Faculty Bibliography

OBJECTIVE/UNASSIGNED:The Society for Vascular Surgery (SVS) is a not-for-profit medical society, whose goal is to further advance in vascular health on a global scale. With its 10th anniversary in sight, we were interested in analyzing the impact of a specific scholarship given under the SVS, the International Scholars Program. Our goal was to examine the awardees' characteristics and academic productivity. MATERIALS AND METHODS/UNASSIGNED:We measured the number of peer-reviewed articles, before and after the program, using PubMed® and Google Scholar® (2008-2018) of the scholarship recipients. Editorials, book chapters, letter to editor, and oral/poster presentations were excluded. A survey was sent out to assess the awardees' current status. RESULTS/UNASSIGNED:The average number of applicants/year was 15.4 (standard deviation ± 6.69), with 17.5% females and a mean age of 37 ± 3.37 years, with 5.6 ± 2.30 years status post vascular fellowship. Brazil had the highest number of recipients (n = 5; 18.5%) followed by China (n = 4; 14.8%). No significant difference was noted between each country in terms of publications ( P = .45), nor with after the SVS scholarship program compared to before ( P = .14, 1.84 vs 2.76). The survey concluded 33% had attended a subsequent SVS meeting after the program, with 27% having presented their research (n = 15). The recipients noted the program helped adopt new practices in clinical management (n = 13, 87%), learn new procedures (n = 10, 67%), gain local/regional leadership (n = 9, 60%), and improve technical skills (n = 8, 53%). The most visited clinical sites were Massachusetts General Hospital and Mayo Clinic (n = 4, 27%). The program was given a 9.1/10 rating. CONCLUSION/UNASSIGNED:The program was successful in maintaining academic productivity by continuing to publish research even after the scholarship, while teaching recipients skills to further improve their career goals. The award remains a competitive process that selects highly skilled recipients and still has much growth and progress to look forward to over the next decade.

OBJECTIVE:Fluoroscopic-guided interventions have become a major part of the modern vascular surgeon's practice. Imaging is typically required to safely and effectively perform both simple and complex endovascular interventions. With an ever-increasing volume of fluoroscopic-guided interventions being performed each year, the minimization of harmful radiation exposure has become of paramount concern for both patients and providers. The purpose of this study was to identify the extent of radiation exposure associated with venography and iliac vein stenting, an intervention utilized in the management of chronic venous insufficiency. METHODS:This was a single-center, retrospective analysis of 40 venograms performed on 29 unique patients over a three-month period. Patients with signs and symptoms of chronic venous insufficiency who failed conservative therapy underwent evaluation of the vena cava and iliofemoral veins with venography and intravascular ultrasound. Stent placement was performed if a >50% cross-sectional area or diameter reduction was identified via intravascular ultrasound. All patients were found to have non-thrombotic iliac vein lesions. All patients wore two individual film badge dosimeters - one on their chest and the other on the abdomen. The same mobile C-arm system was used for all interventions. RESULTS:. Sixteen limbs had C6 disease, 10 had C4 disease, and 14 had C3 disease. Thirty-eight of the 40 procedures resulted in stent placement, with an average of 1.13 stents placed per intervention. The average fluoroscopy time was 76.5 s (SD ± 36.9; range 7.8-209.5), and the mean cumulative air kerma was 1.08 mGy (SD ± 0.55; range 0.362-2.24). Average cumulative air kerma was higher in procedures resulting >1 stent placement compared to those with placement of ≤1 stent (1.44 vs. 1.02 mGy; p = 0.04). Fluoroscopy time was also higher in procedures with >1 stent placed (120.1 vs. 68.8 s; p = 0.0004). The mean deep dose equivalent per procedure from the patient-worn abdominal badge was 0.221 mSv. CONCLUSION/CONCLUSIONS:With the adjunctive use of intravascular ultrasound, iliac vein stenting can be safely and effectively performed with very low utilization of fluoroscopy, and therefore radiation exposure can be minimized for both patients and surgeons. Placement of >1 iliac vein stent resulted in higher cumulative air kerma and fluoroscopy time.

OBJECTIVE:Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive "back-up plan." METHODS:(range 16.8-35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2). RESULTS:The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3-6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3-166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support. CONCLUSION/CONCLUSIONS:These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases, yet there are limited data on risk factors and outcome of lower limb swelling. While many patients improve with endovenous therapy (thermal ablation or iliac vein stenting), some patients' symptoms persist. The goal of this study was to identify clinical factors including race/ethnicity related to persistent leg swelling after treatment with both iliac vein stenting and thermal ablation. Methods From February 2012 to February 2014, this observational study analyzed data for 173 patients with chronic venous insufficiency who underwent both iliac vein stent placement as well as thermal ablation (radiofrequency ablation or endovenous laser ablation). All procedures of the thermal ablations and the iliac vein stenting were staged. Iliac vein stenosis was identified using intravascular ultrasound of the iliofemoral venous segment showing >50% cross-sectional area or diameter reduction. The patients were queried to the resolution of their leg swelling after both procedures were performed. The resolution of swelling was correlated with age, gender, presenting sign according to CEAP classification, race/ethnicity and degree of iliac vein stenosis. Patients were categorized by Caucasians ( n = 97), African Americans ( n = 27), or Hispanics ( n = 49). Statistical analysis performed using Chi-square and Student's t test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 117 (67.6%) patients were women. The average age was 67 (±13 SD) years. The average pain score was 2.9(±3.1 SD). The average degree of iliac vein stenosis was 66.5(±13.3 SD). About 56.1% were Caucasians, 15.6% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 2. One hundred fifty-two (87.9%) patients stated that they had improvement in swelling after combined procedures, 100 (65.8%) patients were women. The average age was 67.3 (±13 SD) years. The average pain score was 2.9 (±3.1 SD). The average degree of iliac vein stenosis was 67.3% (±12.8 SD). About 56.6% were Caucasians, 15.1% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 1. Twenty-one (12.1%) patients stated they had no improvement after both procedures. Correlating these group factors with the group of patients who improved their swelling after the combined procedures we found the following: 17 (81%) of these patients were females ( P=0.16). The average age was 68.4 (±17 SD) years ( P=0.72 SD). The average pain score was 3.2 (±3.7 SD) ( P=0.68). The average degree of iliac vein stenosis was 60.2% (±15.9 SD) ( P=0.02). Around 52.4% were Caucasians, 19% were African Americans, and 28.6% were Hispanics ( P=0.88). The number of patients with iliac vein stent thrombosis was 1 ( P = 0.1). Conclusion These data suggest that the clinical factors including race are not clinically significant factors in the response to swelling after combined iliac stent and endovenous ablation procedures. Interestingly, a higher degree of iliac vein stenosis was associated with improved resolution of swelling.

BACKGROUND:Endovenous thermal ablation in the form of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) has quickly ascended to a prime position in the treatment of venous insufficiency. Although there are good data examining the rates of thrombotic complications, there is a relative paucity of data examining the recanalization rates after endovenous thermal ablation (ETA). METHODS:Data analysis was performed for 1475 thermal ablations in 485 patients from 2012 to 2015 as a retrospective chart review. RFA was performed in 1027 patients and EVLA in 448 patients. The target veins included the great saphenous vein (GSV) (778), short saphenous vein (SSV) (401), accessory saphenous vein (ASV) (140), and perforator veins (PV) (156). Data were collected from follow-up visit within 1 week of procedure, every 3 months for the first year, and every 6 months thereafter. Recurrence was defined as >500 ms for the GSV, SSV, and ASV and as >350 ms for the PV. Data for recanalization were also correlated with age, gender, laterality, presenting symptoms, and treated targeted vein. RESULTS:The average age of the study population was 64.7 years (SD ± 15.6) with 66% women and 326 bilateral veins. At 1-week follow-up, women (2.6%) had higher recanalization rate (P = 0.018). Failure rate of obliteration for GSV and SSV were 0.8% and 0.8%, respectively (P = 0.98). PV had the highest failure rate (16.6%), followed by ASV (2.9%) (P < 0.001). At mean follow-up after 13.5 ± 12 months, PV (41.2%) and ASV (14.85) had higher recanalization rate than GSV (7.7%) and SSV (8.5%) (P < 0.001). Excluding PVs, no difference with recurrence rates between RFA (10%) and EVLA (8.8%) was observed at 1-week and 1-year follow-ups (P = 0.54). Also, 56% of patients with recanalization were symptomatic. Among these 1475 procedures, redo for recurrent symptoms were performed in 76. At 1 week, there was no difference between nonrepeated (92.7%) and repeated procedures (89.5%) (P = 0.41). However, 1 year later, there was significant difference between obliteration rate in nonrepeated (86.9%) and repeated (76.3%) procedures (P = 0.014). CONCLUSIONS:These data do suggest low overall rates of recanalization after thermal ablation of the GSV and SSV. However, at 1-year follow-up, accessory veins had almost twice the recurrence rate as compared with GSV and SSV, and PV had almost 5 times the recurrence rate. There was no significant difference between RFA and EVLA in recanalization rates. Redo procedures in recanalized veins after venous ablation are effective with a success rate at 76.5%.

BACKGROUND:expansion in the iliocaval system. METHODS:was performed. None of the patients in this study underwent pre-or post-stenting balloon angioplasty. Multiway analysis of variance and multiple linear regression analyses were performed to examine the effects of gender, age, stent laterality, location of stenosis, and CEAP (clinical, etiology, anatomy, and pathophysiology) score at presentation on the proportion of observed stent area (OSA) to ESA. RESULTS:Two-hundred three patients (64 male and 139 female; mean age: 68 ± 13.9 years) underwent 242 treatments between December 2012 and January 2016. Presenting symptoms based on CEAP score were: C1 (0), C2 (0), C3 (n = 59, 24%), C4 (n = 148, 61%), C5 (n = 4, 2%), and C6 (n = 31, 13%). On average, stents deployed to 69.58% of the ESA (range, 23.87-123.35%). Multiple linear regression analysis showed a significant negative correlation between increasing MSD and ESA achieved. Regression coefficients for differences in percent difference between ESA and OSA based on MSDs were as follows: 16 mm (-15.0, P = 0.1519), 18 mm (-21.0, P = 0.0077), 20 mm (-23.2, P = 0.0059), and 20-22 mm (-35.3, P < 0.0001). No significant difference was detected based on gender, age, stent laterality, location of stenosis, or CEAP score. CONCLUSIONS:Larger MSD is associated with greater magnitude of stent underexpansion. These findings may have implications for future venous stent designing.

OBJECTIVE:Radiofrequency ablation (RFA) is increasingly being employed for treatment of perforator vein insufficiency and venous ulcer healing. Previous studies have shown a closure rate of 60% to 80% in incompetent perforator veins (IPVs) with RFA. The purpose of the study was to determine the utility of a redo RFA for symptomatic recanalized perforators and to predict factors associated with recanalization. METHODS:A retrospective analysis of 642 procedures in 256 patients with venous insufficiency due to IPVs from 2009 to 2015 was conducted. All 642 procedures were performed using RFA in patients who failed to respond to initial conservative management. Postoperative duplex ultrasound scans were performed within 3 to 7 days. Successful obliteration was defined as lack of color flow on postoperative scan. Recanalization was defined as presence of reflux on duplex ultrasound in symptomatic patients in the targeted vessel at follow-up. Follow-ups were conducted every 3 months in the first year and every 6 months thereafter. RESULTS:Among the 642 procedures, redo ablation was performed in 52 IPVs (29 patients, 37 extremities) including 14 women, with mean age of 65 years (standard deviation [SD], ±15 years). The Clinical, Etiology, Anatomy, and Pathophysiology class of the patients was as follows: C1, 0; C2, 0; C3, 3; C4a, 11; C4b, 7; C5, 0; and C6, 16. The distribution of the targeted IPVs included the calf (40) and ankle (12). The mean maximum diameter of the targeted veins was 4.6 mm (SD, ±1.1 mm). The initial technical success rate was 64.9%. Redo procedures had an early closure rate of 67.3%. At follow-up after a mean duration of 24 months (SD, ±16.8 months), the closure rate was 65.38%. No clinical correlation was found between successful obliteration in the redo procedure and age (P = .54), sex (P = .14), clinical class (P = .82), laterality (P = .84), or location of the vein (P = .54). When data were compared to predict factors associated with a redo procedure, IPVs located in mid and distal calf areas tended to recanalize more compared with the ankle (P = .04). Temperature of the radiofrequency stylet also showed a linear association, with patients treated at 85°C having higher probability of recanalization compared with patients treated at 90°C and 95°C (P = .01). CONCLUSIONS:The rates of successful closure for IPVs on initial and redo procedures are comparable. The data validate the utility of performing redo perforator ablations and suggest that temperature of the radiofrequency stylet and location of the IPVs may be predictive of a successful outcome or recanalization.

Objective Endovascular stent graft repair for exclusion of pseudoaneurysm is currently being explored to replace open surgical repair as current management. The objective of the study was to evaluate the clinical safety and efficacy of endovascular stent graft intervention in pseudoaneurysms complicating arteriovenous reconstructions in patients on chronic hemodialysis. Methods A retrospective analysis of all pseudoaneurysms treated with stent grafts at our institution over a period of five years was performed. The indications for endovascular intervention included bleeding from the pseudoaneurysm, infection, and significant skin compromise overlying the pseudoaneurysm or combination of the above. The rates of technical success, complication, and primary patency were measured at one-week, one-month, and six-month follow-up. Results A total of 33 endovascular stent graft interventions in 29 patients were performed for the treatment of pseudoaneurysms. The average age of patients was 68 years (range 31-90 years), with 13 female. Diabetes and hypertension were present in 15 and 22 patients, respectively. In eight patients, there was evidence of active infection at the fistula site. The choice of stent grafts include Viabahn ( n = 31), Wallgraft ( n = 1), and i-Cast ( n = 1). The initial technical success rate was 94%. The two failed interventions included occlusion of inflow artery with immediate conversion to open procedure ( n = 1) and incomplete pseudoaneurysm exclusion ( n = 1). Primary patency at one month and six months was 83 and 60%, respectively. An additional balloon angioplasty of outflow tract or central stenosis was performed in 18 cases (54%). The explanation of stent grafts due to persistent or recurrent bacteremia/site infection was required in four out of eight patients. The average time to explanation was 93 days (range 6-204 days). Conclusion The stent graft implantation is a safe, minimally invasive and efficient way to control and manage arteriovenous accesses with pseudoaneurysms. In the presence of infection, this approach may be less durable.

Objective In order to examine the academic productivity of US vascular surgery program directors, the number of vascular publications listed in PubMed from 2001 to 2015 for US vascular surgery program directors was reviewed. We suggest that this can be used as a benchmark for academic productivity. Methods The names of the program directors were taken from the Accreditation Council for Graduate Medical Education (ACGME) website at two time points: December 2009 (Independent Programs) and December 2015 (Independent + Integrated). This was used to query PubMed, which listed 5196 publications: 3284 from 2001 to 2009 and 1912 from 2010 to 2015. Results There were 104 program directors (2001-2009) and 114 program directors (2010-2015) with average number of publications in PubMed per program director as 3.68/year (SD ± 2.31) and 2.80/year (SD ± 2.73), respectively ( P = .01). From 2001 to 2009, 1215 (37%) and in 2010 to 2015, 860 (45%) of the publications were from Journal of vascular surgery. The top third produced 67% and 69% of publications in the two time-points. No statistical difference was ascertained regionally: northeast, southeast, midwest and west ( P = .46). The numbers of publications/year decreased by 17% compared to first 10 years. From 2001 to 2009, there were no programs with no publications which increased to five and three with no Journal of Vascular Surgery publications which increased to 21 in 2010-2015. The independent and integrated program directors published average of 2.85 (SD ± 2.69) and 3.47 (SD ± 3.1) total publications; 1.25 (SD ± 1.4) and 3.47 (SD ± 1.7) Journal of Vascular Surgery papers/year, respectively ( P = .28, P = .23). Changes in the study subject were noted by percentage of total publications: endovascular lower extremity arterial (4.7% to 8.9%), Thoracic Endovascular Aortic Repair (TEVAR) (4.5% to 9.9%), Arterio-Venous (AV) access (0.0% to 3.0%), basic science (14.7% to 6.8%), open thoracic (3.0% to 0.6%). Conclusion There seems to be a significant decline in the number of publications over the last 15 years. Yet, the subject of the publications has progressed from Open to TEVAR with an increase in endovascular publications. However, basic science publications reduced by half.