Faculty Bibliography

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)

OBJECTIVES: Nutcracker syndrome, or mesoaortic compression of the left renal vein (LRV), with associated symptoms related to venous hypertension in the left kidney, is a rare entity that may result in severe symptoms requiring operative intervention. We report on three patients who presented with nutcracker syndrome, including one patient with a circumaortic LRV resulting in posterior nutcracker syndrome, who underwent successful endovascular treatment with renal vein stenting. A review of existing literature on endovascular management of nutcracker syndrome follows. METHODS: Three women (age range 28 to 43 years) presented with symptoms and imaging studies consistent with nutcracker syndrome. Symptoms included pelvic and flank pain in all three patients, and episodes of hematuria in two. Imaging studies demonstrated compression of the LRV between the superior mesenteric artery and aorta in two of the patients. The third patient was noted to have a circumaortic LRV. RESULTS: All three patients underwent venography and LRV stenting. Stents included a 12 x 40 mm self-expanding nitinol stent, 14 x 60 mm Wallstent, and 16 x 40 mm Wallstent. All patients were placed on clopidogrel post-operatively. The duration of follow-up ranged from six to twenty-seven months. At follow up, all three patients reported significant symptomatic improvement, and duplex ultrasonography demonstrated stent patency in all. CONCLUSIONS: Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Results are encouraging at follow-up periods beyond two years.

BACKGROUND: Mesenteric venous thrombosis (MVT) is a relatively uncommon but potentially lethal condition associated with bowel ischemia and infarction. The natural history and long-term outcomes are poorly understood and under-reported. METHODS: A single-institution retrospective review of noncirrhotic patients diagnosed with MVT from 1999 to 2015 was performed using International Classification of Diseases, Ninth Revision and radiology codes. Patients were excluded if no radiographic imaging was available for review. Eighty patients were identified for analysis. Demographic, clinical, and radiographic data on presentation and at long-term follow-up were collected. Long-term sequelae of portal venous hypertension were defined as esophageal varices, portal vein cavernous transformation, splenomegaly, or hepatic atrophy, as seen on follow-up imaging. RESULTS: There were 80 patients (57.5% male; mean age, 57.9 +/- 15.6 years) identified; 83.3% were symptomatic, and 80% presented with abdominal pain. Median follow-up was 480 days (range, 1-6183 days). Follow-up radiographic and clinical data were available for 50 patients (62.5%). The underlying causes of MVT included cancer (41.5%), an inflammatory process (25.9%), the postoperative state (20.7%), and idiopathic cases (18.8%). Pancreatic cancer was the most common associated malignant neoplasm (53%), followed by colon cancer (15%). Twenty patients (26%) had prior or concurrent lower extremity deep venous thromboses. Most patients (68.4%) were treated with anticoagulation; the rest were treated expectantly. Ten (12.5%) had bleeding complications related to anticoagulation, including one death from intracranial hemorrhage. Four patients underwent intervention (three pharmacomechanical thrombolysis and one thrombectomy). One patient died of intestinal ischemia. Two patients had recurrent MVT, both on discontinuing anticoagulation. Long-term imaging sequelae of portal hypertension were noted in 25 of 50 patients (50%) who had follow-up imaging available. Patients with long-term sequelae had lower recanalization rates (36.8% vs 65%; P = .079) and significantly higher rates of complete as opposed to partial thrombosis at the initial event (73% vs 43.3%; P < .005). Long-term sequelae were unrelated to the initial cause or treatment with anticoagulation (P = NS). CONCLUSIONS: Most cases of MVT are associated with malignant disease or an inflammatory process, such as pancreatitis. A diagnosis of malignant disease in the setting of MVT has poor prognosis, with a 5-year survival of only 25%. MVT can be effectively treated with anticoagulation in the majority of cases. Operative or endovascular intervention is rarely needed but important to consider in patients with signs of severe ischemia or impending bowel infarction. There is a significant incidence of radiographically noted long-term sequelae from MVT related to portal venous hypertension, especially in cases of initial complete thrombosis of the mesenteric vein.

OBJECTIVE: To define the relative importance of fiber type as compared to laser wavelength on tissue injury depth, postoperative pain, and bruising during endovenous laser ablation. METHODS: This study included 213 limbs that were treated with an 810-, 980-, or 1470-nm laser, with bare-tip (BT) or jacket-tip (JT) fibers. Pain scores (10-point scale) and bruising scores (5-point scale) were recorded. Tissue thermal injury depth (mm) was evaluated in vitro for the 810- and 1470-nm wavelengths with BT and JT fibers. RESULTS: The JT fibers had lower pain scores as compared to the BT fibers at 810 nm (1.69 +/- 1.77 vs 3.70 +/- 1.34; P < .0005) and at 980 nm (1.14 +/- 1.06 vs 2.71 +/- 1.80; P < .0005). The JT fibers had lower bruising scores as compared to the BT fibers at 980 nm (0.89 +/- 1.06 vs 2.00 +/- 1.44; P < .0005). The in vitro study showed lower thermal injury depths for the JT as compared to the BT fibers at 810 nm (0.36 mm +/- 0.26 mm vs 1.05 mm +/- 0.34 mm; P < .0005) and at 1470 nm (0.20 +/- 0.16 mm vs 0.71 +/- 0.31 mm; P < .0005). With regard to wavelength, 980-nm laser had lower pain scores as compared to 810-nm laser with BT fibers (2.71 +/- 1.80 vs 3.70 +/- 1.34; P = .015), and with JT fibers, a similar result trended toward significance (1.14 +/- 1.06 vs 1.69 +/- 1.77; P = .057). The 980-nm JT fiber showed less bruising as compared to the 810-nm JT fiber (0.89 +/- 1.06 vs 1.42 +/- 1.19; P = .019). Similarly, the 1470-nm JT fiber showed less bruising as compared to the 810-nm JT fiber (0.94 +/- 1.02 vs 1.42 +/- 1.19; P = .038). The in vitro study showed thermal injury depths that were less for 1470 nm as compared to 810 nm, with JT fibers (0.20 +/- 0.16 mm vs 0.36 +/- 0.26 mm; P = .013) or with BT fibers (0.71 +/- 0.31 mm vs 1.05 +/- 0.34 mm; P =.001). All mean differences between JT and BT fibers were greater than between differing wavelengths. The multivariate analysis for the in vitro study showed a mean difference between 1470 nm and 810 nm of 0.26 mm, P < .0005 favoring 1470 nm and a mean difference between JT and BT fibers of 0.61 mm, P < .0005 favoring the JT fibers. CONCLUSIONS: The use of a JT fiber appeared to be more significant in reducing pain and bruising as compared to a longer wavelength. Moreover, the results appeared additive, and the cohort using 1470 nm with a JT fiber produced the best treatment outcomes. Additional study is required to confirm the efficacy and durability of the various iterations evaluated; however, these data should be taken into consideration when undertaking treatment with endovenous laser ablation.

Forequarter amputation is a radical operation performed for treatment of malignant neoplasms of the shoulder girdle not amenable to limb salvage. Traditional approaches involve bone and soft tissue resection, followed by ligation of the axillary vessels. We describe a technique to minimize blood loss whereby control of the subclavian vessels is performed before amputation of a large tumor associated with extensive venous congestion. A 34-year-old man presented with proximal humeral osteosarcoma. Surgery involved claviculectomy to facilitate vascular control of the subclavian vessels, followed by guillotine amputation at the proximal upper arm level and completion of the amputation as conventionally described.