Faculty Bibliography

OBJECTIVE:Endovenous thermal ablation has become the primary modality of treatment for patients with venous insufficiency. Previous literature has provided reviews of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) that mostly focus on the great saphenous vein (GSV) and small saphenous vein (SSV). Data with an extended review including the anterior accessory saphenous vein (ASV) and perforator veins (PVs) have been limited. This study examines the treatment of venous insufficiency with RFA and EVLA of these multiple veins to identify clinical and demographic predictors of both the early success and thrombotic complications of endovenous thermal ablation. METHODS:A retrospective analysis of patients who underwent either RFA or EVLA of the GSV, SSV, ASV, or PVs was performed from March 2012 through February 2014. The PVs were treated only using RFA. The success and complication rates of each method were compared. Procedure results were determined by duplex ultrasound examination at the next office visit. Obliteration of the target vein was defined as a success. A complication was defined as thrombosis of any vein proximal to the target vein or acute thrombosis of any tributaries. RESULTS:A total of 808 patients were treated with either RFA or EVLA (2057 procedures); 47 patients were excluded because of incomplete records. In total, 1811 procedures were included with an average of 2.4 procedures per patient. Excluding the PVs, the success rate of RFA was 98.4%, equivalent to EVLA at 98.1% (P = .66). The success rates of thermal ablation for each vein were as follows: GSV, 98.5%; SSV, 98.2%; ASV, 97.2%; and PVs, 82.4%. The overall thrombotic complication rate was 10.5%. The thrombotic complications include endovenous heat-induced thrombosis (EHIT; 5.9%) and acute superficial venous thrombosis (4.6%). However, when EHIT class 1 was excluded, the true EHIT rate was 1.16%. The rate of a thrombotic complication for each vein was as follows: GSV, 11.8%; SSV, 5.5%; ASV, 6.5%; and PVs, 2.4%. The thrombotic complication rate was 7.7% for RFA and 11.4% for EVLA (P = .007). Age, gender, laterality, presenting symptoms (based on Clinical, Etiology, Anatomy, and Pathophysiology class), and vein type and diameter have no effect on successful ablation. Increased vein diameter (P < .001) and type of vein (P < .0001) were significant predictors of acute thrombotic complications; however, on multivariable analysis, only type of vein was an independent statistically significant predictor when nested for within-person correlation. CONCLUSIONS:There were no statistical difference in successful closure rates between RFA and EVLA. The type of procedure (EVLA), larger vein diameters, and treatment of the GSV were associated with a greater thrombotic complication rate, but type of vein was the most significant independent predictor.

Background Venous aneurysms of the upper torso are uncommon in contrast to the abdomen and lower extremities. Mostly silent, they can cause significant morbidity. Large or symptomatic venous aneurysms are generally treated with open resection. To our knowledge, there are no documented cases of head and neck venous aneurysms treated by a hybrid endovascular and open approach. Case Presentation A 56-year-old female presented with the complaint of pain and increasing size of a supraclavicular mass. Imaging revealed a large saccular aneurysm of the subclavian vein with the presence of a large intramural thrombus on computed tomography scan with contrast. A covered stent was deployed in order to exclude the aneurysm from circulation. Three weeks later, the symptoms continued, and an aneurysmorrhaphy was performed to excise the stent and aneurysm resection. Discussion A combined endovascular and open approach to resection of symptomatic subclavian vein aneurysms is a viable method with minimal morbidity.

Background Complete thrombosis of an aortic endograft after an endovascular aortic aneurysm repair is a rare complication. The majority of thrombotic events occur in the iliac limbs. Case presentation We present the case of a patient who presented with acute limb ischemia as the result of a thrombosed infra-renal aortic endograft. After restoration of blood flow to the lower extremities with an axillary to bi-femoral artery bypass, the patient was lost to follow-up. The patient returned two years later with a ruptured abdominal aortic aneurysm due to a type 1A endoleak. Discussion We propose that all patients after endovascular aortic aneurysm repair, including those with a thrombosed aortic endograft, continue to undergo regular graft surveillance. This case report highlights the importance of continued surveillance of the aortic sac, even after total thrombosis of the endovascular aortic aneurysm repair.