Faculty Bibliography

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:Endovenous thermal ablation has become the primary modality of treatment for patients with venous insufficiency. Previous literature has provided reviews of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) that mostly focus on the great saphenous vein (GSV) and small saphenous vein (SSV). Data with an extended review including the anterior accessory saphenous vein (ASV) and perforator veins (PVs) have been limited. This study examines the treatment of venous insufficiency with RFA and EVLA of these multiple veins to identify clinical and demographic predictors of both the early success and thrombotic complications of endovenous thermal ablation. METHODS:A retrospective analysis of patients who underwent either RFA or EVLA of the GSV, SSV, ASV, or PVs was performed from March 2012 through February 2014. The PVs were treated only using RFA. The success and complication rates of each method were compared. Procedure results were determined by duplex ultrasound examination at the next office visit. Obliteration of the target vein was defined as a success. A complication was defined as thrombosis of any vein proximal to the target vein or acute thrombosis of any tributaries. RESULTS:A total of 808 patients were treated with either RFA or EVLA (2057 procedures); 47 patients were excluded because of incomplete records. In total, 1811 procedures were included with an average of 2.4 procedures per patient. Excluding the PVs, the success rate of RFA was 98.4%, equivalent to EVLA at 98.1% (P = .66). The success rates of thermal ablation for each vein were as follows: GSV, 98.5%; SSV, 98.2%; ASV, 97.2%; and PVs, 82.4%. The overall thrombotic complication rate was 10.5%. The thrombotic complications include endovenous heat-induced thrombosis (EHIT; 5.9%) and acute superficial venous thrombosis (4.6%). However, when EHIT class 1 was excluded, the true EHIT rate was 1.16%. The rate of a thrombotic complication for each vein was as follows: GSV, 11.8%; SSV, 5.5%; ASV, 6.5%; and PVs, 2.4%. The thrombotic complication rate was 7.7% for RFA and 11.4% for EVLA (P = .007). Age, gender, laterality, presenting symptoms (based on Clinical, Etiology, Anatomy, and Pathophysiology class), and vein type and diameter have no effect on successful ablation. Increased vein diameter (P < .001) and type of vein (P < .0001) were significant predictors of acute thrombotic complications; however, on multivariable analysis, only type of vein was an independent statistically significant predictor when nested for within-person correlation. CONCLUSIONS:There were no statistical difference in successful closure rates between RFA and EVLA. The type of procedure (EVLA), larger vein diameters, and treatment of the GSV were associated with a greater thrombotic complication rate, but type of vein was the most significant independent predictor.

BACKGROUND:Routine radiofrequency ablation (RFA) of an incompetent perforator vein (IPV) using the standard treatment protocol at 85°C has a treatment time of 6 minutes. To make treatment time more efficient, we sought to determine the effect of a shortened protocol for radiofrequency stylet (RFS) ablation by comparing the early success using three different temperatures: 85°C, 90°C, and 95°C. METHODS:A retrospective study examined 642 procedures of IPV closures in 255 patients with varying degrees of venous insufficiency treated with RFA from 2009 to 2015. The Covidien (Mansfield, Mass) RFA system allows the operator to regulate temperature and allows increments in temperature of the RFS to 85°C, 90°C, and 95°C. The RFS probe was angled at four 90-degree angles at the mentioned temperatures with a shorter treatment time at 6, 4, and 3 minutes, respectively. The three different treatment protocols were compared. All patients had comparative preoperative and postoperative duplex ultrasound scans. Postoperative duplex ultrasound scans were performed 3 to 7 days after the procedure. Successful obliteration was defined as lack of color flow on postoperative duplex ultrasound scanning. Clinical correlation with age, gender, laterality, presenting symptoms (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] classification), location, and vein diameter was also performed. RESULTS:Of the 255 patients who underwent RFS ablation, 138 were female, with a mean age of 65 years (standard deviation, ±14.6 years). These patients had CEAP presentations from C1 to C6 (0 C1, 1 C2, 57 C3, 118 C4, 4 C5, 75 C6). The location of the 642 IPVs was distributed as 472 in the calf and 170 in the ankle; 322 of these procedures were performed on the right leg. Use of a shortened protocol had no significant effect on the early obliteration rates with the 85°C, 90°C, and 95°C protocols, which were 66.1%, 61.8%, and 67.1%, respectively. Significant correlation was seen between location of targeted vein and successful obliteration (P < .001). There was a borderline inverse linear association between higher stylet temperature and successful obliteration in the proximal calf at 85°C. After accounting for within-patient correlation, the middle and distal calf continued to show higher nonobliteration compared with the ankle. No clinical correlation with age, gender, laterality, presenting symptoms of CEAP, or vein diameter was observed. CONCLUSIONS:The study showed that shortening the protocol time for RFA of the perforator did not make a significant difference in the early success rate, regardless of the temperature. The overall early success rate is still low (65.1%). RFA of perforator veins has a higher successful closure rate in proximal calf and ankle areas compared with the middle and distal calf.

A 28-year-old Hispanic female with a history of deep vein thrombosis (DVT) presented to the emergency room with left lower extremity swelling and pain. On duplex venous examination, an extensive left lower extremity DVT extending to her left common iliac vein was identified. A perforator vein measuring 2.6 mm located in the midcalf area was used to access and perform mechanical and chemical thrombolysis. Complete resolution of symptoms was observed.

Background Ureteral arterial fistulas are rare but potentially life threatening. We present a female who developed a ureteral arterial fistula following a right robotic nephrectomy. After several endovascular interventions to control the bleeding had failed, we approached the fistula through the right ureteral stump with coil embolization. Methods Coil embolization of the right ureteral stump was performed. We utilized a 6Fr × 45 cm sheath inserted through one of the cystoscope channels to cannulate the right ureteral orifice. We then performed a retrograde ureterogram. After, we were able to visualize full length of the ureter, ahd we began placing several 10-12 mm Nester coils to pack the ureter and tamponade the fistula for hemostasis. After the ureter was packed, we injected 1 g of Vancomycin into the ureter. The sheath and cytoscope were removed and the patient did well and was sent to the recovery room. Results Postoperatively, the patient had no complaints of hematuria and her hemoglobin level remained unchanged. She was observed for a few days prior to being discharged to home. The patient's follow-up at six months revealed resolution of her hematuria. Conclusion Ureteral arterial fistula is a potentially life-threatening condition. Endovascular stenting has provided a safe, reliable alternative to open surgery. However, when endovascular options are not satisfactory, coil embolization of the ureteral stump may serve as a safe and effective alternative treatment for these cases.

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases. Little literature has examined the effect of race/ethnicity on venous disease. Iliac vein stenting is an emerging technology in treating chronic venous insufficiency. To further characterize this disease and its treatment, we chose to study the effect of selected clinical factors including race/ethnicity on the early complications of non-thrombotic iliac vein stenting. Methods In this observational study, data analysis was performed for 623 patients with chronic venous insufficiency who underwent iliac vein stenting during the time period from August 2012 to September 2014. Patients were categorized by Caucasians ( n = 396), African Americans ( n = 89), Hispanics ( n = 138), and others ( n = 23). These were correlated with the age, gender, presenting sign according to CEAP classification, percentage of iliac vein stenosis, post-operative thrombosis and pain score. Pain score was obtained post-operatively on a Likert scale of 0-10. Follow-up was performed after completion of the procedure, through post-operative visits and duplex exams every three months for the first year. Statistical analysis was performed using Chi-square and Student's t-test, Pearson's test and multivariate regression. Results The average age of the study patients was 67.8 years (age range 23-96 years, +/- 14.2 SD). Sixty-seven patients were women. The presenting sign according to CEAP classification was (C3 = 331, C4 = 175, C5 = 51, C6 = 66). The average pain score was 2.6 (+/-2.9 SD). The average degree of stenosis was 64.9% (+/-3.8 SD). There were insufficient numbers in the "other" race/ethnicity group for further analysis. The number of patients with iliac vein stent thrombosis was 14 (2.2%). When analyzing each race/ethnicity in our dataset with univariate analysis, we found that Caucasians were significantly older than the African Americans and Hispanics ( P < 0.0001). There tended to be more women in the Caucasian group as compared to the Hispanics ( P = 0.04). There were no differences in presenting sign according to CEAP classification or degree of stenosis between the three groups. Hispanics tended to have higher pain scores post-operatively than Caucasians ( P = 0.01). It was found that 1.8% of Caucasians, 3.4% of African Americans and 2.9% of Hispanics had post-operative iliac vein stent thrombosis ( P = 0.55). Men have higher CEAP score than women regardless of race/ethnicity ( P = 0.0001). On the other hand, women tended to have higher pain score than men ( P = 0.04). There were no differences between men and women regarding age, degree of stenosis, and stent thrombosis. Linear multivariate regression test and Pearson's test revealed that age is inversely related to pain score ( P < 0.0001). ANOVA multivariate regression statistical analysis showed no relation between race/ethnicity and pain score ( P = 0.98), and one-way ANOVA showed that the Caucasians were the eldest ethnic group in the study ( P < 0.0001). Linear multivariate regression test and Pearson's correlation test revealed that race/ethnicity is not correlated with thrombosis of iliac vein after stenting ( P = 0.8). Conclusion Race/ethnicity is not significantly associated with CEAP score, degree of iliac vein stenosis, or post-operative thrombosis or pain scores. Age was inversely associated with pain score after iliac vein stenting.

Objective Treatment of non-thrombotic iliac vein lesions is an active area of research. Intravascular ultrasound allows its localization. We chose intravascular ultrasound to clarify the exact anatomical location of non-thrombotic iliac vein lesions and correlate it with clinical findings. Materials and methods Over seven months, we performed ilio-femoral intravascular ultrasound studies on 217 patients, in 141 women and 76 men. The average age +/- standard deviation was 68 +/- 14 years. We used intravascular ultrasound intraoperatively to measure the ilio-femoral veins and compared it with adjacent non-stenotic ilio-femoral veins. If more than 50% area or diameter reduction was found, it was treated with appropriate balloon and stent. Results We identified 244 lesions, 124 in left lower extremity and 120 in the right lower extremity. The most common site was the proximal common iliac vein 38.7% (22.5% females and 16.12% males) in left lower extremity and middle external iliac vein 29.16% (18.33% females and 10.83% males) in right lower extremity. The least common site was the distal external iliac vein in 3.2% (all 3.2% females) and the distal external iliac vein 7.5% (5% females and 2.5% males) in right lower extremity. Clinical correlation was noted between laterality and location of the NIVL lesion ( p < 0.0001). Conclusion This analysis gives an insight into understanding the exact anatomical locations of the non-thrombotic iliac vein lesions helping clinicians and researchers guide their treatment and research.