Faculty Bibliography

BACKGROUND: Reversal of flow in the vertebral artery (RFVA) is an uncommon finding on cerebrovascular duplex ultrasound examination. The clinical significance of RFVA and the natural history of patients presenting with it are poorly understood. Our objective was to better characterize the symptoms and outcomes of patients presenting with RFVA. METHODS: A retrospective review was performed of all cerebrovascular duplex ultrasound studies performed at our institution between January 2010 and January 2016 (N = 2927 patients). Individuals with RFVA in one or both vertebral arteries were included in the analysis. RESULTS: Seventy-four patients (74/2927 patients [2.5%]) with RFVA were identified. Half of the patients were male. Mean age at the time of the first ultrasound study demonstrating RFVA was 71 years (range, 27-92 years); 78% of patients had hypertension, 28% were diabetic, and 66% were current or former smokers. Indications for the ultrasound examination were as follows: 44% screening/asymptomatic, 7% anterior circulation symptoms, 20% posterior circulation symptoms, 28% follow-up studies after cerebrovascular intervention, and 5% upper extremity symptoms. At the time of the initial ultrasound examination, 21 patients (28%) had evidence of a prior carotid intervention (carotid endarterectomy or carotid stenting), 21 patients had evidence of moderate (50%-79%) carotid artery stenosis (CAS) in at least one carotid artery, and 12 patients (16%) had evidence of severe (>80%) CAS. Of the 15 patients presenting with posterior circulation symptoms, 11 (73%) had evidence of concomitant CAS. In contrast, 22 of the 59 patients (37%) without posterior circulation symptoms had duplex ultrasound findings of CAS (P = .01). The mean duration of follow-up was 28 +/- 22 months. Follow-up data were available for 63 patients (85%), including the 15 patients who presented with posterior circulation symptoms. Of these 15 patients, 5 underwent subclavian artery revascularization, including balloon angioplasty and stenting in 4 patients and open/hybrid revascularization in 1 patient. Five individuals were awaiting intervention. Three patients underwent carotid endarterectomy for CAS, with resultant improvement in posterior circulation symptoms. Finally, one patient was deemed too high risk for intervention, and one patient was found to have an alternative cause for symptoms. The remaining 59 patients continued to be asymptomatic during follow-up. One patient progressed to vertebral artery occlusion, and six patients had progression of CAS. CONCLUSIONS: Symptomatic RFVA responds well to intervention, including subclavian artery stenting and carotid intervention in patients with CAS. The majority of patients with this finding are asymptomatic at the time of presentation. Although progression of vertebral artery disease is rare, these patients may benefit from monitoring for progression of CAS with surveillance ultrasound.

OBJECTIVE: The goal of this study is to determine if compression therapy after endovenous ablation (EVA) of the great saphenous vein (GSV) improves efficacy and patient reported outcomes of pain, ecchymosis and quality of life. METHODS: This was a prospective randomized controlled trial from 2009 to 2013 comparing the use of thigh-high 30-40mmHg compression therapy for 7 days vs no compression therapy following endovenous ablation of the GSV. Severity of venous disease was measured by CEAP scale and the venous clinical severity score (VCSS). Quality of life assessments were carried out with a CIVIQ-2 questionnaire at days 1, 7, 14, 30 and 90, and the visual analog pain scale daily for the first week. Bruising score was assessed at 1 week post procedure. Post ablation venous duplex was also performed. RESULTS: 70 patients and 85 limbs with EVA were randomized. EVA modalities included radiofrequency ablation (91%) and laser ablation (9%). CEAP class and VCSS scores were equivalent between the two groups. There was no significant difference in patient reported outcomes of post-procedural pain scores at day 1 (mean 3.0 vs. 3.12, p =0.948) and at day 7 (mean 2.11 vs 2.81,p =0.147), CIVIQ-2 scores at 1 week (mean 36.9 vs 35.1, p=0.594), at 90 days (mean 29.1 vs 22.5, p =0.367) and bruising score (mean 1.2 vs 1.4,p=0.561) in the compression vs. no compression groups respectively. Additionally, there was a 100% rate of GSV closure in both groups and no endothermal heat-induced thrombosis (eHIT) as assessed by post-ablation duplex. CONCLUSION: Compression therapy does not significantly affect both patient reported and clinical outcomes after GSV ablation in patients with non-ulcerated venous insufficiency. It may be an unnecessary adjunct following GSV ablation.

Background: Patients who present acutely with a femoral vein deep venous thrombosis (DVT) diagnosed by ultrasound are often treated with anticoagulation and instructed to follow up electively. This study sought to assess whether obtaining central imaging in this cohort of patients results in an increased diagnosis of iliocaval DVT and consequently an increased consideration for interventional treatments to effect thrombus removal. Methods: This study was a retrospective review of a prospectively maintained RedCap database from November 2014 through August 2016, which is coordinated by the Venous Thromboembolic Center at our institution. Consecutive patients who were diagnosed by ultrasound with a femoral vein DVT were evaluated. The patients who underwent confirmatory central venous imaging (computed tomography venography, magnetic resonance venography; group A) were compared with the patients who did not undergo central venous imaging (group B). Demographic variables were collected. The outcomes evaluated were (1) the presence of iliocaval DVT, (2) candidacy for lytic-based therapies, (3) performance of lytic-based therapy, and (4) performance of any invasive treatment (lytic therapy, mechanical thrombectomy, inferior vena cava filter placement, or venous stenting). Additional outcomes included technical success of invasive treatment and complications associated with invasive treatment. Results:A total of 63 patients were identified who presented with a diagnosis of femoral vein DVT. Group A comprised 20 of 63 (31%) patients. Group B comprised the remainder, 43 of 63 (69%). The baseline demographics did not differ significantly, except for gender (Table). The number of patients who were diagnosed with an iliocaval DVT differed significantly (group A, nine [45%]; group B, nine [20%]; P <.0001). The number of patients who underwent lytic therapy differed significantly (group A, eight [40%] - seven at the index admission and one at 1 month; group B, 0 [0%]; P <.0001). The number of patients without relative contraindications to lytic therapy did not differ significantly (group A, 13 [65%]; group B, 34 [79%]; P =.35). The number of patients who underwent any invasive treatment differed significantly between the two cohorts (group A, 12/20 [60%]; group B, 4/43 [9%]; P =.0001). The majority of interventions were technically successful in both groups (group A, 11/12 [91.7%]; group B, 4/4 [100%]; P = 1.00). Conclusions: This study suggests that a significant percentage of patients diagnosed by ultrasound with femoral vein DVTs have a concomitant iliocaval DVT. The data suggest that in patients with a femoral vein DVT, central venous imaging may be indicated to identify potentially treatable iliocaval thrombosis. Long-term data will be required to see if this results in a decrease in post-thrombotic syndrome on a population basis. (table present)

BACKGROUND: Mesenteric venous thrombosis (MVT) is a relatively uncommon but potentially lethal condition associated with bowel ischemia and infarction. The natural history and long-term outcomes are poorly understood and under-reported. METHODS: A single-institution retrospective review of noncirrhotic patients diagnosed with MVT from 1999 to 2015 was performed using International Classification of Diseases, Ninth Revision and radiology codes. Patients were excluded if no radiographic imaging was available for review. Eighty patients were identified for analysis. Demographic, clinical, and radiographic data on presentation and at long-term follow-up were collected. Long-term sequelae of portal venous hypertension were defined as esophageal varices, portal vein cavernous transformation, splenomegaly, or hepatic atrophy, as seen on follow-up imaging. RESULTS: There were 80 patients (57.5% male; mean age, 57.9 +/- 15.6 years) identified; 83.3% were symptomatic, and 80% presented with abdominal pain. Median follow-up was 480 days (range, 1-6183 days). Follow-up radiographic and clinical data were available for 50 patients (62.5%). The underlying causes of MVT included cancer (41.5%), an inflammatory process (25.9%), the postoperative state (20.7%), and idiopathic cases (18.8%). Pancreatic cancer was the most common associated malignant neoplasm (53%), followed by colon cancer (15%). Twenty patients (26%) had prior or concurrent lower extremity deep venous thromboses. Most patients (68.4%) were treated with anticoagulation; the rest were treated expectantly. Ten (12.5%) had bleeding complications related to anticoagulation, including one death from intracranial hemorrhage. Four patients underwent intervention (three pharmacomechanical thrombolysis and one thrombectomy). One patient died of intestinal ischemia. Two patients had recurrent MVT, both on discontinuing anticoagulation. Long-term imaging sequelae of portal hypertension were noted in 25 of 50 patients (50%) who had follow-up imaging available. Patients with long-term sequelae had lower recanalization rates (36.8% vs 65%; P = .079) and significantly higher rates of complete as opposed to partial thrombosis at the initial event (73% vs 43.3%; P < .005). Long-term sequelae were unrelated to the initial cause or treatment with anticoagulation (P = NS). CONCLUSIONS: Most cases of MVT are associated with malignant disease or an inflammatory process, such as pancreatitis. A diagnosis of malignant disease in the setting of MVT has poor prognosis, with a 5-year survival of only 25%. MVT can be effectively treated with anticoagulation in the majority of cases. Operative or endovascular intervention is rarely needed but important to consider in patients with signs of severe ischemia or impending bowel infarction. There is a significant incidence of radiographically noted long-term sequelae from MVT related to portal venous hypertension, especially in cases of initial complete thrombosis of the mesenteric vein.

OBJECTIVES: Nutcracker syndrome, or mesoaortic compression of the left renal vein (LRV), with associated symptoms related to venous hypertension in the left kidney, is a rare entity that may result in severe symptoms requiring operative intervention. We report on three patients who presented with nutcracker syndrome, including one patient with a circumaortic LRV resulting in posterior nutcracker syndrome, who underwent successful endovascular treatment with renal vein stenting. A review of existing literature on endovascular management of nutcracker syndrome follows. METHODS: Three women (age range 28 to 43 years) presented with symptoms and imaging studies consistent with nutcracker syndrome. Symptoms included pelvic and flank pain in all three patients, and episodes of hematuria in two. Imaging studies demonstrated compression of the LRV between the superior mesenteric artery and aorta in two of the patients. The third patient was noted to have a circumaortic LRV. RESULTS: All three patients underwent venography and LRV stenting. Stents included a 12 x 40 mm self-expanding nitinol stent, 14 x 60 mm Wallstent, and 16 x 40 mm Wallstent. All patients were placed on clopidogrel post-operatively. The duration of follow-up ranged from six to twenty-seven months. At follow up, all three patients reported significant symptomatic improvement, and duplex ultrasonography demonstrated stent patency in all. CONCLUSIONS: Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Results are encouraging at follow-up periods beyond two years.

BACKGROUND: Lymphedema is an incurable and disfiguring disease secondary to excessive fluid and protein in the interstitium as a result of lymphatic obstruction. Pneumatic compression (PC) offers a novel modality for treatment of lymphatic obstruction through targeting lymphatic beds and mimicking a functional drainage system. The objective of this study is to demonstrate improved quality of life in patients with lower-extremity lymphedema. METHODS: Consecutive patients presenting to a single institution for treatment of lymphedema were all treated with PC for at least 3 months. All patients underwent a pre- and post-PC assessment of episodes of cellulitis, number of ulcers, and venous insufficiency. Post-PC symptom questionnaires were administered. Symptom improvement was the primary outcome for analysis. RESULTS: A total of 100 patients met inclusion criteria. At presentation, 70% were female with a mean age of 57.5 years. Secondary lymphedema was present in 78%. Mean length of PC use was 12.7 months with a mean of 5.3 treatments per week. Ankle and calf limb girth decreased after PC use, (28.3 vs. 27.5 cm, P = 0.01) and (44.7 vs. 43.8 cm, P = 0.018), respectively. The number of episodes of cellulitis and ulcers pre- and post-PC decreased from mean of 0.26-0.05 episodes (P = 0.002) and 0.12-0.02 ulcers (P = 0.007), respectively. Fourteen percent had concomitant superficial venous insufficiency, all of whom underwent venous ablation. Overall 100% of patients reported symptomatic improvement post-PC with 54% greatly improved. 90% would recommend the treatment to others. CONCLUSIONS: PC improves symptom relief and reduces episodes of cellulitis and ulceration in lower-extremity lymphedema. It is well tolerated by patients and should be recommended as an adjunct to standard lymphedema therapy. Screening for venous insufficiency is recommended.

Introduction and Objectives: Lymphedema is an incurable and disfiguring disease secondary to excessive fluid and protein in the interstitium as a result of lymphatic obstruction. Pneumatic compression (PC) offers a novel modality for treatment of lymphatic obstruction through targeting lymphatic beds and mimicking a functional drainage system. The objective of this study is to demonstrate improved quality of life in patients with lower extremity lymphedema. Methods: Consecutive patients presenting to a single institution for treatment of lymphedema were all treated with PC for at least three months. All patients underwent a pre-and post-PC assessment of episodes of cellulitis, number of ulcers, and venous insufficiency. Post-PC symptom questionnaires were administered. Symptom improvement was the primary outcome for analysis. Results: 100 patients met inclusion criteria. At presentation, 70 % were female with a mean age of 57.5 years. Secondary lymphedema was present in 78%. Mean length of PC use was 12.7 months with a mean of 5.3 treatments per week. The number of episodes of cellulitis and ulcers pre- and post-PC decreased from mean of 0.26 to 0.05 episodes (p=0.002) and 0.12 to 0.02 ulcers (p=0.007) respectively. 14 % had concomitant superficial venous insufficiency, all of whom underwent venous ablation. 100% of patients reported symptomatic improvement post-PC with 54% greatly improved. 90% would recommend the treatment to others. Conclusions: PC improves symptom relief and reduces episodes of cellulitis and ulceration in lower extremity lymphedema. It is well tolerated by patients and should be recommended as an adjunct to standard lymphedema therapy. Screening for venous insufficiency is recommended

We report the case of a 78-year-old man with coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency with an enlarging 6.7-cm infrarenal abdominal aortic aneurysm. He also had a 4-cm right common iliac artery aneurysm, and right external iliac artery occlusion. The patient had a history of an axillobifemoral bypass graft placed 10 years prior for aortoiliac occlusive disease. We describe the use of an infrarenal aorto-uni-iliac graft and subsequent intentional graft occlusion as an endovascular solution to treat aneurysmal disease in this sick patient. He remains asymptomatic after surgery, with demonstrated occlusion of his aneurysms.