Faculty Bibliography

We describe herein a combined approach to the treatment of popliteal artery aneurysms (PAA) that averts extensive dissections and potential blood loss particularly in cases of behind-the-knee aneurysms. Over the last 4 years, 13 patients (12 males) with mean age of 75 +/- 8 years were treated for PAAs at our institution with a combined surgical and endovascular approach. The mean size of popliteal aneurysms was 2.9 cm +/- 1.7 cm. One of the 13 cases (8%) was performed for acute ischemia and an additional 5 (38%) for claudication. All operations were performed under general anesthesia in supine position. Vein conduits (eight ipsilateral great saphenous veins, two contralateral great saphenous veins and one arm vein) were utilized for 11 bypasses. Of these, eight were from superficial femoral artery (SFA) to below the knee popliteal artery, two popliteal to popliteal and one SFA to posterior tibial artery. In addition, two expanded polytetrafluoroethylene femoral popliteal bypasses were performed. The distal anastomosis was performed after the popliteal artery was ligated distal to the aneurysm. Next, coil embolization of the aneurysmal sac was performed under fluoroscopic or ultrasound guidance. Coils were embolized through a 5F sheath. Lastly, the popliteal artery was ligated distal to the proximal anastomosis. Completion studies were obtained with duplex in six cases and arteriography in the remaining five cases. Mean follow-up was 11.6 months +/- 9.6. One bypass occluded in 2 months after surgery. One patient demonstrated continued growth of his aneurysm despite coil embolization twice and underwent an open ligation of the branches perfusing the aneurysm from within the sac through a posterior approach. This approach may be particularly useful for PAAs located behind the knee where optimal surgical exposure is often difficult and the collateral circulation is abundant. The proposed technique is simple, effective and averts extensive dissections required to minimize blood loss.

In an attempt to identify the fellows' concerns about the future of the field of vascular surgery, we conducted a survey consisting of 22 questions at an annual national meeting in March from 2004 to 2007. In order to obtain accurate data, all surveys were kept anonymous. The fellows were asked (1) what type of practice they anticipated they would be in, (2) what the new training paradigm for fellows should be, (3) to assess their expectation of the needed manpower with respect to the demand for vascular surgeons, (4) what were major threats to the future of vascular surgery, (5) whether they had heard of and were in favor of the American Board of Vascular Surgery (ABVS), (6) who should be able to obtain vascular privileges, and (7) about their interest in an association for vascular surgical trainees. Of 273 attendees, 219 (80%) completed the survey. Males made up 87% of those surveyed, and 60% were between the ages of 31 and 35 years. Second-year fellows made up 82% of those surveyed. Those expecting to join a private, academic, or mixed practice made up 35%, 28%, and 20% of the respondents, respectively, with 71% anticipating entering a 100% vascular practice. Forty percent felt that 5 years of general surgery with 2 years of vascular surgery should be the training paradigm, while 45% suggested 3 and 3 years, respectively. A majority, 79%, felt that future demand would exceed the available manpower, while 17% suggested that manpower would meet demand. The major challenges to the future of vascular surgery were felt to be competition from cardiology (82%) or radiology (30%) and lack of an independent board (29%). Seventeen percent were not aware of the ABVS, and only 2% were against it; 71% suggested that vascular privileges be restricted to board-certified vascular surgeons. Seventy-six percent were interested in forming an association for vascular trainees to address the issues of the future job market (67%), endovascular training during fellowship (56%), increasing focus on the vascular fellows at national meetings (49%), and representation for the fellows on the national councils (37%). This survey suggests that several significant issues exist in the minds of vascular trainees that have not been addressed and may present opportunities for further dialogue.

This is a case report of a patient with Campylobacter fetus involving bilateral internal iliac artery aneurysms. The patient was treated successfully by ligation of the bilateral iliac artery aneurysms and antibiotics. According to a review of the English-language medical literature, this was the first such patient to be reported. A 69-year-old African-American male presented with a past medical history of repair of a 6.6 cm abdominal aortic aneurysm. It had been repaired with a Dacron bifurcated graft in July 2005. The bilateral internal iliac artery aneurysms (right 2.3 cm and left 3.4 cm) were coil embolized intraoperatively. The patient's past medical history was significant for hypertension and coronary artery disease and was status post-stent placement. He re-presented with fever and chills for 8 days in duration at home in March 2007. His fever was 101 to 102 degrees F. He denied vomiting, diarrhea, and a history of recent travel. The patient was admitted to the hospital for a fever workup. After an extensive workup, a left internal iliac artery aneurysm was found to be the source of sepsis. The patient was taken to the operating room for excision of the left internal iliac artery. No purulence was noted, but tissue overlying the aneurysm was thickened and fibrotic. Multiple cultures were taken. The tissue culture came back as C. fetus. Incidentally, the patient's preoperative computed tomographic scan revealed a right internal iliac artery aneurysm that was 4.2 cm on March 28, 2007, and 4.9 cm on April 23, 2007. Postoperatively, the patient's right internal iliac artery aneurysm was noted to be rapidly growing. He was promptly taken to the operating room for ligation of the right internal iliac artery aneurysm. The patient's postoperative course was unremarkable. He was discharged on ciprofloxacin for 14 days.

The short-term effectiveness and safety placement of superior vena cava (SVC) filter in the treatment of upper extremity deep venous thrombosis in patients with contraindication to anticoagulation have been well documented. However, as opposed to the numerous reported experiences with inferior vena cava filter placement and its complications, there has been no documented long-term follow-up on SVC filter placement. We, therefore, reviewed our experience with SVC filter placement. A retrospective review was performed of the 154 cases of patients who underwent SVC filter placement between January 1994 and August 2005 at our institution. Seven additional patients had unsuccessful SVC filter placement due to widespread deep venous thrombosis. The data were evaluated for both insertion complications (pneumothorax, hemorrhage, filter misplacement) and long-term complications (pulmonary embolism, migration, caval occlusion). The follow-up included review of serial chest radiographs to evaluate for filter migration in patients who lived at least 60 days after filter insertion and had chest radiography performed (n = 40), patients' charts, clinic visits, and telephone contacts, hospital databases, city death records, and national databases. There were 69 males and 85 females with a mean age of 73.6 years (range, 16-96 years; +/-15.3 [SD] years). Follow-up ranged from 1 day to 3750 days (256.3 +/- 576 days [mean +/- SD]) and 5 patients were lost to follow-up. Of the 154 patients, 58 survived longer than 60 days with mean follow-up of 628.4 days. All SVC filters (TrapEase, n = 38; Greenfield, n = 116) were successfully deployed in the 154 patients. During the follow-up, 114 (74.0% mortality) of the patients died of chronic illness or from cancer complications. There were three cases of pericardial tamponade (1.9%), and one case of misplaced filter in innominate vein. There were no known cases of symptomatic pulmonary embolism, caval occlusion, pneumothorax, or filter migration. SVC filter placement is associated with a low incidence of complications with long-term follow-up. These data help to reaffirm the safety and effectiveness of SVC filter placement. However, SVC perforation in young males remains a significant issue.

BACKGROUND: The safety of radiofrequency ablation (RFA) of the great saphenous vein (GSV) in patients with previous history of deep venous thrombosis (DVT) has not been determined. METHODS: From April 2003 to June 2006, 274 patients (68% women; mean age, 60 years +/- 15 years) underwent 293 consecutive RFA procedures. In the first 15 months, the temperature probe was maintained at 85 degrees C, with a pullback rate of 2 cm/min (85 limbs, 30%); we subsequently changed the protocol to 90 degrees C and a pullback rate of 2 to 3 cm/min (205 limbs, 70%). We identified 29 patients (10%) with a history of DVT or duplex scan evidence of post-thrombotic venous disease; these were compared with the remaining 264 (90%). Postprocedural acute thrombotic (AT) events were analyzed. By the CEAP classification, 204 limbs (70%) were C(2) to C(4), and 89 (30%) were C(5) to C(6). Thirty-seven patients (13%) had a history of superficial thrombophlebitis (SVT). Proximal mean GSV diameter was 0.95 +/- 0.29 cm (range, 0.4-2.3 cm). Concomitant procedures included avulsion phlebectomy in 88 limbs (30%) and perforator vein surgery in 4 (1%). RESULTS: AT events after RFA were detected in 38 limbs (13%), including thrombus protrusion into the sapheno-femoral junction (SFJ) in 24 (8%), common femoral vein in 7 (2.5%), and calf vein DVT in 7 (2.5%). Overall incidence of AT events in limbs with and without evidence of previous DVT was 7% (2 of 29) and 14% (36 of 264), respectively (P = .36). Variables significantly associated with AT events were previous SVT (10 of 37 [27%] vs 28 of 256 [11%], P = .01), a larger GSV diameter (mean 1.1 +/- .39 vs 0.93 +/- 0.27, P < .01), and first protocol (catheter temperature of 85 degrees C with a slower pullback rate in 18 of 88 [20%] vs 20 of 205 [9.7%], P = .02). Concomitant venous operations were associated with an increase in AT events (23% vs 9%; P < .002). By multivariate analysis, larger proximal GSV diameter and previous SVT remained independently statistically significant (P = .049 and P = .0135, respectively). All AT patients were successfully treated with standard anticoagulation. No pulmonary emboli occurred. CONCLUSION: RFA of the GSV in patients with previous venous thromboembolic events is safe and should be offered as an alternative to surgical procedures. These data demonstrate that AT events increase when larger-diameter GSVs are treated.

Introduction. In an attempt to identify the concerns of vascular fellows regarding their training in vascular surgery, we conducted a survey consisting of 22 questions at an annual national meeting from 2004 to 2007. Methods. The fellows were asked to assess various aspects of their training as excellent, satisfactory, or mixed. Results. 76% were satisfied with their endovascular experience during their fellowship while 82% were satisfied with their experience with open cases. The distribution of non-learning cases was felt to be excellent, satisfactory, or required some or much improvement in: 45%, 44%, 8%, and 2% respectively. However, only 61% felt that their vascular laboratory experience was excellent or satisfactory. Only 36% actually performed the vascular duplex exam, and only 49% felt that they would feel comfortable in managing a vascular laboratory. Conclusions. The results of this Survey suggest that several significant issues are reflected in the minds of vascular trainees.

Although the utility of the superior vena cava (SVC) filter remains controversial, the safety and efficacy of SVC filters in patients with upper extremity deep venous thrombosis in whom anticoagulation is contraindicated or ineffective have been well described. However, few complications have been reported. Herein we describe a series of three cases of SVC perforation in three young males following the placement of SVC filters. All three patients had deep venous thrombosis on upper extremity duplex ultrasonography and contraindication to anticoagulation (n = 1) or failure of anticoagulation (n = 2). Cardiac tamponade was demonstrated on transthoracic echocardiography in all three cases. The pericardial effusion was evacuated with either median sternotomy or pericardiocentesis in two cases. One of the patients died of cardiac arrest, and an autopsy showed aortic perforation in addition to the SVC perforation. This patient underwent chest compression following the cardiac arrest. One patient was lost to follow-up, and the other patient remained asymptomatic at the 1-year follow-up. This is the first case of SVC perforation that is associated with aortic perforation after the placement of an SVC filter. Owing to this occurrence, one has to be aware of these life-threatening complications when placing an SVC filter, especially in males less than 60 years of age.

OBJECTIVE: Following contemporary trend, various vascular interventions being performed in the office. We describe our office experience with radiofrequency ablation (RFA) of incompetent perforating veins (IPV) and duplex-guided balloon angioplasties of failing/nonmaturing arterio-venous fistulas (AVF). DUPLEX-GUIDED BALLOON ANGIOPLASTIES OF AVF: Eighteen patients with 20 failing arterio-venous (AV) fistulas underwent office duplex-guided balloon angioplasties. Thirteen procedures (65%) were on non-maturing fistulas and the remaining 7 (35%)--in dialyzed patients. Sheath insertion, wire and balloon passage and inflation were guided by duplex only. RFA OF IPVS: We performed 25 radiofrequency ablations of 49 IPVs. Early follow-up scan confirmed total occlusion of 45 (92%) treated IPVs. Patients gender, CEAP class, perforator diameter or GSV patency did not correlate with current procedure failure. CONCLUSION: Excellent duplex imaging quality and technical advances in endovascular tools allowed us safely perform AVF balloon angioplasties and RFA of IPVs in the office.

Office-based procedures have witnessed a veritable explosion with more than 10 million procedures being performed in the United States yearly. This is partially because of improvements in technology that allow these procedures to be performed safely in the office. However, as the number of procedures has increased, the reports of significant morbidity and mortality that have been appearing in the media have captured the public's attention. Until recently, this new and growing field has been largely unregulated. This is changing nationwide. The authors review the new regulations in New York State as a model of the future of this rapidly evolving field and their effect on vascular surgery office procedures.

Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex-guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex-guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/ or recoil caused diameter reduction > or = 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 +/- 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 +/- 4.2 months and 5.6 +/- 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p<.04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.