Faculty Bibliography

BACKGROUND:To determine the structural changes of Wallstents (Boston Scientific, Natick, MA) in vivo following deployment in iliac veins. METHODS:This retrospective single-center study was performed from September 2012 to April 2013 and included 100 office-based patients who underwent initial stent placement for nonthrombotic iliac vein lesions with Wallstent as well as a second procedure for stenting of the contralateral iliac vein. Measurements were obtained with marker balloons and the diameters of the stents were compared at the time of the index procedure to the secondary procedure. RESULTS:The average time between the 2 procedures was 28 days (range 3-237, SD ± 39.89). The overall average stent diameter after the index procedure was 16.38 mm (range 10.95-21.45, SD ± 2.24). The overall average stent diameter of the index stent when remeasured during the second intervention was 17.58 mm (range 12.84-24.11, SD ± 2.38, P = 0.0003), which was significantly different from the initial measurements. There was no difference when comparing changes in stent diameter by gender or laterality of procedure. However, there was a significant difference in expansion of stents when placed in the common iliac vein versus the external iliac or common femoral veins. CONCLUSIONS:This study shows that self-expanding Wallstents can continue to expand days to weeks in vivo following initial deployment. Additionally, we found that the change in diameter from initial placement to follow-up was more significant in stents placed in the proximal and middle segments of the common iliac vein. CLINICAL RELEVANCE/CONCLUSIONS:Wallstents are durable implants designed to last within a patient for the rest of their life, it is important to understand the structural changes occurring after their placement. This study allows for a better understanding of Wallstent dynamics in vivo.

BACKGROUND:The minimally invasive procedures of venous ablation and iliac vein stenting are evolving treatment options for venous insufficiency. Yet, there are no studies directly comparing the outcome of these procedures. We performed a survey on patients who had both procedures, to determine if either procedure helped more and if there is any other clinical factor related to the outcome. METHOD/METHODS:We collected data between Jan 2012 and Feb 2019 from 726 patients who failed to improve swelling after conservative management. The patients underwent iliac vein stenting and vein ablations. We recorded patient assessment of the leg immediately after completion of both procedures. Follow-up was performed using in-person questionnaires by asking if improvement in lower extremity swelling occurred and if so, which procedure helped more. RESULTS:= 0.095). CONCLUSION/CONCLUSIONS:In this qualitative assessment, preliminary data suggest that the comparative role of iliac vein stent versus endovenous ablation warrants further study. The data were broadly distributed, and neither procedure was superior. In addition, 16% of the patients stated that neither procedure helped. The age of patients may also play a role in their procedure preferences and their subjective assessment for improvement.

Retropharyngeal internal carotid artery (ICA) is a rare, yet well-described anatomical variant that poses significant challenges to the management of carotid artery stenosis. In this case report, we discuss the treatment of symptomatic ICA stenosis with a retropharyngeal ICA using the transcarotid artery revascularization (TCAR) technique. A 70-year-old female with comorbidities presented with neurological symptoms and severe ICA stenosis. After diagnostic evaluation, TCAR was chosen for surgical intervention. The patient did well postoperatively. This case emphasizes the importance of considering TCAR when treating ICA stenosis in patients with anatomic variation of ICA location. It also supports adding anatomic variants such as retropharyngeal ICA to the list of indications for TCAR.

OBJECTIVE:Previous randomized prospective trials have demonstrated the effectiveness of transcatheter tissue plasminogen activator (tPA) thrombolysis in treating acute limb ischemia (ALI) compared to conventional surgery. These pivotal trials have also highlighted contraindications for these procedures. Given recent advancements in techniques and technology, our aim is to reassess the relevance of these contraindications in contemporary practice. METHODS:A retrospective chart analysis was performed utilizing the inpatient medical records of consecutive individuals who underwent tPA treatment for acute limb ischemia (ALI) from September 2016 to April 2022. Inclusion criteria encompassed patients aged 18 and above displaying clinical symptoms and imaging evidence of ALI within 14 days. All patients received tPA with suction thrombectomy following the fast-track thrombolysis protocol. In cases where a persistent thrombus or stenosis was detected, catheter-directed thrombolysis was considered overnight, and patients underwent angiography and reassessment in the operating room subsequently. RESULTS:= .771). Additionally, no amputations were observed within our population. CONCLUSIONS:In light of our study results and advancements in endovascular therapies, we can now safely and efficiently treat patients who were previously considered contraindicated for such treatments. It is essential to individualize treatments and carefully balance the risks and benefits of endovascular versus open surgical revascularization for these patients. Additionally, we believe that the nearly 30-year-old guidelines for endovascular therapies need to be revisited and updated to align with modern technology.

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.

A dramatic increase in the number of vascular procedures performed in the office-based laboratory setting has been observed since 2008, when the Centers for Medicare and Medicaid Services increased reimbursement for procedures performed in the ambulatory setting. We sought to evaluate the appropriateness of arterial intervention in the office-based laboratory and patient selection. This systematic review was conducted with a search of Google Scholar and PubMed using the following search terms: office-based lab, outpatient, angioplasty, patient selection, arterial, and appropriateness. More than 500 publications were screened and 14 publications related to the topic were selected. The existing literature that examined patient selection for intervention in the outpatient setting, rates of complications after outpatient procedures, and short-term data on the safety and efficacy of these procedures is discussed. Gaps were identified in current knowledge about the long-term outcomes of peripheral arterial interventions performed in the office-based laboratory setting, as well as existing guidelines for the management of patients with peripheral arterial disease.

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.

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.

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.