Faculty Bibliography

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.

Background Dialysis access-associated steal syndrome is a major complication of arteriovenous fistula creation whereby the low-resistance venous conduit shunts arterial inflow through the anastomosis, resulting in clinically significant distal artery insufficiency. Herein, we describe a case of severe steal phenomenon with gangrene of a digit following placement of an arteriovenous fistula that was treated with a novel, entirely endovascular technique. To our knowledge, this was the first totally endovascular approach to dialysis access-associated steal syndrome. Methods Catheterization of the right subclavian, axillary, and brachial arteries was performed. A short 5-Fr sheath was exchanged for a long destination 6-Fr sheath and placed in the proximal brachial artery. An arteriogram showed no stenosis of the arterial system, but did show substantial steal phenomenon with inflow to the arteriovenous fistula, instead of the forearm. We placed a stent graft in the brachial artery across the anastomosis such that the graft covered 3/4 of the length of the opening of the anastomosis. Results Immediately after placement of the stent graft the clinical picture improved dramatically. Patient was followed for 15 months after this procedure until her demise for unrelated causes without ever experiencing dialysis access-associated steal syndrome and with a patent and functional arteriovenous fistula. Conclusion We present a patient with severe dialysis access-associated steal syndrome complicated by third fingertip gangrene, which was successfully treated using a completely endovascular technique. This novel endovascular approach enabled a high-risk patient to avoid open surgery, preserve her limb, and maintain the function of her arteriovenous fistula.

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.

Objective An increasing emphasis on preventive medicine has been supported by the recent reforms in United States health care system. Majority of the patients seen in vascular surgery clinics are elderly with more extensive medical comorbidities compared to the general population. Thus, these patients would be expected at higher risk for common malignant pathologies such as colon, breast and cervical cancer, and nonmalignant diseases such as diabetic retinopathy. This study looked at the screening compliance of vascular patients compared to data provided by Centers for Disease Control on the national and state levels. Methods The office records of 851 consecutive patients seen in Brooklyn and Staten Island vascular clinics were examined. We queried patients regarding their last colonoscopy, diabetic eye exams, recent mammograms, and Pap smears. Our patient screening compliance was compared between the two clinics as well as to the national and New York state data provided by Centers for Disease Control. Compliance with regard to patient's age was also examined. Results Patients referred to the Staten Island office have a better colonoscopy compliance compared to the Brooklyn office ( P = .0001) and the national Centers for Disease Control average ( P = .026). Compliance for mammography and cervical cancer screening was higher in Staten Island office compared to the Brooklyn office ( P = .0001, P < .0001), respectively. Compliance was lower for Pap smear ( P = .0273) in Brooklyn when compared to the national average. Compliance for colonoscopy increased with age for both clinics ( P = .001, P < .001), while Pap smear decreased ( P < .001, P = .004). Conclusion Patients in vascular clinics in an urban setting had better adherence to screening protocol than the national and state average, with the exception of female patients for colonoscopy in our Brooklyn vascular office. There exists variability in both patient populations based on sub-specific locality and demographics including socioeconomic status. Overall, however patients in Staten Island had better compliance and adherence to the screening protocol than Brooklyn vascular clinic.

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:It has been a widely accepted practice that a previous placed pacemaker, automatic implantable cardioverter defibrillators, or central line can be a contraindication to placing a hemodialysis catheter in the ipsilateral jugular vein. Fear of dislodging pacing wires, tunneling close to the battery site or causing venous obstruction has been a concern for surgeons and interventionalists alike. We suggest that this phobia may be unfounded. METHODS:A retrospective review was conducted of patients in whom hemodialysis catheters were placed over a period of 10 years. For each hemodialysis catheter that was placed, perioperative chest X-ray performed was used to evaluate for pre-existing pacemakers and central lines. The position and laterality of placement of the hemodialysis catheter along with presence of arteriovenous fistula with functional capacity for access were noted. RESULTS:A total of 600 hemodialysis catheters were placed in patients over the period of 10 years. The mean age of the patients was 73.6 ± 12 years with a median age of 76 years. We found 20 pacemakers or automatic implantable cardioverter defibrillators and 19 central lines on the same side of the neck as the hemodialysis catheter that was placed in the ipsilateral jugular vein. No patient exhibited malfunction or dislodgment of the central line, the pacemaker, or automatic implantable cardioverter defibrillator or evidence of upper extremity venous obstruction based upon signs symptoms or duplex exams. CONCLUSION/CONCLUSIONS:Based on our experience, we suggest that placement of hemodialysis catheter in the internal jugular vein ipsilateral to the pre-existing catheter/leads is safe and spares the contralateral limb for arteriovenous fistula creation.

Objectives Treatment options for venous insufficiency are rapidly evolving in the office setting and include venography, intravascular ultrasound, and venous stenting. Non-thrombotic iliac vein lesions assessment and treatment in an office setting is currently an area of interest. The purpose of this study is to demonstrate the safety and efficacy of evaluating non-thrombotic iliac vein lesion with this office-based procedure in octogenarians and nonagenarians. Methods From January 2012 through December 2013, 300 non-thrombotic iliac vein lesion limbs in 192 patients with venous insufficiency ≥80 years old were evaluated for non-thrombotic iliac vein lesion. Patients were evaluated and treated with venography, intravascular ultrasound, and stent placement for significant lesions demonstrated by greater than 50% diameter or cross-sectional area reduction. Group 1: 168 of these patients were octogenarians; female/male ratio was 1.75:1, bilateral in 89/168 patients (53%), left sided in 131/259 limbs (51%), right sided in 128 limbs (49%), average age 83.5 ± 2.6 years (range 80-89) compared to Group 2: 24 nonagenarians; female/male was 3:1, bilateral in 17/24 patients (70%), left sided in 20/41 limbs (49%), right sided in 21/41 limbs (51%), average age 92.9 ± 2.2 years (range 90-99). Stent related outcomes were evaluated with communication to the patient within 24 h to assess post-procedure pain followed by serial iliocaval ultrasonography. Results Out of the 300 limbs evaluated, in Group 1, 86% of limbs had stents placed compared to 90% in Group 2 and 11% of both groups had two stents placed. Overall improvement in pain, edema, and ulcers was reported in 147 (59%) of octogenarians and 24 (65%) of nonagenarians. There were no surgical site infections, pseudo-aneurysms, arteriovenous fistulas, or femoral artery injuries. No patients required transfusion within three days post-operatively and there were no 30-day mortalities in both sets of patients. Conclusions Our results demonstrate that there is no statistical difference in the outcome of performing venography, intravascular ultrasound, and stent placement in an office-based setting in octogenarians and nonagenarians. Both groups maintained a similar safety profile with low morbidity and mortality. In conclusion, we believe that the treatment of non-thrombotic iliac vein lesion in an office-based setting is safe and efficacious in both groups.

OBJECTIVE:The purpose of the study was to aggressively salvage acutely occluded arteriovenous fistulas (AVFs) using duplex imaging as the sole imaging modality for percutaneous transluminal angioplasty of acutely thrombosed AVF. METHODS:Over a period of 12 months, 14 patients with acute thrombosis of their AVFs underwent 18 procedures in a single center for AVF salvage. All 14 patients presented with chronic renal failure, and six were diabetic. All patients were treated under duplex guidance alone. Treatment included simple balloon dilation and maceration (group A; n =10 procedures [56%]) for subacute thrombosis or pharmacomechanical thrombectomy (group B; n = 8 procedures [44%]) for more hypoechoic thrombus. A successful procedure was defined as immediate restoration of flow through the AVF. RESULTS:Of the 18 procedures, 13 (72%) were successful. Of the 14 patients, thrombus was located at the perianastomotic AVF in 6 (43%), proximal-mid AVF in 6 (43%), mid AVF in 1 (7%), and distal AVF in 1 (7%). From group A, six (60%) were successful. From group B, seven (88%) were successful. Among the unsuccessful procedures, one group B patient was hypercoagulable (polycythemia vera). Of the 18 procedures, 16 (89%) were treated within 2 weeks from when duplex revealed the presence of thrombus. Early rethrombosis (<1-month patency) occurred in three cases (17%), and these patients received new fistulas. Full restoration of the fistula flow was established in 14 cases (78%). Of these 14 patients, 8 (57%) are currently on hemodialysis via fistula, 3 patients (21%) had newly placed fistulas after failed interventions, 2 patients (14%) are not on dialysis yet, and 1 patient (7%) with polycythemia vera disorder is on dialysis via a Tesio catheter (MedComp, Harleysville, Pa). CONCLUSIONS:The sole use of duplex ultrasound imaging to salvage acutely occluded AVFs using percutaneous transluminal angioplasty is a safe and effective alternative to traditional treatment of thrombosed failing/maturing AVF.