Faculty Bibliography

BACKGROUND: Endovenous therapy by venoplasty and stenting is rapidly gaining momentum and popularity in treatment of chronic venous insufficiency (nonthrombotic iliac vein lesions, in particular). The purpose of this study was to examine the results of office-based venoplasty and stenting procedures that were performed at our office-based facility from July 28, 2012, until April 28, 2013. The study focused on any complications during and after the procedure. METHODS: From July 2012 to April 2013, 245 patients underwent venography for the correction of suspected iliac vein stenosis in the office setting. Data included 74 patients undergoing bilateral iliac procedures and 137 patients undergoing unilateral procedures. The remaining 34 patients underwent venography only, without any intervention. The remaining 285 limbs were classified according to the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification as follows: C1, n = 0; C2, n = 84; C3, n = 97; C4, n = 34; C5, n = 53, and C6, n = 17. Postprocedure pain was assessed with a Likert scale of 0 to 10, and scores were collected in 108 patients in the latter portion of the study once this was established to be our primary complication. Pain was considered to be significant if >/= 5 (n = 20) and insignificant if <5 (n = 88). Pearson correlation was used to evaluate any correlation between pain and gender, age, laterality, CEAP scores (2-6), stent size, and balloon size. Fourteen patients had a history of prior deep venous thrombosis (DVT). RESULTS: Out of the series, 90 women and 47 men underwent unilateral intervention, and 23 women and 14 men underwent bilateral intervention. The average age was 69 years (range, 22-96; standard deviation [SD], +/- 13). In 20 patients with significant pain, the average pain score was 6 (range, 5-10; SD, +/- 1.4). In 88 patients with insignificant pain, the average pain score was 1.15 (range, 0-4; SD, +/- 1.5). The overall average pain score for 108 cases was 2 (range, 0-10; SD, +/- 2.4). Five patients (2%) who underwent intervention developed thrombosis of the iliac stent either <30 days (n = 4) or >30 days (n = 1); all five patients had history of DVT. No statistically significant correlation of pain to age, gender, laterality, CEAP scores (2-6), or stent and balloon size was found. No correlation was found between stent thrombosis and gender, age, laterality, CEAP scores (2-6), or stent and balloon size. No complications were reported, such as pseudoaneurysm formation, infection, and insertion site DVT, within 5 days. Iliac fossa hematoma developed 30 days after the procedure in one patient, who required hospital admission for evaluation and treatment. CONCLUSIONS: The correction of iliac vein outflow obstruction in office-based settings results in a low incidence of complications, such as thrombosis (2%), and average pain score of 2 of 10 on the Likert scale. The procedure is minimally invasive with minimal complications.

The sticky platelet syndrome is a congenital disorder, characterized by abnormal platelet aggregation in response to epinephrine and/or adenosine phosphate. We present a case of intraoperative carotid artery thrombosis, after patch angioplasty. The successful repair was only feasible on administration of antiplatelet therapy. Presence of sticky platelet syndrome should be considered during vascular operative interventions, and load of antiplatelet agents should be given in patients with unexplained repeated thrombosis of arterial repair, as we described and reported this case.

We present a 68-year-old female who developed multiple pseudo-aneurysms (PSAs) following cardiac catheterization via the right groin. During subsequent thrombin injection of PSAs, the patient developed acute occlusion of the popliteal artery. A covered stent was placed to obliterate the PSAs and allow for successful endovascular treatment of the occlusion without hemorrhage from the previous arteriotomy sites. This report demonstrates a safe and successful method to treating high surgical risk patients with recent PSA's and a necessity for thrombolysis.

BACKGROUND: Balloon-assisted maturation (BAM) of arteriovenous fistula (AVF) is a fairly new procedure used to accelerate the process of maturation. As with any procedure, complications do arise. In this retrospective analysis of 336 office-based BAM procedures, 5 major complications were analyzed. These were categorized as formation of wall hematoma, extravasation or rupture, spasm, thrombosis, and formation of puncture-site hematoma. METHODS: Prospective data were collected from May 14, 2009 to March 3, 2011 on 336 office-based duplex-guided BAM procedures. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex guided. Balloon calibers were chosen based on duplex vein measurements and surgeon preference (approximately 1-2 mm larger than minimal vein diameter). Vascular injuries were classified based on postprocedural duplex assessment. All patients had follow-up duplex scans within a week after BAM. RESULTS: Of the 336 procedures, the most common injury was formation of wall hematoma (136, 40.5%) followed by extravasation or rupture (32, 9.5%), spasm (26, 7.7%), formation of puncture-site hematoma (13, 3.9%), and thrombosis (5, 1.5%). The injuries were further compared based on balloon size, ranging from small balloon group (3-6 mm) to large balloon group (7-12 mm); entry position, retrograde (n=177) versus antegrade (n=159); and type of fistula; radial-cephalic (n=232), brachial-cephalic (n=64), brachial-basilic (n=34), brachial-brachial (n=4), and ulnar-cephalic (n=2). A significant increase in complications was noted in BAM procedures performed in forearm AVF versus upper arm AVF (67% vs 54%, P=0.02) and in the large balloon group versus small balloon group (72% vs 52%, P<0.001). CONCLUSIONS: The data suggest that office-based BAM procedures are safe. Fortunately, major complications are not seen at an alarming rate. While increased complications are seen in BAM procedures performed in the forearm and with larger balloons, except for wall hematoma formation (40.19%), each complication occurs in <10% of the procedures. Further studies to help clarify the nature of these complications and their relationship to fistula maturation are warranted.