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251


NICE Guidelines for AAA Repair: An Enigma [Editorial]

Sultan, Sherif; Veith, Frank J; Ascher, Enrico; Ouriel, Kenneth; Hynes, Niamh
PMID: 32659137
ISSN: 1545-1550
CID: 4527912

Compartment Syndrome of the Leg After Intraosseous (IO) Needle Insertion

Kibrik, Pavel; Alsheekh, Ahmad; Rajaee, Sareh; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections and compartment syndrome. We present a case of an 87 year old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.
PMID: 31676383
ISSN: 1615-5947
CID: 4184362

Reply [Letter]

Ascher, Enrico; Chait, Jesse; Marks, Natalie; Hingorani, Anil; Kibrik, Pavel
PMID: 32305121
ISSN: 2213-3348
CID: 4395432

Reply [Letter]

Chait, Jesse; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
PMID: 32305118
ISSN: 2213-3348
CID: 4396662

Etiology of iliocaval stent thrombosis

Aurshina, Afsha; Ascher, Enrico; Haggerty, James; Marks, Natalie; Rajaee, Sareh; Hingorani, Anil
OBJECTIVE:Although correction of iliac vein stenosis is safe and efficacious, one of its major complications is iliac vein stent thrombosis. In an attempt to examine the cause of iliac vein stent thrombosis, we reviewed the location of underlying lesions encountered after thrombectomy or thrombolysis of iliac vein stents. METHODS:A retrospective analysis was performed of all iliac vein venograms with intravascular ultrasound examinations at our office-based surgical center from February 2012 to July 2016. Patients included in the study had chronic venous insufficiency and failed compression therapy. All procedures were performed with local anesthesia and conscious sedation. Wallstents were used in all procedures for nonthrombotic iliac vein stenosis, ranging from 8 to 24 mm in diameter and 40 to 90 mm in length. Patients were followed with transcutaneous duplex every 3 months for the first year and every 6 to 12 months thereafter. Patients were placed on clopidogrel for 3 months or continued on their preexisting anticoagulants. RESULTS:From February 2012 to July 2016, we performed 2228 iliac vein venograms with intravascular ultrasound examination in 1381 patients. The mean age of the patient population was 65 ±14 years (range, 21-99 years), among which 876 were female. A total of 1037 procedures were performed in the left lower extremity. Of these, 240 venograms were diagnostic. Presenting symptoms based on CEAP classification included C2 (n = 21), C3 (n = 633), C4 (n = 1065), C5 (n = 269), and C6 (n = 241). Complete thrombosis of the iliac vein stent was noted in 18 patients (0.8%) who thereafter underwent suction thrombectomy with thrombolysis. None of these patients had a prior history of deep vein thrombosis. In-stent restenosis was noted in 11 patients. Proximal lesions were found in no patients. An external iliac vein lesion was found distal to the common iliac vein stent in two patients. Common femoral vein lesions were found in six patients. These encountered lesions were then stented. All patients who underwent thrombectomy were placed on anticoagulation for 6 months. No patient were noted to suffer rethrombosis upon follow-up. No correlation with stent thrombosis was encountered for age, gender, laterality, location, presenting symptoms, or length or diameter of the stent. CONCLUSIONS:Based on our experience, in-stent restenosis followed by inflow lesions in the common femoral vein are the most common causes of stent thrombosis. These data suggest a need for future research to target these areas.
PMID: 31843484
ISSN: 2213-3348
CID: 4242302

Iliac Vein Stent Placement and the Iliocaval Confluence

Alsheekh, Ahmad; Hingorani, Anil; Aurshina, Afsha; Kibrik, Pavel; Chait, Jesse; Ascher, Enrico
OBJECTIVE:Prior literature has recommended routine iliac vein stent extension into the inferior vena cava (IVC) to assure adequate outflow for iliac vein stenting procedures. Our bias was that only the lesion should be stented without routine stent extension up to the IVC. We report our experience with this limited stenting technique. METHODS:From 2012 to 2015, (844) patients (1216 limbs) underwent iliac vein stenting for non-thrombotic iliac vein lesions (NIVLs). All limbs were evaluated according to the presenting sign of the CEAP score, duplex scans and intravascular ultrasound (IVUS) showing more than 50% cross-section area or diameter reduction. All study patients had failed 3 months of conservative management. The procedures of iliac vein stenting were all office-based. Two techniques were compared: 1) placement of the iliac vein stent to cover the lesion and terminating cephalad into the IVC if the lesion involved the common iliac vein and 2) placement of the iliac vein stent to cover the lesion only and not passing the iliocaval confluence if the lesion only involved the external iliac vein. Complications were assessed during 30 days follow up using the duplex scan to look for thrombosis. RESULTS:Of the total 844 patients, 543 (64%) were women. The average age was 66 (±14. 2) years (range, 21-99 years). The stent was placed in the left lower limb in 474 patients and bilateral in 370 patients. The presenting sign according to CEAP classification was (C3 = 626, C4 = 404, C5 = 44, C6 = 141). The average iliac vein stenosis by IVUS was 62% (± 12% SD). We had 715 patients with the iliac vein stent extending into the IVC and of these, 8 patients had thrombosis within 30days after the procedure. On the other hand, 501 patients had the iliac vein stent without crossing the iliocaval confluence and of these, 4 patients had thrombosis within 30 days of the procedure. There was no difference between these two groups in regards to gender (P=0. 1) or age (P=0. 3). Laterality was statistically different (P<0.0001) with more stents to be extended into the IVC if the lesion is in the left lower limb. Comparing these two groups in regard to 30-days thrombosis as a complication was not statically significant (P= 0. 6). There was no statistical difference between the two groups in regards to the presenting sign CEAP (P=0.6). CONCLUSION/CONCLUSIONS:These results question the need for routine iliac vein stent extension into the IVC in patients with NIVLs. We were not able to demonstrate a significant risk of thrombosis with just placing the stent to cover the lesion only with short-term follow up.
PMID: 31648035
ISSN: 1615-5947
CID: 4147682

Effect of venous access site on postintervention stent thrombosis for nonthrombotic iliac vein stenting

Chait, Jesse; Alsheekh, Ahmad; Aurshina, Afsha; Haggerty, James; Ostrozhynskyy, Yuriy; Rajaee, Sareh; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Prior literature suggests that routine femoral vein (FV) puncture is necessary for interrogation of the iliac veins for stenosis to avoid missing common femoral vein (CFV) lesions. However, this can be technically challenging and poses small but increased risks. The purpose of this study was to compare the incidence of stent thrombosis after iliac vein stenting in the treatment of nonthrombotic iliac vein lesions with use of two discrete venous access sites-the CFV and FV. METHODS:During 4 years, we performed 1605 lower extremity venography studies with intravascular ultrasound (IVUS). There were 372 men and 689 women with an average age of 66 years (range, 21-99 years; standard deviation [SD], ± 14.3 years). After IVUS interrogation, 1513 procedures resulted in venous stenting; 964 patients received stent placement in the common iliac vein, 513 in the external iliac vein, 24 involving the CFV, and 12 involving the FV. The venous puncture site, accessed by ultrasound guidance, varied between the CFV and FV per the surgeon's choice and was documented on the basis of the most distal vein area measured by IVUS during the procedure. Patients were followed up with iliocaval and lower extremity duplex ultrasound within 2 weeks and every 3 months thereafter for the first year. RESULTS:There were 994 patients who received CFV puncture and 611 patients who received FV puncture. In 39 (4.2%) patients receiving CFV punctures with subsequent stent placement, any stent thrombosis developed within 30 days of the intervention; 27 (69.2%) were complete thromboses. In 21 (3.6%) patients who received FV punctures with subsequent stent placement, any stent thrombosis developed within 30 days of intervention; 17 (81.0%) were complete thromboses. There was no significant difference (P = .57) in ≤30-day thromboses between the CFV and FV cohorts. Any in-stent thrombosis developed >30 days after intervention in 18 patients, 11 in limbs that received CFV puncture and 7 with FV puncture (P = .98). Complete stent occlusion occurred in three cases of CFV puncture. No FV punctures led to >30-day complete stent thromboses. The median time to diagnosis of >30-day thrombosis was 11.1 months (range, 2.6-31.9 months; SD, ± 12.86 months). Median follow-up was 20 months (SD, ± 19.18 months). CONCLUSIONS:There was no significant difference between in-stent thrombosis rate and location of initial venous puncture in the setting of outpatient IVUS-guided venography. Both the CFV and FV can be safely used as puncture sites for lower extremity venography.
PMID: 31231060
ISSN: 2213-3348
CID: 3954982

Radiofrequency Ablation Increases the Incidence of Endothermal Heat-Induced Thrombosis

Chait, Jesse; Kibrik, Pavel; Alsheekh, Ahmad; Ostrozhynskyy, Yuriy; Marks, Natalie; Rajaee, Sareh; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Endovenous thermal ablation has become the procedure of choice in the treatment of superficial venous reflux disease. The current armamentarium of devices and techniques aimed at the elimination of saphenous reflux offers surgeons and interventionalists a variety of treatment options, however there is a lack of data comparing the safety of these products. The most concerning complication following endovenous thermal ablation is endothermal heat-induced thrombosis (EHIT) due to the risk of progression to deep venous thrombosis (DVT). This study aimed to compare the incidence rate of EHIT between radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). METHODS:This was a single-center, office-based, retrospective study over the course of 5 years, in which 3218 consecutive patients underwent 10,029 endovenous saphenous ablations. The patient cohort was 66.2% female, with an average age of 61.9 years old. At the time of each individual intervention, 24, 212, 3620, 4806, 200, and 1167 patients had Clinical-Etiology-Anatomy-Pathophysiology (CEAP) disease 1, 2, 3, 4, 5, and 6, respectively. RESULTS:There was a total of 3983 EVLT and 6091 RFA procedures. The most common vessel treated was the great saphenous vein, 63.6% of the time, followed by the small saphenous vein (25.6%), accessory saphenous vein (6.1%), and perforator vein (4.6%). There were 186 cases of EHIT, with 137 (73.6%) identified as type 1 per the Kabnick classification. Endovenous ablation performed via RFA resulted in significantly more cases of EHIT when compared to EVLT (109 vs 77; p = 0.034; OR = 1.52), which was confirmed by multivariate analysis. CONCLUSION/CONCLUSIONS:In the largest single-center study of endovenous saphenous ablations to date, RFA was shown to pose a significantly higher risk of EHIT when compared to EVLT.
PMID: 31394220
ISSN: 1615-5947
CID: 4033472

Safety and efficacy of endovenous ablations in octogenarians, nonagenarians, and centenarians

Kibrik, Pavel; Chait, Jesse; Arustamyan, Michael; Alsheekh, Ahmad; Rajaee, Sareh; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Endovenous ablation of the lower extremity veins has become the primary treatment of symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) and recanalization are two well-known complications of these venous ablative procedures. Because the elderly represent the fastest growing demographic, our goal was to look at whether there is a difference of these complications and age distribution in octogenarians, nonagenarians, and centenarians vs the younger population. METHODS:test and analysis of variance were used for statistical analysis. RESULTS:Ages ranged from 15 years to 103 years. The average age of the patients was 61.9 ± 15.2 years. Average overall follow-up for all age groups was 25.8 ± 12.9 months. Of the 3218 patients, 2700 were younger than 80 years, 380 were between 80 and 89 years, 132 were between 90 and 99 years, and 6 were 100 years or older. Of the 10,029 procedures, 8730 were performed on patients younger than 80 years; 1124, on patients 80 to 89 years; 159, on patients 90 to 99 years; and 16, on patients 100 years or older. There were 111 patients who had bilateral procedures in the accessory saphenous vein, 1878 patients who had bilateral procedures in the great saphenous vein, 99 patients who had bilateral procedures in the perforator vein, and 760 patients who had bilateral procedures in the small saphenous vein. There were statistically significant increases in EHIT rates between octogenarians and those in the age group <80 years (P = .047); between nonagenarians and those in the age group <80 years (P = .04); and between the combined group of octogenarians, nonagenarians, and centenarians and the age group <80 years (P = .012). No statistical difference was found in rates of EHIT between octogenarians and nonagenarians (P = .5). Overall age is a risk factor for the development of EHIT (odds ratio, 1.03; 95% confidence interval, 1.02-1.04; P < .00001). There were statistically significant increases in recanalization rates between octogenarians and those in the age group <80 years (P = .000013); between nonagenarians and those in the age group <80 years (P = .00022); and between the combined group of octogenarians, nonagenarians, and centenarians and the age group <80 years (P < .00001). No statistical difference was found in rates of recanalization between octogenarians and nonagenarians (P = .48). Statistical analysis of centenarians alone was not done because of zero patients available in the EHIT or recanalization category. Overall age was found to be a risk factor for recanalization (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P < .00002). CONCLUSIONS:Whereas there is a relatively higher chance of EHIT and recanalization in the age group >80 years, our study shows that the majority of EHITs were class 1 and class 2. According to our study, venous ablation is safe and effective across all age groups, and age alone should not be used to deny patients venous ablations.
PMID: 31471274
ISSN: 2213-3348
CID: 4066652

Spontaneous hemorrhage from varicose veins: A single-center experience

Hingorani, Amrit; Chait, Jesse; Kibrik, Pavel; Alsheekh, Ahmad; Marks, Natalie; Rajaee, Sareh; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Whereas the commonly described manifestations of venous insufficiency include telangiectasia, varicose veins (VVs), edema, skin changes, and ulcers, we have noted some patients who present with external hemorrhage from lower extremity VVs. Because there are few recent data examining this entity, we herein describe our experience. METHODS:During 29 months, we had 32 patients present with hemorrhage from lower extremity VVs. There were 15 men and 17 women with a mean age of 60.2 years (range, 38-89 years; standard deviation [SD], ±14.9 years). Interestingly, 16 of these patients presented after coming into contact with warm water; 28 patients, 19 patients, and 1 patient presented with reflux >500 milliseconds in the great, small, and accessory saphenous veins, respectively. Eight patients and six patients had reflux >1 second in the femoral and popliteal veins, respectively. RESULTS:All patients were treated with weekly Unna boots. Mean ulcer healing time was 2.12 weeks (range, 1-8 weeks; SD, ± 2.15 weeks). Patients with VV hemorrhage after contact with warm water had a mean healing time of 1.75 weeks, whereas those who bled without such exposure took an average of 3.5 weeks (P = .0426). Twenty patients underwent at least one endovenous thermal ablation procedure, with the average patient in the cohort receiving 2.16 procedures (range, 0-9; SD, ± 2.37). There was no significant difference between laterality, age, or sex between patients who bled after warm water contact and those who bled spontaneously. The ulcers recurred in three of the patients, and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2 months (range, 26 months; SD, ± 8.9 months), and we noted no recurrent bleeding episodes. CONCLUSIONS:Spontaneous hemorrhage of VVs, although relatively under-reported, is not a rare occurrence. Risk factors are unknown; however, half of our patient cohort reported VV hemorrhage during or directly after coming into contact with warm water. Furthermore, these patients demonstrated a significantly shorter wound healing time compared with the rest of the cohort. Basic first aid, wound care, and hemostasis control education should be provided to all patients with VVs. Further investigation surrounding the risk factors associated with VV hemorrhage is warranted.
PMID: 31843245
ISSN: 2213-3348
CID: 4242282