Compartment Syndrome of the Leg After Intraosseous (IO) Needle Insertion
Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections and compartment syndrome. We present a case of an 87 year old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.
Etiology of iliocaval stent thrombosis
OBJECTIVE:Although correction of iliac vein stenosis is safe and efficacious, one of its major complications is iliac vein stent thrombosis. In an attempt to examine the cause of iliac vein stent thrombosis, we reviewed the location of underlying lesions encountered after thrombectomy or thrombolysis of iliac vein stents. METHODS:A retrospective analysis was performed of all iliac vein venograms with intravascular ultrasound examinations at our office-based surgical center from February 2012 to July 2016. Patients included in the study had chronic venous insufficiency and failed compression therapy. All procedures were performed with local anesthesia and conscious sedation. Wallstents were used in all procedures for nonthrombotic iliac vein stenosis, ranging from 8 to 24Â mm in diameter and 40 to 90Â mm in length. Patients were followed with transcutaneous duplex every 3Â months for the first year and every 6 to 12Â months thereafter. Patients were placed on clopidogrel for 3Â months or continued on their preexisting anticoagulants. RESULTS:From February 2012 to July 2016, we performed 2228 iliac vein venograms with intravascular ultrasound examination in 1381 patients. The mean age of the patient population was 65Â Â±14Â years (range, 21-99Â years), among which 876 were female. A total of 1037 procedures were performed in the left lower extremity. Of these, 240 venograms were diagnostic. Presenting symptoms based on CEAP classification included C2 (nÂ = 21), C3 (nÂ = 633), C4 (nÂ = 1065), C5 (nÂ = 269), and C6 (nÂ = 241). Complete thrombosis of the iliac vein stent was noted in 18 patients (0.8%) who thereafter underwent suction thrombectomy with thrombolysis. None of these patients had a prior history of deep vein thrombosis. In-stent restenosis was noted in 11 patients. Proximal lesions were found in no patients. An external iliac vein lesion was found distal to the common iliac vein stent in two patients. Common femoral vein lesions were found in six patients. These encountered lesions were then stented. All patients who underwent thrombectomy were placed on anticoagulation for 6Â months. No patient were noted to suffer rethrombosis upon follow-up. No correlation with stent thrombosis was encountered for age, gender, laterality, location, presenting symptoms, or length or diameter of the stent. CONCLUSIONS:Based on our experience, in-stent restenosis followed by inflow lesions in the common femoral vein are the most common causes of stent thrombosis. These data suggest a need for future research to target these areas.
Spontaneous hemorrhage from varicose veins: A single-center experience
OBJECTIVE:Whereas the commonly described manifestations of venous insufficiency include telangiectasia, varicose veins (VVs), edema, skin changes, and ulcers, we have noted some patients who present with external hemorrhage from lower extremity VVs. Because there are few recent data examining this entity, we herein describe our experience. METHODS:During 29Â months, we had 32 patients present with hemorrhage from lower extremity VVs. There were 15 men and 17 women with a mean age of 60.2Â years (range, 38-89Â years; standard deviation [SD],Â Â±14.9Â years). Interestingly, 16 of these patients presented after coming into contact with warm water; 28 patients, 19 patients, and 1 patient presented with reflux >500Â milliseconds in the great, small, and accessory saphenous veins, respectively. Eight patients and six patients had reflux >1Â second in the femoral and popliteal veins, respectively. RESULTS:All patients were treated with weekly Unna boots. Mean ulcer healing time was 2.12Â weeks (range, 1-8Â weeks; SD,Â Â± 2.15Â weeks). Patients with VV hemorrhage after contact with warm water had a mean healing time of 1.75Â weeks, whereas those who bled without such exposure took an average of 3.5Â weeks (PÂ = .0426). Twenty patients underwent at least one endovenous thermal ablation procedure, with the average patient in the cohort receiving 2.16 procedures (range, 0-9; SD,Â Â± 2.37). There was no significant difference between laterality, age, or sex between patients who bled after warm water contact and those who bled spontaneously. The ulcers recurred in three of the patients, and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2Â months (range, 26Â months; SD,Â Â± 8.9Â months), and we noted no recurrent bleeding episodes. CONCLUSIONS:Spontaneous hemorrhage of VVs, although relatively under-reported, is not a rare occurrence. Risk factors are unknown; however, half of our patient cohort reported VV hemorrhage during or directly after coming into contact with warm water. Furthermore, these patients demonstrated a significantly shorter wound healing time compared with the rest of the cohort. Basic first aid, wound care, and hemostasis control education should be provided to all patients with VVs. Further investigation surrounding the risk factors associated with VV hemorrhage is warranted.
Radiofrequency Ablation Increases the Incidence of Endothermal Heat-Induced Thrombosis
OBJECTIVE:Endovenous thermal ablation has become the procedure of choice in the treatment of superficial venous reflux disease. The current armamentarium of devices and techniques aimed at the elimination of saphenous reflux offers surgeons and interventionalists a variety of treatment options, however there is a lack of data comparing the safety of these products. The most concerning complication following endovenous thermal ablation is endothermal heat-induced thrombosis (EHIT) due to the risk of progression to deep venous thrombosis (DVT). This study aimed to compare the incidence rate of EHIT between radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). METHODS:This was a single-center, office-based, retrospective study over the course of 5 years, in which 3218 consecutive patients underwent 10,029 endovenous saphenous ablations. The patient cohort was 66.2% female, with an average age of 61.9 years old. At the time of each individual intervention, 24, 212, 3620, 4806, 200, and 1167 patients had Clinical-Etiology-Anatomy-Pathophysiology (CEAP) disease 1, 2, 3, 4, 5, and 6, respectively. RESULTS:There was a total of 3983 EVLT and 6091 RFA procedures. The most common vessel treated was the great saphenous vein, 63.6% of the time, followed by the small saphenous vein (25.6%), accessory saphenous vein (6.1%), and perforator vein (4.6%). There were 186 cases of EHIT, with 137 (73.6%) identified as type 1 per the Kabnick classification. Endovenous ablation performed via RFA resulted in significantly more cases of EHIT when compared to EVLT (109 vs 77; p = 0.034; OR = 1.52), which was confirmed by multivariate analysis. CONCLUSION/CONCLUSIONS:In the largest single-center study of endovenous saphenous ablations to date, RFA was shown to pose a significantly higher risk of EHIT when compared to EVLT.
Safety and efficacy of endovenous ablations in octogenarians, nonagenarians, and centenarians
OBJECTIVE:Endovenous ablation of the lower extremity veins has become the primary treatment of symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) and recanalization are two well-known complications of these venous ablative procedures. Because the elderly represent the fastest growing demographic, our goal was to look at whether there is a difference of these complications and age distribution in octogenarians, nonagenarians, and centenarians vs the younger population. METHODS:test and analysis of variance were used for statistical analysis. RESULTS:Ages ranged from 15Â years to 103Â years. The average age of the patients was 61.9Â Â± 15.2Â years. Average overall follow-up for all age groups was 25.8Â Â± 12.9Â months. Of the 3218 patients, 2700 were younger than 80Â years, 380 were between 80 and 89Â years, 132 were between 90 and 99Â years, and 6 were 100Â years or older. Of the 10,029 procedures, 8730 were performed on patients younger than 80Â years; 1124, on patients 80 to 89Â years; 159, on patients 90 to 99Â years; and 16, on patients 100Â years or older. There were 111 patients who had bilateral procedures in the accessory saphenous vein, 1878 patients who had bilateral procedures in the great saphenous vein, 99 patients who had bilateral procedures in the perforator vein, and 760 patients who had bilateral procedures in the small saphenous vein. There were statistically significant increases in EHIT rates between octogenarians and those in the age groupÂ <80Â years (PÂ = .047); between nonagenarians and those in the age groupÂ <80Â years (PÂ = .04); and between the combined group of octogenarians, nonagenarians, and centenarians and the age groupÂ <80Â years (PÂ = .012). No statistical difference was found in rates of EHIT between octogenarians and nonagenarians (PÂ = .5). Overall age is a risk factor for the development of EHIT (odds ratio, 1.03; 95% confidence interval, 1.02-1.04; PÂ <Â .00001). There were statistically significant increases in recanalization rates between octogenarians and those in the age groupÂ <80Â years (PÂ = .000013); between nonagenarians and those in the age groupÂ <80Â years (PÂ = .00022); and between the combined group of octogenarians, nonagenarians, and centenarians and the age groupÂ <80Â years (PÂ < .00001). No statistical difference was found in rates of recanalization between octogenarians and nonagenarians (PÂ = .48). Statistical analysis of centenarians alone was not done because of zero patients available in the EHIT or recanalization category. Overall age was found to be a risk factor for recanalization (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; PÂ < .00002). CONCLUSIONS:Whereas there is a relatively higher chance of EHIT and recanalization in the age group >80Â years, our study shows that the majority of EHITs were class 1 and class 2. According to our study, venous ablation is safe and effective across all age groups, and age alone should not be used to deny patients venous ablations.
Early hemodynamic characteristics of eversion and patch carotid endarterectomies
OBJECTIVE:Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs. METHODS:All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUSâ€‰>â€‰90Â days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs. RESULTS:One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96;â€‰Â±â€‰9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with aâ€‰>â€‰90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid-subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (pâ€‰>â€‰0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; pâ€‰=â€‰0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (pâ€‰>â€‰0.05). Post-operative DUS was performed at 17.0 and 12.9Â days in the eversion and patch CEA cohorts, respectively (pâ€‰=â€‰0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (pâ€‰>â€‰0.05). CONCLUSION/CONCLUSIONS:Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.
Fast-track thrombolysis protocol: A single-session approach for acute iliofemoral deep venous thrombosis
OBJECTIVE:Catheter-directed thrombolysis in the treatment of acute iliofemoral deep venous thrombosis (IFDVT) often requires more than one interventional session to yield successful outcomes. Catheter-directed thrombolysis is generally expensive, requiring prolonged hospital stay that may be associated with increased local and systemic hemorrhagic complications. We developed the fast-track thrombolysis protocol (FTTP) to address these issues. The goal of FTTP is to restore patency during the initial session of thrombolysis, thereby minimizing costs and complications associated with prolonged thrombolysis. METHODS:A retrospective analysis of 38 patients treated for acute IFDVT using FTTP at our institution from January 2014 to February 2019 was performed. The protocol includes periadventitial injection of lidocaine at the venipuncture site under ultrasound guidance, contrast venography of the entire target segment, pharmacomechanical rheolytic thrombectomy of the occluded venous segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and, if indicated, venous stent placement in areas of significant (â‰¥50%) stenosis refractory to thrombolysis and balloon angioplasty. Once the thrombus was cleared, patients were prescribed oral antithrombotic therapy. RESULTS:Thirty-eight primary FTTPs (45 total interventions) were performed in 38 patients. The median age was 66Â years (range, 39-93Â years); 60.5% were female. Initial venous access was most often obtained through the popliteal vein, followed by the femoral and great saphenous veins. The mean operative time was 122Â minutes (range, 59-249Â minutes), and the median volume of tissue plasminogen activator infused was 10Â mg (range, 4-20Â mg). The median cost per procedure, including devices and medication, was $5374.45. Median postoperative length of stay was 1Â day (range, 1-45Â days). Successful single-session FTTP, as determined by completion venography, was accomplished in 81.5%Â (nÂ =Â 31/38) of cases. The remaining seven cases (18.5%) required one additional session. Of the 38 patients, 30 (79%) required iliac vein stenting. Periprocedural complications consisted of one patient with retroperitoneal hemorrhage that was managed conservatively. No patients experienced rethrombosis within 30Â days of FTTP. During the 5-year study period, there were no cases of pulmonary embolism, significant local or systemic hemorrhage, limb loss, or mortality. CONCLUSIONS:FTTP, as presented herein, appears to be a safe, effective, and cost-effective technique in the resolution of acute IFDVT.
Efficacy of balloon venoplasty alone in the correction of nonthrombotic iliac vein lesions
OBJECTIVE:Iliac vein stenting of nonthrombotic iliac vein lesions is an evolving treatment course for management of chronic venous insufficiency. To characterize these lesions, we examined our experience treating these lesions with balloon venoplasty before stenting. METHODS:A retrospective analysis was performed to study all patients who underwent venograms with venoplasty and stenting of iliac veins from February 2013 to July 2016. All patients included in the study were treated with a trial conservative management for 3 consecutive months before venogram and, if indicated, venoplasty was performed. If a greater than 50% reduction in cross-sectional area or diameter was observed on intravascular ultrasound examination, the stenotic area was treated with balloon angioplasty, sized to nonstenotic distal vein segment (range, 10Â Ã—Â 40Â mm to 16Â Ã—Â 60Â mm). Intravascular ultrasound examination was also used to measure the area of stenotic iliofemoral veins before and after balloon angioplasty. RESULTS:). There were 227 patients (22.2%) who had the same area before and after venoplasty. Left-sided lesions had a greater increase in area than right-sided lesions (51.3% vs 46.2%, respectively; PÂ = .048). No significant correlation of stenotic area response with age, presenting symptoms of Clinical, Etiology, Anatomy, and Pathophysiology (C2-C6), gender, or location of targeted lesion was observed. CONCLUSIONS:Our data show there is a highly variable response after venoplasty of stenotic area of nonthrombotic iliac vein lesions. Balloon venoplasty showed greater improvement in improving the area of stenotic left-sided lesions. However, stenting of the lesions should be performed routinely owing to recoil and spasm in lesions.