How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia.

OBJECTIVE: Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them. METHODS: All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers. RESULTS: From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance. CONCLUSIONS: LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.

Revascularization Outcomes Stratified by Glycemic Control in Patients with Diabetes Mellitus and Chronic Limb-Threatening Ischemia.

BACKGROUND: The prevalence of chronic limb-threatening ischemia (CLTI) has increased alongside rising rates of diabetes mellitus (DM). While diabetic patients with CLTI have worse outcomes compared to patients without diabetes, conflicting data exist on the relationship between the severity of DM and CLTI outcomes. Close inspection of the relationship between DM severity and outcomes in CLTI may benefit surgical decision-making and patient education. METHODS: We retrospectively reviewed patients who received endovascular intervention or surgical bypass for CLTI at our multidisciplinary Limb Preservation Program from 2013 to 2019 to collect patient characteristics using Society for Vascular Surgery (SVS) reporting standards, arterial lesion characteristics from recorded angiograms, and outcomes, including survival, amputation, wound healing, and revascularization patency. Controlled DM was defined as SVS Grade 1 (controlled, not requiring insulin) and Grade 2 (controlled, requiring insulin), while uncontrolled DM was defined as SVS Grade 3 (uncontrolled), and DM severity was assessed using preoperative hemoglobin A1c (HgbA1c) values. Product-limit Kaplan-Meier was used to estimate survival functions. Univariable Cox proportional hazards analyses guided variable selection for multivariable analyses. RESULTS: Our Limb Preservation Program treated 177 limbs from 141 patients with DM. Patients with uncontrolled DM were younger (60.44 ± 10.67 vs. 65.93 ± 10.89 years old, P = 0.0009) and had higher HgbA1c values (8.97 ± 1.85% vs. 6.79 ± 1.10%, P < 0.0001). Fewer patients with uncontrolled DM were on dialysis compared to patients with controlled DM (15.6% vs. 30.9%, P = 0.0278). By Kaplan-Meier analysis, DM control did not affect time to mortality, limb salvage, wound healing, or loss of patency. However, multivariable proportional hazards analysis demonstrated increased risk of limb loss in patients with increasing HgbA1C (hazard ratio (HR) = 1.96 [1.42-2.80], P < 0.0001) or dialysis dependence (HR = 15.37 [3.44-68.73], P = 0.0003), increased risk of death in patients with worsening pulmonary status (HR = 1.70 [1.20-2.39], P = 0.0026), and increased risk of delayed wound healing in patients who are male (HR = 0.48 [0.29-0.79], P = 0.0495). No independent association existed between loss of patency with any of the variables we collected. CONCLUSIONS: Patients with uncontrolled DM, as defined by SVS reporting standards, do not have worse outcomes following revascularization for CLTI compared to patients with controlled DM. However, increasing HgbA1c is associated with a greater risk for early amputation. Before revascularization, specific attention to the level of glycemic control in patients with DM is important, even if DM is "controlled." In addition to aggressive attempts at improved glycemic control, those with elevated HgbA1c should receive careful education regarding their increased risk of amputation despite revascularization. Future work is necessary to incorporate the severity of DM into risk models of revascularization for the CLTI population.

Physician Reimbursement for Vascular Surgery Procedures and Vascular Laboratory Studies Before and After the Affordable Care Act.

OBJECTIVES: The Patient Protection and Affordable Care Act (ACA), fully implemented by 2015, has significantly increased the number of Americans with health insurance. However, its impact on physician reimbursement (PR) is not well studied. Our objective was to determine the ACA's impact on the professional component of PR for selected vascular surgery (VS) procedures and vascular laboratory (VL) studies at our institution. METHODS: PR for the following 5 VS procedures and 4 VL studies were obtained from our billing department: CPT 34803 (Endovascular aortic repair, EVAR), 35301 (carotid endarterectomy, CEA), 35656 (lower extremity bypass, LEB), 36010 (introduction of catheter into vena cava, ICVC), 36200 first, 93922 (ankle brachial index, ABI), 93925 (lower extremity arterial duplex, LEA duplex), 93970 (lower extremity venous duplex, LEV Duplex), and 93990 (hemodialysis duplex). The data was organized by payer: Medicare, Medicaid, Commercial Insurers (CI), and Other. PR was studied pre-ACA (January 2008 through December 2009) and post-ACA (January 2015 through December 2016). The post-ACA PR and inflation adjusted reimbursement (IAR) in 2016 dollars using the consumer price index (CPI) were calculated and compared using one-sample t-test. The percent difference between the post-ACA PR and IAR was also compared. RESULTS: PR for 1,637 VS procedures and 16,333 VL studies was analyzed. The post-ACA PR was significantly lower than the IAR for most Medicare and Medicaid procedures. For EVAR, post-ACA reimbursement was overall on par with the IAR but significantly lower for Medicare. For CEA, post-ACA reimbursement was overall lower than IAR. For LEB, overall average PR was lower than IAR, with statistically significant lower Medicare and Medicaid (P < 0.001) payments. For ICAo, overall PR was significantly lower than the IAR and this was true across all insurance types. In contrast, for ICV, the post-ACA reimbursement was higher than IAR for all payers but did not reach statistical significance (P = 0.25). The post-ACA PR was significantly higher than the IAR for most VL studies, except for Medicare PR. The percent change for VS procedures were mostly negative for the Medicaid and Medicare groups. This results in potential annual shortcomings of $2, 862 and $20,923 respectively. CONCLUSION: When comparing reimbursement before and after ACA implementation, Medicare and Medicaid PR for most VS procedures has not kept up with inflation. However, for most VL procedures, PR has exceeded inflation. Further efforts are needed to support Vascular Surgery reimbursement including higher valuation of the Medicare Conversion factor.

Addition of Efficiency Measures to Current Accuracy Measures in the Vascular Laboratory Can Be Used for Future Accreditation and Payment Models.

BACKGROUND: The Medicare Access and CHIP Reauthorization Act (MACRA) brings with it increased regulatory requirements not traditionally addressed by standard vascular laboratory accreditation, which is based on accuracy. The new quality improvement project of the Intersocietal Accreditation Commission (IAC) may satisfy an improvement activity (IA) of the MACRA. We hypothesize that other IAs in the MACRA such as timeliness of test results or patient care quality performance requirements can be met by analyzing data already being collected by the vascular laboratory. After a process improvement strategy, we chose to review progress in our vascular laboratory related to time to interpretation (TI), patient check-in to study completion (study time), wait time for first available outpatient venous duplex scan (wait time), technologist productivity, and critical results reporting. METHODS: Data from our hospital-based vascular laboratory were collected from 2010 to 2016. TI was collected through our reporting software VascuPro (Consensus Medical), and study time and wait time were obtained from electronic medical records (EMR) (Epic). Technologist productivity was calculated by commercially available productivity tools, and compliance with critical results reporting was calculated quarterly as per our quality assurance program. Appropriateness of carotid duplex scan testing was performed by expert review of International Classification of Disease codes used to request the test. RESULTS: TI analysis comprised 91,352 studies with a mean of 3.3 hr between test completion and final interpretation. The TI improved from 5.0 to 2.1 hr on weekdays and was longer on weekends (4.9 hr; P < 0.001). The study time improved from 29.8 to 27.2 min and was 14.9 min shorter on the weekends (P < 0.001). The wait time ranged from a mean of 1-2.08 days. Technologist productivity improved from 90.7% to 93.6%. Critical results reporting quarterly audits showed a 100% compliance rate. On expert review, the International Classification of Disease code on carotid duplex scan requests in the EMR was deemed inaccurate in 17.4% of cases. CONCLUSIONS: TI and study time improved; wait time and critical results reporting remained steady. Most of the data are readily available in a vascular laboratory standard EMR. The plan-do-study-act (PDSA or Shewhart Cycle) principle is critical to process improvement and needed as we transition from traditional accreditation mostly based on test accuracy to one demanding efficiency, timeliness, patient satisfaction, productivity, accountability, and appropriateness of testing. Process improvement studies will improve patient care and satisfaction, increase efficiency and throughput, while satisfying changing IAC standards and preparing for upcoming regulatory requirements of the MACRA.

A Case of Acute Iliocaval Thrombosis in the Setting of a Suprarenal Inferior Vena Cava Saccular Aneurysm.

Inferior vena cava (IVC) aneurysms are a rare finding, whose management and outcomes remain uncertain due to their low incidence and long-term follow-up. As IVC aneurysms remain a poorly understood clinical entity, it is important to expand upon our existing knowledge base as new cases arise. We present a patient with a suprarenal IVC saccular aneurysm and an overview of the current literature regarding IVC aneurysm classification, presentation, and management. Based on the expanding literature, we propose that IVC aneurysms may be simplified into a 2-type classification, which can further guide clinicians on management of the aneurysm.

Common carotid artery end-diastolic velocity and acceleration time can predict degree of internal carotid artery stenosis.

OBJECTIVE: Whereas duplex ultrasound parameters for predicting internal carotid artery (ICA) stenosis are well defined, the use of common carotid artery (CCA) Doppler characteristics to predict ICA stenosis when the ICA cannot be insonated directly or accurately because of anatomy, calcification, or tortuosity has not been studied. The objective of this study was to identify CCA Doppler parameters that may predict ICA stenosis. METHODS: We reviewed all patients at our institution who underwent carotid duplex ultrasound (CDU) from 2008 to 2015 and also had a comparison computed tomography, magnetic resonance, or catheter angiogram. We excluded patients whose CDU examination did not correlate with the comparison study, those whose arteries were not visualized on the comparison study, and those with complete occlusion of the CCA. We collected CCA peak systolic velocity (PSV), end-diastolic velocity (EDV), and acceleration time (AT) in addition to CDU and comparison imaging interpretation of degree of stenosis. A multivariate model was used to identify predictors of ICA stenosis. RESULTS: There were 99 CDU examinations with corresponding comparison imaging included. For every increase of 10 cm/s in EDV in the CCA, the odds of a >50% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 37% (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.41-0.97; P = .03). For every increase of 10 cm/s in EDV in the CCA, the odds of a 70% to 99% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 48% (OR, 0.52; 95% CI, 0.28-0.94; P = .03). A CCA EDV of 19 cm/s or below was associated with a 64% probability of a 70% to 99% ICA stenosis. For every 50-millisecond increase in AT in the CCA, the odds of a >50% stenosis being present vs a ≤50% ICA stenosis increased by 56% (OR, 1.56; 95% CI, 1.03-2.35; P = .04). A CCA AT of 80 milliseconds or above was associated with a 69% probability of a >50% ICA stenosis. There was no correlation between CCA PSV and ICA stenosis. CONCLUSIONS: CCA EDV and AT are independent predictors of ICA stenosis and may be used in the setting of patients whose ICA cannot be directly insonated or when standard duplex ultrasound parameters of ICA PSV, EDV, or ICA/CCA ratio conflict.

Comparison of time utilization in an academic inpatient versus an outpatient vascular laboratory.

PURPOSE: Efficient, cost-effective services in vascular laboratories (VLs) will be required in tomorrow's health care environment. Inpatient VLs (IPVL) are burdened with complex patients, excessive workload, and a high percentage of bedside tests. Outpatient VLs (OPVL) are therefore presumed to be more productive and efficient. We compared time utilization in OPVLs and IPVL to test this hypothesis. METHODS: Vascular sonographers at an academic IPVL and OPVL were asked to track their daily activities during five consecutive weekdays. Test type, scan time, delays in patient arrival, preparation for the test, computer entry, and administrative time (patient- and non-patient-related) were logged. RESULTS: Delay in patient arrival and non-patient-related administration activities were both significantly greater in the OPVL (p < 0.01 and 0.03, respectively). Actual scan time occupied only 38.8% of the technologist's day, with the rest spent on patient- and non-patient-related activities. CONCLUSIONS: No appreciable differences were noted between IPVL and OPVL in most of the efficiency parameters measured. General administration time and delay in patient arrival were greater in the OPVL. Thus, OPVL were not more efficient than IPVL. In order to maximize efficiency in the OPVL, non-patient-related activities, which occupy over a quarter of the daily workday, must be shifted from technologists to support staff. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:540-544, 2016.

Complete "in situ" avulsion of the radial artery complicating transradial coronary rotational atherectomy.

BACKGROUND: Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage. METHODS: A 48-year-old, devout Jehovah's Witness, woman with a history of coronary artery bypass surgery presented with a non-ST-segment elevation acute myocardial infarction. Pretransfer catheterization demonstrated a heavily calcified, 90% distal left main stenosis with an occluded left internal mammary artery graft to the left anterior descending coronary artery. To minimize the risk of bleeding requiring a blood transfusion, a coronary rotational atherectomy via a TR was performed. A nonhydrophilic, 7F sheath was used to accommodate the larger rotational atherectomy burr sizes. The coronary procedure was successful, but the sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. Post procedure she developed a hematoma with motor and neurological deficits of her hand. RESULTS: Emergent surgical exploration with fasciotomy was planned. The radial artery was explored and found to be redundant and pulseless, prompting proximal evaluation and revealing complete avulsion of the radial artery at its origin. An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch and surgical ligation of the radial artery was conducted. CONCLUSION: Vascular surgeons need to be aware of potential complications related to TR which are likely to increase as this method is more widely disseminated.

Clinical evaluation of suspected deep vein thrombosis guides the decision to anticoagulate prophylactically but does not impact the decision to perform after hours duplex venous scanning or increase its yield.

OBJECTIVE: The utility of after-hours duplex venous scanning (DVS) for suspected deep vein thrombosis (DVT) in emergency department (ED) patients has been debated. Availability of safe prophylactic low molecular weight heparin, cost containment efforts, and retention of scarce sonographers have to be balanced against 24/7 demand for services. We determined the incidence of DVT in DVS ordered after-hours, correlation between Wells' score and prophylactic anticoagulation as well as urgently performed DVS, and complications of delaying DVS until regular hours. METHODS: Records of all ED encounters between July 1, 2009 and June 30, 2010 associated with a DVS ordered after-hours were reviewed. The decisions to prophylactically anticoagulate and whether to perform DVS urgently or delayed until regular hours were at the discretion of the ED physician and a vascular surgeon. DVS findings, number of urgent and delayed studies, Wells' scores, D-dimers, and outcomes were recorded. RESULTS: DVT was found in 12% (22) of 181 DVS ordered after-hours. DVT was found in 19% of 42 DVS done urgently and in 10% of 139 DVS delayed an average 10 hours 17 minutes (P = NS). All patients had Wells' scores and 43 had D-dimers. Furthermore, 76% of patients with a Wells' score ≥3 had prophylactic anticoagulation whereas only 39% of patients with a Wells' score <3 had prophylactic anticoagulation (P = .0001). In contrast, 36% of patients with a Wells' score ≥3 had urgent DVS and 20% of patients with a Wells' score <3 had urgent DVS (P = NS). Prophylactic anticoagulation was given to 86% of patients eventually found to have DVT vs 40% of patients eventually found to have no DVT (P < .0001). There were no pulmonary emboli or bleeding complications. CONCLUSIONS: The incidence of DVT in ED patients who had urgent after-hours DVS was no different than in those whose DVS was delayed until regular hours. High pretest probability can be achieved with clinical evaluation prior to DVS, and this guided the decision to prophylactically anticoagulate but did not impact the decision to perform urgent DVS. Most patients eventually found to have DVT did receive prophylactic anticoagulation, and delay of DVS did not result in complications. We believe that most patients in whom there is high clinical suspicion for DVT can safely get prophylactic anticoagulation and delayed DVS. Patients in whom there is low clinical suspicion should not get urgent DVS.

Differential effect of zoledronic acid on human vascular smooth muscle cells.

INTRODUCTION: The activation of human vascular smooth muscle cell proliferation, adhesion and migration is essential for intimal hyperplasia formation. These experiments were designed to test whether zoledronic acid (ZA) would modulate indices of human smooth muscle cell activation, exert differential effects on proliferating versus quiescent cells, and determine whether these effects were dependent on GTPase binding proteins prenylation. ZA was chosen for testing in these experiments because it is clinically used in humans with cancer, and has been shown to modulate rat smooth muscle cell proliferation and migration. METHODS: Human aortic smooth muscle cells (HASMC) were cultured under either proliferating or growth arrest (quiescent) conditions in the presence or absence of ZA for 48 hours, whereupon the effect of ZA on HASMC proliferation, cellular viability, metabolic activity, and membrane integrity were compared. In addition, the effect of ZA on adhesion and migration were assessed in proliferating cells. The effect of increased concentration of ZA on the mevalonate pathway and genomic/cellular stress related poly-adenosine diphosphate ribose polymerase enzyme activity were assessed using the relative prenylation of Rap-1A/B protein and the formation of poly adenosine diphosphate-ribosylated protein, respectively. RESULTS: There was a dose dependent inhibition of cellular proliferation, adhesion and migration following ZA treatment. ZA treatment decreased indices of cellular viability and significantly increased membrane injury in proliferating versus quiescent cells. This was correlated with the appearance of unprenylated Rap-1A protein and dose dependent down regulation of activity. CONCLUSIONS: These data suggest that ZA is effective in inhibiting HASMC proliferation, adhesion, and migration, which coincide with the appearance of unprenylated RAP-1A/B protein, thereby suggesting that the mevalonate pathway may play a role in the inhibition of HASMC activation.

Four-extremity venous duplex ultrasound for suspected deep venous thrombosis is an anachronism.

BACKGROUND: Duplex ultrasound is the "gold standard" for diagnosis of acute deep venous thrombosis (DVT) because of its high specificity, sensitivity, safety, and portability. However, unnecessary testing epitomizes inefficient use of scarce health care resources. Here we hypothesize that the majority of simultaneous four-extremity duplex ultrasound (FED) examinations are unnecessary. By analyzing clinical factors of patients with acute DVT found on FED, we aimed to identify a subset of high-risk patients who may have a valid indication for four-extremity testing. METHODS: We retrospectively reviewed all venous duplex ultrasound examinations performed in our Intersocietal Accreditation Commission-accredited vascular laboratory from January 1, 2009, to December 31, 2016. Patients with duplex ultrasound scans of all four limbs were included. DVT risk factors and indication for duplex ultrasound examination were recorded. The primary outcome was finding of acute DVT. RESULTS: There were 188 patients who met our search criteria, of whom 31 patients (16.5%) had acute DVT (11 upper extremity, 16 lower extremity, and 4 upper and lower extremity). Fever of unknown origin (FUO) was the main indication for requesting FED (53.7%). Patients who underwent FED for FUO had a significantly lower likelihood of DVT (odds ratio, 0.21; P = .01). DVT was rarely the proximate cause (<1% of all cases) as follow-up culture results and clinical course most often revealed other sources of fever. Only patients with an upper extremity central venous catheter (CVC; n = 103) with at least two associated risk factors had an upper extremity DVT, which was usually line associated (93%). Only patients with at least two associated risk factors had a lower extremity DVT. CONCLUSIONS: FED for FUO is inefficient, given that DVT was rarely the proximate cause of fever. Acute upper extremity DVT was found only in patients with an upper extremity CVC, demonstrating that patients without upper extremity CVC do not benefit from upper extremity duplex ultrasound examination. Upper extremity DVT is usually line associated and dependent on the number of cumulative risk factors present, suggesting that only the extremity associated with the CVC in the right clinical context should be imaged. Lower extremity DVT is also dependent on the number of cumulative risk factors present, and testing should be reserved for patients according to the clinical context. Our results indicate that a restrictive strategy can reduce testing inefficiency and health care cost without compromising patients' safety.

Adventitial fibroblast reactive oxygen species as autacrine and paracrine mediators of remodeling: bellwether for vascular disease?

The importance of the vascular adventitia is increasingly being recognized not only in vascular disease but also in normal maintenance and homeostasis of vessels. Activation of the adventitia and its resident fibrocytic cells in response to injury, stretch, cytokines, and hormones has been shown to stimulate differentiation, collagen deposition, migration, and proliferation. Importantly, the effects of adventitial fibroblasts are increasingly being ascribed to reactive oxygen species (ROS) produced by adventitial fibroblast NAD(P)H oxidases. Much historical and recent evidence suggests that fibroblast NAD(P)H oxidase) is a harbinger and initiator of vascular disease and remodeling. Data from our laboratory indicate that adventitial fibroblast NAD(P)H oxidase plays a direct and/or paracrine role in neointimal hyperplasia as well as a paracrine role in medial smooth muscle hypertrophy in vivo. We propose that adventitial NAD(P)H oxidase-derived cell-permeant hydrogen peroxide or a byproduct of its oxidation of lipids activates signaling mechanisms in medial smooth muscle leading to the growth response. This review will address the potential role of this adventitial ROS in vascular inflammation and cytokine release to potentiate smooth muscle hypertrophy. We will also survey other signaling pathways involving adventitial NAD(P)H oxidase ultimately leading to changes in vascular phenotype.

Presence and degree of residual venous obstruction on serial duplex imaging is associated with increased risk of recurrence and progression of infrainguinal lower extremity deep venous thrombosis.

OBJECTIVE: The role of follow-up venous duplex ultrasound (DUS) after acute lower extremity deep vein thrombosis (DVT) remains unclear, yet it is commonly performed. We aimed to clarify the role of follow-up DUS. Our primary objective was to determine the association between the presence of residual venous obstruction (RVO) on DUS and DVT recurrence or propagation (rDVT). Secondary objectives included finding risk factors associated with RVO and rDVT. METHODS: We conducted a retrospective study of patients diagnosed with DVT on DUS from January 1, 2011, to December 31, 2013, that received a follow-up DUS. Patient demographics, risk factors, medications, and DUS findings were recorded. Ten segments from the common femoral to distal calf veins were checked for the presence of RVO, DVT propagation, and recurrence. RVO was defined as any nonacute venous obstruction with more than 40% of luminal diameter remaining during compression or the presence of chronic post-thrombotic occlusive disease. rDVT was measured as either a new acute DVT in the previously involved segment, or involvement of a new segment in the same extremity. RESULTS: A total of 185 lower extremities representing 156 patients met the inclusion criteria. RVO was noted in 61.1% of limbs. The 3-year rDVT rate was 10.3%. Patients with recurrent venous thromboembolism or thrombophilia had a higher risk of developing RVO (odds ratio [OR], 2.89, P < .01; OR, 4.39, P = .04, respectively). Extremities with larger clot burden had an increased risk of RVO on follow-up DUS (OR, 1.25 per segment; P < .01). The presence and degree of RVO on follow-up DUS had an increased risk of rDVT on subsequent DUS (OR, 3.90, P = .04; OR, 1.21 per segment, P = .04, respectively). Limbs with complete resolution of DVT by DUS had a significantly decreased risk of rDVT (OR, 0.26; P = .04). CONCLUSIONS: Extremities with larger initial clot burden exhibited an increased risk of subsequent RVO. The presence of RVO and, interestingly, the number of involved segments on follow-up DUS increased the risk of rDVT. Our results suggest that the presence of residual disease and increased RVO burden on follow-up DUS after an acute DVT may identify those patients who are at an increased risk for rDVT and may help guide the duration of anticoagulation therapy.

Ultrasound-Guided Thrombin Injection Is a Safe and Effective Treatment for Femoral Artery Pseudoaneurysm in the Morbidly Obese.

INTRODUCTION: Ultrasound-guided thrombin injection (UGTI) is a well-established practice for the treatment of femoral artery pseudoaneurysm. This procedure is highly successful but dependent on appropriate pseudoaneurysm anatomy and adequate ultrasound visualization. Morbid obesity can present a significant technical challenge due to increased groin adiposity, resulting in poor visualization of critical structures needed to safely perform the procedure. We aim to evaluate the safety and efficacy of UGTI to treat femoral artery pseudoaneurysm in the morbidly obese. METHODS: This is a retrospective cohort study in which all patients who underwent UGTI at The Ohio State University Ross Heart Hospital from 2009 to 2014 were analyzed for patient characteristics and stratified by body mass index (BMI). Patients with BMI ≥ 35 were considered morbidly obese and were compared to patients with a BMI < 35. Outcome was failed treatment resulting in residual pseudoaneurysm. RESULTS: Our cohort consisted of 54 patients who underwent thrombin injection. There were 41 nonmorbidly obese and 13 morbidly obese patients. Mean age was 64.5 years. The cohort was 44.4% male. There were 6 failures, of which 1 underwent successful repeat injection and 5 underwent open surgical repair. There was no statistically significant difference in failure between nonmorbidly obese and morbidly obese patients (9.8% vs 15.4%, P = .45). There were no embolic/thrombotic complications. CONCLUSION: Ultrasound-guided thrombin injection is a safe and effective therapy in the morbidly obese for the treatment of femoral artery pseudoaneurysm. In the hands of experienced sonographers and surgeons with adequate visualization of the pseudoaneurysm sac, UGTI should remain a standard therapy in the morbidly obese.

Elimination of medically unnecessary duplex venous scanning based on an established algorithm can result in significant cost savings under Medicare for the institution and the taxpayer.

OBJECTIVE: The utility of duplex venous scanning (DVS) for suspected deep venous thrombosis in the emergency department (ED) remains controversial. We aimed to measure potential cost savings and economic impact in our institution and nationally for unnecessary DVS in Medicare patients seen in the ED. METHODS: We have previously calculated that 15.3% of DVS studies can safely be avoided in patients with suspected deep venous thrombosis in our ED with adherence to our protocol. The Medicare database was queried for the number of DVS studies performed in the ED and charges/payments made in 2011. Cost savings at our institution and nationally by Medicare were computed with the 15.3% number. RESULTS: In the study period, 2087 DVS studies were performed in our ED across all payers; 572 Medicare patients had 249 (43%) bilateral and 323 (57%) unilateral studies. Annual savings at our institution, with use of our protocol, were estimated at $113,778. Eliminating unnecessary after-hours DVS for 306,307 Medicare beneficiaries would result in $5,285,090 savings annually. CONCLUSIONS: Increasing pressure for cost containment under a value-based payment model necessitates critical evaluation of resource utilization. Applying this schema for all noninvasive vascular tests is an opportunity for responsible management of finite resources, reducing wasteful care, and significant cost containment.

Endovascular intervention for pelvic congestion syndrome is justified for chronic pelvic pain relief and patient satisfaction.

OBJECTIVE: Pelvic congestion syndrome (PCS) is difficult to diagnose, poorly understood, and often confused with other causes of chronic pelvic pain. Thus, gonadal vein reflux, its relation to lower extremity venous insufficiency (LEVI), and treatment remains controversial to physicians and payors. We present our experience with endovascular PCS treatment and hypothesize that properly selected patients can realize significant improvement. METHODS: A retrospective study of patients treated for PCS at our institution from 2008 to 2012 was performed. Diagnosis was made clinically by the presence of pelvic pain, dyspareunia, and/or perineal varicosities. Clinical parameters, procedural details, and follow-up were reviewed. A questionnaire including a visual analog scale was sent to patients. RESULTS: Diagnosis was made in 15 women (mean age, 36 years; mean parity, two). All had pelvic pain, 6 had dyspareunia, 14 had perineal varicosities, and 10 had concomitant LEVI. Fourteen had gonadal vein reflux (mean diameter, 7.4 mm) and pelvic varicosities at angiography and had coiling (n = 12) and/or Amplatzer plug (St. Jude Medical, Inc, St. Paul, Minn) (n = 4). One patient had stenting of a stenotic left common iliac vein. All patients with concomitant LEVI had successful appropriate treatment. Eight patients completed the questionnaire at a mean follow-up of 4 years. The mean pelvic pain score went from 9.375 to 1.875 post-procedure (P < .0001; Student t-test). Mean dyspareunia score went from 8.875 to 1.5 (P < .0001). Mean perineal varicosity pain score went from 9.285 to 1.285 (P < .0001). Two patients had recurrence with a mean pelvic pain score of 4.5 at a mean 21 months. On a five-point Likert scale, all patients were satisfied (one) or extremely satisfied (seven) with treatment. CONCLUSIONS: Endovascular PCS treatment offers excellent pelvic pain relief and patient satisfaction. Women with pelvic pain, dyspareunia, or perineal varicosities with gonadal vein reflux and pelvic varicosities or iliac vein stenosis should not be denied treatment. A significant number may have concomitant LEVI and should be screened accordingly.

Aortic arch replacement through a left thoracotomy for right-sided aortic arch aneurysm with complete vascular ring.

Right-sided aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum is the second most common vascular ring. Aneurysms of the arch in its retroesophageal portion are rare. The surgical repair of a retroesophageal arch aneurysm poses a significant challenge because no single approach provides access to the whole arch and all of its branches. We describe a 39-year-old patient with aneurysmal dilatation of the retroesophageal arch who presented with airway obstruction. The arch aneurysm was repaired with a staged approach. A right-sided carotid-subclavian artery bypass was performed, followed by distal ascending aorta and aortic arch replacement under hypothermic circulatory arrest through a left thoracotomy.

Delayed presentation and management of blunt traumatic inferior gluteal artery pseudoaneurysm with associated arteriovenous fistula.

Disruption of arterial wall integrity as a result of trauma, iatrogeny, inflammation, or infection may result in pseudoaneurysm formation. Gluteal artery aneurysms are rare and represent less than 1% of all arterial aneurysms. Pseudoaneurysms of the inferior gluteal artery (IGA) following blunt trauma are exceptionally rare with only 6 reported cases in the English literature. We describe an 82-year-old female with a remote history of a fall presenting with an enlarging buttock mass. Imaging confirmed an IGA pseudoaneurysm with associated arteriovenous fistula that was successfully treated with endovascular embolization.

Adventitia-derived hydrogen peroxide impairs relaxation of the rat carotid artery via smooth muscle cell p38 mitogen-activated protein kinase.

The role of adventitia-derived reactive oxygen species (ROS) in vascular disease and impaired vascular relaxation is not clear. Based on robust adventitial ROS generation and effects on MAPK involvement in vascular dysfunction, we hypothesized that adventitia-derived ROS hydrogen peroxide (H(2)O(2)) impairs vascular relaxation through activation of medial smooth muscle p38 MAPK. By using a novel in vivo model, the adventitial surface of rat carotid arteries was bathed in situ for 90 min with vehicle, angiotensin II (AngII; 500 nM), AngII+H(2)O(2)-scavenger catalase (3,000 U/ml), AngII+p38 MAPK inhibitor SB203580 (10 µM), or AngII+superoxide dismutase (SOD; 150 U/ml). After these in vivo treatments, ex vivo tone measurements on isolated vessels revealed that periadventitial application of AngII impaired both acetylcholine-induced (endothelium-dependent) and sodium nitroprusside-induced (endothelium-independent) relaxations. In vivo coincubation with catalase or SB203580 significantly improved, but SOD exacerbated AngII-induced impairment of in vitro endothelium-dependent and -independent vascular relaxations. Western blots of vascular media, separated from the adventitia, demonstrated increased medial p38 MAPK activation and decreased medial phosphatase SHP-2 activity in AngII-treated vessels. These effects were reversed by in vivo periadventitial addition of catalase. These findings provide the first evidence that adventitia-derived H(2)O(2) participates in vascular dysfunction through p38 MAPK activation and SHP-2 inhibition.