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Superior Mesenteric Artery Thrombosis after Necrotizing Pancreatitis

Chait, Jesse; Duffy, Eric; Marks, Natalie; Rajaee, Sareh; Hingorani, Anil; Ascher, Enrico
Vascular complications secondary to acute pancreatitis carry a high morbidity and mortality, often because of their hemorrhagic or thrombotic effects. When thrombosis presents, it is typically localized to the splanchnic venous system. In this report, we present a case of acute superior mesenteric artery thrombosis secondary to necrotizing pancreatitis after a laparoscopic cholecystectomy. The patient was successfully treated with catheter-directed thrombolysis and mechanical thrombectomy.
PMID: 31075475
ISSN: 1615-5947
CID: 3919282

Comparison of Ultrasound-Accelerated Versus Multi-Hole Infusion Catheter-Directed Thrombolysis for the Treatment of Acute Limb Ischemia

Chait, Jesse; Aurshina, Afsha; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVE/UNASSIGNED:Thrombolytic therapy is widely used in the treatment of arterial occlusions causing acute limb ischemia (ALI); however, knowledge regarding the efficacy of the different catheter systems available is scarce. The objective of this study was to compare the safety and efficacy of 2 catheter-directed infusion systems for intra-arterial thrombolysis in the setting of ALI. METHODS/UNASSIGNED:A retrospective analysis was conducted to study all catheter-directed thrombolysis procedures performed over 32 months in patients diagnosed with ALI. Patients with thrombosis in both native arteries and bypass grafts were included. Patients with contraindications to thrombolysis, or those receiving thrombolysis for deep venous thrombosis, were excluded. The duration of thrombolysis, amount of thrombolytic agent, and technical success rate were recorded. Technical success was defined as complete or near-complete resolution of thrombus burden, allowing for further intervention. Data were stratified to include location of thrombus, procedural complications, mortality, and rates of limb loss. RESULTS/UNASSIGNED:> .4). The overall complication rate was 14% in both groups, with a 30-day mortality rate of 4% when treated with either catheter system. CONCLUSION/UNASSIGNED:This study suggests that a standard multi-hole infusion catheter demonstrates similar clinical safety and efficacy as the ultrasound-accelerated EKOS system in the treatment of ALI.
PMID: 31327305
ISSN: 1938-9116
CID: 3986602

Routine use of ultrasound to avert mechanical complications during placement of tunneled dialysis catheters for hemodialysis

Aurshina, Afsha; Hingorani, Amrit; Hingorani, Anil; Marks, Natalie; Ascher, Enrico
OBJECTIVE:While placement of tunneled dialysis catheters for hemodialysis access is considered a routine procedure, it is associated with a small chance of mechanical complications. Because the literature examining these issues is not recent and our impression of the incidence of these postprocedural complications is at variance with the existing literature, we decided to review our experience. METHODS:Since 1998, our vascular service has placed 1766 tunneled hemodialysis catheters in 1065 patients for hemodialysis access. All catheters were placed with ultrasound guidance for the puncture, with selective use of a micropuncture set for patients with low-volume status. All patients underwent chest radiography at the end of each procedure. RESULTS:The average age of the patients was 61 ± 21 (standard deviation) years. Among the 1065 patients, 44% were female; 93% of catheters were placed in the right internal jugular vein and 7% in the left internal jugular vein. The prevalence of diabetes and hypertension in our population of patients was 52% and 72%, respectively. In this consecutive series, no case of postprocedure hemothorax or pneumothorax was encountered. Two cutdowns had to be performed because of injury to branches of the external carotid artery. Three patients had to have a subsequent revision because of malpositioning of the catheter. CONCLUSIONS:Using modern-day techniques, the incidence of mechanical complications during placement of tunneled catheters can be diminished. Hence, routine use of ultrasound guidance for insertion of tunneled dialysis catheters should become the standard of care.
PMID: 30922984
ISSN: 2213-3348
CID: 3777442

Is it necessary to dilate stents in management of nonthrombotic iliac vein lesions?

Aurshina, Afsha; Ostrozhynskyy, Yuriy; Nguyen, Hoang; Alsheekh, Ahmad; Marks, Natalie; Rajaee, Sareh; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Iliac vein stenting is an evolving treatment option for chronic venous insufficiency and management of nonthrombotic iliac vein lesions (NIVLs). Currently described protocols recommend deployed stents to be dilated with balloon venoplasty before completion of the procedure, based on previous literature established from management of arterial lesions. The objective of the study was to investigate the role of balloon venoplasty after stent deployment in the management of NIVLs. METHODS:During the course of 6 months, 71 balloon venoplasties with stenting of iliac veins (34 right and 37 left limbs) were performed. Intraoperatively, we used intravascular ultrasound to measure and to record area of iliofemoral veins. The measurement of stenosis was compared with adjacent nonstenotic iliofemoral veins. If >50% cross-sectional area or diameter reduction was found, it was treated with an appropriate balloon size (range, 10 × 40 mm to 16 × 60 mm) and Wallstent (Boston Scientific, Natick, Mass; 12-24 mm in diameter by 40-90 in mm length). All stents were dilated with a balloon after deployment. Intravascular ultrasound was used to measure the preoperative area of stenotic lesion, area of lesion after stenting, and area after balloon dilation of the stent. RESULTS:; P = .22). No statistically significant correlation was found between difference in areas and age of the patient, clinical class (C2-C6), sex, lesion, laterality, and location of targeted lesion. One patient developed an intraluminal partial thrombus within 30 days of intervention. CONCLUSIONS:Our preliminary data show no significant clinical or technical benefit with use of balloon venoplasty to dilate stents after deployment in NIVLs. Postdilation should thus be limited to only those with suboptimal self-expansion of stent after initial deployment on fluoroscopic imaging.
PMID: 31203858
ISSN: 2213-3348
CID: 3955912

Bilateral iliac vein stenting reduces great and small saphenous venous reflux

Chait, Jesse; Kibrik, Pavel; Kenney, Kevin; Alsheekh, Ahmad; Ostrozhynskyy, Yuriy; Marks, Natalie; Hingorani, Anil; Rajaee, Sareh; Ascher, Enrico
OBJECTIVE:Iliac vein stenting has been an evolving treatment option in the management of CVI secondary to iliac vein obstruction. Historically, treatment of CVI has been focused on the elimination of saphenous vein disease; however, the effect of reduction of iliac vein obstruction on superficial venous reflux remains largely unknown. This study aimed to identify the effect of iliac vein stenting on saphenous vein reflux. METHODS:In this retrospective study spanning course of five years, we performed 2681 venograms with venoplasties and stenting of the iliac veins. Pre-operative and post-operative venous mapping was performed via duplex ultrasonography. Patients who received any lower extremity vascular intervention between "pre-" and "post-stenting" duplex ultrasonography examination, other than iliac vein stenting, were excluded from analysis. RESULTS:(18%). Bilateral iliac vein stenting significantly reduced reflux in the bilateral great saphenous and small saphenous veins by 363.8 ms ( p < 0.0001) and 345.4 ms ( p < 0.0002), respectively, but had no effect on ASV reflux. Unilateral stenting did not produce significant reductions in reflux, besides an average reduction of 573.2 ms ( p = 0.004) in the left great saphenous vein. CONCLUSION/CONCLUSIONS:Bilateral iliac vein stenting decreased great saphenous vein and small saphenous vein reflux. Unilateral stenting did not demonstrate a significant reduction in saphenous reflux. Bilateral reduction in stenosis of the iliac veins may influence superficial venous reflux.
PMID: 31169465
ISSN: 1708-539x
CID: 3918032

The Society of Vascular Surgery International Scholars Program: The First Decade

Narala, Bhavya; Aurshina, Afsha; Hingorani, Anil; Marks, Natalie; Rajaee, Sareh; Iadgarova, Eleanor; Ascher, Enrico
OBJECTIVE/UNASSIGNED:The Society for Vascular Surgery (SVS) is a not-for-profit medical society, whose goal is to further advance in vascular health on a global scale. With its 10th anniversary in sight, we were interested in analyzing the impact of a specific scholarship given under the SVS, the International Scholars Program. Our goal was to examine the awardees' characteristics and academic productivity. MATERIALS AND METHODS/UNASSIGNED:We measured the number of peer-reviewed articles, before and after the program, using PubMed® and Google Scholar® (2008-2018) of the scholarship recipients. Editorials, book chapters, letter to editor, and oral/poster presentations were excluded. A survey was sent out to assess the awardees' current status. RESULTS/UNASSIGNED:The average number of applicants/year was 15.4 (standard deviation ± 6.69), with 17.5% females and a mean age of 37 ± 3.37 years, with 5.6 ± 2.30 years status post vascular fellowship. Brazil had the highest number of recipients (n = 5; 18.5%) followed by China (n = 4; 14.8%). No significant difference was noted between each country in terms of publications ( P = .45), nor with after the SVS scholarship program compared to before ( P = .14, 1.84 vs 2.76). The survey concluded 33% had attended a subsequent SVS meeting after the program, with 27% having presented their research (n = 15). The recipients noted the program helped adopt new practices in clinical management (n = 13, 87%), learn new procedures (n = 10, 67%), gain local/regional leadership (n = 9, 60%), and improve technical skills (n = 8, 53%). The most visited clinical sites were Massachusetts General Hospital and Mayo Clinic (n = 4, 27%). The program was given a 9.1/10 rating. CONCLUSION/UNASSIGNED:The program was successful in maintaining academic productivity by continuing to publish research even after the scholarship, while teaching recipients skills to further improve their career goals. The award remains a competitive process that selects highly skilled recipients and still has much growth and progress to look forward to over the next decade.
PMID: 31159686
ISSN: 1938-9116
CID: 3922512

Radiation exposure during non-thrombotic iliac vein stenting

Chait, Jesse; Davis, Nikolay; Ostrozhynskyy, Yuriy; Rajaee, Sareh; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Fluoroscopic-guided interventions have become a major part of the modern vascular surgeon's practice. Imaging is typically required to safely and effectively perform both simple and complex endovascular interventions. With an ever-increasing volume of fluoroscopic-guided interventions being performed each year, the minimization of harmful radiation exposure has become of paramount concern for both patients and providers. The purpose of this study was to identify the extent of radiation exposure associated with venography and iliac vein stenting, an intervention utilized in the management of chronic venous insufficiency. METHODS:This was a single-center, retrospective analysis of 40 venograms performed on 29 unique patients over a three-month period. Patients with signs and symptoms of chronic venous insufficiency who failed conservative therapy underwent evaluation of the vena cava and iliofemoral veins with venography and intravascular ultrasound. Stent placement was performed if a >50% cross-sectional area or diameter reduction was identified via intravascular ultrasound. All patients were found to have non-thrombotic iliac vein lesions. All patients wore two individual film badge dosimeters - one on their chest and the other on the abdomen. The same mobile C-arm system was used for all interventions. RESULTS:. Sixteen limbs had C6 disease, 10 had C4 disease, and 14 had C3 disease. Thirty-eight of the 40 procedures resulted in stent placement, with an average of 1.13 stents placed per intervention. The average fluoroscopy time was 76.5 s (SD ± 36.9; range 7.8-209.5), and the mean cumulative air kerma was 1.08 mGy (SD ± 0.55; range 0.362-2.24). Average cumulative air kerma was higher in procedures resulting >1 stent placement compared to those with placement of ≤1 stent (1.44 vs. 1.02 mGy; p = 0.04). Fluoroscopy time was also higher in procedures with >1 stent placed (120.1 vs. 68.8 s; p = 0.0004). The mean deep dose equivalent per procedure from the patient-worn abdominal badge was 0.221 mSv. CONCLUSION/CONCLUSIONS:With the adjunctive use of intravascular ultrasound, iliac vein stenting can be safely and effectively performed with very low utilization of fluoroscopy, and therefore radiation exposure can be minimized for both patients and surgeons. Placement of >1 iliac vein stent resulted in higher cumulative air kerma and fluoroscopy time.
PMID: 31067208
ISSN: 1708-539x
CID: 3919012

Descending thoracic endovascular aortic repair does not require cardiothoracic surgery support

Chait, Jesse; Kibrik, Pavel; Alsheekh, Ahmad; Marks, Natalie; Rajaee, Sareh; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive "back-up plan." METHODS:(range 16.8-35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2). RESULTS:The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3-6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3-166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support. CONCLUSION/CONCLUSIONS:These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.
PMID: 30866752
ISSN: 1708-539x
CID: 3733282

A Comprehensive Evaluation of Infrainguinal Endotherapy at Our Institution: Cost, Time, Radiation, and Outcomes [Meeting Abstract]

Pavalonis, Albert; Ascher, Enrico; Marks, Natalie; Hingorani, Anil; Ostrozhynskyy, Yuri; Chait, Jesse; Berg, Jennifer
ISSN: 0741-5214
CID: 3512162

Demographic and clinical features do not affect the outcome of combined endovenous therapy to treat leg swelling

Alsheekh, Ahmad; Hingorani, Anil; Aurshina, Afsha; Kibrik, Pavel; Marks, Natalie; Ostrozhynskyy, Yuriy; Ascher, Enrico
Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases, yet there are limited data on risk factors and outcome of lower limb swelling. While many patients improve with endovenous therapy (thermal ablation or iliac vein stenting), some patients' symptoms persist. The goal of this study was to identify clinical factors including race/ethnicity related to persistent leg swelling after treatment with both iliac vein stenting and thermal ablation. Methods From February 2012 to February 2014, this observational study analyzed data for 173 patients with chronic venous insufficiency who underwent both iliac vein stent placement as well as thermal ablation (radiofrequency ablation or endovenous laser ablation). All procedures of the thermal ablations and the iliac vein stenting were staged. Iliac vein stenosis was identified using intravascular ultrasound of the iliofemoral venous segment showing >50% cross-sectional area or diameter reduction. The patients were queried to the resolution of their leg swelling after both procedures were performed. The resolution of swelling was correlated with age, gender, presenting sign according to CEAP classification, race/ethnicity and degree of iliac vein stenosis. Patients were categorized by Caucasians ( n = 97), African Americans ( n = 27), or Hispanics ( n = 49). Statistical analysis performed using Chi-square and Student's t test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 117 (67.6%) patients were women. The average age was 67 (±13 SD) years. The average pain score was 2.9(±3.1 SD). The average degree of iliac vein stenosis was 66.5(±13.3 SD). About 56.1% were Caucasians, 15.6% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 2. One hundred fifty-two (87.9%) patients stated that they had improvement in swelling after combined procedures, 100 (65.8%) patients were women. The average age was 67.3 (±13 SD) years. The average pain score was 2.9 (±3.1 SD). The average degree of iliac vein stenosis was 67.3% (±12.8 SD). About 56.6% were Caucasians, 15.1% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 1. Twenty-one (12.1%) patients stated they had no improvement after both procedures. Correlating these group factors with the group of patients who improved their swelling after the combined procedures we found the following: 17 (81%) of these patients were females ( P=0.16). The average age was 68.4 (±17 SD) years ( P=0.72 SD). The average pain score was 3.2 (±3.7 SD) ( P=0.68). The average degree of iliac vein stenosis was 60.2% (±15.9 SD) ( P=0.02). Around 52.4% were Caucasians, 19% were African Americans, and 28.6% were Hispanics ( P=0.88). The number of patients with iliac vein stent thrombosis was 1 ( P = 0.1). Conclusion These data suggest that the clinical factors including race are not clinically significant factors in the response to swelling after combined iliac stent and endovenous ablation procedures. Interestingly, a higher degree of iliac vein stenosis was associated with improved resolution of swelling.
PMID: 29473448
ISSN: 1708-539x
CID: 2991162