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Increasing ablation distance peripheral to the saphenofemoral junction may result in a diminished rate of ehits [Meeting Abstract]

Sadek M.; Kabnick L.S.; Berland T.; Giammaria L.E.; Zhou D.; Mussa F.; Cayne N.S.; Maldonado T.; Rockman C.B.; Jacobowitz G.R.; Lamparello P.J.; Adelman M.A.
Background: The treatment of venous insufficiency using endovenous laser ablation or radiofrequency ablation may result in endothermal heat induced thrombosis (EHIT), a form of deep venous thrombosis. This study sought to assess the effect of ablation distance peripheral to the deep venous system on the incidence of EHIT. Methods: This study was a retrospective review of a prospectively maintained database from 4/2007 to 7/2011. Consecutive patients undergoing great saphenous vein (GSV) or small saphenous vein (SSV) ablation were evaluated. Previous to 2/2011, all venous ablations were performed 2cm peripheral to the saphenofemoral or saphenopopliteal junctions (Group I). Subsequent to 2/2011, ablations were performed 2.5cm peripheral to the respective deep system junctions (Group II). The primary outcome was the development of EHIT II or greater, i.e. thrombus protruding into the deep venous system. Secondary outcomes included procedure-site complications such as hematomas and saphenous nerve injury. Chi-square tests were performed for all discrete variables, and unpaired Students t-tests were performed for all continuous variables. P<.05 was considered statistically significant. Results: A total of 3,526 procedures were performed, Group I (N=2672) and Group II (N=854). General demographics and CEAP classification did not differ significantly between the two groups. EHIT demonstrated a trend towards diminished frequency in Group II (Group I: 2.8% vs Group II: 1.6%, P=.077). There were no reported cases of EHIT III or IV in this patient cohort. Patients in Group I were treated using anticoagulation 56% of the time, and patients in Group II were treated using anticoagulation 100% of the time. The frequency of procedure site complications was low and did not differ significantly between the two groups. Conclusions: This study suggests that changing the treatment distance from 2cm to 2.5cm peripheral to the deep venous junction may result in a diminished incidence of EHIT. Ongoing evaluation is required to validate these results and to reaffirm the durability of the technique
ISSN: 0741-5214
CID: 149973

Update on Endovenous Laser Ablation: 2011

Sadek M; Kabnick LS; Berland T; Cayne NS; Mussa F; Maldonado T; Rockman CB; Jacobowitz GR; Lamparello PJ; Adelman MA
In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success
PMID: 22131021
ISSN: 1521-5768
CID: 150013

Midterm Outcome of Endovascular Popliteal Artery Aneurysm Repair Using the Viabahn Endoprosthesis [Meeting Abstract]

Garg, Karan; Rockman, Caron B; Kim, Billy J; Jacobowitz, Glenn R; Maldonado, Thomas S; Lamparello, Patrick J; Adelman, Mark A; Veith, Frank J; Cayne, Neal S
ISSN: 0741-5214
CID: 2726002

Endovenous Laser Ablation Using Higher Wavelength Lasers Results in Diminished Post-Procedural Symptoms [Meeting Abstract]

Sadek, Mikel; Kabnick, Lowell S.; Berland, Todd; Chasin, Cara; Cayne, Neal S.; Maldonado, Thomas S.; Rockman, Caron B.; Jacobowitz, Glenn R.; Lamparello, Patrick J.; Adelman, Mark A.
ISSN: 0741-5214
CID: 134491

Cystic adventitial disease of the popliteal artery: is there a consensus in management?

Baxter, Andrew R; Garg, Karan; Lamparello, Patrick J; Mussa, Firas F; Cayne, Neal S; Berland, Todd
Cystic adventitial disease (CAD) is a well described disease entity that commonly affects the popliteal artery, presenting as a rare cause of non-atherosclerotic claudication. The traditional surgical approaches are cyst resection and bypass, or cyst evacuation or aspiration. We report the case of a 58-year-old female with CAD of the popliteal artery treated successfully with cyst resection and bypass using an autologous graft. We reviewed the literature over the last 25 years on management and outcomes of CAD of the popliteal artery. We identified a total of 123 cases; most cases were treated using a traditional repair, while 3 cases used an endovascular approach. The overall success rate using bypass was 93.3%, compared to 85% in the evacuation/aspiration cohort. All cases treated endovascularly resulted in failure. While no consensus exists regarding the preferred modality to treat CAD, we believe that resection of the cyst and bypass affords the best outcomes
PMID: 21652669
ISSN: 1708-5381
CID: 134316

Laser saphenous ablations in more than 1,000 limbs with long-term duplex examination follow-up

Spreafico, Giorgio; Kabnick, Lowell; Berland, Todd L; Cayne, Neal S; Maldonado, Tom S; Jacobowitz, Glenn S; Rockman, Caron R; Lamparello, Pat J; Baccaglini, Ugo; Rudarakanchana, Nung; Adelman, Mark A
BACKGROUND: The goal of this study was to evaluate the duplex results of endovenous laser ablation in the treatment of incompetent great saphenous veins (GSV) and small saphenous veins (SSV) with at least 1-year follow-up. METHODS: A retrospective registry was entered by 11 centers from Europe and America, organized by the International Endovenous Laser Working Group. Data concerning 1,020 limbs in patients with incompetence of the GSV and/or SSV, treated with the Endovenous Laser Ablation (EVLA) procedure, were collected. EVLA failures were defined on duplex imaging as reflux confined to the saphenofemoral or saphenopopliteal junction, reflux confined to the main saphenous trunk, or reflux of both junction and main trunk (totally patent saphenous vein) were analyzed at one or more years postoperatively. RESULTS: The mean age of patients was 54 +/- 5 years (range: 18-91 years). The average body mass index was 25. There was a paucity of severe complications: One case of third-degree skin burn, six patients with postsurgical deep vein thrombosis (0.6%), and 27 cases of sensory nerve damage (2.7%). At 1-year, the rate of complete occlusion of the saphenous trunk was 93.1%. There were 79 cases of treatment failures as evidenced by duplex: 22 isolated junction failures (2.2%), 44 isolated trunk failures (4.4%), and 13 totally patent veins (1.3%). Two-year duplex results were reported for 329 limbs with the identification of 19 new cases of failure. No new cases of failure were reported at 3-year follow-up of 130 limbs. Cumulative failure rates estimated by Kaplan-Meier analysis were 7.7% at 1-year and 13.1% at 2- and 3-year follow-up. CONCLUSIONS: On the basis of a duplex scan performed at least 1-year post-treatment, this multicenter registry confirms the safety and efficacy of the EVLA procedure in the treatment of GSV and SSV reflux. Considering the continued failure rate documented in the present study, an annual follow-up by duplex is recommended to 2 years after EVLA
PMID: 21172581
ISSN: 1615-5947
CID: 120627

Intermediate-term EVAR outcomes in octogenarians

Fonseca, Rodrigo; Rockman, Caron; Pitti, Abhishek; Cayne, Neal; Maldonado, Tom S; Lamparello, Patrick J; Riles, Thomas; Adelman, Mark
OBJECTIVE: The utilization of endovascular abdominal aortic aneurysm repair (EVAR) in suitable patients has resulted in decreased perioperative morbidity and mortality. Octogenarians as a subgroup have been more readily offered EVAR, as it is less invasive, and therefore presumably better tolerated than conventional open aortic repair. The purpose of this study is to investigate periprocedural and late EVAR outcomes in octogenarians compared with patients less than 80 years of age. METHODS: From January 2003 to May 2008, 322 patients underwent EVAR. A total of 117 octogenarians were compared with 205 patients less than 80 years of age. A retrospective review of the demographic data, aneurysm details, perioperative morbidity, mortality, and late outcomes were analyzed. RESULTS: Octogenarians were significantly more likely to have a history of diabetes mellitus (51% vs 23%; P < .001), coronary artery disease (45% vs 32%; P = .0165), chronic obstructive pulmonary disease (44% vs 30%; P = .0113), and renal insufficiency (57% vs 31%; P < .0001). There were no significant differences in the rates of perioperative myocardial infarction, stroke, death, intestinal, or arterial ischemic complications between the two groups. Octogenarians had a significant higher rate of pulmonary complications (5.1% vs 1%; P < .03) and access-site hematomas (12% vs 2.4%; P = .001) than younger patients. When all significant perioperative morbidity was combined, octogenarians were twice as likely to develop complications following EVAR than younger patients (27.4% vs 11.7%; P = .001). At 5-year follow-up, younger patients were twice as likely to develop type II endoleaks. CONCLUSIONS: EVAR can be performed safely and effectively in octogenarians, and the incidence of major complications including myocardial infarction, stroke, and death is unchanged compared with younger patients. However, there is a significantly increased rate of access-site hematomas, pulmonary, and perioperative complications in octogenarians as a whole. Our findings suggest EVAR remains a suitable form of therapy in the elderly group provided there is an appropriate preoperative evaluation and perioperative monitoring following repair
PMID: 20620011
ISSN: 1097-6809
CID: 136563

Improved hemodynamic outcomes with glycopyrrolate over atropine in carotid angioplasty and stenting

Chung, Christine; Cayne, Neal S; Adelman, Mark A; Riles, Thomas S; Lamparello, Patrick; Han, Daniel; Marin, Michael L; Faries, Peter L
OBJECTIVE: Prophylactic atropine traditionally has been used to prevent CAS-associated hemodynamic depression. Glycopyrrolate may serve as an alternative with decreased cardiac effects. This study aims to compare the efficacy of prophylactic glycopyrrolate to atropine in preventing CAS-induced hemodynamic instability and cardiac complications. METHODS: 115 consecutive CAS patients from 2004-2010 were evaluated. Primary endpoints were stroke, MI, bradycardia (HR<60 beats/min), and hypotension (systolic BP <90 mm Hg). Additional outcomes included tachycardia (HR >100 beats/min), hypertension (systolic BP >160 mm Hg), pre- and postoperative systolic BP difference, vasopressor use, arrhythmias, cardiac enzyme elevations, and access site complications. RESULTS: Of 115 patients, 65 (56.5%) patients who received atropine or glycopyrrolate prior to CAS were analyzed [40 (61.5%) patients received glycopyrrolate, 25 (38.5%) received atropine]. Mean age was 70.0 +/- 8.5 years (range, 48-86 years). Mean stenosis was 86.2 +/- 7.4% (range, 70-99%). No MI, major stroke, or death was observed in the 30-day postoperative period. Baseline systolic BP and HR were equivalent between groups. Postoperative bradycardia and hypotension were significantly lower in glycopyrrolate patients compared with atropine patients (30% vs 72%, P = .002; 2.5% vs 36%, P < .001, respectively). Postoperative hypertension was also significantly lower in the glycopyrrolate cohort (2.5% vs 16%, P = .047), whereas tachycardia, pressure changes, vasopressor use, and cardiac complications did not differ significantly. No significant differences in neurologic and access site complications were observed. CONCLUSIONS: Prophylactic glycopyrrolate, compared with atropine, reduces hemodynamic instability during CAS. The authors recommend glycopyrrolate use to prevent CAS-induced bradycardia and hypotension
PMID: 21098497
ISSN: 1521-5768
CID: 133478

Comparison of Endovascular and Open Popliteal Artery Aneurysm Repair [Meeting Abstract]

Kim, BJ; Garg, K; Rockman, C; Jacobowitz, GR; Maldonado, T; Lamparello, P; Riles, T; Adelman, MA; Veith, FJ; Cayne, NS
ISSN: 0741-5214
CID: 111900

Experience and Technique for the Endovascular Management of Iatrogenic Subclavian Artery Injury

Cayne, N S; Berland, T L; Rockman, C B; Maldonado, T S; Adelman, M A; Jacobowitz, G R; Lamparello, P J; Mussa, F; Bauer, S; Saltzberg, S S; Veith, F J
OBJECTIVES: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. DISCUSSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair
PMID: 19734007
ISSN: 1615-5947
CID: 106166