Faculty Bibliography

Endovascular repair of ruptured abdominal aortic aneurysms seems to have better outcomes than open repair if certain strategies, techniques, and adjuncts are employed. These include a standard approach or protocol; use of fluid restriction (hypotensive hemostasis), performance of the procedure in a site equipped for excellent fluoroscopic imaging and open surgery, use of percutaneous approaches and local anesthesia for initial guide wire and catheter placement, placement of a large supraceliac aortic sheath, and obtaining balloon control only when absolutely necessary. Details of obtaining this control are critical, and aortic control must not be lost until the rupture site is excluded. Multiple balloons might be required, including ones placed within the endograft. Sheath placement and fixation until the balloon is removed are also critically important. Bifurcated and unilateral endografts can be used successfully. Abdominal compartment syndrome must be looked for and treated aggressively; endovascular repair must be used in the highest-risk patients, including those in profound hemorrhagic shock, to gain the greatest advantages of this approach.

Endovenous ablation, using radiofrequency or laser, is becoming the mainstay of treatment for symptomatic varicose veins in the setting of saphenous vein incompetency. Both procedures have been shown to produce high rates of truncal vein occlusion with few complications. This article presents three patients who developed arteriovenous fistula (AVF) following great saphenous vein treatment: two following radiofrequency ablation (RFA) and one following laser ablation. This is the first published report of AVF following RFA for which operative details are known. We review the literature and discuss possible causes and management of this rare complication.

Endovenous laser ablation (EVLA) and radiofrequencey ablation have become the procedures of choice for the treatment of superficial venous insufficiency. Their minimally invasive technique and safety profile when compared with operative saphenectomy have led to this change. As EVLA has replaced saphenectomy as the procedure of choice, the distribution of complications has changed. We evaluated the most common and most devastating complications in the literature including burns, nerve injury, arterio-venous fistula (AVF), endothermal heat-induced thrombosis and deep venous thrombosis. The following review will discuss the most frequently encountered complications of treatment of superficial venous insufficiency using EVLA. The majority of the complications described can be avoided with the use of good surgical technique and appropriate duplex ultrasound guidance. Overall, EVLA has an excellent safety profile and should be considered among the first line for treatment of superficial venous reflux.

Background: The treatment of venous insufficiency using endovenous laser ablation or radiofrequency ablation may result in endothermal heat induced thrombosis (EHIT), a form of deep venous thrombosis. This study sought to assess the effect of ablation distance peripheral to the deep venous system on the incidence of EHIT. Methods: This study was a retrospective review of a prospectively maintained database from 4/2007 to 7/2011. Consecutive patients undergoing great saphenous vein (GSV) or small saphenous vein (SSV) ablation were evaluated. Previous to 2/2011, all venous ablations were performed 2cm peripheral to the saphenofemoral or saphenopopliteal junctions (Group I). Subsequent to 2/2011, ablations were performed 2.5cm peripheral to the respective deep system junctions (Group II). The primary outcome was the development of EHIT II or greater, i.e. thrombus protruding into the deep venous system. Secondary outcomes included procedure-site complications such as hematomas and saphenous nerve injury. Chi-square tests were performed for all discrete variables, and unpaired Students t-tests were performed for all continuous variables. P<.05 was considered statistically significant. Results: A total of 3,526 procedures were performed, Group I (N=2672) and Group II (N=854). General demographics and CEAP classification did not differ significantly between the two groups. EHIT demonstrated a trend towards diminished frequency in Group II (Group I: 2.8% vs Group II: 1.6%, P=.077). There were no reported cases of EHIT III or IV in this patient cohort. Patients in Group I were treated using anticoagulation 56% of the time, and patients in Group II were treated using anticoagulation 100% of the time. The frequency of procedure site complications was low and did not differ significantly between the two groups. Conclusions: This study suggests that changing the treatment distance from 2cm to 2.5cm peripheral to the deep venous junction may result in a diminished incidence of EHIT. Ongoing evaluation is required to validate these results and to reaffirm the durability of the technique

In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success

INTRODUCTION: Ask a dysphasic patient who has received a carotid artery stent if he or she would instead have rather had a troponin enzyme leak or minor myocardial infarction (MI). Although the answer is clear to most of us, there are many interventionalists and clinicians who have inappropriately interpreted recent data from the CREST trial to conclude that carotid artery stenting (CAS) is equivalent to carotid endarterectomy (CEA)

Cystic adventitial disease (CAD) is a well described disease entity that commonly affects the popliteal artery, presenting as a rare cause of non-atherosclerotic claudication. The traditional surgical approaches are cyst resection and bypass, or cyst evacuation or aspiration. We report the case of a 58-year-old female with CAD of the popliteal artery treated successfully with cyst resection and bypass using an autologous graft. We reviewed the literature over the last 25 years on management and outcomes of CAD of the popliteal artery. We identified a total of 123 cases; most cases were treated using a traditional repair, while 3 cases used an endovascular approach. The overall success rate using bypass was 93.3%, compared to 85% in the evacuation/aspiration cohort. All cases treated endovascularly resulted in failure. While no consensus exists regarding the preferred modality to treat CAD, we believe that resection of the cyst and bypass affords the best outcomes