Faculty Bibliography

INTRODUCTION: We examined the rate of positive findings and the distribution of vascular ultrasounds in the pediatric and adult population. Prior literature has noted a low rate of positive findings in adult vascular ultrasounds but there is little literature on pediatric vascular ultrasound. METHODS: We reviewed our vascular duplex database on inpatients less than 18 years old and compared it to the adult inpatient vascular duplex exams from 2005 to 2010. RESULTS: The adult patients had more extremity vascular exams while the pediatric patients had more abdominal and renal exams. Moreover, the positive rate of adult lower extremity arterial duplex was significantly higher than the pediatric group (p = 0.002). CONCLUSION: We had a higher yield of positive findings in the adult cases. We observed a higher proportion of more complex duplex exams in the pediatric cases suggesting that a higher level expertise is needed to perform the pediatric vascular duplexes.

BACKGROUND: Accreditation in peripheral venous testing can be obtained based upon femoropopliteal duplex ultrasound evaluation, and many laboratories limit their examination to this segment only. This simplified protocol detects acute femoropopliteal deep venous thrombosis (DVT) but misses calf vein DVT, superficial venous thrombosis, chronic DVT, venous reflux, and other non-venous findings potentially responsible of the patients' presenting conditions. A protocol limited to the femoropopliteal segment results in additional unnecessary testing and can create patient dissatisfaction. We evaluated the differences in the diagnosis between a limited femoropopliteal versus a complete approach to the venous ultrasound evaluation of the lower extremities in patients examined in an outpatient vascular laboratory. METHODS: A data base with the complete ultrasound exams of the lower extremity including the common femoral, deep femoral, popliteal, tibial and peroneal veins, calf muscular veins, great and lesser saphenous veins, performed in 812 consecutive patients over an 8 month period, was queried. RESULTS: Acute femoropopliteal DVT was found in (32/812) = 3.94% of the patients. Chronic femoropopliteal DVT was found in (54/812) = 6.65%. Acute infrapopliteal DVT was found in (33/812) = 4.06%. Chronic infrapopliteal DVT was found in (41/812) = 5.04%. Superficial venous thrombosis of lower extremities (124/812) = 15.27%. In addition, deep venous insufficiency (>500 milliseconds) was found in (404/812) = 49.75% and superficial venous insufficiency in (254/812) = 31.28 % (>500 milliseconds). A mass (cyst, hematoma, solid mass or aneurysm) was found in (23 cysts, 2 Hematomas, 23 solid mass, 4 aneurysms) 52/812 = 6.4%. CONCLUSIONS: Limited femoropopliteal ultrasound examination for acute DVT would have only detected a small percentage of the positive findings. These data suggest that a complete duplex exam can be used to further delineate the cause of outpatients' symptoms as compared to the limited protocol.

OBJECTIVE: There is an increasing number of procedures that traditionally were performed in the inpatient setting that are now becoming office-based procedures. These include peripheral endovascular procedures such as angiograms, angioplasties, dialysis access interventions, and treatment for venous insufficiency. We chose to evaluate the feasibility, safety of inferior vena cava (IVC) filter placement in the office-based setting. METHODS: All procedures were performed using local anesthesia, and ultrasound guidance for puncture. All venograms were performed with manual injection of iodinated contrast. An IVC filter was placed in the cases (except one failure of placement) using fluoroscopy in the infrarenal position. Patients were observed in a recovery area and then discharged. Follow-up data were obtained through an interview, physical examination, and 24-hour postoperative phone call. RESULTS: Over the course of 27 months, 29 Greenfield filters (Boston Scientific, Marlborough, Mass) and three Celect temporary filters (Cook, Bloomington, Ind) were placed in the infrarenal IVC for 18 women and 14 men, with an average age of 75.3 +/- 15.6 years (range, 38-97 years). Twenty-four acute, 6 recent (<6 months ago) and three subacute lower extremity deep vein thromboses (DVTs) were identified. The indications for the procedure were patients with: DVT who were to undergo surgery (n = 6), acute large free-floating iliofemoral DVT (deemed high-risk for long-term anticoagulation) (n = 7), new DVT during anticoagulation therapy (n = 6), DVT with gastrointestinal bleeding (n = 4), DVT with hematuria (n = 2), recent DVT (which extended during full dose anticoagulation treatment) while undergoing a long flight (n = 1) (temporary filter placement), DVT with arm hematoma (n = 1), DVT with unsteady gait and history of falls (n = 2), DVT with nose bleeding (n = 1), DVT with dementia and inability to receive anticoagulation treatment (n = 1), DVT and receiving chemotherapy and with thrombocytopenia (n = 1), and DVT and refusal to take anticoagulation medication (n = 1). One patient had a failure to place a filter because of chronic IVC occlusion found on venogram. One patient with history of gastrointestinal bleeding, acute DVT, and atrial fibrillation suffered IVC filter thrombosis 1 month after the procedure. We attempted removal of the temporary filters in the hospital in two patients but failed to retrieve the filter in these two cases. We noted no insertion site DVT, extension of DVT, or pulmonary embolism. CONCLUSIONS: Our preliminary experience suggests that placement of IVC filters for treatment of venous thrombotic events in an office-based facility is safe and efficacious with basic endovascular equipment. Long-term outcome cannot be determined at this point.