Faculty Bibliography

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.

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 healthgrades.com, 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.

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.

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.

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.

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.

BACKGROUND:Acute type B aortic dissection with origin of the left subclavian artery (LSA) is generally managed with endovascular therapy for acute coverage of the LSA with (a) no revascularization, (b) revascularization with open methods, or (c) endovascular revascularization. To identify an alternative solution, we critically evaluated a small cohort of patients who had partial coverage of their LSA. METHODS:Three thoracic endovascular repairs were performed from January-March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative management. Indications included acute type B dissection with lower extremity ischemia, ruptured dissection, and persistent symptoms of dissection after medical therapy. RESULTS:Technical success was achieved in all three patients, and all procedures were performed percutaneously. The mean distance between the ostium of the LSA and the entry point of dissection was 11.1 ± 3.4 mm. Within the 30-day post-operative period, there were no deaths, aortic ruptures, myocardial infarctions, or conversions to open repair. Freedom from re-intervention was noted in all 3 patients. There was no spinal cord ischemia. CONCLUSIONS:There is no strong evidence to support the current optimal approach for treatment of the thoracic aorta. Partial coverage of LSA in patients with <2 cm seal zones may be considered as an alternative. However, due to our small sample size, limited followup, and lack of comparison cohort, further investigation is necessary.

BACKGROUND:Several veins have been well-recognized as acceptable conduits for infrainguinal bypass surgery when the ipsilateral greater saphenous vein is unavailable. However, there is a paucity of literature describing the brachial vein as an adequate alternative. In the absence of other viable autogenous conduits, we describe the use of a brachial vein as a successful alternative for lower extremity revascularization. METHODS:A 70-year-old man presented with a chief complaint of right calf pain. Duplex ultrasound imaging of his right lower extremity revealed right-sided 2.5 cm acutely thrombosed superficial femoral artery and popliteal artery aneurysms. The patient underwent a suction thrombectomy with tissue plasminogen activator using the Power Pulse feature and Solent catheter from the AngioJet® (Boston-Scientific, Marlborough, MA) system. To repair the thrombosed aneurysms, an open bypass was planned. Due to lack of viable alternative traditionally used venous conduits, a bypass was created using the patient's brachial vein. RESULTS:A bypass was created from the superficial femoral artery to the P2 segment of the popliteal artery using a non-reversed brachial vein with ligation of the side branches of the superficial femoral artery and popliteal artery aneurysm from within the sac lumen. Completion angiogram revealed runoff through the anterior tibial artery only. Follow-up imaging at three months demonstrated a patent brachial bypass. CONCLUSION/CONCLUSIONS:Brachial veins can be safely used as viable venous conduits for lower extremity bypass surgery and should therefore be considered as an alternative when more commonly used veins are unsuitable or unavailable. However, more research is needed to determine the potential opportunities and challenges this alternative may present.

OBJECTIVES/OBJECTIVE:Iatrogenic guidewire perforation is a well-known complication of lower extremity angioplasty that is often benign or can be easily treated with endovascular techniques. However, perforations that occur in arterial side branches may be more challenging to manage. If bleeding persists, open surgery and fasciotomy may be required to evacuate the resulting hematoma and prevent compartment syndrome. These subsequent procedures increase morbidity and, if the angioplasty was performed in the outpatient setting, necessitate patient transfer to a hospital. To address these challenges, we describe a non-invasive hemostasis technique involving serial sphygmomanometer cuff inflations over the affected site in a series of five patients who experienced this complication at our office. METHODS:We retrospectively reviewed the medical records of consecutive patients undergoing lower extremity angioplasty that were found to have an arterial guidewire perforation on completion angiogram at our outpatient center between February 2012 and February 2017. Patients found to have iatrogenic guidewire perforations were administered intravenous protamine sulfate and were transferred to the surgical recovery room. Patients received ibuprofen or acetaminophen for pain management. A blood pressure cuff was placed around the site of perforation, and patients received serial cuff inflation cycles with repeated examinations of both limbs until patients reported cessation of pain and there were no signs of a developing hematoma. Patients were observed for two hours before they were discharged home. A follow-up duplex ultrasound examination was completed within one week of the intervention. RESULTS:Over the course of five years, 536 angioplasties were performed at our outpatient office. Five of these patients experienced iatrogenic guidewire perforation (0.93%). Perforations occurred in branches of the anterior or posterior tibial artery. All of these patients were successfully managed with the aforementioned hemostasis technique. None of these patients required transfer to a hospital for further management, and no complications were reported at follow-up. CONCLUSIONS:Complications of iatrogenic guidewire perforations in lower extremity arterial side branches can be safely and effectively managed by applying external compression around the affected site with an automatic blood pressure cuff.