Faculty Bibliography

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: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: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.

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.

BACKGROUND/UNASSIGNED:Metformin is the most commonly used drug for type 2 diabetes. Research has shown that metformin also has a protective effect on endothelium by decreasing endothelial vascular reactivity. We hypothesize that metformin will decrease restenosis/reintervention rates in patients receiving lower extremity non-drug-eluting stents (nDESs) in the superficial femoral artery(SFA) and/or popliteal artery. MATERIALS/METHODS/UNASSIGNED:Retrospective study was performed on 187 patients from October 2012 to December 2015 who received an nDES in the SFA and/or popliteal artery. Patients were divided into 3 groups (Table 1) and compared against for duplex based restenosis (>60%) rates, limb loss rates, and reintervention rates. Each patient's Trans-Atlantic-Inter-Society-Consensus II (TASC-II) class was collected. Postoperative duplex was performed 1 week after the procedure, then every 3 months for the first year, then, every 6 months to check for patency. IBM-SPSS-22 was used for all analyses. RESULTS/UNASSIGNED:Average age of the patients was 64.65 ± 73.4 years. 101 patients had 101 procedures performed on the left lower extremity; 86 patients had 86 procedures performed on the right lower extremity; 123 patients were male and 64 were female. Average length of follow-up was 13.1±9.7 months. Most common indication for intervention was claudication, followed by critical limb threatening ischemia. Restenosis and reintervention by groups can be seen in Table 1. No patients experienced limb loss. There were no statistically significant differences between any of the 3 groups and their limb loss, restenosis, or reintervention rates. CONCLUSIONS/UNASSIGNED:Despite having multiple proven effects in improving certain clinical outcomes and a proven protective effect on endothelium by decreasing endothelial vascular reactivity, metformin does not appear to reduce restenosis or reintervention rates in patients receiving lower extremity nDESs in the SFA and/or popliteal artery.

OBJECTIVE:Iliac vein stenting has been an evolving treatment option in the management of CVI secondary to iliac vein obstruction. Historically, treatment of CVI has been focused on the elimination of saphenous vein disease; however, the effect of reduction of iliac vein obstruction on superficial venous reflux remains largely unknown. This study aimed to identify the effect of iliac vein stenting on saphenous vein reflux. METHODS:In this retrospective study spanning course of five years, we performed 2681 venograms with venoplasties and stenting of the iliac veins. Pre-operative and post-operative venous mapping was performed via duplex ultrasonography. Patients who received any lower extremity vascular intervention between "pre-" and "post-stenting" duplex ultrasonography examination, other than iliac vein stenting, were excluded from analysis. RESULTS:(18%). Bilateral iliac vein stenting significantly reduced reflux in the bilateral great saphenous and small saphenous veins by 363.8 ms ( p < 0.0001) and 345.4 ms ( p < 0.0002), respectively, but had no effect on ASV reflux. Unilateral stenting did not produce significant reductions in reflux, besides an average reduction of 573.2 ms ( p = 0.004) in the left great saphenous vein. CONCLUSION/CONCLUSIONS:Bilateral iliac vein stenting decreased great saphenous vein and small saphenous vein reflux. Unilateral stenting did not demonstrate a significant reduction in saphenous reflux. Bilateral reduction in stenosis of the iliac veins may influence superficial venous reflux.

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.

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.