Faculty Bibliography

OBJECTIVE: When assessing the common femoral and suprainguinal veins in patients with venous stasis, it is generally agreed that use of intravascular ultrasound (IVUS) is mandatory. This widely held dogma is reinforced by the fact that extrinsic compression of the iliac veins does not reproduce images consistent with eccentric stenosis as one sees in the arterial system. In an attempt to identify a subgroup of patients where the use of IVUS could be averted, we analyzed and carefully evaluated the images of patients who had both standard contrast venograms and IVUS examinations. METHODS: Ninety-two common femoral and suprainguinal venograms performed during a recent 6-month period were randomly selected for analysis. Good quality venographic images were found in 88 of these limbs (78 patients) that also had IVUS data formed the basis of this analysis. All venograms included visualization of the common femoral, external and common iliac veins, and inferior vena cava. These veins were classified as (1) normal to mild (type I) vein narrowing or dilatation of /=21%-40%, (3) severe (type III) >/=41%, and (4) bull's eye sign (type IV). The latter was defined as a central circle with minimal or no dye within a dilated vein and forking of the dye around the circle. RESULTS: In the present series, no 1-month mortality or 1-month morbidity was observed in these patients. The Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification score was class II in 24 cases (26%), class III in 36 cases (39%), class IV in 17 cases (18%), class V in nine cases (10%), and class VI in six cases (7%). There was no venographic or IVUS evidence of inferior vena cava stenosis or dilatation in this series. Of the venograms studied, 88 had positive intravascular ultrasound (PIVUS) or positive predictive value findings. The correlation of venographic findings and PIVUS was as follows: type I cases (26) had 85% PIVUS; type II (22) had 100% PIVUS; type III (25) had 100% PIVUS, and type IV (19) had 100% PIVUS. CONCLUSIONS: The new proposed classification of venographic findings can be used to treat more than two-thirds of the patients without resorting to the use of IVUS.

Background Venous aneurysms of the upper torso are uncommon in contrast to the abdomen and lower extremities. Mostly silent, they can cause significant morbidity. Large or symptomatic venous aneurysms are generally treated with open resection. To our knowledge, there are no documented cases of head and neck venous aneurysms treated by a hybrid endovascular and open approach. Case Presentation A 56-year-old female presented with the complaint of pain and increasing size of a supraclavicular mass. Imaging revealed a large saccular aneurysm of the subclavian vein with the presence of a large intramural thrombus on computed tomography scan with contrast. A covered stent was deployed in order to exclude the aneurysm from circulation. Three weeks later, the symptoms continued, and an aneurysmorrhaphy was performed to excise the stent and aneurysm resection. Discussion A combined endovascular and open approach to resection of symptomatic subclavian vein aneurysms is a viable method with minimal morbidity.

OBJECTIVE: Delayed maturation of arteriovenous fistulae (AVF) among patients who require hemodialysis (HD) can lead to catheter sepsis with its resultant morbidity and mortality. Some have proposed that sequential balloon-assisted maturation (BAM) may accelerate the maturation times of these accesses. On the other hand, serial balloon angioplasty of normal vein may result in stenosis and delay maturation. Although the safety of BAM has been shown, direct comparison to non-matured AVF has not been explored. Therefore, we conducted a retrospective analysis of our prospectively maintained vascular access database to compare the duration of time period to AVF maturation between patients who received BAM and those who were not referred for BAM at our institution. METHODS: Prospectively collected data over a three-year period in 194 patients who underwent AVF creation at our institution were retrospectively analyzed. The duration to maturation of the AVF was determined by comparing the time period between the creation of the fistula and the first successful cannulation of the fistula. Only patients on hemodialysis were included. Patients who underwent BAM or placement of AVF at an outside institution were excluded. Follow-up consisted reviewing of post-operative AVF duplex for patency, hospital and clinic databases, hemodialysis center databases, and telephone interviews. RESULTS: Of the 194 patients who had AVF placement, 172 patients were on HD within 2 weeks of AVF placement while 22 patients had AVF placed in anticipation of the need for HD. Of the 172 patients on HD within two weeks, 54 patients had BAM performed at our institution and 4 patients had BAM at an outside institution while 114 patients were not referred for BAM. 33 of these 114 patients were age and gender matched to compare to the patients who underwent BAM at our institution. At the time of this analysis, of the 54 patients who had BAM, 30 had functional AVF (19 males, 11 females; mean age of 62 years (range, 26-86years (SD +/- 18 years)). In the BAM group of functioning AVF, n=30, the total number of procedures was 125 (range: 1-8, average 4). The overall average duration to maturation of the AVF was 119 days (SD +/- 84 days) and 146 days (SD +/- 157 days) P = .73, for BAM and non-BAM, respectively. CONCLUSION: These preliminary data suggest the role of BAM did not decrease maturation times of AVF and that BAM warrants further scrutiny before further adoption.

Background Complete thrombosis of an aortic endograft after an endovascular aortic aneurysm repair is a rare complication. The majority of thrombotic events occur in the iliac limbs. Case presentation We present the case of a patient who presented with acute limb ischemia as the result of a thrombosed infra-renal aortic endograft. After restoration of blood flow to the lower extremities with an axillary to bi-femoral artery bypass, the patient was lost to follow-up. The patient returned two years later with a ruptured abdominal aortic aneurysm due to a type 1A endoleak. Discussion We propose that all patients after endovascular aortic aneurysm repair, including those with a thrombosed aortic endograft, continue to undergo regular graft surveillance. This case report highlights the importance of continued surveillance of the aortic sac, even after total thrombosis of the endovascular aortic aneurysm repair.

Objective Treatment of non-thrombotic iliac vein lesions is an active area of research. Intravascular ultrasound allows its localization. We chose intravascular ultrasound to clarify the exact anatomical location of non-thrombotic iliac vein lesions and correlate it with clinical findings. Materials and methods Over seven months, we performed ilio-femoral intravascular ultrasound studies on 217 patients, in 141 women and 76 men. The average age +/- standard deviation was 68 +/- 14 years. We used intravascular ultrasound intraoperatively to measure the ilio-femoral veins and compared it with adjacent non-stenotic ilio-femoral veins. If more than 50% area or diameter reduction was found, it was treated with appropriate balloon and stent. Results We identified 244 lesions, 124 in left lower extremity and 120 in the right lower extremity. The most common site was the proximal common iliac vein 38.7% (22.5% females and 16.12% males) in left lower extremity and middle external iliac vein 29.16% (18.33% females and 10.83% males) in right lower extremity. The least common site was the distal external iliac vein in 3.2% (all 3.2% females) and the distal external iliac vein 7.5% (5% females and 2.5% males) in right lower extremity. Clinical correlation was noted between laterality and location of the NIVL lesion ( p < 0.0001). Conclusion This analysis gives an insight into understanding the exact anatomical locations of the non-thrombotic iliac vein lesions helping clinicians and researchers guide their treatment and research.

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases. Little literature has examined the effect of race/ethnicity on venous disease. Iliac vein stenting is an emerging technology in treating chronic venous insufficiency. To further characterize this disease and its treatment, we chose to study the effect of selected clinical factors including race/ethnicity on the early complications of non-thrombotic iliac vein stenting. Methods In this observational study, data analysis was performed for 623 patients with chronic venous insufficiency who underwent iliac vein stenting during the time period from August 2012 to September 2014. Patients were categorized by Caucasians ( n = 396), African Americans ( n = 89), Hispanics ( n = 138), and others ( n = 23). These were correlated with the age, gender, presenting sign according to CEAP classification, percentage of iliac vein stenosis, post-operative thrombosis and pain score. Pain score was obtained post-operatively on a Likert scale of 0-10. Follow-up was performed after completion of the procedure, through post-operative visits and duplex exams every three months for the first year. Statistical analysis was performed using Chi-square and Student's t-test, Pearson's test and multivariate regression. Results The average age of the study patients was 67.8 years (age range 23-96 years, +/- 14.2 SD). Sixty-seven patients were women. The presenting sign according to CEAP classification was (C3 = 331, C4 = 175, C5 = 51, C6 = 66). The average pain score was 2.6 (+/-2.9 SD). The average degree of stenosis was 64.9% (+/-3.8 SD). There were insufficient numbers in the "other" race/ethnicity group for further analysis. The number of patients with iliac vein stent thrombosis was 14 (2.2%). When analyzing each race/ethnicity in our dataset with univariate analysis, we found that Caucasians were significantly older than the African Americans and Hispanics ( P < 0.0001). There tended to be more women in the Caucasian group as compared to the Hispanics ( P = 0.04). There were no differences in presenting sign according to CEAP classification or degree of stenosis between the three groups. Hispanics tended to have higher pain scores post-operatively than Caucasians ( P = 0.01). It was found that 1.8% of Caucasians, 3.4% of African Americans and 2.9% of Hispanics had post-operative iliac vein stent thrombosis ( P = 0.55). Men have higher CEAP score than women regardless of race/ethnicity ( P = 0.0001). On the other hand, women tended to have higher pain score than men ( P = 0.04). There were no differences between men and women regarding age, degree of stenosis, and stent thrombosis. Linear multivariate regression test and Pearson's test revealed that age is inversely related to pain score ( P < 0.0001). ANOVA multivariate regression statistical analysis showed no relation between race/ethnicity and pain score ( P = 0.98), and one-way ANOVA showed that the Caucasians were the eldest ethnic group in the study ( P < 0.0001). Linear multivariate regression test and Pearson's correlation test revealed that race/ethnicity is not correlated with thrombosis of iliac vein after stenting ( P = 0.8). Conclusion Race/ethnicity is not significantly associated with CEAP score, degree of iliac vein stenosis, or post-operative thrombosis or pain scores. Age was inversely associated with pain score after iliac vein stenting.