Faculty Bibliography

Background: Validated diagnostic assessment tools such as the Venous Clinical Severity Score (VCSS) and the Clinical Etiologic Anatomic Pathophysiologic (CEAP) help determine how superficial venous disease impacts a patient. No single assessment tool provides accurate scoring for disease severity, and this is most clearly exemplified by the variability seen in C2 patient clinical presentations. This has resulted in inconsistent treatment algorithms, patient care, and payer reimbursement. The purpose of this study was to generate an algorithm that incorporates patient reported scores (VVSymQVR ) and physician reported scores (VCSS) in order to improve stratification for disease severity in C2 patients.
Method(s): Consecutive patients with symptomatic varicose veins were included. They were pooled from the VANISH-1 and VANISH-2 cohorts. VCSS and CEAP were calculated for each patient. Patients completed a 7-day electronic daily diary (VVSymQVR ) to capture the type and severity of symptoms, including-Heaviness, Achiness, Swelling, Throbbing, and Itching (HASTI). The relationship between the VCSS and VVSymQVR scores were evaluated using Pearson's correlation. Frequency distribution analysis was used to classify patients according to VCSS and VVSymQVR .
Result(s): Two-hundred ten patients were identified with C2 disease. Patient demographics were as follows: Female 73%; Age 50 years (mean). Scoring systems revealed VCSS: mean=6.32 (range 3-16); VVSymQVR : mean 8.72 (range 1.29-22.86]. A weak correlation was demonstrated between VCSS and VVSymQVR scores (r=0.22 and P=0.05). Figure 1 depicts the frequency distribution analysis: 61.4% of patients had low VVSymQVR and VCSS scores, indicative of mild symptomatology; 31.3% of patients had increased VCSS (range 7-9) and VVSymQVR scores (mean 10.7), indicative of daily symptoms of moderate severity; and an additional 7.3% of patients had VVSymQVR and VCSS scores that were inconsistent for patients with C2 disease.
Conclusion(s): These data highlight the utility of combining patient reported scores and physician reported scores in order to stratify for disease severity in patients with C2 disease. For patients with combined elevated VCSS (7-9) and VVSymQVR (>9) scores, moderate to severe disease severity is corroborated, and interventional treatment may be indicated. For patients who do not meet the combined criterion of the algorithm, the disease severity is likely mild and conservative therapy such as lifestyle modification and compliance with compression may be the more appropriate treatment. Further prospective evaluation correlated to patient outcomes will help to determine the efficacy of this approach

Spontaneous renal artery dissection (SRAD) is a rare disease with approximately 200 cases reported in the literature. The severity of renal compromise, the anatomic location of the dissection, and the presence of uncontrollable hypertension are used to guide the initial management of SRAD. However, there are no reported guidelines for managing the progression of SRAD after acute failure of medical management. In this case, a 40-year-old man with a recently diagnosed SRAD was managed appropriately with therapeutic anticoagulation, yet presented with progression of his dissection and a new acute renal infarct. A covered endovascular stent was used to successfully control dissection progression and prevent further renal compromise.

BACKGROUND: The Vascular Quality Initiative (VQI) Varicose Vein Registry (VVR) represents a patient-centered database launched in January 2015. Previous work describing overall trends and outcomes of varicose vein procedures across the United States demonstrates a benefit from these procedures. The existing gaps in evidence to support current and future Medicare coverage of varicose vein procedures necessitate further description of clinical outcomes in patients >/=65 years old compared with the population <65 years old. METHODS: This study analyzed prospectively captured anatomic, procedural, and outcome data for all patients in a national cohort of all VQI VVR-participating centers. The VQI VVR database was queried for all patients undergoing varicose vein procedures between January 2015 and July 2016. Preprocedural and postprocedural Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, Venous Clinical Severity Score (VCSS), and patient-reported outcomes (PROs) were compared between patients <65 years and >/=65 years old. Univariate descriptive statistics of demographic and procedural data were performed. Student t-tests were then performed on change in CEAP classification, VCSS score, and PROs (heaviness, achiness, throbbing, swelling, itching, appearance, and impact on work) for each group. RESULTS: There were 4841 varicose vein procedures performed from January 2015 to May 2016. There were 3441 procedures performed in 2691 patients (3631 limbs) in the group <65 years old and 1400 procedures performed in 1068 patients (1467 limbs) in the group >/=65 years old. Truncal veins alone were the most common veins treated in both groups. The majority of patients were white and female in both groups. Most of the demographic characteristics were clinically similar (although statistically different) in both groups with the exception of a higher body mass index in the group <65 years old and a history of bilateral varicose vein treatment, and anticoagulation was more common among patients >/=65 years old. Patients in both groups experienced statistically significant improvement in VCSS, PROs, and CEAP class. There was no difference in overall complications between age groups. CONCLUSIONS: All patients demonstrated an associated improvement in both clinical outcomes (CEAP class, VCSS) and PROs. There was no significant difference in the improvement in CEAP class and VCSS between patients younger and older than 65 years, although the younger population reported greater improvement in PROs. Given these findings, patients older than 65 years appear to benefit from varicose vein procedures and should not be denied interventions on their varicose veins and venous insufficiency on the basis of their age only.

OBJECTIVE: The goal of this study is to determine if compression therapy after endovenous ablation (EVA) of the great saphenous vein (GSV) improves efficacy and patient reported outcomes of pain, ecchymosis and quality of life. METHODS: This was a prospective randomized controlled trial from 2009 to 2013 comparing the use of thigh-high 30-40mmHg compression therapy for 7 days vs no compression therapy following endovenous ablation of the GSV. Severity of venous disease was measured by CEAP scale and the venous clinical severity score (VCSS). Quality of life assessments were carried out with a CIVIQ-2 questionnaire at days 1, 7, 14, 30 and 90, and the visual analog pain scale daily for the first week. Bruising score was assessed at 1 week post procedure. Post ablation venous duplex was also performed. RESULTS: 70 patients and 85 limbs with EVA were randomized. EVA modalities included radiofrequency ablation (91%) and laser ablation (9%). CEAP class and VCSS scores were equivalent between the two groups. There was no significant difference in patient reported outcomes of post-procedural pain scores at day 1 (mean 3.0 vs. 3.12, p =0.948) and at day 7 (mean 2.11 vs 2.81,p =0.147), CIVIQ-2 scores at 1 week (mean 36.9 vs 35.1, p=0.594), at 90 days (mean 29.1 vs 22.5, p =0.367) and bruising score (mean 1.2 vs 1.4,p=0.561) in the compression vs. no compression groups respectively. Additionally, there was a 100% rate of GSV closure in both groups and no endothermal heat-induced thrombosis (eHIT) as assessed by post-ablation duplex. CONCLUSION: Compression therapy does not significantly affect both patient reported and clinical outcomes after GSV ablation in patients with non-ulcerated venous insufficiency. It may be an unnecessary adjunct following GSV ablation.

Background: The Vascular Quality Initiative/Varicose Vein Registry (VQI/VVR) represents a patient-centered database launched in January 2015. Previous work describing overall trends and outcomes of varicose vein surgery across the United States demonstrates a benefit from these procedures. The existing gaps in Medicare coverage of varicose vein procedures necessitate further description of clinical outcomes in patients >65 years old compared with the <65-year-old population. Methods: This study analyzed prospectively captured anatomic, procedural, and outcome data for all patients in a national cohort of all VQI/VVR-participating centers. The VQI/VVR database was queried for all patients undergoing varicose vein surgery between January 2015 and July 2016. Preprocedural and postprocedural scores were compared between patients <65 years old and >65 years old for the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification, Venous Clinical Severity Score (VCSS), and patient-reported outcomes (PROs). Univariate descriptive statistics of demographic and procedural data were performed. Paired t-tests were then performed on change in CEAP classification, VCSS, and PROs (heaviness, achiness, throbbing, swelling, itching, appearance, and work impact) for each group. Results:There were 3124 patients (4254 limbs) in the <65-year group and 1232 patients (1698 limbs) in the >65-year group. The most common anatomic location treated was the great saphenous vein in both groups. The majority of patients were white and female in both groups. Most of the demographic characteristics were clinically similar (although statistically different) in both groups, with the exception that anticoagulation was more common among patients >65 years (Table I). Patients in both groups experienced improvement in VCSS and PROs (Table II). CEAP classification stayed the same or improved in 95.1% in the <65-year group and 92.4% in the >65-year group; considering only improved scores, benefit was seen in 57.4% and 52%, respectively. There was no difference in complications between age groups. Conclusions: All patients demonstrated an associated improvement in both clinical outcomes (CEAP class, VCSS) and PROs. There was no significant difference in the improvement in CEAP class and VCSS between patients younger and older than 65 years, although PROs did improve more in the younger population. Given these findings, patients older than 65 years appear to benefit equally from varicose vein interventions as younger patients. (figure present)

Background: Patients who present acutely with a femoral vein deep venous thrombosis (DVT) diagnosed by ultrasound are often treated with anticoagulation and instructed to follow up electively. This study sought to assess whether obtaining central imaging in this cohort of patients results in an increased diagnosis of iliocaval DVT and consequently an increased consideration for interventional treatments to effect thrombus removal. Methods: This study was a retrospective review of a prospectively maintained RedCap database from November 2014 through August 2016, which is coordinated by the Venous Thromboembolic Center at our institution. Consecutive patients who were diagnosed by ultrasound with a femoral vein DVT were evaluated. The patients who underwent confirmatory central venous imaging (computed tomography venography, magnetic resonance venography; group A) were compared with the patients who did not undergo central venous imaging (group B). Demographic variables were collected. The outcomes evaluated were (1) the presence of iliocaval DVT, (2) candidacy for lytic-based therapies, (3) performance of lytic-based therapy, and (4) performance of any invasive treatment (lytic therapy, mechanical thrombectomy, inferior vena cava filter placement, or venous stenting). Additional outcomes included technical success of invasive treatment and complications associated with invasive treatment. Results:A total of 63 patients were identified who presented with a diagnosis of femoral vein DVT. Group A comprised 20 of 63 (31%) patients. Group B comprised the remainder, 43 of 63 (69%). The baseline demographics did not differ significantly, except for gender (Table). The number of patients who were diagnosed with an iliocaval DVT differed significantly (group A, nine [45%]; group B, nine [20%]; P <.0001). The number of patients who underwent lytic therapy differed significantly (group A, eight [40%] - seven at the index admission and one at 1 month; group B, 0 [0%]; P <.0001). The number of patients without relative contraindications to lytic therapy did not differ significantly (group A, 13 [65%]; group B, 34 [79%]; P =.35). The number of patients who underwent any invasive treatment differed significantly between the two cohorts (group A, 12/20 [60%]; group B, 4/43 [9%]; P =.0001). The majority of interventions were technically successful in both groups (group A, 11/12 [91.7%]; group B, 4/4 [100%]; P = 1.00). Conclusions: This study suggests that a significant percentage of patients diagnosed by ultrasound with femoral vein DVTs have a concomitant iliocaval DVT. The data suggest that in patients with a femoral vein DVT, central venous imaging may be indicated to identify potentially treatable iliocaval thrombosis. Long-term data will be required to see if this results in a decrease in post-thrombotic syndrome on a population basis. (table present)