Faculty Bibliography

OBJECTIVE:Iliac vein stenting is increasingly being explored for the treatment of chronic venous insufficiency. While venography is considered the gold standard for assessing iliac veins, some have proposed that intravascular ultrasound should be utilized instead due to its greater sensitivity at detecting stenotic lesions. Routinely, our service uses both intravascular ultrasound and venography, but we have noted that some patients cannot tolerate dye due to allergy, renal insufficiency, or deemed high-risk by the interventionalist due to uncontrolled medical co-morbidities. This study aimed to investigate whether forgoing dye had an impact on iliac vein stent thrombosis. METHODS:From 2012 to 2016, 1482 iliac vein procedures (91 intravascular ultrasound-only and 1391 intravascular ultrasound plus venography) were performed on 992 patients who failed conservative treatment for chronic venous insufficiency. Our mean patient age was 65.8 years (range 21-99; SD ± 14.3) with 347 male and 645 female patients. The clinical presenting symptoms per clinical-etiology-anatomy-pathophysiology classification for the intravascular ultrasound-only cohort were C1:0, C2:3, C3:31, C433, C5:5, C6:20 and for the intravascular ultrasound plus venography cohort were C1:0, C2:24, C3:566, C4:583, C5:30, C6:188. Stent thrombi that developed within or at 30 days of stenting were categorized as early and greater than 30 days as late. Transcutaneous duplex ultrasound classified stent thrombi as either partial or occlusive. Our average follow-up time was 19.4 months (0-42, SD ± 12.5). RESULTS:0.55. CONCLUSION/CONCLUSIONS:Results of our study show no significant difference in stent thrombosis between the intravascular ultrasound-only and intravascular ultrasound plus venogram cohorts. This concludes that using intravascular ultrasound alone is safe for iliac vein stenting.

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT.One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed.Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

INTRODUCTION/BACKGROUND:Noninfectious aortitis has been increasingly reported worldwide with a growing prevalence in western medicine. Attributed to our increasingly diverse population, western surgeons must be vigilant to promptly differentiate these cases from its more common infectious counterpart in order to ensure subsequent appropriate management of these patients. METHODS:While our patient's process was ultimately managed without surgical intervention, the varied clinical presentation along with the lack of specific laboratory markers pose a challenge for surgeons to appropriately diagnose and manage aortitis. Appropriate diagnostic imaging, the utilization of a multidisciplinary team, and close patient monitoring are key components for effective management of this increasingly prevalent disease process.

OBJECTIVE:Lower extremity endovenous ablation has become the primary treatment modality for symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) has been reported as one of the primary complications of these venous ablative procedures. Our aim was to determine how long EHITs take to resolve and the factors affecting this length of time. METHODS:A retrospective analysis was performed of 10,029 consecutive procedures from March 2012 to September 2018 performed on 3218 patients who underwent endovenous ablation for lower extremity venous reflux. There were 6091 procedures performed with radiofrequency ablation (RFA) and 3938 with endovenous laser ablation (EVLA). Postprocedural venous duplex ultrasound was performed to evaluate for EHIT and recanalization at 3 to 7 days, every 3 months for the first year, and every 6 to 12 months thereafter. JMP version 14 (SAS Institute, Cary, NC) was used for all statistical analysis. RESULTS:EHIT was found to have developed in 186 patients; 109 patients had been treated with RFA and 77 with EVLA. The average age of the patients receiving EVLA in whom EHIT developed was 59.97 ± 11.61 years. The patients who received RFA and in whom EHIT developed had an average age of 73.4 ± 9.64 years. The average time of resolution for the EVLA group was 75 ± 71.97 days. The average resolution time for the RFA group was 139.8 ± 232.52 days. There were no statistical differences between EHIT resolution times and age, sex, body mass index, clinical class, laterality, type of vein treated, or whether the patient was taking clopidogrel preoperatively or postoperatively. A statistical difference was found between EHIT resolution time and whether the patient was treated with EVLA or RFA (P = .0332). CONCLUSIONS:Our study seems to suggest that EHIT resolution times may be related to the difference in treatment modality between EVLA and RFA. The data suggest that EHIT resolves more quickly with the use of EVLA than with RFA.

OBJECTIVE:Although correction of iliac vein stenosis is safe and efficacious, one of its major complications is iliac vein stent thrombosis. In an attempt to examine the cause of iliac vein stent thrombosis, we reviewed the location of underlying lesions encountered after thrombectomy or thrombolysis of iliac vein stents. METHODS:A retrospective analysis was performed of all iliac vein venograms with intravascular ultrasound examinations at our office-based surgical center from February 2012 to July 2016. Patients included in the study had chronic venous insufficiency and failed compression therapy. All procedures were performed with local anesthesia and conscious sedation. Wallstents were used in all procedures for nonthrombotic iliac vein stenosis, ranging from 8 to 24 mm in diameter and 40 to 90 mm in length. Patients were followed with transcutaneous duplex every 3 months for the first year and every 6 to 12 months thereafter. Patients were placed on clopidogrel for 3 months or continued on their preexisting anticoagulants. RESULTS:From February 2012 to July 2016, we performed 2228 iliac vein venograms with intravascular ultrasound examination in 1381 patients. The mean age of the patient population was 65 ±14 years (range, 21-99 years), among which 876 were female. A total of 1037 procedures were performed in the left lower extremity. Of these, 240 venograms were diagnostic. Presenting symptoms based on CEAP classification included C2 (n = 21), C3 (n = 633), C4 (n = 1065), C5 (n = 269), and C6 (n = 241). Complete thrombosis of the iliac vein stent was noted in 18 patients (0.8%) who thereafter underwent suction thrombectomy with thrombolysis. None of these patients had a prior history of deep vein thrombosis. In-stent restenosis was noted in 11 patients. Proximal lesions were found in no patients. An external iliac vein lesion was found distal to the common iliac vein stent in two patients. Common femoral vein lesions were found in six patients. These encountered lesions were then stented. All patients who underwent thrombectomy were placed on anticoagulation for 6 months. No patient were noted to suffer rethrombosis upon follow-up. No correlation with stent thrombosis was encountered for age, gender, laterality, location, presenting symptoms, or length or diameter of the stent. CONCLUSIONS:Based on our experience, in-stent restenosis followed by inflow lesions in the common femoral vein are the most common causes of stent thrombosis. These data suggest a need for future research to target these areas.

OBJECTIVE:Whereas the commonly described manifestations of venous insufficiency include telangiectasia, varicose veins (VVs), edema, skin changes, and ulcers, we have noted some patients who present with external hemorrhage from lower extremity VVs. Because there are few recent data examining this entity, we herein describe our experience. METHODS:During 29 months, we had 32 patients present with hemorrhage from lower extremity VVs. There were 15 men and 17 women with a mean age of 60.2 years (range, 38-89 years; standard deviation [SD], ±14.9 years). Interestingly, 16 of these patients presented after coming into contact with warm water; 28 patients, 19 patients, and 1 patient presented with reflux >500 milliseconds in the great, small, and accessory saphenous veins, respectively. Eight patients and six patients had reflux >1 second in the femoral and popliteal veins, respectively. RESULTS:All patients were treated with weekly Unna boots. Mean ulcer healing time was 2.12 weeks (range, 1-8 weeks; SD, ± 2.15 weeks). Patients with VV hemorrhage after contact with warm water had a mean healing time of 1.75 weeks, whereas those who bled without such exposure took an average of 3.5 weeks (P = .0426). Twenty patients underwent at least one endovenous thermal ablation procedure, with the average patient in the cohort receiving 2.16 procedures (range, 0-9; SD, ± 2.37). There was no significant difference between laterality, age, or sex between patients who bled after warm water contact and those who bled spontaneously. The ulcers recurred in three of the patients, and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2 months (range, 26 months; SD, ± 8.9 months), and we noted no recurrent bleeding episodes. CONCLUSIONS:Spontaneous hemorrhage of VVs, although relatively under-reported, is not a rare occurrence. Risk factors are unknown; however, half of our patient cohort reported VV hemorrhage during or directly after coming into contact with warm water. Furthermore, these patients demonstrated a significantly shorter wound healing time compared with the rest of the cohort. Basic first aid, wound care, and hemostasis control education should be provided to all patients with VVs. Further investigation surrounding the risk factors associated with VV hemorrhage is warranted.

Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections and compartment syndrome. We present a case of an 87 year old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.