Faculty Bibliography

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.

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases, yet there are limited data on risk factors and outcome of lower limb swelling. While many patients improve with endovenous therapy (thermal ablation or iliac vein stenting), some patients' symptoms persist. The goal of this study was to identify clinical factors including race/ethnicity related to persistent leg swelling after treatment with both iliac vein stenting and thermal ablation. Methods From February 2012 to February 2014, this observational study analyzed data for 173 patients with chronic venous insufficiency who underwent both iliac vein stent placement as well as thermal ablation (radiofrequency ablation or endovenous laser ablation). All procedures of the thermal ablations and the iliac vein stenting were staged. Iliac vein stenosis was identified using intravascular ultrasound of the iliofemoral venous segment showing >50% cross-sectional area or diameter reduction. The patients were queried to the resolution of their leg swelling after both procedures were performed. The resolution of swelling was correlated with age, gender, presenting sign according to CEAP classification, race/ethnicity and degree of iliac vein stenosis. Patients were categorized by Caucasians ( n = 97), African Americans ( n = 27), or Hispanics ( n = 49). Statistical analysis performed using Chi-square and Student's t test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 117 (67.6%) patients were women. The average age was 67 (±13 SD) years. The average pain score was 2.9(±3.1 SD). The average degree of iliac vein stenosis was 66.5(±13.3 SD). About 56.1% were Caucasians, 15.6% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 2. One hundred fifty-two (87.9%) patients stated that they had improvement in swelling after combined procedures, 100 (65.8%) patients were women. The average age was 67.3 (±13 SD) years. The average pain score was 2.9 (±3.1 SD). The average degree of iliac vein stenosis was 67.3% (±12.8 SD). About 56.6% were Caucasians, 15.1% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 1. Twenty-one (12.1%) patients stated they had no improvement after both procedures. Correlating these group factors with the group of patients who improved their swelling after the combined procedures we found the following: 17 (81%) of these patients were females ( P=0.16). The average age was 68.4 (±17 SD) years ( P=0.72 SD). The average pain score was 3.2 (±3.7 SD) ( P=0.68). The average degree of iliac vein stenosis was 60.2% (±15.9 SD) ( P=0.02). Around 52.4% were Caucasians, 19% were African Americans, and 28.6% were Hispanics ( P=0.88). The number of patients with iliac vein stent thrombosis was 1 ( P = 0.1). Conclusion These data suggest that the clinical factors including race are not clinically significant factors in the response to swelling after combined iliac stent and endovenous ablation procedures. Interestingly, a higher degree of iliac vein stenosis was associated with improved resolution of swelling.

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: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 A quality improvement initiative was employed to decrease single institution surgical site infection rate in open lower extremity revascularization procedures.

OBJECTIVE:The purpose of the study was to aggressively salvage acutely occluded arteriovenous fistulas (AVFs) using duplex imaging as the sole imaging modality for percutaneous transluminal angioplasty of acutely thrombosed AVF. METHODS:Over a period of 12 months, 14 patients with acute thrombosis of their AVFs underwent 18 procedures in a single center for AVF salvage. All 14 patients presented with chronic renal failure, and six were diabetic. All patients were treated under duplex guidance alone. Treatment included simple balloon dilation and maceration (group A; n =10 procedures [56%]) for subacute thrombosis or pharmacomechanical thrombectomy (group B; n = 8 procedures [44%]) for more hypoechoic thrombus. A successful procedure was defined as immediate restoration of flow through the AVF. RESULTS:Of the 18 procedures, 13 (72%) were successful. Of the 14 patients, thrombus was located at the perianastomotic AVF in 6 (43%), proximal-mid AVF in 6 (43%), mid AVF in 1 (7%), and distal AVF in 1 (7%). From group A, six (60%) were successful. From group B, seven (88%) were successful. Among the unsuccessful procedures, one group B patient was hypercoagulable (polycythemia vera). Of the 18 procedures, 16 (89%) were treated within 2 weeks from when duplex revealed the presence of thrombus. Early rethrombosis (<1-month patency) occurred in three cases (17%), and these patients received new fistulas. Full restoration of the fistula flow was established in 14 cases (78%). Of these 14 patients, 8 (57%) are currently on hemodialysis via fistula, 3 patients (21%) had newly placed fistulas after failed interventions, 2 patients (14%) are not on dialysis yet, and 1 patient (7%) with polycythemia vera disorder is on dialysis via a Tesio catheter (MedComp, Harleysville, Pa). CONCLUSIONS:The sole use of duplex ultrasound imaging to salvage acutely occluded AVFs using percutaneous transluminal angioplasty is a safe and effective alternative to traditional treatment of thrombosed failing/maturing AVF.

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.

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.

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