Primary tibial vein aneurysm: a source of pulmonary emboli.

OBJECTIVE: To describe a case of a rare type of venous aneurysm (posterior tibial) with associated pulmonary embolus. We will discuss options and considerations germane to the diagnostic evaluation and possible interventions for this challenging clinical scenario. METHODS: Case presentation and literature review. RESULTS: A 36-year-old man presented to an outside hospital with a three-day history of left calf pain, acute shortness of breath and syncope elicited by exercise. Work-up demonstrated a pulmonary embolus and a posterior tibial venous aneurysm with mural thrombus. The patient presented to us 18 months later with persistent calf pain seeking an alternative to recommendations of lifelong anticoagulation. The patient was treated with surgical resection of the venous aneurysm with subsequent discontinuation of his anticoagulation. There were no surgical or thrombotic complications of this treatment course and the patient's discomfort improved. CONCLUSION: Primary aneurysms of the tibial veins as a cause of pulmonary emboli are rare. A review of the literature suggests that anticoagulation alone does not provide effective amelioration of thromboembolic risk from lower extremity venous aneurysms. We have reported a case of successful surgical treatment of a posterior tibial venous aneurysm and recommend that surgical correction be strongly considered for accessible venous aneurysms.

The role of perforators in chronic venous insufficiency.

The treatment of incompetent calf perforating veins (ICPVs) has been ascribed an important role in the therapeutic strategy for reducing superficial venous hypertension in patients with advanced chronic venous insufficiency (C4-C6). Since the open approach to ligation of ICPVs was developed by Linton over 70 years ago, there has been an evolution toward less invasive techniques with lower morbidity. This paper will review the evidence for interruption of ICPVs through a series of systematic analyses of (1) subfascial endoscopic perforating surgery (SEPS) and (2) percutaneous thermal ablation techniques (PAPS). The effectiveness and morbidity of each approach will be discussed as well as the strength of evidence supporting that technique. While there are numerous case series that suggest that SEPS is beneficial for ulcer healing and for the prevention of ulcer recurrence, the sole two RCTs that have compared either open division or SEPS for ICPVs have failed to show a statistical advantage for ICPV ablation. The results of these studies are clouded by the inclusion of patients who received concomitant treatment of their great saphenous vein (GSV). The evidence for PAPS is based on a few (n = 5) case series in peer-reviewed journals, which are limited by small patient populations, limited follow-up, and a focus on surrogate outcomes (occlusion of the perforator) rather than clinical or functional outcomes. Moreover, most of these series were carried out in patients with mild disease. Sclerotherapy of ICPVs, by either liquid or foam, shows promise, but requires greater evidence. Our current approach for limbs with C4-C6 disease is to treat the GSV first and limit treatment of ICPVs to those with high volume flow and large-diameter ICPVs. [corrected]

The small saphenous vein and other 'neglected' veins of the popliteal fossa: a review.

The small saphenous vein (SSV) and other veins in the popliteal fossa merit little discussion in the literature or in didactic programmes regarding their role in chronic venous insufficiency (CVI) and, in this sense, they are neglected. The purpose of this review is to present both duplex ultrasound findings and the associated clinical characteristics of patients with SSV reflux, from several large series. Both the anatomic variations and the epidemiology of the SSV, as well as other veins of the popliteal fossa, the gastrocnemius veins, Gocamini vein, popliteal area veins and popliteal vein, will be discussed. Findings from our review of the current available literature will demonstrate the important role that these veins play in association with CVI. The implications for open and endovenous surgery will be underlined.

Factors predicting prolonged length of stay after carotid endarterectomy.

BACKGROUND: Over the last several years, implementation of critical pathways in patients undergoing carotid endarterectomy has decreased postoperative length of stay significantly. Discharge the day after surgery has become commonplace in many centers, including our own. Unfortunately, managed care may interpret this refinement as a standard of care and limit reimbursement or even disallow admissions extending beyond 1 day. We therefore examined our carotid registry to identify risk factors associated with postoperative length of stay exceeding 1 day. METHODS: We retrospectively reviewed all patients undergoing carotid endarterectomy at our academic center from May 1996 through April 1999. Combined procedures and patients undergoing subsequent noncarotid-related procedures on those admissions were excluded. The charts were inspected for atherosclerosis risk factors, including sex and age, specific attending surgeon, side of the surgery, use of intravenous vasoactive drugs, actual preoperative blood pressure, and presence of neurologic symptoms or postoperative complications. Multiple regression analysis was performed on all collected variables. Statistical significance was inferred for P less than.05. RESULTS: A total of 188 patients met the study criteria and had complete, retrievable medical records. A mean postoperative length of stay of 1.65 +/- 0.08 days and a mean total length of stay of 2.17 +/- 0.14 days were observed. Fifty-seven percent of patients went home the day after surgery. There was a 1.6% stroke-mortality rate. Significant predictors of a prolonged stay, listed in order of decreasing importance on the basis of their calculated contribution to prolonging the postoperative length of stay, are as follows (P value; beta coefficient): postoperative complications (<.0001; 1.03), age > 79 years (.008; 0.547), diabetes mellitus (.011; 0.407), female sex (.007; 0.398), and intravenous vasodilator requirement (. 035; 0.382). Other atherosclerosis risk factors, prior neurologic symptoms, the postoperative use of vasopressors, and reoperative surgery did not contribute to extended length of stay. CONCLUSIONS: Discharge on the first postoperative day is feasible in many, but not all, patients undergoing carotid endarterectomy. Our data help define subsets of patients at risk for prolonged postoperative stay. Targeting these subsets for preoperative medical and social interventions may allow safe early discharge more frequently.

The Balanced Budget Act: potential implications for the practice of vascular surgery.

PURPOSE: Previous study results have shown a favorable impact on stroke rate with an increasing hospital volume of carotid endarterectomies (CEAs). This is not only the most frequently performed peripheral vascular procedure in the United States but also perhaps the most widely dispersed procedure relative to hospital type. Medical centers have adopted various strategies to lower the cost of hospitalization by reducing the length of stay (LOS), the major component of hospital cost. By 2002, the Balanced Budget Act is projected to reduce Medicare provider payments to academic medical centers (AMCs) by 15.5%, a reduction that is twice that for minor or nonteaching hospitals. We assessed the relationships between hospital costs, CEA volume, and stroke-mortality rates in AMCs and non-AMCs in Massachusetts. METHODS: With patient level data from the Massachusetts Division of Health Care Finance and Policy and with hospital cost and charge reports from the Health Care Financing Administration, HealthShare Technology provided data for all the patients discharged from a Massachusetts hospital who underwent CEA (n = 10,211) during the fiscal years 1995, 1996, and 1997, including cost, LOS, and disposition. The outcomes were further defined with in-hospital stroke and mortality rates. Five high volume AMCs (HVAMCs) were compared with all other nonacademic hospitals, which were further subdivided by annual volume into high volume non-AMCs (> or =50 cases), medium volume non-AMCs (24-49 cases), and low volume non-AMCs (12-23 cases). Statistical analysis was performed with analysis of variance to compare the means of all the cost and LOS data, and chi(2) test was used for comparison of incidence (significance assumed for P < or =. 05). RESULTS: Hospital costs were comparable among the four hospital types during individual years and averaged $6200, but HVAMCs were significantly more expensive overall, with a mean cost of $7882. The only centers to decrease their costs during the years evaluated were the HVAMCs, from $8706 to $6784. Length of stay did not differ among the groups in any year or overall, with a mean of 3.8 days, but did decrease between years at HVAMCs from 3.9 to 2.5 days. The combined stroke-mortality rates were significantly less at the HVAMCs (0.9%) than at either the high volume non-AMCs (1.9%) or the medium volume non-AMCs (2.5%). There was no significance in the analysis results of all the data within the low volume non-AMCs. CONCLUSION: Patients in HVAMCs have the best outcomes after CEA. Despite the achievement of significant efficiencies, AMCs have a small cushion to reduce further either LOS or resources to maintain a competitive cost position and to compensate for the fixed expenses of academic medicine. The Balanced Budget Act raises an equity concern for AMCs because it differentially affects the centers with the best outcomes. The financial implication of this may be a direct incentive for procedures to be done in centers with less optimal outcomes.

Adjuvant techniques for the management of large carotid body tumors. A case report and review.

Although the first successful resection of a carotid body tumor was reported over 100 years ago this operation remains technically challenging with many potential pitfalls. The case of a man with a large (8 cm) carotid body tumor will be presented in order to identify key issues that pertain to effective diagnostic and therapeutic modalities. A multidisciplinary team (vascular surgeon, neurosurgeon, neuroradiologist, interventional radiologist and oromaxillofacial surgeon) provided specific expertise on each aspect of the patient's evaluation and treatment. Adjuvant techniques employed in this case included angiographic tumor embolization, jaw subluxation, strap muscle division, nasotracheal intubation, carotid resection and saphenous vein interposition grafting.

Reduction of hospital resources utilization in vascular surgery: a four-year experience.

PURPOSE: Managed care whether through risk or through capitated contracts results in reduction in resources, reduced length of hospital stay, and reduced utilization of hospital resources (collectively referred to as resource reductions). These resource reductions will become even more noticeable as a greater proportion of Medicare patients who need vascular operations select a managed-care senior product. We examined the results of a 4-year experience with resource management in an academic vascular surgery practice during which best practice plans were developed and implemented. METHODS: We analyzed hospital cost data, which included both total hospital and intensive care unit length of stay, average units per operation for laboratory, pharmacy, and radiology services and operating room and direct hospital costs for 257 carotid endarterectomies performed over fiscal years (FY) 1994, 1995, 1996, and 1997 (6 month data) and 175 infrainguinal bypass procedures performed during the same period. RESULTS: For carotid endarterectomy, length of stay decreased 66% over the 4-year period to an average of 2.07 days in FY97. Both radiology and pharmacy utilization were reduced after the first year of institution of best practice plans (56% and 32% respectively) with 4-year total reductions of 86% and 55% by FY97. The most notable changes included elimination of routine postoperative laboratory testing, use of aspirin rather than low-molecular-weight dextran, emphasis on oral rather than intravenous vasoactive drugs, and routine use of duplex scanning alone rather than angiography for diagnosis after FY94-95. The length of operating room time for carotid endarterectomy remained relatively constant from FY94 to FY97. As a result of these multiple factors, our study showed a 30% decrease in total average direct hospital costs for carotid endarterectomy from $9974 to $7002 in this 4-year period. Infrainguinal bypass graft procedures showed a progressive decrease in total cost of 28% for patients without complications to $15,186 but remained unchanged for those with complications. Laboratory use, pharmacy use, and radiology use were not significantly different. CONCLUSIONS: Case management for patients undergoing carotid endarterectomy and infrainguinal bypass grafting involving an integrated team of vascular surgeons, surgical house staff, a dedicated vascular nurse, and a social work case manager resulted in dramatic reductions both in length of stay and hospital resource utilization. As these costs decreased, operating room expenses assumed increasing importance. Operating room costs account for 60% of the direct costs of carotid endarterectomy and a comparable percentage for uncomplicated infrainguinal bypass grafting. Further substantial reductions in direct hospital costs will depend primarily on reductions in operating room costs, particularly those related to length of time in the operating room.

Endoscopic in situ bypass. A gentler dissection.

We believe that this is the first report of a gasless endoscopic in situ bypass technique. We have pursued this minimally invasive procedure with the hope that wound complications and operative time might be improved without compromising graft patency. Having demonstrated the feasibility of minimally invasive lower-extremity bypass we would urge further study to assess the safety and efficacy of this promising approach.

Surgical reconstruction for deep venous insufficiency.

All patients with significant venous stasis disease should undergo noninvasive evaluation to determine the magnitude, precise location, and etiology of the problem (i.e. obstruction and/or reflux). Patients who fail aggressive medical therapy (compression and skin care) and who have significant symptoms should be considered candidates for surgical correction. The majority of patients screened will have a significant component of superficial venous insufficiency with or without the presence of incompetent perforating veins. In this case we address the superficial and perforating venous systems prior to consideration of deep venous reconstruction. When correction of superficial venous incompetence fails to improve the patient's symptoms, they are then considered for deep venous reconstruction. Patients with primary venous insufficiency are typically good candidates for direct valvuloplasty performed using the open or angioscopic techniques, while patients with damaged (post thrombotic) or absent valves are best managed by vein valve transplantation or segmental transposition. Results for both valvuloplasty and vein valve transplantation demonstrate good intermediate term valvular patency and ulcer healing. It appears that when used as part of a complete treatment protocol addressing superficial, deep, and perforating venous systems, as well as attention to skin care and appropriate compressive therapy that surgical reconstruction for deep venous reflux affords significant benefit to our patients.

Subfascial endoscopic perforator ligation: an analysis of early clinical outcomes and cost.

PURPOSE: Early results of subfascial endoscopic perforator surgery (SEPS) were examined. Data on ulcer healing, complications, and costs are presented. METHODS: Data were prospectively collected for all patients who underwent SEPS at our institution. A concurrent control group was not available because primary open perforator ligation is no longer performed at our hospital. Preoperative assessment included duplex scanning (valve closure times and perforator mapping), plethysmography, and phlebography. Completeness of therapy was assessed with postoperative duplex mapping of perforating veins. Clinical status was monitored after surgery, and actual costs, including equipment, personnel, and facilities management, are reported. RESULTS: Eighteen procedures were performed in 15 patients (mean age, 52 years; range, 42 to 65 years). Two patients underwent bilateral SEPS, and one patient underwent a second procedure on the same leg. Active ulceration (class 6) was present in 14 of 18 limbs (78%), recently healed ulcers (class 5) in two of 18 (11%), and lipodermatosclerosis with edema (class 4) in two. Deep venous insufficiency was present in 14 of 18 (78%). The number of perforating veins ligated per leg ranged from 0 to 12 (mean, 4.3). Follow-up ranged from 3 to 64 weeks (mean, 22 weeks). Complete ulcer healing occurred in eight of 14 limbs (57%) at a mean of 14 weeks. Reduction in ulcer size was noted in four of 14 (29%), and two limbs were not improved. There were no new ulcers. Residual perforating veins were noted in four of 18 limbs. None of the limbs with residual perforating veins had complete healing of ulceration. Operating room costs were higher than those associated with limited-incision open perforator ligation ($2570 vs $1883). CONCLUSION: These preliminary data suggest that when used as part of a treatment plan to correct deep and superficial venous insufficiency SEPS results in a high rate of wound healing, with no recurrent ulceration in this series. Increased operating room costs associated with longer operations and greater disposable expenses will likely be overcome by shortened length of stay and diminished wound complications. These findings emphasize the importance of ligating all incompetent perforating veins, as ulcer healing was never achieved when residual perforating veins were found at follow-up.

Estrogen inhibits the vascular injury response in estrogen receptor alpha-deficient mice.

The atheroprotective effects of estrogen in women are well recognized, but the underlying mechanisms responsible are not well understood. Blood vessel cells express the classic estrogen receptor, ER alpha (ref. 2-6), and are directly affected by estrogen, which inhibits the development of atherosclerotic and injury-induced vascular lesions. We have generated mice in which the ER alpha gene is disrupted and have used a mouse model of carotid arterial injury to compare the effects of estrogen on wild-type and estrogen receptor-deficient mice. Increases in vascular medial area and smooth muscle cell proliferation were quantified following vascular injury in ovariectomized mice treated with vehicle or with physiologic levels of 17 beta-estradiol. Surprisingly, in both wild-type and estrogen receptor-deficient mice, 17 beta-estradiol markedly inhibited to the same degree all measures of vascular injury. These data demonstrate that estrogen inhibits vascular by a novel mechanism that is independent of the classic estrogen receptor, ER alpha.

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry.

PURPOSE: The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency. METHODS: Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996. RESULTS: SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120). CONCLUSIONS: The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Clinical results of common strategies used to revise infrainguinal vein grafts.

PURPOSE: Patients who have failing infrainguinal bypass grafts or failed grafts reopened with lytic therapy represent a group at high risk of subsequent failure. Previous studies suggest that vein patch angioplasty and jump grafting may be less durable than interposition grafting as a method of correcting graft lesions. Our objective was to assess the value of various technical strategies for graft revision in a series of autogenous infrainguinal bypass grafts and to assess how these variables might affect cumulative graft patency (CGP) rates. METHODS: We retrospectively reviewed the clinical course, anatomic sites of revision, and type of revision performed on 67 grafts in 58 patients who underwent at least one revision from 1991 to 1995. Results were assessed with regression analysis and Kaplan-Meier estimates of CGP rates (p < 0.05 was considered significant). RESULTS: Sixty-seven vein grafts underwent revision of 112 anatomical sites in 95 operations. Forty-nine of 67 grafts were single-segment greater saphenous vein grafts and 18 were composite (> 1 segment) grafts, with an overall 5-year CGP rate of 72%. No difference was observed between the 4-year CGP rate in grafts with hemodynamically significant distal anastomotic stenoses repaired primarily with jump grafts (n = 20, 71% CGP rate) and those with stenoses found only in the graft body (n = 41, 89% CGP rate). Vein patch angioplasty was used primarily, but not exclusively, for focal graft body stenoses (n = 35), whereas interposition grafts (n = 11) were reserved for more diffuse strictures; no significant difference in 3-year CGP rates was observed (94% and 73%, respectively). CONCLUSION: Using an appropriate revision strategy that favors vein patch angioplasty for graft body lesions and jump grafts for distal anastomotic lesions, acceptable assisted patency rates can be achieved in grafts that are at risk for repeated failure.