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.

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.

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.

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.

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.