Faculty Bibliography

Background The development and use of minimally invasive procedures provide improved options for the management of symptoms of chronic venous insufficiency. While many patients with iliac venous occlusive disease and superficial venous insufficiency improve with combined iliac venous stenting and correction of superficial venous reflux, some patients have symptoms which persist. The goal of this study was to identify clinical factors related to persistent symptoms in patients with leg swelling after treatment of both iliac vein stenting and thermal ablation. Methods This observational study analyzed data for patients who underwent both iliac vein stent placement as well as endovenous ablation (either RFA or EVLT) as a management for chronic venous insufficiency between February 2012 and February 2014. Follow-up was performed after completion of both procedures and inquiring for improvement of swelling. 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, 55 (31.8%) patients were men; 29 (16%) patients stated they had no improvement after these procedures. The average age of patients who did not improve was 68.8 (±16.7 SD) years and 66.2 (±13.3 SD) years for patients who improved. Over all, the classification of the presenting symptoms by CEAP classification demonstrated 25.4%, 53.2%, 5.8%, and 15.6%, for C3-C6, respectively. There was no correlation with failure to improve the swelling with: age ( P = .44), gender ( P = .33), presenting symptom ( P = .67), use of calcium channel blockers ( P = .85), nitroglycerin ( P = .86), Plavix ( P = .07), aspirin ( P = .55), Synthyroid ( P = .55), Coumadin ( P = .14), angiotensin receptor blocker ( P = .81), β Blockers ( P = .61), angiotensin converting enzyme inhibitors ( P = .88), furosemide 40 mg ( P = .74), hydrochlorothiazide 12.5 mg ( P = .07), hydrochlorothiazide 25 mg ( P = .48), and EVLT vs. RFA ( P = .91). The use of furosemide (20 mg) was associated with continued swelling ( P = .01). The use of dual diuretics (furosemide and hydrochlorothiazide) was associated with persistent swelling even after these combined endovenous procedures P = .03). Conclusion These preliminary data suggest that the treatment with diuretics may be associated with failure to relieve lower extremity swelling despite combined endovascular therapy for chronic venous insufficiency.

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: 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.

INTRODUCTION: We examined the rate of positive findings and the distribution of vascular ultrasounds in the pediatric and adult population. Prior literature has noted a low rate of positive findings in adult vascular ultrasounds but there is little literature on pediatric vascular ultrasound. METHODS: We reviewed our vascular duplex database on inpatients less than 18 years old and compared it to the adult inpatient vascular duplex exams from 2005 to 2010. RESULTS: The adult patients had more extremity vascular exams while the pediatric patients had more abdominal and renal exams. Moreover, the positive rate of adult lower extremity arterial duplex was significantly higher than the pediatric group (p = 0.002). CONCLUSION: We had a higher yield of positive findings in the adult cases. We observed a higher proportion of more complex duplex exams in the pediatric cases suggesting that a higher level expertise is needed to perform the pediatric vascular duplexes.

BACKGROUND: Accreditation in peripheral venous testing can be obtained based upon femoropopliteal duplex ultrasound evaluation, and many laboratories limit their examination to this segment only. This simplified protocol detects acute femoropopliteal deep venous thrombosis (DVT) but misses calf vein DVT, superficial venous thrombosis, chronic DVT, venous reflux, and other non-venous findings potentially responsible of the patients' presenting conditions. A protocol limited to the femoropopliteal segment results in additional unnecessary testing and can create patient dissatisfaction. We evaluated the differences in the diagnosis between a limited femoropopliteal versus a complete approach to the venous ultrasound evaluation of the lower extremities in patients examined in an outpatient vascular laboratory. METHODS: A data base with the complete ultrasound exams of the lower extremity including the common femoral, deep femoral, popliteal, tibial and peroneal veins, calf muscular veins, great and lesser saphenous veins, performed in 812 consecutive patients over an 8 month period, was queried. RESULTS: Acute femoropopliteal DVT was found in (32/812) = 3.94% of the patients. Chronic femoropopliteal DVT was found in (54/812) = 6.65%. Acute infrapopliteal DVT was found in (33/812) = 4.06%. Chronic infrapopliteal DVT was found in (41/812) = 5.04%. Superficial venous thrombosis of lower extremities (124/812) = 15.27%. In addition, deep venous insufficiency (>500 milliseconds) was found in (404/812) = 49.75% and superficial venous insufficiency in (254/812) = 31.28 % (>500 milliseconds). A mass (cyst, hematoma, solid mass or aneurysm) was found in (23 cysts, 2 Hematomas, 23 solid mass, 4 aneurysms) 52/812 = 6.4%. CONCLUSIONS: Limited femoropopliteal ultrasound examination for acute DVT would have only detected a small percentage of the positive findings. These data suggest that a complete duplex exam can be used to further delineate the cause of outpatients' symptoms as compared to the limited protocol.

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.

Standard approaches to lower extremity arteries may be rendered difficult or unusable because of scarring or infection, or both. This article describes unusual alternative approaches to facilitate lower extremity bypasses that would normally require approaches to the common femoral, deep femoral, or popliteal arteries. Techniques are described for using the distal external iliac artery, the distal two-thirds of the deep femoral artery, and the above-knee and below-knee popliteal artery approached laterally.