 days. Comparing the closed and recanalized veins, we found no significant difference in age (P = .90), treated laterality (P = .14), patient body mass index (P = .59), preprocedural CEAP (clinical-etiology-anatomy-pathophysiology) score (P = .79), recanalization rate in GSVs vs SSVs (P = .06), or administered PEM volume (P = .24). The recanalized veins had significantly larger preprocedural diameters than the veins that remained closed (recanalized, 4.9 mm; closed, 4.3 mm; P = .001). Men had higher incidence of recanalization than women (men, 14.2%; women, 8%; P = .015). Anticoagulation use was associated with recanalization (odds ratio, 1.96; 95% confidence interval, 1.1-3.6; P = .03). Early recanalization at the first DU accounted for 31 failures (49.2%) and had a significantly lower administered PEM volume compared with later recanalization (early, 4 mL; late, 5 mL; P = .025). There were no significant differences between the 33 recanalized patients requiring reintervention (52.4%) and the 30 who did not. Twenty-four reinterventions were performed with PEM, 100% of which remained closed at a median of 160 days (interquartile range, 257 days). CONCLUSIONS:PEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 89% at a mean of 231 days and shows promise as salvage therapy. Most cases of recanalization were noted in the early postprocedure period and were associated with a lower PEM volume. A larger vein diameter, male sex, and anticoagulation use are associated with higher rates of recanalization.

BACKGROUND:In the last couple decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. METHODS:Data was extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, and miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). Also, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999-2006, 2006-2013, and 2013-2021; the integrated vascular surgery residency was grouped into two intervals: 2012-2017 and 2017-2021. Data were standardized to represent the average number of cases per trainee per year. RESULTS:Within the fellowship, we found a 362.37% increase in endovascular procedures (Mean±standard deviation, 56.80±32.57 vs. 262.63±9.91, p<0.001), while only a 32.47% increase in open procedures (220.19±4.55 vs. 291.68±8.20) between the first to last time intervals. There was a decrease in abdominal aneurysm repair (24.46±7.30 vs. 13.85±0.58, p<0.001) and visceral (6.41±0.44 vs. 5.80±0.42, p=0.039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18±8.23 vs. 382.20±5.84, p<0.001). Residents had a greater total, open, and endovascular procedures per year than fellows (all p<0.001). Chief residents had about half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04±0.80 vs. 12.40±1.32, p=0.007) and visceral (5.83±0.41 vs. 4.88±0.46, p>0.001) procedures than residents. Overall, 52-53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56±12.10 vs. 261.27±10.13, 365.52±17.23 vs. 319.58±6.62, both p<0.001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. CONCLUSION/CONCLUSIONS:Vascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.

BACKGROUND:We noted distinct differences between the demographics among the presidents of various vascular societies. To help characterize these among the present United States, Canadian, and European vascular societies, we queried the websites for the United States, Canadian, and European vascular societies in a systematic review for the names of their presidents since their respective inceptions. METHODS:Age and ethnicity were determined by a search on healthgrades.com, Google, and online obituaries. The year of ascendency to the presidency and the year of birth were used as identifying time points. RESULTS:There are significant differences between the ages of the presidents of the various vascular societies. While the presidents of Vascular and Endovascular Surgical Society were significantly younger than those of every other vascular society examined, Midwestern Vascular Surgical Society, Canadian Society for Vascular Surgery, and Society of Vascular Medicine were also significantly younger than the remainder of the societies examined (P < 0.0001). The presidents of the remaining societies were not significantly different in age from each other. When comparing the ages of the presidents in the first and last decades of each society, 2 were found to have significantly increased (Society of Vascular Medicine [P = 0.0029] and Vascular and Endovascular Surgical Society [P < 0.0001]), while 2 others were found to have significantly decreased (New England Society for Vascular Surgery [P = 0.0092] and Eastern Vascular Society [P = 0.0085]). Of the 532 total entries for these presidents examined over these 13 societies, 19 (3.6%) of these were filled by women and 37 (7%) with minorities. CONCLUSIONS:There was a great deal of variability in terms of age, gender, and minority representation of the presidents among the vascular societies examined. While the share of women and minorities to serve as presidents in vascular societies varied between societies, both groups were under-represented across the board. However, in recent years, the number of women and minorities elected as presidents of vascular societies has been trending upwards.

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

OBJECTIVE:Endothermal ablation, such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), has been increasingly used for treatment of small saphenous vein (SSV) insufficiency. Prior studies have shown recurrence rates of 0% to 10% in incompetent SSVs (ISSVs). The objective of the present study was to determine the efficacy of redo venous ablation for symptomatic recanalized SSVs and to predict the factors related to recanalization. METHODS:A retrospective analysis of 2566 procedures in 1752 patients with chronic venous insufficiency due to ISSVs from 2012 to 2018 was performed, using individual medical record review for data extraction. All 2566 procedures were performed using endothermal ablation for patients in whom initial conservative management had failed. Postoperative duplex ultrasound scans were performed within 3 to 7 days after treatment. We defined successful obliteration as a lack of color flow using postoperative duplex ultrasound. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel during follow-up. We conducted follow-up examinations every 3 months during the first year and every 6 months subsequently. RESULTS:. The mean age was 62.4 ± 15.10 years. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class was C1, C2, C3, C4, C5, and C6 for 0, 0, 29, 43, 1, and 18 patients, respectively. The mean maximum diameter of the targeted veins for the redo procedures was 4.51 ± 1.33 mm. Of the 91 procedures, 40 were performed using EVLA and 51 were performed using RFA. The initial technical success was 98.9%. The redo procedures showed an early closure of 96.7%. At a mean follow-up duration of 24.9 ± 14.9 months, the closure rate was 96.5%. No correlation was found between successful obliteration with the redo procedure and age, gender, CEAP class, laterality, EVLA vs RFA, body mass index, or vein diameter. CONCLUSIONS:The rates of successful closure for ISSVs with initial and redo procedures were comparable. These data have validated the potential usefulness of performing redo SSV ablation.

OBJECTIVE:Chronic venous insufficiency (CVI) has an increased prevalence among obese individuals with body mass indices (BMI) over 30. A safe, efficacious, and evidence-based recommended treatment for CVI due to superficial venous reflux (SVR) in great saphenous veins (GSV), small saphenous veins (SSV), accessory saphenous veins (ASV), and reflux in the perforator veins (PV) is endovenous thermal ablation (EVTA). We sought to identify if BMI is an independent risk factor for recanalization following EVTA. METHODS:All patients with CVI were initially managed conservatively, and those with pathologic SVR refractory to compression therapy were offered EVTAs dependent on the site of reflux. Sonographic confirmation of SVR was defined as >500 milliseconds of reflux in the GSV, SSV, and ASV and a diameter >4 millimeters. PV reflux was confirmed as >350 milliseconds of reflux and a diameter >2.5 millimeters. All patients received a follow-up duplex ultrasound 1 week after the procedure, every 3 months for the first year, and every 6 months thereafter. Multivariate analysis with logistic regression was performed regarding patients' age, ablation modality (laser vs radiofrequency ablation), vein location and laterality, BMI, and recanalization. RESULTS:for recanalizations. PVs were statistically more likely to recanalize than any other vein (p=0.0001). A secondary analysis was performed with the exclusion of PVs, due to their 5 times increased risk of recanalization, and showed no significant difference of recanalization across all BMI subgroups (p=0.127). CONCLUSION/CONCLUSIONS:BMI does not predict recanalization risk following EVTA, except for ablations performed on PVs.

BACKGROUND:Several veins have been well-recognized as acceptable conduits for infrainguinal bypass surgery when the ipsilateral greater saphenous vein is unavailable. However, there is a paucity of literature describing the brachial vein as an adequate alternative. In the absence of other viable autogenous conduits, we describe the use of a brachial vein as a successful alternative for lower extremity revascularization. METHODS:A 70-year-old man presented with a chief complaint of right calf pain. Duplex ultrasound imaging of his right lower extremity revealed right-sided 2.5 cm acutely thrombosed superficial femoral artery and popliteal artery aneurysms. The patient underwent a suction thrombectomy with tissue plasminogen activator using the Power Pulse feature and Solent catheter from the AngioJet® (Boston-Scientific, Marlborough, MA) system. To repair the thrombosed aneurysms, an open bypass was planned. Due to lack of viable alternative traditionally used venous conduits, a bypass was created using the patient's brachial vein. RESULTS:A bypass was created from the superficial femoral artery to the P2 segment of the popliteal artery using a non-reversed brachial vein with ligation of the side branches of the superficial femoral artery and popliteal artery aneurysm from within the sac lumen. Completion angiogram revealed runoff through the anterior tibial artery only. Follow-up imaging at three months demonstrated a patent brachial bypass. CONCLUSION/CONCLUSIONS:Brachial veins can be safely used as viable venous conduits for lower extremity bypass surgery and should therefore be considered as an alternative when more commonly used veins are unsuitable or unavailable. However, more research is needed to determine the potential opportunities and challenges this alternative may present.

OBJECTIVES/OBJECTIVE:Iatrogenic guidewire perforation is a well-known complication of lower extremity angioplasty that is often benign or can be easily treated with endovascular techniques. However, perforations that occur in arterial side branches may be more challenging to manage. If bleeding persists, open surgery and fasciotomy may be required to evacuate the resulting hematoma and prevent compartment syndrome. These subsequent procedures increase morbidity and, if the angioplasty was performed in the outpatient setting, necessitate patient transfer to a hospital. To address these challenges, we describe a non-invasive hemostasis technique involving serial sphygmomanometer cuff inflations over the affected site in a series of five patients who experienced this complication at our office. METHODS:We retrospectively reviewed the medical records of consecutive patients undergoing lower extremity angioplasty that were found to have an arterial guidewire perforation on completion angiogram at our outpatient center between February 2012 and February 2017. Patients found to have iatrogenic guidewire perforations were administered intravenous protamine sulfate and were transferred to the surgical recovery room. Patients received ibuprofen or acetaminophen for pain management. A blood pressure cuff was placed around the site of perforation, and patients received serial cuff inflation cycles with repeated examinations of both limbs until patients reported cessation of pain and there were no signs of a developing hematoma. Patients were observed for two hours before they were discharged home. A follow-up duplex ultrasound examination was completed within one week of the intervention. RESULTS:Over the course of five years, 536 angioplasties were performed at our outpatient office. Five of these patients experienced iatrogenic guidewire perforation (0.93%). Perforations occurred in branches of the anterior or posterior tibial artery. All of these patients were successfully managed with the aforementioned hemostasis technique. None of these patients required transfer to a hospital for further management, and no complications were reported at follow-up. CONCLUSIONS:Complications of iatrogenic guidewire perforations in lower extremity arterial side branches can be safely and effectively managed by applying external compression around the affected site with an automatic blood pressure cuff.