Faculty Bibliography

OBJECTIVES/OBJECTIVE:Drug-eluting stents (DES) have been promoted as an alternative to the traditional non-drug eluting stents (nDES), and offer the potential for improved patency rates. However, DES are more expensive than nDES, and results comparing these stents outside of clinical trials have been limited. MATERIALS AND METHODS/METHODS:A retrospective review was performed on all in patient infrainguinal lower extremity endovascular procedures between January 2014 and September 2016, which involved stent implantation. Procedures involving the common femoral artery, superficial femoral artery, and above knee popliteal artery were included. Procedures involving iliac, below knee popliteal, tibial, peroneal, and pedal arteries were excluded. The type of stent, number of stents, length of each stent, and location of stent were recorded for each procedure. Data on each patients Trans-Atlantic Inter Society Consensus II class were collected. End-points included stent thrombosis, restenosis, re-intervention, and limb loss. Post-operative arterial duplexes were obtained every three months to determine stent patency during follow-up visits. In-stent stenosis was defined as >60% narrowing on arterial duplex. Thrombosis was defined as in-stent occlusion, and limb loss involved only major amputations in the treated extremity. Bivariate analysis and Students two-sample T-test were used to analyze the data. IBM-SPSS - 22 was used for all analyses. RESULTS:Two hundred and twelve patients underwent at total of 252 procedures during the study period. Of this group, 191 procedures met inclusion criteria. There were 21 lesions that were treated with both nDES and DES and they were excluded from further analysis. The average patient age was 73.2 ± 11.6 years; 68.6% had hypertension, and 58.1% had diabetes. Mean follow-up was 7.18 ± 7.96 months. The most common indication for intervention was claudication (53%), followed by critical limb threatening ischemia (47%); 124 procedures involved only nDES (Lifestent®)(Bard, Tempe, AZ), 46 procedures involved only DES (Zilver®) (Cook, Bloomington, IN). Comparison of nDES and DES showed the overall rate of thrombosis (11.1% vs. 16.7%, p = 0.81), overall rates of re-stenosis (48.2% vs. 46%, p = 1.0), re-intervention (13.7% vs. 14.3%, p = 1.0), and limb loss (9.7% vs. 0.0%, p = 0.38) was equivalent between the groups. The six-month primary patency rate for nDES and DES (41.9% vs. 40.0%, p = 1.0) was also equivalent. On average, the average lengths of nDES were longer than DES (19.2 ± 14.3 cm vs.11.4 ± 5.7 cm) ( p < .0001). DES results showed overall rates of 33% re-stenosis, 7.1% thrombosis, and no limb loss. There were no statistical differences between the nDES or DES groups with respect to gender, age, laterality, diabetes mellitus, coronary artery disease, gangrene, ulcers, hyperlipidemia, atrial fibrillation, deep vein thrombosis, claudication, critical limb-threatening ischemia, ipsilateral bypass, re-stenosis, thrombosis, limb loss, or ipsilateral amputation. Bivariate analysis showed a higher incidence of hypertension for nDES patients ( p = .001). There was no statistical difference between Trans-Atlantic Inter Society Consensus II classes and type of stent used ( p = .95). CONCLUSIONS:In this retrospective analysis from one institution, the use of an nDES or DES did not result in a statistically significant difference in the rate of thrombosis, re-stenosis, ipsilateral re-intervention, or ipsilateral amputation over a two-year period when involving the CFA, SFA, and above knee popliteal artery.

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.

Isolated celiac artery vasculitis is an uncommon disease rarely reported in the Western literature. In this case report, we describe a 52-year-old Chinese male presenting with abdominal pain who was diagnosed with nonspecific celiac artery vasculitis and was successfully treated with a short course of oral corticosteroids.

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.

INTRODUCTION/BACKGROUND:Abdominal endovascular aneurysm repair is a minimally invasive alternative to major open surgery for the repair of abdominal aortic aneurysms that results in reduced recovery times and early survival rates. METHODS:The TriVascular Ovation® Abdominal Stent Graft System is a low-profile endovascular device with active fixation used for endovascular aneurysm repair. The stent graft is designed to reline the diseased vasculature, providing an endovascular blood conduit for isolating the aneurysm from the high-pressure flow of blood, thereby reducing the risk of rupture. The stent graft is a modular configuration comprised of an aortic body section, iliac limbs, and iliac extensions as required. Results and Conclusion: We present a case of symptomatic aortic body graft stenosis in the unsupported segment below the O-rings, 26 months after the treatment of abdominal aortic aneurysm with Ovation® Abdominal Stent Graft System. The successful repair was performed by ballooning the stenotic area which resulted in complete resolution of the symptoms.

This study is a case series describing the management of complex aneurysmal disease using the principles of both open and endovascular techniques.

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.

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%.