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Factors associated with recanalization and reintervention following below knee polidocanol endovenous microfoam ablation for great saphenous and small saphenous veins

Fang, John; Fang, Christian; Moyal, Andy; Ascher, Enrico; Hingorani, Anil; Marks, Natalie
BACKGROUND:Polidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost one decade with specific advantages for below knee (BK) truncal veins where thermal ablation poses a risk of injury to adjacent nerves. The current literature of the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients. METHODS:We performed a retrospective study of a prospectively maintained database of patients from a single institution who underwent 1% PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasound (DU) within 7 days after injection, every 3 to 6 months for 1 year, and every 6 to 12 months thereafter. Patients with symptomatic recanalization underwent reintervention. The 26 patients lost to follow-up without DU after ablation were excluded. The factors associated with recanalization and reintervention were examined by multivariate and nonparametric analyses. RESULTS:Between March 2018 and July 2023, 411 patients (166 male, 245 female) with 573 treated limbs (284 right, 289 left) met the study criteria. Of the 573 included limbs, 457 (79.8%) had undergone prior above knee saphenous ablations. A total of 554 BK GSV and 42 SSV ablations were performed. The most recent DU was performed at a mean of 231 ± 329 days. The overall recanalization rate was 10.6% (55 GSVs and 8 SSVs) at a mean follow-up of 104 ± 180 days. Comparing the closed and recanalized veins, we found no significant difference in age (P = .90), treated laterality (P = .14), patient body mass index (P = .59), preprocedural CEAP (clinical-etiology-anatomy-pathophysiology) score (P = .79), recanalization rate in GSVs vs SSVs (P = .06), or administered PEM volume (P = .24). The recanalized veins had significantly larger preprocedural diameters than the veins that remained closed (recanalized, 4.9 mm; closed, 4.3 mm; P = .001). Men had higher incidence of recanalization than women (men, 14.2%; women, 8%; P = .015). Anticoagulation use was associated with recanalization (odds ratio, 1.96; 95% confidence interval, 1.1-3.6; P = .03). Early recanalization at the first DU accounted for 31 failures (49.2%) and had a significantly lower administered PEM volume compared with later recanalization (early, 4 mL; late, 5 mL; P = .025). There were no significant differences between the 33 recanalized patients requiring reintervention (52.4%) and the 30 who did not. Twenty-four reinterventions were performed with PEM, 100% of which remained closed at a median of 160 days (interquartile range, 257 days). CONCLUSIONS:PEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 89% at a mean of 231 days and shows promise as salvage therapy. Most cases of recanalization were noted in the early postprocedure period and were associated with a lower PEM volume. A larger vein diameter, male sex, and anticoagulation use are associated with higher rates of recanalization.
PMID: 38580208
ISSN: 2213-3348
CID: 5657212

Impact of the Endovascular Revolution on Vascular Training Through Analysis of National Data Case Reports

Roth, Alexis; Moreno, Oscar; Santos, Tyler; Khan, Hason; Marks, Natalie; Ascher, Enrico; Hingorani, Anil
BACKGROUND:In the last couple decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. METHODS:Data was extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, and miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). Also, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999-2006, 2006-2013, and 2013-2021; the integrated vascular surgery residency was grouped into two intervals: 2012-2017 and 2017-2021. Data were standardized to represent the average number of cases per trainee per year. RESULTS:Within the fellowship, we found a 362.37% increase in endovascular procedures (Mean±standard deviation, 56.80±32.57 vs. 262.63±9.91, p<0.001), while only a 32.47% increase in open procedures (220.19±4.55 vs. 291.68±8.20) between the first to last time intervals. There was a decrease in abdominal aneurysm repair (24.46±7.30 vs. 13.85±0.58, p<0.001) and visceral (6.41±0.44 vs. 5.80±0.42, p=0.039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18±8.23 vs. 382.20±5.84, p<0.001). Residents had a greater total, open, and endovascular procedures per year than fellows (all p<0.001). Chief residents had about half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04±0.80 vs. 12.40±1.32, p=0.007) and visceral (5.83±0.41 vs. 4.88±0.46, p>0.001) procedures than residents. Overall, 52-53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56±12.10 vs. 261.27±10.13, 365.52±17.23 vs. 319.58±6.62, both p<0.001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. CONCLUSION/CONCLUSIONS:Vascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.
PMID: 38367849
ISSN: 1097-6809
CID: 5636152

The robotic approach for vascular and endovascular procedures: a narrative review

Huber, Michael A.; Robbins, Justin M.; Sebastian, Stacy M.; Vu, Alexander Hien; Ferzli, George; Schutzer, Richard; Hingorani, Anil
Background and Objective: The use of robot technology has greatly expanded the field of general surgery. While robot technology has become almost standard for many general surgeons, there is an increasing interest in how this same technology may be utilized within more specialized fields. We sought to explore the advances and current uses of robot technology within the field of vascular surgery. We evaluated this topic broadly in the context of both the open and endovascular approach. Methods: A comprehensive literature search was employed using the following search strategy on PubMed: ("Robotic Surgical Procedures"[Mesh]) AND ("Vascular Surgical Procedures"[Mesh]). A total of 381 articles were identified. No filters were applied. All articles were then screened manually for applicability. Articles relating to cardiothoracic and neurosurgery were excluded (n=366), as the authors were most interested in performing this literature review from the focus of the vascular surgeon, and procedures involving the heart and brain are outside his or her scope of practice. The remaining (n=15) articles were then utilized to provide a synopsis of the advances made in robotic-assisted procedures within the field of vascular surgery. Key Content and Findings: Robot technology is currently being utilized by vascular surgeons to assist in both open and endovascular procedures. Some typical open procedures wherein the robot has shown to be most effective are in complex aortic reconstruction, first rib resection, venous thrombectomy and venous reconstruction following oncologic resection. In addition to open procedures, there is also evidence that robot technology may offer some benefits in purely endovascular ones, such as in inferior vena cava (IVC) filter retrieval and in standard angiograms. Conclusions: This work highlights that robot technology is greatly expanding the field of vascular surgery. In addition to offering a less invasive approach for both major and minor procedures, robot technology has also led to significant increases in team members"™ safety by decreasing radiation exposure. This review will hopefully act as a catalyst to further expand the use of robot technology in vascular procedures, and by effect increase the value that the vascular surgeon brings to the health care system.
ISSN: 2518-6973
CID: 5614882

Systematic Review of Groin Incision Surgical Site Infection Preventative Measures in Vascular Surgery

Robbins, Justin M; Courtney, James; Hingorani, Anil
OBJECTIVE:Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention techniques including: prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy and adhesive drapes METHODS: This review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic review was conducted utilizing the Google Scholar ©, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1,371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics. RESULTS:The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are: - We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin. [Grade 2C] - We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention. [Grade 2C] - Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use. - We suggest closed-incision negative pressure wound therapy be utilized in groin surgical incisions at high risk for SSI. [Grade 2B] - Given the paucity of data regarding adhesive drapes, such as Ioban ®, no recommendation can be made regarding its use. CONCLUSIONS:This review highlights the effects of various preventative techniques and their potential benefit in prevention of SSI in the groin. However, there is a glaring deficit in the available data emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. While the use of endovascular techniques continues to increase thus limiting the amount of open arterial procedures and the potential for further studies to be conducted. In order to provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.
PMID: 36804782
ISSN: 1097-6809
CID: 5433792

Who are the Vascular Society Presidents?

Hingorani, Amrit; Ascher, Enrico; Hingorani, Anil
BACKGROUND:We noted distinct differences between the demographics among the presidents of various vascular societies. To help characterize these among the present United States, Canadian, and European vascular societies, we queried the websites for the United States, Canadian, and European vascular societies in a systematic review for the names of their presidents since their respective inceptions. METHODS:Age and ethnicity were determined by a search on, Google, and online obituaries. The year of ascendency to the presidency and the year of birth were used as identifying time points. RESULTS:There are significant differences between the ages of the presidents of the various vascular societies. While the presidents of Vascular and Endovascular Surgical Society were significantly younger than those of every other vascular society examined, Midwestern Vascular Surgical Society, Canadian Society for Vascular Surgery, and Society of Vascular Medicine were also significantly younger than the remainder of the societies examined (P < 0.0001). The presidents of the remaining societies were not significantly different in age from each other. When comparing the ages of the presidents in the first and last decades of each society, 2 were found to have significantly increased (Society of Vascular Medicine [P = 0.0029] and Vascular and Endovascular Surgical Society [P < 0.0001]), while 2 others were found to have significantly decreased (New England Society for Vascular Surgery [P = 0.0092] and Eastern Vascular Society [P = 0.0085]). Of the 532 total entries for these presidents examined over these 13 societies, 19 (3.6%) of these were filled by women and 37 (7%) with minorities. CONCLUSIONS:There was a great deal of variability in terms of age, gender, and minority representation of the presidents among the vascular societies examined. While the share of women and minorities to serve as presidents in vascular societies varied between societies, both groups were under-represented across the board. However, in recent years, the number of women and minorities elected as presidents of vascular societies has been trending upwards.
PMID: 36642170
ISSN: 1615-5947
CID: 5464712

Success rate and factors predictive of redo endothermal ablation of small saphenous veins

Kibrik, Pavel; Chait, Jesse; Arustamyan, Michael; Alsheekh, Ahmad; Kenney, Kevin; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Endothermal ablation, such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), has been increasingly used for treatment of small saphenous vein (SSV) insufficiency. Prior studies have shown recurrence rates of 0% to 10% in incompetent SSVs (ISSVs). The objective of the present study was to determine the efficacy of redo venous ablation for symptomatic recanalized SSVs and to predict the factors related to recanalization. METHODS:A retrospective analysis of 2566 procedures in 1752 patients with chronic venous insufficiency due to ISSVs from 2012 to 2018 was performed, using individual medical record review for data extraction. All 2566 procedures were performed using endothermal ablation for patients in whom initial conservative management had failed. Postoperative duplex ultrasound scans were performed within 3 to 7 days after treatment. We defined successful obliteration as a lack of color flow using postoperative duplex ultrasound. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel during follow-up. We conducted follow-up examinations every 3 months during the first year and every 6 months subsequently. RESULTS:. The mean age was 62.4 ± 15.10 years. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class was C1, C2, C3, C4, C5, and C6 for 0, 0, 29, 43, 1, and 18 patients, respectively. The mean maximum diameter of the targeted veins for the redo procedures was 4.51 ± 1.33 mm. Of the 91 procedures, 40 were performed using EVLA and 51 were performed using RFA. The initial technical success was 98.9%. The redo procedures showed an early closure of 96.7%. At a mean follow-up duration of 24.9 ± 14.9 months, the closure rate was 96.5%. No correlation was found between successful obliteration with the redo procedure and age, gender, CEAP class, laterality, EVLA vs RFA, body mass index, or vein diameter. CONCLUSIONS:The rates of successful closure for ISSVs with initial and redo procedures were comparable. These data have validated the potential usefulness of performing redo SSV ablation.
PMID: 34715387
ISSN: 2213-3348
CID: 5138262

Correlation of Body Mass Index with Recanalization Risk after Endovenous Thermal Ablation

Ahmed, Taqwa; Portnoy, Reid; Chachati, George; Chait, Jesse; Alsheekh, Ahmad; Kibrik, Pavel; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Chronic venous insufficiency (CVI) has an increased prevalence among obese individuals with body mass indices (BMI) over 30. A safe, efficacious, and evidence-based recommended treatment for CVI due to superficial venous reflux (SVR) in great saphenous veins (GSV), small saphenous veins (SSV), accessory saphenous veins (ASV), and reflux in the perforator veins (PV) is endovenous thermal ablation (EVTA). We sought to identify if BMI is an independent risk factor for recanalization following EVTA. METHODS:All patients with CVI were initially managed conservatively, and those with pathologic SVR refractory to compression therapy were offered EVTAs dependent on the site of reflux. Sonographic confirmation of SVR was defined as >500 milliseconds of reflux in the GSV, SSV, and ASV and a diameter >4 millimeters. PV reflux was confirmed as >350 milliseconds of reflux and a diameter >2.5 millimeters. All patients received a follow-up duplex ultrasound 1 week after the procedure, every 3 months for the first year, and every 6 months thereafter. Multivariate analysis with logistic regression was performed regarding patients' age, ablation modality (laser vs radiofrequency ablation), vein location and laterality, BMI, and recanalization. RESULTS:for recanalizations. PVs were statistically more likely to recanalize than any other vein (p=0.0001). A secondary analysis was performed with the exclusion of PVs, due to their 5 times increased risk of recanalization, and showed no significant difference of recanalization across all BMI subgroups (p=0.127). CONCLUSION/CONCLUSIONS:BMI does not predict recanalization risk following EVTA, except for ablations performed on PVs.
PMID: 34271246
ISSN: 2213-3348
CID: 4939042

Outcomes of Cadaveric Veins as Conduits for Lower Extremity Arterial Bypass [Meeting Abstract]

Patel, Ronak; Marks, Natalie A.; Hingorani, Anil P.; Ascher, Enrico
ISSN: 0741-5214
CID: 5243422

Physician Impact on Use of Fluoroscopy During Endovascular Procedures to Improve Radiation Safety

Aurshina, Afsha; Victory, Jesse; Velez, Lady; Kibrik, Pavel; Hingorani, Anil; Marks, Natalie; Rajaee, Sareh; Ascher, Enrico
OBJECTIVES/OBJECTIVE:To determine whether differences exist in fluoroscopy time and radiation exposure during lower extremity endovascular procedures performed by fellowship trained vascular surgeons versus general surgeons, to minimize radiation exposure to operating room staff. METHODS:, 2016. The procedures were performed by the surgical department's 4 surgeons with endovascular privileges: 2 vascular surgeons and 2 general surgeons. Only procedures involving lower extremity arterial angiograms with balloon angioplasty, stenting, or atherectomy were included. The operative records were reviewed for each case. The total fluoroscopy time, and total radiation dose for each procedure were recorded. Procedures were grouped according to the number of endovascular interventions as 1-2 interventions, 3-4 and ≥5 interventions performed. Statistical analysis was performed with a p-value of <.05 as significant. RESULTS:About 271 lower extremity endovascular procedures were performed during the study period by 4 surgeons. The average age of the patient population was 70 years. The total number of procedures performed over the study period were 112, 45, 91, and 25 for surgeons 1-4 respectively. On average, 3.24 interventions were performed during each procedure. Vascular surgeons were found to have shorter fluoroscopy time for procedures involving 1-2 (7.8 vs. 30.1, p<.01), 3-4 (9.3 vs. 34.2, p<.01), and ≥5 (11.5 vs. 51.9, p<.01) interventions. Vascular surgeons were also found to have less radiation exposure compared to general surgeons in procedures with 1-2 (1.69 vs. 3.53, p=.001) and ≥5 (2.3 vs. 5.4, p=.003) interventions. There was no significant difference in radiation exposure between vascular and general surgeons for procedures with 3-4 interventions (5.86 vs. 5.59, p=.95). CONCLUSION/CONCLUSIONS:In this small series at our institution, lower extremity endovascular procedures performed by specialty-trained vascular surgeons were associated with both decreased operative fluoroscopy time and decreased radiation exposure when compared to general surgeons.
PMID: 33684480
ISSN: 1097-6809
CID: 4809132


Singh, Nikita; Jaikaran, Omkaar; Kibrik, Pavel; Hingorani, Anil; Ascher, Enrico
Vasospasm-induced acute limb ischemia (ALI), also known as vasospastic limb ischemia (VLI), is a rare, underreported vascular event. Unlike thrombotic and embolic occlusive etiologies, which often warrant revascularization, vasospasm is a transient phenomenon that may be successfully managed conservatively without surgical intervention. Thus, prompt recognition and accurate diagnosis of VLI is imperative to avoid unnecessary surgical or endovascular procedures. This diagnosis, however, can pose as a challenge for clinicians, as it can present with clinical signs and symptoms near-identical to the presentation of thrombotic-induced ALI. In this report, we present a patient that experienced two vasospasm-induced ischemic events; the patient developed Rutherford IIb acute limb-threatening ischemia following cardiac catheterization for myocardial infarction (MI). Computer tomography angiography (CTA) findings of her right leg revealed acute occlusion suggesting the need for immediate operative intervention for limb salvage. However, due to her critical state, she instead was managed with medical treatments. Despite no intervention, the patient had full resolution of her right leg symptoms. We present this case to highlight the unusual multifocality of vasospastic events and to increase awareness of the diagnostic challenges associated with VLI.
PMID: 33556503
ISSN: 1615-5947
CID: 4779412