Faculty Bibliography

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%.

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: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.

Objectives The use of postoperative anticoagulation is not uncommon for patients undergoing lower extremity arterial procedures as adjunctive therapy. Longer postoperative length of stay is necessary to achieve adequate therapeutic international normalized ratio with traditional protocols that call for the use of unfractionated heparin and warfarin therapy. We hypothesized the direct oral anticoagulants are an attractive alternative to provide adequate anticoagulation in patients who undergo lower extremity arterial procedures. Methods We retrospectively studied patients who had lower extremity arterial procedures between 2012 and 2015 to examine the safety and efficacy of the direct oral anticoagulants in a single institution. Patency, freedom from re-intervention, and major adverse limb event were evaluated. The direct oral anticoagulant agents used included dabigatran, rivaroxaban, and apixaban. The primary patency, adverse effects and freedom from re-intervention were then compared to a control group of patients who were treated with traditional heparin-warfarin therapy after lower extremity bypass procedures. Results Direct oral anticoagulants were utilized in a total of 23 patients (48% men; mean age 69 ± 11 years) during the study period. Indication for use of direct oral anticoagulant after procedure included use of polytetrafluoroethylene (PTFE) bypass graft below the knee joint or after lower extremity angioplasty with disadvantaged runoff. Mean follow-up of the drugs was 23 months (SD ± 16 months). At the end of follow-up, the direct oral anticoagulants have been discontinued in four patients, who are currently only on plavix. Among 82.6% of patients who were given direct oral anticoagulants for PTFE bypasses, graft patency, freedom from re-intervention, and major adverse limb event were 100%, 100%, and 0%, respectively. Patients (17.4%) treated with direct oral anticoagulants for disadvantaged runoff after balloon angioplasty of the lower extremity, patency, freedom from re-intervention, and major adverse limb event were 100%, 100%, and 0%, respectively. For the patients who underwent direct oral anticoagulant administration for disadvantaged runoff primary patency was 100%. One patient developed wound dehiscence which was unrelated to direct oral anticoagulant administration. Our control group consisted of 100 patients who were treated with heparin-warfarin therapy for 30 days after lower extremity bypass procedures. The graft patency, freedom from intervention, and major adverse limb event were 93%, 12%, and 0%, respectively. There was however no statistically significant difference in graft patency rate ( P = .34) or freedom from intervention ( P = .07) between the two groups. Conclusions The preliminary data suggest that there may be a role for using the direct oral anticoagulants with patients who undergo lower extremity arterial procedures for prevention of thrombosis and warrants further investigation.

Objective With the implementation of the K-DOQI guidelines, more patients are in need of long-term dialysis catheters until maturation of the arteriovenous fistula. However, on occasion, when placing a tunneled cuffed catheter for hemodialysis, we have encountered difficulty with passing the guidewire in spite of demonstration of a patent cervical portion of the internal jugular vein on duplex. Herein, we review our experience with intraoperative venoplasty for placement of Tesioâ„¢ catheters (Medcomp Harleysville, PA). Methods Of the 1147 Tesioâ„¢ catheters placed since 1997 by our service, 35 venograms were performed due to difficulty encountered with placement of the guidewire. Patent veins were all crossed with the use of angle-guiding catheters, angled glidewires, and a torque vise. If chronically occluded intrathoracic veins were identified, an alternate site was selected for the placement of the Tesioâ„¢ catheter. Results Of the 35 cases with difficulty in catheter placement, venogram demonstrated a patent but tortuous vein in 9, chronically occluded intrathoracic veins in 6, and severe stenosis of the intrathoracic veins in 20. In 19 cases with severe stenosis of the intrathoracic veins, balloon angioplasty with an 8-mm balloon was successfully performed, which allowed successful placement of a functional Tesioâ„¢ catheter. In the additional one case, the catheter was not able to be placed despite angioplasty. Seven lesions that underwent balloon angioplasty were in the innominate vein, 11 were in the proximal internal jugular vein, and two were in the superior vena cava. Conclusion Venous balloon angioplasty can be used to maintain options for the site of access for tunneled cuffed catheters and may be necessary to assist with placement of long term cuffed dialysis catheters.

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.

Background Dialysis access-associated steal syndrome is a major complication of arteriovenous fistula creation whereby the low-resistance venous conduit shunts arterial inflow through the anastomosis, resulting in clinically significant distal artery insufficiency. Herein, we describe a case of severe steal phenomenon with gangrene of a digit following placement of an arteriovenous fistula that was treated with a novel, entirely endovascular technique. To our knowledge, this was the first totally endovascular approach to dialysis access-associated steal syndrome. Methods Catheterization of the right subclavian, axillary, and brachial arteries was performed. A short 5-Fr sheath was exchanged for a long destination 6-Fr sheath and placed in the proximal brachial artery. An arteriogram showed no stenosis of the arterial system, but did show substantial steal phenomenon with inflow to the arteriovenous fistula, instead of the forearm. We placed a stent graft in the brachial artery across the anastomosis such that the graft covered 3/4 of the length of the opening of the anastomosis. Results Immediately after placement of the stent graft the clinical picture improved dramatically. Patient was followed for 15 months after this procedure until her demise for unrelated causes without ever experiencing dialysis access-associated steal syndrome and with a patent and functional arteriovenous fistula. Conclusion We present a patient with severe dialysis access-associated steal syndrome complicated by third fingertip gangrene, which was successfully treated using a completely endovascular technique. This novel endovascular approach enabled a high-risk patient to avoid open surgery, preserve her limb, and maintain the function of her arteriovenous fistula.

Objective The purpose of the study is to evaluate normal anatomical areas of infrarenal inferior vena cava, common iliac, external iliac and common femoral veins by intravascular ultrasound with the goal of assisting the development of venous-specific stents in the treatment of iliac vein stenosis. Method From February 2012 to December 2013, 656 office-based venograms were performed in our facility. Among them, 576 were stented and 80 were not. The measurements of veins were done intraoperatively using an intravascular ultrasound catheter to record areas of the inferior vena cava, proximal, middle and distal segments of common iliac vein, external iliac vein and common femoral vein. The data were compared between non-diseased segments of patients who were stented and those not stented. The stented diseased segments were excluded. Results The mean patient age was 67.33 years (range 22-96, SD ±13.99). Our data included 218 males, 438 females and 324 right lower extremities and 332 left lower extremities. The presenting symptoms of these patients based on CEAP were C1(0), C2 (185), C3(233), C4(107), C5(89) and C6(42). No correlation was found between area of veins and age, gender, laterality and CEAP score (P > .13). Comparison of the areas of non-diseased iliac vein segments between patients not stented and patients who underwent stenting showed a significant difference, with larger areas in non-stented patients in the distal common iliac vein (P = .039) and inferior vena cava (P = .012). Younger age (P = .03) and male gender (P < .0001) were associated with increased area of iliac vein segments. Conclusion Utilizing the intravascular ultrasound-guided technique, we were able to define normal anatomical areas of non-diseased inferior vena cava, iliac and femoral veins, which could be employed to guide the development of appropriate-sized stents and other tools needed for the treatment of venous insufficiency. There is specific variability in areas of normal vein segments with age and gender with/without stents.

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 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.