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1.
Semin Vasc Surg ; 37(2): 150-155, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-39151994

RESUMEN

Chronic superficial venous disease, including superficial venous insufficiency, superficial venous thrombosis, and aneurysms, are prevalent conditions that affect millions of individuals worldwide. With chronic venous insufficiency specifically, the advent of office-based minimally invasive procedures in recent decades has significantly expanded access to outpatient treatment. However, as venous insufficiency is rarely life- or limb-threatening, the clinical diagnosis, diagnostic evaluation, and treatment indications should be considered carefully when recommending elective intervention. Appropriateness of care guidelines intend to aid providers and patients in the decision-making process, based on the available evidence in the scientific literature, to select the best care for the patient when treating their superficial venous disease.


Asunto(s)
Toma de Decisiones Clínicas , Insuficiencia Venosa , Humanos , Insuficiencia Venosa/terapia , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/fisiopatología , Enfermedad Crónica , Resultado del Tratamiento , Trombosis de la Vena/terapia , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/diagnóstico , Selección de Paciente , Guías de Práctica Clínica como Asunto/normas , Procedimientos Quirúrgicos Vasculares/normas , Procedimientos Quirúrgicos Vasculares/efectos adversos , Factores de Riesgo , Valor Predictivo de las Pruebas , Aneurisma/terapia , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía
2.
Semin Vasc Surg ; 37(2): 156-163, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-39151995

RESUMEN

In the past decade, technologies to treat venous pathologies have increased dramatically, to the benefit of an often underserved and overlooked population of patients with venous disease. However, given the rapid release of various technologies, including venous-dedicated stents and thrombectomy devices across varied venous pathologies, evidence-based guidelines have been slow to develop. When discussing appropriateness of care, one needs to consider optimal patient selection, technical approach, medical management, and surveillance protocols, to name a few. All of which, in the venous space, are currently widely varied in practice. The future of deep venous work is limitless, but multicenter, randomized controlled trials are needed to optimally treat patients with venous disease.


Asunto(s)
Toma de Decisiones Clínicas , Procedimientos Endovasculares , Selección de Paciente , Humanos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/normas , Resultado del Tratamiento , Trombectomía/efectos adversos , Trombectomía/normas , Trombosis de la Vena/terapia , Trombosis de la Vena/diagnóstico por imagen , Stents , Factores de Riesgo , Guías de Práctica Clínica como Asunto/normas
3.
Circ Cardiovasc Interv ; 17(8): e014160, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-39034930

RESUMEN

A nonthrombotic iliac vein lesion is defined as the extrinsic compression of the iliac vein. Symptoms of lower extremity chronic venous insufficiency or pelvic venous disease can develop secondary to nonthrombotic iliac vein lesion. Anatomic compression has been observed in both symptomatic and asymptomatic patients. Causative factors that lead to symptomatic manifestations remain unclear. To provide guidance for providers treating patients with nonthrombotic iliac vein lesion, the VIVA Foundation convened a multidisciplinary group of leaders in venous disease management with representatives from the American Venous Forum and the American Vein and Lymphatic Society. Consensus statements regarding nonthrombotic iliac vein lesions were drafted by the participants to address patient selection, imaging for diagnosis, technical considerations for stent placement, postprocedure management, and future research/educational needs.


Asunto(s)
Consenso , Vena Ilíaca , Stents , Insuficiencia Venosa , Humanos , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/fisiopatología , Insuficiencia Venosa/terapia , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/fisiopatología , Procedimientos Endovasculares , Resultado del Tratamiento , Factores de Riesgo , Valor Predictivo de las Pruebas
4.
J Vasc Surg Venous Lymphat Disord ; : 101893, 2024 May 20.
Artículo en Inglés | MEDLINE | ID: mdl-38777041

RESUMEN

OBJECTIVE: Venous stents are a common treatment modality for obstructive venous disease. Venous stents differentiate themselves by either a woven or braided structure, open or closed cell arrangement or based on material composition (elgiloy vs nitinol). Changes in the morphology of venous stents over time may contribute to restenosis or thrombosis. Woven elgiloy stents are prone to proximal and distal edge deformation compared with dedicated venous stents, which offer increased radial force at stent edges. The objective of this study is to describe luminal morphological changes among various venous stents and between woven to nonwoven venous stent configuration, over time. METHODS: A retrospective review at a single institution between January 2014 and June 2021 identified patients treated with venous stents. Patients with iliac and/or femoral venous stents with intraoperative intravascular ultrasound and a postoperative computed tomography scan were included in the study. Cross-sectional diameters measurements were taken at proximal, middle, and distal portions of each stent from intravascular ultrasound examination at the time of initial stenting and compared with the cross-sectional diameter measurements taken from computed tomography imaging at follow-up. A paired t test was used to compare the luminal change with a D'Agostino-Pearson test used for normality. RESULTS: Fifty-four stents distributed among 38 patients were identified. The mean time to follow-up was 17.5 months. Stents were placed in the common iliac vein (n = 37, 68.5%), external iliac vein (n = 14, 25.9%), and common femoral vein (n = 3, 5.6%). Implanted stents included the Boston Scientific Wallstent (n = 23, 42.6%), Bard Venovo (n = 3, 5.6%), Boston Scientific Vici (n = 23, 42.6%), and Medtronic Abre (n = 5, 9.3%). The mean luminal loss was measured at 2.12 mm proximally (95% confidence interval [CI], 1.64-2.60; P<.001), 1.29 mm at the mid-stent (95% CI, 0.83-1.74, P<.001), and 1.56 mm distally (95% CI, 0.99-2.12; P<.001). There was no significant difference in luminal changes between woven and nonwoven stents at proximal (P = .374), middle (P = .179), and distal (P = .609) stent measurements. CONCLUSIONS: This study reports morphological changes within venous stents and between woven and nonwoven venous stents. Our findings demonstrate that the edge-stent luminal decrease traditionally attributed to woven configurations also occurs with the newer nonwoven stents. Additional factors such as anatomical location, pelvic curvature, and other external forces may be accountable for this change rather than geometrical configuration of the stent.

5.
J Vasc Surg Venous Lymphat Disord ; 11(5): 897-903, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37343787

RESUMEN

OBJECTIVE: Superficial venous disease has a U.S. prevalence of nearly 30%, with advanced disease contributing to a significant healthcare burden. Although the risk factors for venous disease are well known, the correlation between race, sex, socioeconomic status, and disease severity on presentation is not well established. The area deprivation index (ADI) is a validated metric with respect to regional geography, social determinants of health, and degree of socioeconomic disadvantage. In the present study, we aimed to identify the disparities and the effect that the ADI, in addition to race and sex, has among patients associated with an advanced venous disease presentation. METHODS: A retrospective review between 2012 and 2022 was performed at four tertiary U.S. institutions to identify patients who underwent endovenous closure of their saphenous veins. Patient demographics, state ADI, comorbidities, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, and periprocedural outcomes were included. Pearson's correlation was performed between the CEAP classification and ADI. Poisson regression analysis was performed to identify factors predicting for an increasing CEAP classification at presentation. Variables with P < .05 were deemed significant. RESULTS: A total of 2346 patients underwent endovenous saphenous vein closure during the study period, of whom 7 were excluded because of a lack of follow-up data. The mean age was 60.4 ± 14.9 years, 65.9% were women, and 55.4% were White. Of the 2339 patients, 73.3% presented with an advanced CEAP class (≥3). The mean state ADI for the entire cohort was 4.9 ± 3.1. The percent change in the CEAP classification is an increase of 2% and 1% for every level increase in the state ADI for unadjusted (incidence rate ratio [IRR] = 1.02; P < .001) and adjusted (IRR = 1.01; P < .001) models, respectively. Black race has a 12% increased risk of a higher CEAP class on presentation compared with White race (IRR = 1.12; P = .005). Female sex had a 16% lower risk of a higher CEAP presentation compared with male sex (IRR = 0.84; P < .01). CONCLUSIONS: Low socioeconomic status, Black race, and male sex are predictive of an advanced CEAP classification on initial presentation. These findings highlight the opportunity for improved mechanisms for identification of venous disease and at-risk patients before advanced disease progression in known disadvantaged patient populations.


Asunto(s)
Várices , Insuficiencia Venosa , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Disparidades Socioeconómicas en Salud , Várices/diagnóstico por imagen , Várices/epidemiología , Várices/cirugía , Factores de Riesgo , Índice de Severidad de la Enfermedad , Vena Safena/diagnóstico por imagen , Vena Safena/cirugía , Estudios Retrospectivos , Resultado del Tratamiento
6.
J Vasc Surg Venous Lymphat Disord ; 11(5): 1063-1069.e1, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37353156

RESUMEN

BACKGROUND: Biases and gender disparities influence career pathways within medicine, and vascular surgery is no exception. Venous disease comprises an estimated 1% to 3% of total health care expenditures. However, its value among vascular surgeons is poorly understood. This study aims to investigate the factors that influence vascular surgeons' current perceptions of superficial and deep venous disease treatments. METHODS: An anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. The respondents were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥25% of the total volume. Changes in practice patterns over the respondent's career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA (StataCorp). RESULTS: A total of 315 practicing vascular surgeons responded, with 81.5% from the United States. Their mean age was 46.6 ± 9.6 years, and most identified as men (63.3%). The race and ethnicity breakdown was as follows: White (non-Hispanic), 63.0%; Asian or Asian Indian, 17.1%; Hispanic, Latinx, or Spanish, 8.4%; Black, 1.6%; and unknown, 9.9%. The practice settings were academic for 47.0%, private practice for 26.5%, hospital employed for 23.3%, and other for 3.2%. The female respondents were significantly younger (P < .0001), with fewer years in practice (P < .0001) and were more likely to perceive a gender bias within a career encompassing venous disease compared with the male respondents (P = .02). Of the 315 participants, 143 (45.4%) had a venous-heavy practice. No differences were found in age or gender between the venous-heavy and venous-light practices. Those with a venous-heavy practice had significantly more years in practice statistically (P = .02), had sought more venous training after graduation (P < .0001), were more likely to be in private practice (P < .0001), and were more likely to desire a practice change (P = .001) compared with those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work might be less "valued" than arterial work in the field of vascular surgery. On multivariable regression, the predictors for the perception of venous work being less valued were female gender (odds ratio, 2.01; 95% confidence interval, 1.14-4.03) and completion of a vascular surgery fellowship (odds ratio, 2.0; 95% confidence interval, 1.15-3.57). CONCLUSIONS: Vascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly by women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the U.S. healthcare budget, cannot be overstated. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.


Asunto(s)
Especialidades Quirúrgicas , Cirujanos , Enfermedades Vasculares , Humanos , Masculino , Femenino , Estados Unidos , Adulto , Persona de Mediana Edad , Sexismo , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/educación , Percepción
7.
Ann Vasc Surg ; 95: 218-223, 2023 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-37301253

RESUMEN

BACKGROUND: Nonthermal endovenous closure techniques are routinely utilized to treat superficial axial venous reflux. Cyanoacrylate closure is a safe and effective modality implemented for truncal closure. However, an adverse reaction of type IV hypersensitivity (T4H), unique to cyanoacrylate, is a known risk. This study aims to evaluate the real-world incidence of T4H and examine risk factors that may predispose its development. METHODS: A retrospective review between 2012- and 2022 was performed at four tertiary US institutions to examine patients who underwent cyanoacrylate vein closure of their saphenous veins. Patient demographics, comorbidities, CEAP (Clinical [C], Etiological [E], Anatomical [A], and Pathophysiological [P]) classification, and periprocedural outcomes were included. The primary endpoint was development of T4H post procedure. Logistic regression analysis for risk factors predictive of T4H was performed. Variables with a P-value of <0.05 were deemed significant. RESULTS: 595 patients underwent 881 cyanoacrylate venous closures. Mean age was 66.2 ± 14.9, and 66% of patients were female. There were 92 (10.4%) T4H events in 79 (13%) patients. Oral steroids were administered to 23% for persistent and/or severe symptoms. There were no systemic allergic reactions to cyanoacrylate. Multivariate analysis revealed younger age (P = 0.015), active smoking status (P = 0.033), and CEAP 3 (P < 0.001) and 4 (P = 0.005) classifications as independent risk factors associated with development of T4H. CONCLUSIONS: This real-world multicenter study shows the overall incidence of T4H to be 10%. CEAP 3 and 4 patients of younger age and smokers predicted a higher risk of T4H to cyanoacrylate.


Asunto(s)
Hipersensibilidad Tardía , Várices , Insuficiencia Venosa , Humanos , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Cianoacrilatos/efectos adversos , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/terapia , Resultado del Tratamiento , Factores de Riesgo , Hipersensibilidad Tardía/inducido químicamente , Estudios Retrospectivos , Vena Safena/diagnóstico por imagen , Várices/diagnóstico por imagen , Várices/cirugía
8.
J Vasc Surg ; 77(5): 1487-1494, 2023 05.
Artículo en Inglés | MEDLINE | ID: mdl-36717038

RESUMEN

OBJECTIVE: Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data. METHODS: Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates. RESULTS: A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01). CONCLUSIONS: In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.


Asunto(s)
Pie , Recuperación del Miembro , Humanos , Estudios Retrospectivos , Pie/irrigación sanguínea , Amputación Quirúrgica , Extremidad Inferior/cirugía , Isquemia , Resultado del Tratamiento , Factores de Riesgo , Grado de Desobstrucción Vascular
9.
J Vasc Surg Venous Lymphat Disord ; 10(6): 1221-1228, 2022 11.
Artículo en Inglés | MEDLINE | ID: mdl-35843596

RESUMEN

OBJECTIVE: Chronic venous insufficiency (CVI) affects >40% of the U.S. population; thus, intervention for symptomatic venous disease comprises a large portion of many vascular practices. The treatment of superficial CVI has evolved from open surgical treatment to minimally invasive endovenous closure, including both thermal and nonthermal techniques. Thrombotic complications of thermal ablation have been well reported, with an overall complication rate of <2%. However, a paucity of high-powered, real-world data is available on the thrombotic outcomes of nonthermal techniques. In the present study, we compared the incidence of endovenous heat-induced thrombosis (EHIT) and endovenous glue-induced thrombosis (EGIT) in a large cohort of patients with CVI. METHODS: A retrospective review was conducted at two tertiary-level institutions of patients who had undergone superficial endovenous ablation from 2018 to 2021. The patient demographics, comorbidities, and periprocedural outcomes were collected through medical record review. A Caprini risk assessment model score was assigned using the information available from the electronic medical records. The patients were categorized by procedure type (ClosureFast [Medtronic Inc, Minneapolis, MN] radiofrequency ablation [RFA] vs VenaSeal [Medtronic Inc] cyanoacrylate glue closure [CAG]). The primary end point was the incidence of EHIT or EGIT. The secondary end point was the incidence of deep vein thrombosis and/or pulmonary embolism. RESULTS: A total of 803 patients had undergone 1096 procedures during the study period. Their mean age was 62 ± 15 years, and 67% were women. Of the 1096 procedures, 700 were RFA and 396 were CAG procedures, with a combined closure rate of 98% by postprocedure duplex ultrasound at 7 days. The average Caprini score was 5.2 ± 1.8 (RFA, 5.0; vs CAG, 5.4; P < .001). The incidence of EHIT and EGIT was 1.9% and 1.3%, respectively (P = .57). The deep vein thrombosis rate was 0.1% in the RFA cohort and 0.3% in the CAG cohort (P = .81). A comparative analysis of thermal vs nonthermal techniques was performed. A univariate analysis of the risk factors for EHIT and EGIT revealed no significant factors predisposing to thrombotic events. CONCLUSIONS: The results from the present study have demonstrated the safety of RFA and CAG closure techniques for CVI, with lower thrombotic rates than previously reported. Further work might help to identify how these results can be achieved across all venous ablative techniques for CVI, even for patient populations with advanced venous disease and possibly a greater than average risk of thrombotic events.


Asunto(s)
Ablación por Catéter , Terapia por Láser , Trombosis , Insuficiencia Venosa , Trombosis de la Vena , Anciano , Ablación por Catéter/efectos adversos , Cianoacrilatos/efectos adversos , Femenino , Humanos , Terapia por Láser/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Vena Safena/diagnóstico por imagen , Vena Safena/cirugía , Trombosis/etiología , Factores de Tiempo , Resultado del Tratamiento , Insuficiencia Venosa/complicaciones , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/cirugía , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/epidemiología , Trombosis de la Vena/etiología
10.
J Vasc Surg Venous Lymphat Disord ; 10(1): 87-93, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-33957279

RESUMEN

OBJECTIVE: Venous insufficiency is often not readily recognized as a contributing etiology to nonhealing wounds by nonvascular surgery specialists, potentially delaying appropriate treatment to achieve wound healing and increasing healthcare costs. The objective of the present study was to understand the time and resources used before the definitive treatment of venous ulcers. METHODS: A single-institution retrospective medical record review of C6 patients undergoing radiofrequency saphenous and perforator vein ablation from May 2016 to January 2018 identified 56 patients with 67 diseased limbs. The numbers of inpatient, emergency department, and wound care visits and the intervals to vein ablation from the initial evaluation of the ulceration by a healthcare provider were collected. The demographics, comorbidities, previous venous interventions, wound characteristics, duplex ultrasound imaging, and available wound healing follow-up through July 2018 were assessed for all patients. RESULTS: For the 67 limbs examined, 588 total healthcare visits were performed for wound assessment before a referral to a vascular surgeon, with 413 visits at a wound care center (70% of all visits). Other specialty visits included emergency medicine (17.9% of limbs) and rheumatology (22.4% of limbs). Six patients (nine limbs) were admitted to inpatient services for treatment of their ulceration. Overall, the patients were seen an average of 8.6 ± 9.7 times for their ulcer with the wound center before determination of a contributing venous etiology and subsequent treatment. These visits translated to a median of 230 days (interquartile range, 86.5-1088 days) between the first identification of the ulcer by healthcare providers and subsequent accurate diagnosis and definitive treatment of their venous disease with radiofrequency saphenous and perforator vein ablation. After intervention, 18.64% of the limbs had healed at 1 month, 33.92% had healed at 3 months, 50% had healed at 6 months, and 82.92% had healed by 12 months. CONCLUSIONS: An earlier and accurate diagnosis of the venous contribution to ulcers and subsequent appropriate treatment of venous etiologies in wound formation by a vascular venous specialist could significantly improve healing and minimize resource usage.


Asunto(s)
Recursos en Salud/estadística & datos numéricos , Tiempo de Tratamiento , Úlcera Varicosa/diagnóstico , Úlcera Varicosa/terapia , Anciano , Anciano de 80 o más Años , Diagnóstico Precoz , Femenino , Humanos , Masculino , Persona de Mediana Edad , Derivación y Consulta , Estudios Retrospectivos
11.
J Perioper Pract ; 32(11): 286-294, 2022 11.
Artículo en Inglés | MEDLINE | ID: mdl-34301162

RESUMEN

BACKGROUND: There is a wide ranging incidence of venous thromboembolism after surgery and it continues to be a major cause of morbidity after spinal procedures.This study's aim was to investigate the relationship between timing and administration of venous thromboembolism (VTE) pharmacologic chemoprophylaxis after spinal surgery and the resulting VTE and bleeding complications by reviewing current practices and outcomes at a high-volume single institution to better define opportunities for perioperative intervention to prevent VTE without increasing bleeding complications. METHODS: All patients who underwent elective one or two-stage lumbar spinal fusion procedures were identified. A logistic regression was used to evaluate (1) risk of symptomatic VTE within 30 days of surgery and (2) bleeding-related complications. The odds of developing a VTE as well as bleeding-related complications were compared among the three treatment groups: no chemoprophylaxis, chemoprophylaxis < 24h of surgery and chemoprophylaxis given > 24h post-surgery. RESULTS: When adjusted for doses administered, the odds of developing a postoperative VTE within 30 days were 0.189 (95% confidence interval (0.044, 0.808)) in patients who received anticoagulation < 24h postoperatively, compared to those who received no anticoagulation (p = 0.025). There was no difference in bleeding rates. CONCLUSION: Patients undergoing elective spinal surgery who received anticoagulation within 24h of the conclusion of their procedure had an 81% reduction in the odds of developing a deep vein thrombosis within 30 days with no significant difference in bleeding complications.


Asunto(s)
Tromboembolia Venosa , Humanos , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/epidemiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Factores de Riesgo , Estudios Retrospectivos , Anticoagulantes/uso terapéutico , Medición de Riesgo
12.
Vascular ; 30(2): 199-205, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33853456

RESUMEN

OBJECTIVES: Spinal cord ischemia following thoracic endovascular aortic repair (TEVAR) is a devastating complication. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia affects incidence in patients undergoing TEVAR. METHODS: Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Patients who had concomitant ascending aortic repairs or a TEVAR for traumatic indications were excluded from analysis, leaving 130 TEVAR procedures. Comorbid conditions, procedural characteristics, extent of coverage, peri-procedural management strategies, and post-operative outcomes were collected and analyzed retrospectively. RESULTS: One hundred thirty patients undergoing TEVAR were examined for four perioperative variables: postoperative hemoglobin greater than 10 g/dL, subclavian revascularization, preoperative spinal drain placement, and somatosensory evoked potential monitoring (SSEP). All conditions were met in 46.2% (60/130) of procedures; 37.8% (28/74) in emergent/urgent cases and 61.5% (32/52) in elective cases. Of patients who required subclavian coverage, 87.1% (54/62) underwent subclavian revascularization; 70.8% (92/130) of patients received spinal drains preoperatively; 68.5% (89/130) of patients had SSEP monitoring; 73.8% (93/130) of patients obtained a postoperative hemoglobin of >10 g/dL. Out of all patients, two (1.5%) developed spinal cord ischemia. CONCLUSION: Incidence of spinal cord ischemia in our cohort was low at 1.5% (2/130). Individual and bundled interventions for the prevention of spinal cord ischemia were unable to demonstrate a statistically significant effect given the low rate. Nonetheless, we advocate for a proactive approach for the prevention of spinal cord ischemia given our experience in this complex population.


Asunto(s)
Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Isquemia de la Médula Espinal , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Humanos , Estudios Retrospectivos , Factores de Riesgo , Isquemia de la Médula Espinal/diagnóstico , Isquemia de la Médula Espinal/epidemiología , Isquemia de la Médula Espinal/etiología , Factores de Tiempo , Resultado del Tratamiento
13.
Ann Vasc Surg ; 78: 45-51, 2022 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-34481884

RESUMEN

BACKGROUND: Transcarotid arterial revascularization (TCAR) offers a novel technique for carotid artery stenting (CAS) that provides flow reversal in the carotid artery and avoids aortic arch manipulation, thus, potentially lowering ipsilateral and contralateral periprocedural stroke rates. As a new technology, adoption may be limited by concern for learning a new technique. This study seeks to examine the number of cases needed for a surgeon to reach technical proficiency. METHODS: Retrospective analysis was performed using a prospectively collected database of all TCAR procedures performed in a tertiary health care system between 2016 and 2020. Patient demographics and anatomic characteristics were collected. Intraoperative variables and perioperative outcomes were examined. These variables were collated into groups for the first 4 procedures, procedures 5-8, and after 8. Independent Samples t test, 1-way ANOVA, and logarithmic regression were used to statistically analyze the data. RESULTS: One-hundred and eighty-seven TCARs were performed by 14 surgeons. One hundred and twenty-two (65%) were male, 59 (32%) were older than 75 years, and 83 (44%) were symptomatic. The most common indications were high-lesions in 87 patients (47%) and recurrent stenosis after CEA in 37 patients (20%). Significant differences were found between the first and second groups of 4 cases when comparing mean operative time (71 vs. 58 min; P = 0.001) and flow reversal time (10.8 vs. 7.9 min; P= 0.004). similar significant differences were found between the first and third groups of 4 cases but not between the second and third groups. There was a reduction in contrast usage and fluoroscopy time after the first 4 cases, however, this did not reach statistical significance. There was no ipsilateral perioperative strokes. One patient had a contralateral stroke on postoperative day 2 due to intracranial atherosclerosis, and there was one perioperative mortality that occurred on postoperative day 3 after discharge. CONCLUSIONS: Procedural and flow reversal times significantly shorten after 4 TCAR procedures are performed. Other metrics, such as fluoroscopy time and contrast usage, are also decreased. Complications, in general, are minimal. Proficiency in TCAR, as measured by these metrics, is met after performing only 4 procedures.


Asunto(s)
Competencia Clínica , Curva de Aprendizaje , Procedimientos Quirúrgicos Vasculares/educación , Anciano , Análisis de Varianza , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversos
14.
J Vasc Surg Venous Lymphat Disord ; 9(6): 1600-1601, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-34657673
15.
J Vasc Surg Venous Lymphat Disord ; 9(5): 1350-1351, 2021 09.
Artículo en Inglés | MEDLINE | ID: mdl-34399943
16.
J Vasc Surg Venous Lymphat Disord ; 9(6): 1510-1516, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-34111593

RESUMEN

OBJECTIVE: The authors have previously demonstrated that VenaSeal (Medtronic, Inc, Minneapolis, Minn) adhesive, compared with radiofrequency ablation (RFA, ClosureFast; Medtronic, Inc), in treatment of refluxing saphenous veins in CEAP 6 limbs, results in shorter healing times of venous ulcers. The authors hypothesize that the longer treated length possible with VenaSeal's nonthermal modality may affect the number of critical refluxing perforators contributing to the nonhealing wound. This follow-up study compares the need for follow-up treatment of perforator veins after saphenous vein treatment with either radiofrequency ablation (ClosureFast RFA) or adhesive closure (VenaSeal). METHODS: A multi-institutional retrospective review of CEAP 6 patients who had closure of their saphenous veins from 2015 to 2020 was conducted. Patients who underwent follow-up treatment of perforator veins were grouped according to their method of initial management of their saphenous veins. The primary end point was incidence of a perforator procedure after ClosureFast or VenaSeal ablation. Secondary end points included sclerotherapy to facilitate wound healing. Bivariate analysis used the χ2 test, Fisher exact test, t-test, and Wilcoxon rank sum test. A P value of <.05 defined statistical significance. RESULTS: There were 119 CEAP 6 patients with saphenous closure: 51 limbs treated with VenaSeal and 68 with RFA. Median follow-up was 105 days (interquartile range: 44, 208). All limbs achieved wound healing during the study period. Mean time to wound healing post index procedure was shorter for VenaSeal than RFA (72 vs 293.8 days, P > .0009), as was median time (43 vs 104 days, P = .001). More limbs treated with RFA had previous known deep vein thrombosis (29% vs 10%, P = .009), deep venous insufficiency (82% vs 51%, P = .0003), and perforator reflux (57% vs 29%, P = .002). Limbs with identified follow-up perforator reflux treated with RFA had a higher prevalence of initially treated saphenous veins with RFA compared with those treated with VenaSeal (49% vs 27%, P = .003). There was no difference between the methods of vein closure and use of concurrent sclerotherapy. CONCLUSIONS: ClosureFast and VenaSeal are both effective and safe modalities of saphenous ablation, but VenaSeal treatment was associated with less perforator RFA intervention.


Asunto(s)
Procedimientos Endovasculares , Ablación por Radiofrecuencia , Vena Safena/cirugía , Adhesivos Tisulares , Enfermedades Vasculares/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
17.
J Cardiovasc Surg (Torino) ; 62(5): 420-426, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-33890755

RESUMEN

Endovenous ablation has become the preferred means to treat superficial venous insufficiency. Ablative technologies have evolved to include a variety of both thermal and non-thermal techniques. The reported thrombotic complications of endovenous heat induced thrombosis (EHIT) and deep venous thrombosis (DVT) associated with thermal techniques are low (<2% overall). However, the limited data on newer non-thermal technologies suggest these modalities may have thrombotic complication rates upwards of 6%. Additionally, the pathophysiology of thrombotic events related to mechanochemical ablative techniques may differ from EHIT, and thus, may have different implications for management. Described is a case report of a stroke after cyanoacrylate ablation of the great saphenous vein, and a review of the current literature reporting the thrombotic complications associated with current thermal and non-thermal techniques. There exists a need for high-volume studies on newer ablative techniques to fully understand their associated thrombotic complications. This review highlights the need for a comprehensive classification system and standard treatment algorithm encompassing of thrombotic complications associated with both thermal and non-thermal ablative techniques.


Asunto(s)
Técnicas de Ablación/efectos adversos , Procedimientos Endovasculares/efectos adversos , Accidente Cerebrovascular Isquémico/etiología , Vena Safena/cirugía , Úlcera Varicosa/cirugía , Insuficiencia Venosa/cirugía , Trombosis de la Vena/etiología , Anticoagulantes/uso terapéutico , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Vena Safena/diagnóstico por imagen , Vena Safena/fisiopatología , Resultado del Tratamiento , Úlcera Varicosa/diagnóstico por imagen , Úlcera Varicosa/fisiopatología , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/fisiopatología , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/tratamiento farmacológico
18.
Ann Vasc Surg ; 75: 144-149, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-33848584

RESUMEN

BACKGROUND: Arterial bypass tunneling via the obturator foramen (OFB) can be performed to circumvent groin infections during lower extremity revascularization. The objective of this study is to report safety and efficacy outcomes of OFB in the setting of infected femoral pseudoaneurysms and infected prosthetic femoral bypass grafts. METHODS: A multihospital, single-entity healthcare system retrospective review was conducted for all patients who underwent OFB between January 2014 through June 2020. Any patient >18 years of age who underwent OFB in the setting of groin infection with a minimum of 30 days follow-up was included in the trial. Demographic, operative, and clinical characteristics of patients were gathered during chart review. Statistical analysis was performed using Microsoft Excel and R studio. RESULTS: Seventeen patients underwent OFB during the defined time-period. Demographic data are presented in the first table (Demographic Characteristics). Mean American Society of Anesthesiologists score was 3.25. Mean estimated blood loss was 500 mL. Mean operative time was 307 min. Mean follow-up time was 8.5 months (range 0-35 months). In total, 41.2% patients underwent fluoroscopic-guided tunneling, and, when compared to blind tunneling, showed no difference in intraoperative complications or operative time (P value 0.3). In total, 52.9% of patients required ICU admission resulting in a mean number of 0.8 ICU days. The overall mean length of stay was 16.8 days. Two major amputations were reported during follow-up. Patient mortality within 30 days was 0%. Primary patency within 30 days was 100%. Intravenous drug use was not associated with an increased number of subsequent groin wound procedures (P value 0.3). Intravenous drug use was not associated with concomitant methicillin-resistant Staphylococcus aureus infection (P value 0.3). CONCLUSION: OFB is a safe and effective surgical option in patients who are unable to undergo anatomic tunneling during lower extremity bypass. OFB is associated with favorable rates of primary patency and amputation-free survival at midterm follow-up.


Asunto(s)
Aneurisma Falso/cirugía , Aneurisma Infectado/cirugía , Implantación de Prótesis Vascular/efectos adversos , Prótesis Vascular/efectos adversos , Arteria Femoral/cirugía , Extremidad Inferior/irrigación sanguínea , Infecciones Relacionadas con Prótesis/cirugía , Adulto , Anciano , Amputación Quirúrgica , Aneurisma Falso/diagnóstico , Aneurisma Falso/microbiología , Aneurisma Falso/fisiopatología , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/microbiología , Aneurisma Infectado/fisiopatología , Implantación de Prótesis Vascular/instrumentación , Femenino , Arteria Femoral/microbiología , Arteria Femoral/fisiopatología , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/fisiopatología , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
19.
J Vasc Surg ; 74(5): 1721-1731.e4, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-33592292

RESUMEN

OBJECTIVE: The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach. METHODS: The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model. RESULTS: Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2. CONCLUSIONS: The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.


Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Toma de Decisiones Clínicas , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento
20.
Ann Vasc Surg ; 74: 237-245, 2021 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-33549798

RESUMEN

BACKGROUND: Parallel grafting presents a viable method for treating patients with complex aortic aneurysms. The current literature is limited to mostly pararenal configurations. We examined our results in patients with SMA and/or Celiac artery involvement. METHODS: A retrospective analysis was performed for all patients undergoing parallel grafting during the period of 2014 to 2018 at a single institution. All patients had at least SMA with and/or without Celiac artery parallel grafting. RESULTS: Seventy-nine patients (65% male, median age 74) were treated with 208 parallel grafts. Median ASA score is 4. Forty-nine cases were elective, 22 urgent, and 8 emergent. Mean pre-operative aneurysm diameter was 7.1 cm (4.6-15 cm). Self-expanding covered stents were used for the renal arteries (mean 6.3mm), and balloon-expandable covered stents were used for the SMA and Celiac (mean SMA 8.6 mm, mean celiac 8.3 mm). Axillary exposure was the choice of access in 68 patients (86%). Technical success was achieved in all cases. We defined this as aneurysm sac exclusion with patent visceral stent grafts, and absent to mild gutter leaks. Mean aortic graft proximal seal achieved was 48mm. Coverage extended above the celiac artery in 75% (10% stented and 65% covered). Median contrast volume was 145ml, operative duration was 4 hours, fluoroscopy time was 56 min, and EBL was 250 ml. Perioperative mortality was 6.1%. 4.5%, and 25%, for the elective, urgent, and emergent groups, respectively. There was no incidence of spinal cord ischemia. Axillary access was complicated in 4 patients, requiring patch closure of the axillary artery. One patient developed postprocedural ESRD from a rupture and ATN despite patent renal stents. Of those patients with a patent GDA and celiac coverage, 2 required a cholecystectomy. Nine patients had a persistent gutter leak at the conclusion of the procedure. Median follow-up was 12 months. On follow-up imaging, all SMA and Celiac stents were patent. Six renal stents were occluded and 2 patients progressed to ESRD, both solitary renal periscope configurations at the index procedure. Only 4 patients had persistent gutter leaks with 2 requiring reintervention. Ninety-five percent of patients demonstrated sac regression or stabilization with a mean sac size of 6.5 cm. CONCLUSIONS: Parallel grafting presents a safe, efficacious and off the shelf alternative to conventional repair of complex aortic aneurysms involving the visceral aorta.


Asunto(s)
Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular , Arteria Celíaca/cirugía , Procedimientos Endovasculares , Arteria Mesentérica Superior/cirugía , Arteria Renal/cirugía , Anciano , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Aneurisma de la Aorta/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/fisiopatología , Toma de Decisiones Clínicas , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Arteria Mesentérica Superior/diagnóstico por imagen , Arteria Mesentérica Superior/fisiopatología , Complicaciones Posoperatorias/mortalidad , Arteria Renal/diagnóstico por imagen , Arteria Renal/fisiopatología , Circulación Renal , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Circulación Esplácnica , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
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