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:Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs. METHODS:All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUS > 90 days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs. RESULTS:One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96; ± 9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with a > 90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid-subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (p > 0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; p = 0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (p > 0.05). Post-operative DUS was performed at 17.0 and 12.9 days in the eversion and patch CEA cohorts, respectively (p = 0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (p > 0.05). CONCLUSION/CONCLUSIONS:Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.

OBJECTIVE:While placement of tunneled dialysis catheters for hemodialysis access is considered a routine procedure, it is associated with a small chance of mechanical complications. Because the literature examining these issues is not recent and our impression of the incidence of these postprocedural complications is at variance with the existing literature, we decided to review our experience. METHODS:Since 1998, our vascular service has placed 1766 tunneled hemodialysis catheters in 1065 patients for hemodialysis access. All catheters were placed with ultrasound guidance for the puncture, with selective use of a micropuncture set for patients with low-volume status. All patients underwent chest radiography at the end of each procedure. RESULTS:The average age of the patients was 61 ± 21 (standard deviation) years. Among the 1065 patients, 44% were female; 93% of catheters were placed in the right internal jugular vein and 7% in the left internal jugular vein. The prevalence of diabetes and hypertension in our population of patients was 52% and 72%, respectively. In this consecutive series, no case of postprocedure hemothorax or pneumothorax was encountered. Two cutdowns had to be performed because of injury to branches of the external carotid artery. Three patients had to have a subsequent revision because of malpositioning of the catheter. CONCLUSIONS:Using modern-day techniques, the incidence of mechanical complications during placement of tunneled catheters can be diminished. Hence, routine use of ultrasound guidance for insertion of tunneled dialysis catheters should become the standard of care.

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: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:Midterm patency results of iliac vein stents placed for nonthrombotic iliac vein lesions (NIVLs) are not widely known. Previously published studies involving large series of patients with iliac vein stent placement have failed to clearly demonstrate the outcomes for patients with NIVLs and advanced disease. To further study this issue, we reviewed our series of 268 iliac vein stents placed for NIVLs. METHODS:Retrospective analysis was performed of 210 patients who underwent common or external iliac vein angioplasty and stent placement procedures between January 2013 and December 2014. Only patients with Clinical, Etiology, Anatomy, and Pathophysiology classification scores of C3, C4, or C5 were included. Patients were excluded if they had either active ulcer disease or signs of post-thrombotic lesions at initial venography or intravascular ultrasound (IVUS). Ultrasound-guided puncture was performed of the femoral or common femoral vein at the discretion of the surgeon. This was followed by ascending venography. IVUS was used in cases in which a definite stenosis was not appreciated on initial ascending venography. Balloon angioplasty and stents were applied across lesions. After the procedure, patients were instructed to use clopidogrel 75 mg daily. Patency of the stents was assessed during a follow-up visit with abdominal venous duplex ultrasound scans. The length of the patients' follow-up and stent patency rates were based on the last previous duplex ultrasound scan available. RESULTS:A total of 268 procedures were performed in 210 patients. Bilateral lower extremity stent placements were required in 58 patients; 173 (64.6%) procedures were performed in women. The average age of our patients was 72 ± 15 (standard deviation) years. Of the 268 procedures, 144 (53.7%) were performed in the left lower extremity. The Clinical, Etiology, Anatomy, and Pathophysiology classification of lower extremity venous disease was 58%, 30%, and 12% for C3, C4, and C5, respectively. Our average follow-up period was 437 days (median, 499 days; range, 1-1060 days). Patients were observed for >6 months, 1 year, and 2 years in 71.3%, 57.1%, and 28.7% of cases, respectively. During this period, 4 of the 268 (1.5%) limbs experienced in-stent thrombosis. Primary stent patency of 98.7%, 98.3%, and 97.9% was noted at 6 months, 1 year, and 2 years of follow-up, respectively. CONCLUSIONS:Our midterm patency rates for iliac vein stents placed in patients with advanced chronic venous disease demonstrated excellent (98.5%) results. Furthermore, with IVUS assistance, we have clearly documented the average area of iliac venous segments as well as the most common locations of the stenoses.

Objective With the implementation of the K-DOQI guidelines, more patients are in need of long-term dialysis catheters until maturation of the arteriovenous fistula. However, on occasion, when placing a tunneled cuffed catheter for hemodialysis, we have encountered difficulty with passing the guidewire in spite of demonstration of a patent cervical portion of the internal jugular vein on duplex. Herein, we review our experience with intraoperative venoplasty for placement of Tesioâ„¢ catheters (Medcomp Harleysville, PA). Methods Of the 1147 Tesioâ„¢ catheters placed since 1997 by our service, 35 venograms were performed due to difficulty encountered with placement of the guidewire. Patent veins were all crossed with the use of angle-guiding catheters, angled glidewires, and a torque vise. If chronically occluded intrathoracic veins were identified, an alternate site was selected for the placement of the Tesioâ„¢ catheter. Results Of the 35 cases with difficulty in catheter placement, venogram demonstrated a patent but tortuous vein in 9, chronically occluded intrathoracic veins in 6, and severe stenosis of the intrathoracic veins in 20. In 19 cases with severe stenosis of the intrathoracic veins, balloon angioplasty with an 8-mm balloon was successfully performed, which allowed successful placement of a functional Tesioâ„¢ catheter. In the additional one case, the catheter was not able to be placed despite angioplasty. Seven lesions that underwent balloon angioplasty were in the innominate vein, 11 were in the proximal internal jugular vein, and two were in the superior vena cava. Conclusion Venous balloon angioplasty can be used to maintain options for the site of access for tunneled cuffed catheters and may be necessary to assist with placement of long term cuffed dialysis catheters.