Faculty Bibliography

OBJECTIVE:Endovenous thermal ablation has become the procedure of choice in the treatment of superficial venous reflux disease. The current armamentarium of devices and techniques aimed at the elimination of saphenous reflux offers surgeons and interventionalists a variety of treatment options, however there is a lack of data comparing the safety of these products. The most concerning complication following endovenous thermal ablation is endothermal heat-induced thrombosis (EHIT) due to the risk of progression to deep venous thrombosis (DVT). This study aimed to compare the incidence rate of EHIT between radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). METHODS:This was a single-center, office-based, retrospective study over the course of 5 years, in which 3218 consecutive patients underwent 10,029 endovenous saphenous ablations. The patient cohort was 66.2% female, with an average age of 61.9 years old. At the time of each individual intervention, 24, 212, 3620, 4806, 200, and 1167 patients had Clinical-Etiology-Anatomy-Pathophysiology (CEAP) disease 1, 2, 3, 4, 5, and 6, respectively. RESULTS:There was a total of 3983 EVLT and 6091 RFA procedures. The most common vessel treated was the great saphenous vein, 63.6% of the time, followed by the small saphenous vein (25.6%), accessory saphenous vein (6.1%), and perforator vein (4.6%). There were 186 cases of EHIT, with 137 (73.6%) identified as type 1 per the Kabnick classification. Endovenous ablation performed via RFA resulted in significantly more cases of EHIT when compared to EVLT (109 vs 77; p = 0.034; OR = 1.52), which was confirmed by multivariate analysis. CONCLUSION/CONCLUSIONS:In the largest single-center study of endovenous saphenous ablations to date, RFA was shown to pose a significantly higher risk of EHIT when compared to EVLT.

OBJECTIVE:Endovenous ablation of the lower extremity veins has become the primary treatment of symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) and recanalization are two well-known complications of these venous ablative procedures. Because the elderly represent the fastest growing demographic, our goal was to look at whether there is a difference of these complications and age distribution in octogenarians, nonagenarians, and centenarians vs the younger population. METHODS:test and analysis of variance were used for statistical analysis. RESULTS:Ages ranged from 15 years to 103 years. The average age of the patients was 61.9 ± 15.2 years. Average overall follow-up for all age groups was 25.8 ± 12.9 months. Of the 3218 patients, 2700 were younger than 80 years, 380 were between 80 and 89 years, 132 were between 90 and 99 years, and 6 were 100 years or older. Of the 10,029 procedures, 8730 were performed on patients younger than 80 years; 1124, on patients 80 to 89 years; 159, on patients 90 to 99 years; and 16, on patients 100 years or older. There were 111 patients who had bilateral procedures in the accessory saphenous vein, 1878 patients who had bilateral procedures in the great saphenous vein, 99 patients who had bilateral procedures in the perforator vein, and 760 patients who had bilateral procedures in the small saphenous vein. There were statistically significant increases in EHIT rates between octogenarians and those in the age group <80 years (P = .047); between nonagenarians and those in the age group <80 years (P = .04); and between the combined group of octogenarians, nonagenarians, and centenarians and the age group <80 years (P = .012). No statistical difference was found in rates of EHIT between octogenarians and nonagenarians (P = .5). Overall age is a risk factor for the development of EHIT (odds ratio, 1.03; 95% confidence interval, 1.02-1.04; P < .00001). There were statistically significant increases in recanalization rates between octogenarians and those in the age group <80 years (P = .000013); between nonagenarians and those in the age group <80 years (P = .00022); and between the combined group of octogenarians, nonagenarians, and centenarians and the age group <80 years (P < .00001). No statistical difference was found in rates of recanalization between octogenarians and nonagenarians (P = .48). Statistical analysis of centenarians alone was not done because of zero patients available in the EHIT or recanalization category. Overall age was found to be a risk factor for recanalization (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P < .00002). CONCLUSIONS:Whereas there is a relatively higher chance of EHIT and recanalization in the age group >80 years, our study shows that the majority of EHITs were class 1 and class 2. According to our study, venous ablation is safe and effective across all age groups, and age alone should not be used to deny patients venous ablations.

OBJECTIVE:Prior literature suggests that routine femoral vein (FV) puncture is necessary for interrogation of the iliac veins for stenosis to avoid missing common femoral vein (CFV) lesions. However, this can be technically challenging and poses small but increased risks. The purpose of this study was to compare the incidence of stent thrombosis after iliac vein stenting in the treatment of nonthrombotic iliac vein lesions with use of two discrete venous access sites-the CFV and FV. METHODS:During 4 years, we performed 1605 lower extremity venography studies with intravascular ultrasound (IVUS). There were 372 men and 689 women with an average age of 66 years (range, 21-99 years; standard deviation [SD], ± 14.3 years). After IVUS interrogation, 1513 procedures resulted in venous stenting; 964 patients received stent placement in the common iliac vein, 513 in the external iliac vein, 24 involving the CFV, and 12 involving the FV. The venous puncture site, accessed by ultrasound guidance, varied between the CFV and FV per the surgeon's choice and was documented on the basis of the most distal vein area measured by IVUS during the procedure. Patients were followed up with iliocaval and lower extremity duplex ultrasound within 2 weeks and every 3 months thereafter for the first year. RESULTS:There were 994 patients who received CFV puncture and 611 patients who received FV puncture. In 39 (4.2%) patients receiving CFV punctures with subsequent stent placement, any stent thrombosis developed within 30 days of the intervention; 27 (69.2%) were complete thromboses. In 21 (3.6%) patients who received FV punctures with subsequent stent placement, any stent thrombosis developed within 30 days of intervention; 17 (81.0%) were complete thromboses. There was no significant difference (P = .57) in ≤30-day thromboses between the CFV and FV cohorts. Any in-stent thrombosis developed >30 days after intervention in 18 patients, 11 in limbs that received CFV puncture and 7 with FV puncture (P = .98). Complete stent occlusion occurred in three cases of CFV puncture. No FV punctures led to >30-day complete stent thromboses. The median time to diagnosis of >30-day thrombosis was 11.1 months (range, 2.6-31.9 months; SD, ± 12.86 months). Median follow-up was 20 months (SD, ± 19.18 months). CONCLUSIONS:There was no significant difference between in-stent thrombosis rate and location of initial venous puncture in the setting of outpatient IVUS-guided venography. Both the CFV and FV can be safely used as puncture sites for lower extremity venography.

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:Catheter-directed thrombolysis in the treatment of acute iliofemoral deep venous thrombosis (IFDVT) often requires more than one interventional session to yield successful outcomes. Catheter-directed thrombolysis is generally expensive, requiring prolonged hospital stay that may be associated with increased local and systemic hemorrhagic complications. We developed the fast-track thrombolysis protocol (FTTP) to address these issues. The goal of FTTP is to restore patency during the initial session of thrombolysis, thereby minimizing costs and complications associated with prolonged thrombolysis. METHODS:A retrospective analysis of 38 patients treated for acute IFDVT using FTTP at our institution from January 2014 to February 2019 was performed. The protocol includes periadventitial injection of lidocaine at the venipuncture site under ultrasound guidance, contrast venography of the entire target segment, pharmacomechanical rheolytic thrombectomy of the occluded venous segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and, if indicated, venous stent placement in areas of significant (≥50%) stenosis refractory to thrombolysis and balloon angioplasty. Once the thrombus was cleared, patients were prescribed oral antithrombotic therapy. RESULTS:Thirty-eight primary FTTPs (45 total interventions) were performed in 38 patients. The median age was 66 years (range, 39-93 years); 60.5% were female. Initial venous access was most often obtained through the popliteal vein, followed by the femoral and great saphenous veins. The mean operative time was 122 minutes (range, 59-249 minutes), and the median volume of tissue plasminogen activator infused was 10 mg (range, 4-20 mg). The median cost per procedure, including devices and medication, was $5374.45. Median postoperative length of stay was 1 day (range, 1-45 days). Successful single-session FTTP, as determined by completion venography, was accomplished in 81.5% (n = 31/38) of cases. The remaining seven cases (18.5%) required one additional session. Of the 38 patients, 30 (79%) required iliac vein stenting. Periprocedural complications consisted of one patient with retroperitoneal hemorrhage that was managed conservatively. No patients experienced rethrombosis within 30 days of FTTP. During the 5-year study period, there were no cases of pulmonary embolism, significant local or systemic hemorrhage, limb loss, or mortality. CONCLUSIONS:FTTP, as presented herein, appears to be a safe, effective, and cost-effective technique in the resolution of acute IFDVT.

OBJECTIVE:While arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access due to their high patency rates, they are associated with an appreciable rate of non-maturation. Balloon Assisted Maturation (BAM) has been described to treat this issue. BAM is defined as repeated sequential graduated dilatation of the outflow vein. This study aims to evaluate the short-term complications of using the radial artery as an access for BAM procedures and fisutloplasties. Trans-radial access was used preferentially with multiple lesions in the AVF that were difficult to access with a single venous puncture. METHODS:Data were collected over 3 years on 44 office-based duplex-guided trans-radial access BAM procedures in 27 patients and 19 were men. 324 cases of BAM with ultrasound guidance were performed using a venous puncture during this time period. The indication for the procedures was a failure of AVF maturation and 5 cases with short segment thrombectomy. All procedures were performed with local anesthesia only. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex guided. The radial artery was punctured with ultrasound guidance and a 4-5 French low profile sheath was placed. After crossing the lesion(s), 5.000 units of heparin were given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. Vascular injuries were classified based on the post-procedural duplex assessment. All patients had follow-up duplex scans within a week. RESULTS:The average age was 79 years (±14 SD, range 39-99 years). The types of AVF were: 35 radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The sites of lesions were 17 on the venous outflow, 7 perianastomotic and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. The balloon size ranged from 3-6 mm (28 patients) and 7-12 mm (16 patients). The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma (2), and intimal flap (3). Extravasation was controlled with duplex guided compression. There were no radial artery thromboses and all the AVFs were patent on completion duplex and follow-up duplex. CONCLUSION/CONCLUSIONS:These data suggest that the radial artery could be used as a safe access route for BAM procedures with relatively low rates of complication. This approach can be considered as an adjunct in the armamentarium for angioplasty of AVF.

OBJECTIVE:Iliac vein stenting of nonthrombotic iliac vein lesions is an evolving treatment course for management of chronic venous insufficiency. To characterize these lesions, we examined our experience treating these lesions with balloon venoplasty before stenting. METHODS:A retrospective analysis was performed to study all patients who underwent venograms with venoplasty and stenting of iliac veins from February 2013 to July 2016. All patients included in the study were treated with a trial conservative management for 3 consecutive months before venogram and, if indicated, venoplasty was performed. If a greater than 50% reduction in cross-sectional area or diameter was observed on intravascular ultrasound examination, the stenotic area was treated with balloon angioplasty, sized to nonstenotic distal vein segment (range, 10 × 40 mm to 16 × 60 mm). Intravascular ultrasound examination was also used to measure the area of stenotic iliofemoral veins before and after balloon angioplasty. RESULTS:). There were 227 patients (22.2%) who had the same area before and after venoplasty. Left-sided lesions had a greater increase in area than right-sided lesions (51.3% vs 46.2%, respectively; P = .048). No significant correlation of stenotic area response with age, presenting symptoms of Clinical, Etiology, Anatomy, and Pathophysiology (C2-C6), gender, or location of targeted lesion was observed. CONCLUSIONS:Our data show there is a highly variable response after venoplasty of stenotic area of nonthrombotic iliac vein lesions. Balloon venoplasty showed greater improvement in improving the area of stenotic left-sided lesions. However, stenting of the lesions should be performed routinely owing to recoil and spasm in lesions.

Vascular complications secondary to acute pancreatitis carry a high morbidity and mortality, often because of their hemorrhagic or thrombotic effects. When thrombosis presents, it is typically localized to the splanchnic venous system. In this report, we present a case of acute superior mesenteric artery thrombosis secondary to necrotizing pancreatitis after a laparoscopic cholecystectomy. The patient was successfully treated with catheter-directed thrombolysis and mechanical thrombectomy.

OBJECTIVE/UNASSIGNED:Thrombolytic therapy is widely used in the treatment of arterial occlusions causing acute limb ischemia (ALI); however, knowledge regarding the efficacy of the different catheter systems available is scarce. The objective of this study was to compare the safety and efficacy of 2 catheter-directed infusion systems for intra-arterial thrombolysis in the setting of ALI. METHODS/UNASSIGNED:A retrospective analysis was conducted to study all catheter-directed thrombolysis procedures performed over 32 months in patients diagnosed with ALI. Patients with thrombosis in both native arteries and bypass grafts were included. Patients with contraindications to thrombolysis, or those receiving thrombolysis for deep venous thrombosis, were excluded. The duration of thrombolysis, amount of thrombolytic agent, and technical success rate were recorded. Technical success was defined as complete or near-complete resolution of thrombus burden, allowing for further intervention. Data were stratified to include location of thrombus, procedural complications, mortality, and rates of limb loss. RESULTS/UNASSIGNED:> .4). The overall complication rate was 14% in both groups, with a 30-day mortality rate of 4% when treated with either catheter system. CONCLUSION/UNASSIGNED:This study suggests that a standard multi-hole infusion catheter demonstrates similar clinical safety and efficacy as the ultrasound-accelerated EKOS system in the treatment of ALI.

OBJECTIVE:Iliac vein stenting is an evolving treatment option for chronic venous insufficiency and management of nonthrombotic iliac vein lesions (NIVLs). Currently described protocols recommend deployed stents to be dilated with balloon venoplasty before completion of the procedure, based on previous literature established from management of arterial lesions. The objective of the study was to investigate the role of balloon venoplasty after stent deployment in the management of NIVLs. METHODS:During the course of 6 months, 71 balloon venoplasties with stenting of iliac veins (34 right and 37 left limbs) were performed. Intraoperatively, we used intravascular ultrasound to measure and to record area of iliofemoral veins. The measurement of stenosis was compared with adjacent nonstenotic iliofemoral veins. If >50% cross-sectional area or diameter reduction was found, it was treated with an appropriate balloon size (range, 10 × 40 mm to 16 × 60 mm) and Wallstent (Boston Scientific, Natick, Mass; 12-24 mm in diameter by 40-90 in mm length). All stents were dilated with a balloon after deployment. Intravascular ultrasound was used to measure the preoperative area of stenotic lesion, area of lesion after stenting, and area after balloon dilation of the stent. RESULTS:; P = .22). No statistically significant correlation was found between difference in areas and age of the patient, clinical class (C2-C6), sex, lesion, laterality, and location of targeted lesion. One patient developed an intraluminal partial thrombus within 30 days of intervention. CONCLUSIONS:Our preliminary data show no significant clinical or technical benefit with use of balloon venoplasty to dilate stents after deployment in NIVLs. Postdilation should thus be limited to only those with suboptimal self-expansion of stent after initial deployment on fluoroscopic imaging.