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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

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

PRINZMETAL-LIKE ACUTE LIMB ISCHEMIA [Case Report]

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

Partial subclavian artery coverage in TEVAR patients for acute type B aortic dissections: an alternative solution

Chait, Jesse D; Hingorani, Anil P; Singh, Nikita; Marks, Natalie A; Ascher, Enrico
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.
PMID: 33635042
ISSN: 1827-191x
CID: 4795102

Case report of superficial femoral artery and popliteal artery aneurysm repair using brachial vein

Singh, Nikita; Patel, Ronak; Hingorani, Anil; Ascher, Enrico
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.
PMID: 34056975
ISSN: 1708-539x
CID: 4890972

Sphygmomanometer-induced hemostasis following iatrogenic guidewire perforation during lower extremity angioplasty

Chait, Jesse; Ostrozhynskyy, Yuriy; Marks, Natalie; Singh, Nikita; Hingorani, Anil; Ascher, Enrico
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.
PMID: 34037487
ISSN: 1708-539x
CID: 4887882

Safety of Vascular Interventions Performed in an Office-Based Lab in Patients with Low/Moderate Procedural Risk

Aurshina, Afsha; Ostrozhynskyy, Yuriy; Alsheekh, Ahmad; Kibrik, Pavel; Chait, Jesse; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
Objective An exponential increase in number of office-based labs (OBLs) has occurred in the United States, since the Center for Medicare and Medicaid Services increased reimbursement for outpatient vascular interventions in 2008. This dramatic shift to office based procedures directed to the objective to assess safety of vascular procedures in OBLs. Methods A retrospective analysis was performed to include all procedures performed in a 4-year period at an accredited OBL. The procedures were categorized into groups for analysis; group I: venous procedures, group II: arterial, group III: arterio-venous and group IV included IVC filter placement procedures. Local anesthesia, analgesics and conscious sedation were used in all interventions, individualized to patient and procedure performed. Arterial closures devices were used in all arterial interventions. Patient selection for procedure at OBL was highly selective to include only patients with low/moderate procedural risk. Results Nearly 6201 procedures were performed in 2779 patients from 2011-2015. The mean age of the study population was 66.5 ± 13.31 years. There were 1852(67%) females and 928 (33%) males. In group I, 5783 venous procedures were performed (3491 vein ablation, 2292 iliac vein stenting); with group-II 238 arterial procedures (125 femoral/popliteal, 71 infra-popliteal, iliac 42); group III-129 arterial-venous accesses and group IV-51 inferior vena cava filter placements. The majority of procedures belonged to ASA II with venous (61%) and arterial (74%). A total of 5% patients were deemed ASA class 4 (all on hemodialysis). There were no OBL mortality, major bleed, acute limb ischemia, MI, stroke or hospital transfer within 72 hours. Minor complications occurred in 14 patients (0.5%). 30-day mortality, unrelated to procedure were noted in 9 patients (0.32%). No statistically significant differences were noted in outcomes between the 4 groups. Conclusion Our data suggests that it is safe to use OBL for minimally invasive, non-complex vascular interventions in patients with low-moderate cardiovascular procedural risk.
PMID: 33065244
ISSN: 1097-6809
CID: 4641732

Fast-Track Thrombolysis Protocol for Acute Limb Ischemia

Ascher, Enrico; Kibrik, Pavel; Rizvi, Syed Ali; Alsheekh, Ahmad; Marks, Natalie; Hingorani, Anil
OBJECTIVE:Catheter-directed thrombolysis (CDT) in the treatment of acute lower-extremity arterial occlusions (ALI) often requires several interventional sessions to generate successful outcomes. CDT is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the Fast-Track Thrombolysis Protocol for Arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. METHODS:A retrospective study of 42 patients was performed at our institution who were treated for ALI utilizing FTTP-A from January 2014 to February 2019. FTTP-A includes: peri-adventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanicalrheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator (tPA) infusion along the occluded segment, balloon maceration of the thrombus, and if deemed necessary, placing a stent in areas of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus was cleared, patients were placed on an oral anticoagulant agent. RESULTS:Forty-two primary FTTP-As (50 total interventions) were performed in 42 patients. The median age was 67.2±12.2 years (range 41-98), of which 54.8% were male. 59.5% of the procedures were performed on the left lower extremity. Initial arterial access sites as obtained via the common femoral artery (CFA), in 39/42 cases (92.9%), with the remaining three being obtained in a left bypass access site, a right femoral-popliteal graft and a right femoral-femoral graft. The mean operative time was 148.9±62.9 minutes (range: 83-313), and the mean volume of tPA infused was 9.7±4.0 mg (range: 2-20). The median cost including medications and interventional tools was $4673.19 per procedure. The mean post-operative length of stay was 3.1±4.5 days (range: 1-25). Median post-operative length of stay was 1 day. Mean post-operative follow-up was 27±19.2 months (range: 0-62). Single-session FTTP-A was successful in 81% (n = 34/42) of patients. The remaining 8 patients (19%) required a single additional session. Thirty-four of the 42 patients (81%) required arterial stenting. Peri-procedural complications consisted of 1 patient with hematuria, which resolved, and 1 patient with thrombocytopenia, which resolved. No patients experienced re-thrombosis within 30-days of FTTP-A. Over the five-year study period, there were no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. CONCLUSION/CONCLUSIONS:FTTP-A, appears to be safe, efficacious and a cost-effective procedure in the resolution of acute lower-extremity arterial occlusions.
PMID: 32437952
ISSN: 1097-6809
CID: 4444612

Effect of Pre-Procedure Clopidogrel With Iliac Vein Stenting in Non-Thrombotic Vein Lesions

Kibrik, Pavel; Arustamyan, Michael; Alsheekh, Ahmad; Ostrozhynskyy, Yuriy; Rabinovich, Vera; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVES/UNASSIGNED:Iliac vein stenting is a relatively new procedure in the treatment of chronic venous insufficiency. Research has shown that it is a safe and effective form of treatment, however, one of the well-known risks is in-stent thrombosis. We hypothesize that a single 75 mg dose of Clopidogrel the night prior to the procedures along with a 3-month regimen post-op would decrease the 30-day thrombosis rate. METHODS/UNASSIGNED:A retrospective study was performed on 3,518 patients from September 2012 to August 2018 who received an iliofemoral stent. Patients were broken down into 2 main groups: those given Clopidogrel post-stent and those given Clopidogrel both pre- and post-stent. In our practice, we prescribe a 3-month course of Clopidogrel after iliac vein stenting. Patients were also checked for any anticoagulant medications pre- and/or post-stent. The 30-day thrombosis rates were recorded for each patient. RESULTS/UNASSIGNED:1,205 patients received Clopidogrel pre-procedurally and post-procedurally, 1,941 patients received Clopidogrel only post-procedurally. 372 patients were excluded from the study because they were on other anti-coagulant medications. Mean follow-up for this cohort was 17 months. 112 total patients developed some degree of 30 day in-stent thrombosis (3.6%). 74 patients developed a complete thrombosis of the stent and 38 developed a partial (≤60% occlusion) thrombosis. Of the 1,205 patients who were on clopidogrel pre-stenting, 28 had a complete thrombosis and 10 had a partial in-stent thrombosis. Of the 1,941 patients on Clopidogrel only post-stenting, 46 had a complete thrombosis and 28 had a partial in-stent thrombosis. Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day any degree of thrombosis rates (complete and partial thrombosis) (p = .33). Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day complete thrombosis rates (p = .93). CONCLUSIONS/UNASSIGNED:There appears to be no statistical difference in 30-day thrombosis rates between those receiving Clopidogrel the night prior vs. those who do not receive Clopidogrel the night prior. Therefore, we conclude that it is not necessary to give this single dose the night prior to iliac vein stenting procedures.
PMID: 33602039
ISSN: 1938-9116
CID: 4787112

Malignant Transformation of Non-healing Ulcer - Basal Cell Carcinoma [Case Report]

Nicoara, Michael; Bain, Kevin; Patel, Ronak; Jaikaran, Omkaar; Hingorani, Anil; Asher, Enrico
We discuss the rare case of a 72 year old female with a history of a non-healing lower extremity ulcer that was biopsied revealing malignant transformation to basal cell carcinoma (BCC). Although basal cell carcinoma is the most common malignancy worldwide, malignant transformation of non-healing wounds are more often associated with squamous cell carcinoma. Current literature estimates the rate of BCC arising from venous stasis ulcer to occur between 1.5-15%. When diagnosed early, BCC can have cure rates of up to 95%. However, metastatic BCC has a median survival of roughly 8 months. We believe it is important to raise awareness of this rare, but often curable clinical diagnosis in order to improve long term outcomes.
PMID: 32035267
ISSN: 1615-5947
CID: 4301672