Faculty Bibliography

In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success

BACKGROUND: The benefit of carotid endarterectomy (CEA) in female patients has been questioned by various randomized, prospective trials, particularly in asymptomatic cases; several have noted an increase in perioperative stroke among women after CEA. The outcome of carotid angioplasty and stenting (CAS) has not been extensively examined in women. This study examined the outcome of CEA and CAS in women vs men by using a national database. METHODS: Outcomes of CEA and CAS were stratified by sex using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. The NIS was used to identify patient discharges that occurred during 2004 and 2005. Appropriate International Classification of Diseases, 9th Revision (ICD-9) procedure and diagnosis codes were used to identify CEA and CAS cases. Outcome measures included in-hospital perioperative stroke and death. Comparisons of demographics, procedures, and outcome were performed between men and women. Additional analysis was performed among women alone to attempt to identify whether improved outcome was noted with either procedure. RESULTS: Of 54,658 procedures, 94.2% were CEA and 5.8% were CAS. Women comprised 42.3% of the analyzed cases. Women and men were equally likely to be symptomatic (5.3% vs 5.3%, P = .8). Women were significantly less likely to undergo CAS than men (5.4% vs 6.1%, P < .001). Women and men had equivalent rates of perioperative stroke when undergoing CEA (1.0% vs 1.0%, P = .9) and CAS (2.7% vs 2.0%, P = .2). Symptomatic women had a significantly higher rate of perioperative stroke overall than did symptomatic men (3.8% vs 2.3%, P = .03). Asymptomatic women had a significantly lower perioperative stroke rate after CEA than after CAS (0.9% vs 2.1%, P < .001). Rates of perioperative showed a trend favoring CEA vs CAS among symptomatic women (3.4% vs 6.2%, P = .1). CONCLUSIONS: The concern regarding an increased perioperative stroke rate after CEA among asymptomatic women appears to be unfounded. The perioperative stroke rate among symptomatic women was higher than that of symptomatic men, but still well within the acceptable range for symptomatic patients undergoing a cerebrovascular intervention. Nationally, women underwent CAS significantly less frequently than did men. Outcome among women for perioperative stroke favored CEA over CAS, particularly in asymptomatic patients. CEA may be the preferred treatment in women seeking intervention for cerebrovascular disease, unless compelling reasons exist to perform CAS

Current treatment guidelines of symptomatic and asymptomatic carotid stenosis are based on studies performed over a decade ago. Since that time, significant advances have been made in medical management, namely high dose statin therapy and improved antiplatelet agents, and in carotid interventions, namely the advent of carotid artery stenting. Especially with carotid stenting, the technology has grown by leaps and bounds and continues to advance at a rapid pace. These advances have necessitated new studies to compare these treatments with the gold standard of carotid endarterectomy. In asymptomatic patients, the current data does not justify medical management alone for severe (>80%) carotid stenosis. Furthermore, in both asymptomatic and symptomatic patients current studies have failed to demonstrate equivalence of CAS to CEA for significant carotid stenosis. Clearly additional studies comparing CAS, CEA, and medical management are needed to further clarify this issue. In the future, advances in CAS technology and techniques may greatly expand the role of CAS beyond its current role in certain high-risk patient subsets. However, for the time being CEA still remains the gold standard for carotid intervention

BACKGROUND: The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. METHODS: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score-Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used chi(2) analysis and Student t-tests. RESULTS: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P = .108). VT patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P = .007). VT patients with an ISS score >24 had a higher mortality compared with NVT patients (61% vs 28.6%, P = .04). VT patients with an APACHE II score <14 also had a higher mortality rate (18.2% vs 0%, P = .007). Finally, VT patients with a TRISS probability of survival of >80% had a higher mortality rate (13.9% vs 0%, P = .05). CONCLUSIONS: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma