Faculty Bibliography

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.

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 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 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:Vascular surgery training and practice have been constantly evolving in the last two decades.The goal of this study is to report the changing trends in perspectives of vascular surgery trainees on current training program and issues that need redressal in vascular training and practice. METHODS:Vascular surgery trainees in the US who attended the Society of Clinical Vascular Surgery meeting from 2004-2015 were surveyed annually with an anonymous questionnaire during the meet. Questions pertaining to their endovascular and open surgical learning experience,independent performance of procedures, challenges of job search, starting an independent practice and their perception of issues in vascular surgery training were analyzed. Responses from the first half of the decade (2004-2009) were compared to the second half (2010-2015) to identify evolving trends in trainee perception. RESULTS:Among the 908 vascular surgery trainees who attended the annual meeting from 2004-2015, 670 (74%) trainees responded to the questionnaire. The mean age of vascular trainees was 32.5 years. In the latter half of the decade, there was a two-fold increase in female trainees, from 12.3% to 23.6% (p=0.002), and the integrated program trainees also increased from 0% to 12% of respondents (p=0.0023). Trainee satisfaction with endovascular training improved from 78% to 90% (p=0.0001) and satisfaction with open surgical experience was unchanged at 83% over the ten-year period (p=0.16) . The perception of vascular laboratory experience improved with only 35% vs. 27% (p=0.016) of respondents dissatisfied, despite only a third of respondents actually performing the non-invasive tests in both the former and the latter half of the decade respectively. CONCLUSION/CONCLUSIONS:Although the quality of vascular cases during training has improved, vascular trainees desire shorter training paradigms and vascular laboratory education is still viewed as deficient These findings can be used by training programs to reexamine their curricula and implement changes to improve the quality of training the next generation of vascular surgeons.

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.

OBJECTIVE:We hypothesized that there may be significant differences between academic productivity of the vascular training programs in the United States (US) and Europe. In an effort to explore theory, we reviewed the number of vascular publications listed in PubMed from 2010 to 2015 for US and European directors in vascular surgery. METHODS:The list of program directors from the Association of Program directors in Vascular Surgery (APDVS) and the European Union of Medical Specialists (EUMS) were queried for the names of the directors of vascular surgical training programs at the end of 2015. PubMed listed 5474 citations published from 2010 - 2015. 3561 were from Europe while 1912 were from the US. UK and German programs did not list their directors' names in the EUMS website and were thus not included in the European data. RESULTS:The average number of citations in PubMed per program director was 2.36 per year. In Europe, each of the 273 program directors averaged 2.17 publications per year while each of the 114 US program directors averaged 2.80 publications per year (P=.37). Journal of Vascular Surgery publications made up 24.0% (12.7% in Europe and 45.0% in the US). In the US, the top third produced 69% of the publications and 77% of the JVS publications while in Europe, the top third produced 87% of the publications and 98% of the JVS publications. In the US, 5 program directors (4.4%) had no publications and 21 (18.4%) had no JVS publications. In Europe, 82 program directors (30.0%) had no publications while 180 (65.9%) had no JVS publications. Abstracts were categorized by topic for comparison. CONCLUSIONS:In both Europe and the US, the top third produced more than two-thirds of the publications, with the disparity being even more pronounced in Europe where the top third produced almost 90% of the total publications. Comparing the topics of the publications from Europe and the US, it was found that the US program directors published a great deal more on Endo Lower Extremity, Open Lower Extremity, Education, TEVAR, Open Carotid, and Endo Venous while their European counterparts published more in the areas of Vascular Medicine, Replies, and Not Vascular.

OBJECTIVE:Midterm patency results of iliac vein stents placed for nonthrombotic iliac vein lesions (NIVLs) are not widely known. Previously published studies involving large series of patients with iliac vein stent placement have failed to clearly demonstrate the outcomes for patients with NIVLs and advanced disease. To further study this issue, we reviewed our series of 268 iliac vein stents placed for NIVLs. METHODS:Retrospective analysis was performed of 210 patients who underwent common or external iliac vein angioplasty and stent placement procedures between January 2013 and December 2014. Only patients with Clinical, Etiology, Anatomy, and Pathophysiology classification scores of C3, C4, or C5 were included. Patients were excluded if they had either active ulcer disease or signs of post-thrombotic lesions at initial venography or intravascular ultrasound (IVUS). Ultrasound-guided puncture was performed of the femoral or common femoral vein at the discretion of the surgeon. This was followed by ascending venography. IVUS was used in cases in which a definite stenosis was not appreciated on initial ascending venography. Balloon angioplasty and stents were applied across lesions. After the procedure, patients were instructed to use clopidogrel 75 mg daily. Patency of the stents was assessed during a follow-up visit with abdominal venous duplex ultrasound scans. The length of the patients' follow-up and stent patency rates were based on the last previous duplex ultrasound scan available. RESULTS:A total of 268 procedures were performed in 210 patients. Bilateral lower extremity stent placements were required in 58 patients; 173 (64.6%) procedures were performed in women. The average age of our patients was 72 ± 15 (standard deviation) years. Of the 268 procedures, 144 (53.7%) were performed in the left lower extremity. The Clinical, Etiology, Anatomy, and Pathophysiology classification of lower extremity venous disease was 58%, 30%, and 12% for C3, C4, and C5, respectively. Our average follow-up period was 437 days (median, 499 days; range, 1-1060 days). Patients were observed for >6 months, 1 year, and 2 years in 71.3%, 57.1%, and 28.7% of cases, respectively. During this period, 4 of the 268 (1.5%) limbs experienced in-stent thrombosis. Primary stent patency of 98.7%, 98.3%, and 97.9% was noted at 6 months, 1 year, and 2 years of follow-up, respectively. CONCLUSIONS:Our midterm patency rates for iliac vein stents placed in patients with advanced chronic venous disease demonstrated excellent (98.5%) results. Furthermore, with IVUS assistance, we have clearly documented the average area of iliac venous segments as well as the most common locations of the stenoses.