Faculty Bibliography

OBJECTIVE: The treatment of venous insufficiency using endovenous laser ablation or radiofrequency ablation may result in endothermal heat-induced thrombosis (EHIT), a form of deep venous thrombosis. This study sought to assess whether increasing the ablation distance peripheral to the deep venous junction would result in a reduction in the incidence of EHIT II. METHODS: This study was a retrospective review of a prospectively maintained database from April 2007 to December 2011. Consecutive patients undergoing great saphenous vein (GSV) or small saphenous vein (SSV) ablation were evaluated. Previous to February 2011, all venous ablations were performed 2 cm peripheral to the saphenofemoral or saphenopopliteal junction (group I). Subsequent to February 2011, ablations were performed greater than or equal to 2.5 cm peripheral to the respective deep system junction (group II). The primary outcome was the development of EHIT II or greater (ie, thrombus protruding into the deep venous system but comprising less than 50% of the deep vein lumen). Secondary outcomes included procedure-site complications such as thrombophlebitis and hematomas. chi2 tests were performed for all discrete variables, and unpaired Student's t-tests were performed for all continuous variables. P < .05 was considered statistically significant. RESULTS: A total of 4223 procedures were performed among group I (n = 3239) and group II (n = 984). Patient demographics were similar between the two groups; however, the CEAP classification was higher by a small margin in group II, and the result was significant (group I: 2.6% +/- 0.9% vs group II: 2.8% +/- 1.0%; P = .006). The incidence of EHIT II was 76 in group I and 13 in group II. This represented a trend toward diminished frequency in group II as compared with group I (group I: 2.3% vs group II: 1.3%; P = .066). There were no reported cases of EHIT III or IV in this patient cohort. Patients who developed an EHIT II in group I were treated using anticoagulation 54% of the time, and patients who developed an EHIT II in group II were treated using anticoagulation 100% of the time. CONCLUSIONS: This study suggests that changing the treatment distance from 2 cm to greater than or equal to 2.5 cm peripheral to the deep venous junction may result in a diminished incidence of EHIT II. Ongoing evaluation is required to validate these results and to affirm the long-term durability of this technique.

BACKGROUND: Cannulation of the radial artery is frequently performed for invasive hemodynamic monitoring. Complications arising from indwelling catheters have been described in small case series; however, their surgical management is not well described. Understanding the presentation and management of such complications is imperative to offer optimal treatment, particularly because the radial artery is increasingly accessed for percutaneous coronary interventions. METHODS: We conducted a retrospective review to identify patients who underwent surgical intervention for complications arising from indwelling radial artery catheters from 1997 to 2011. RESULTS: We identified 30 patients who developed complications requiring surgical intervention. These complications were categorized into ischemic and nonischemic, with 15 patients identified in each cohort. All patients presenting with clinical hand or digital ischemia underwent thrombectomy and revascularization. Complications in the nonischemic group included three patients with deep abscesses with concomitant arterial thrombosis, two with deep abscesses alone, and 10 with pseudoaneurysms. Treatment strategy in this group varied with the presenting pathology. Among the entire case series, three patients required reintervention after the initial surgery, all in individuals initially presenting with ischemia who developed recurrent thrombosis of the radial artery. There were no digital or hand amputations in this series. However, the overall in-hospital mortality in these patients was 37%, reflecting the severity of illness in this patient cohort. Three patients who were positive for heparin-induced thrombocytopenia antibody had 100% mortality compared with those who were negative (P = .04, Fisher exact test). In-hospital mortality was higher in patients presenting with initial ischemia than in those with nonischemic complications (53% vs 20%; P = .06). Among 10 patients who presented with pseudoaneurysms, five (50%) were septic at presentation with positive blood cultures, and six (60%) had positive operating room cultures. Staphylococcus aureus was identified as the causative organism in all of these patients. CONCLUSIONS: Complications of radial artery cannulation requiring surgical intervention can represent infectious and ischemic sequelae and have the potential to result in major morbidity, including digital or hand amputation and sepsis, or death. Although surgical treatment is successful and often required in these patients to treat severe hand ischemia, hemorrhage, or vascular infection, these complications tend to occur in critically ill hospitalized patients with an extremely high mortality. This must be taken into consideration when planning surgical intervention in this patient cohort. Finally, radial arterial cannulation sites should not be overlooked when searching for occult septic sources in critically ill patients.

BACKGROUND: Endoleak and sac growth remain unpredictable occurrences after EVAR, necessitating regular surveillance imaging, including CT angiography. This study was designed to identify preoperative CT variables that predict AAA remodeling and sac behavior post-EVAR. METHODS: Pre- and postoperative CT scans from 136 abdominal aortic aneurysms treated with EVAR were analyzed using M2S (West Lebanon, NH) software for size measurements. Preoperative total sac volume and proportion of thrombus and calcium in the sac were assessed. Sac change was defined as a 3-mm difference in diameter and a 10-mm(3) difference in volume when compared with preoperative measurements. Univariate analysis was performed for age, gender, AAA size, relative thrombus/calcium volume, device type, presence of endoleak, and the effects on sac size. RESULTS: Gender, device type, age, AAA size, and percent calcium were not predictive of sac change post-EVAR. Increased proportion of thrombus on pre-EVAR resulted in a greater likelihood of sac shrinkage (P = 0.002). Patients with aneurysms that grew on postoperative CT scan had less sac thrombus on pre-EVAR (mean 27.5%) than patients without evidence of endoleak (mean 41.9%, P < 0.0001). Only 2 of 30 patients with >50% pre-EVAR thrombus developed endoleak. A >50% thrombus burden resulted in endoleak in significantly fewer patients (6.7%) compared with those who had <50% thrombus (43.1%). CONCLUSIONS: The proportion of thrombus on preoperative CT may predict sac behavior after EVAR and development of an endoleak. Greater than 50% thrombus appears to predict absence of endoleak after EVAR. Aneurysms with large thrombus burden are less likely to grow and may require less vigilant postoperative surveillance than comparable AAA with relatively little thrombus.

OBJECTIVE: Specific guidelines for management of cerebrovascular risk in women are currently lacking. This study aims to provide a consensus expert opinion to help make clinical decisions in women with carotid stenosis. METHODS: Proposals for the use of carotid endarterectomy (CEA), carotid stenting (CAS), and medical therapy for stroke prevention in women with carotid stenosis were provided by a group of 9 international experts with consensus method. RESULTS: Symptomatic women with severe carotid stenosis can be managed by CEA provided that the perioperative risk of the operators is low (<4%). Periprocedural stroke risks may be increased in symptomatic women if revascularization is performed by CAS; however, the choice of CAS vs CEA can be tailored in subgroups best fit for each procedure (e.g., women with restenosis or severe coronary disease, best suited for CAS; women with tortuous vessels or old age, best suited for CEA). There is currently limited evidence to consider medical therapy alone as the best choice for women with neurologically severe asymptomatic carotid stenosis, who should be best managed within randomized trials including a medical arm. Medical management and cardiovascular risk factor control must be implemented in all women with carotid stenosis in periprocedural period and lifelong regardless of whether or not intervention is planned. CONCLUSIONS: The suggestions provided in this article may constitute a decision-making basis for planning treatment of carotid stenosis in women. Most recommendations are of limited strength; however, it is unlikely that new robust data will emerge soon to induce relevant changes.

BACKGROUND: The precise relationship between risk factor burden and prevalence of peripheral artery disease (PAD) in different vascular territories (PAD, carotid artery stenosis [CAS], and abdominal aortic aneurysms [AAAs]) is unclear. METHODS: We investigated the association of modifiable risk factors (hypertension, hypercholesterolemia, smoking, diabetes, and sedentary lifestyle) with any and type-specific peripheral vascular disease (PVD) among 3.3 million patients in the U.S., aged 40 to 99, who underwent screening bilateral ankle brachial indices, carotid duplex ultrasound, and abdominal aortic ultrasound in the Life Line Screening program between 2004 and 2008. Multivariate logistic regression analysis was used to estimate the odds of disease in different risk factor categories. Population-attributable risk was calculated to estimate the proportion of disease that could be potentially ascribed to modifiable risk factors. RESULTS: Among 3,319,993 participants, prevalence of any PVD was 7.51% (95% confidence interval [CI], 7.50%-7.53%). PAD was present in 3.56% (95% CI, 3.54%-3.58%), CAS in 3.94% (95% CI, 3.92%-3.96%), and AAAs in 0.88% (95% CI, 0.86%-0.89%). The multivariate-adjusted prevalence with the presence of 0, 1, 2, 3, 4, and 5 modifiable risk factors was 2.76, 4.63, 7.12, 10.73, 16.00, and 22.08 (P < .0001 for trend) for any PVD; 1.18, 2.09, 3.28, 5.14, 8.32, and 12.43 (P < .0001 for trend) for PAD; 1.41, 2.36, 3.72, 5.73, 8.48, and 11.58 (P < .0001 for trend) for CAS; and 0.31, 0.54, 0.85, 1.28, 1.82, and 2.39 (P < .0001 for trend) for AAAs, respectively. These associations were similar for men and women. For every additional modifiable risk factor that was present, the multivariate-adjusted odds of having vascular disease increased significantly (any PVD [odds ratio (OR), 1.58; 95% CI, 1.58-1.59]; PAD [OR, 1.62; 95% CI, 1.62-1.63]; CAS [OR, 1.57; 95% CI, 1.56-1.57]; and AAA [OR, 1.51; 95% CI, 1.50-1.53]). CONCLUSION: This very large contemporary database demonstrates that risk factor burden is associated with an increased prevalence of PVD, and there is a graded association between the number of risk factors present and the prevalence of PAD, CAS, and AAAs.