Impact of the endovascular revolution on vascular training through analysis of national data case reports.

BACKGROUND: In the last couple of decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether the surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. METHODS: Data were extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, or miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). In addition, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999 to 2006, 2006 to 2013, and 2013 to 2021; the integrated vascular surgery residency was grouped into two intervals: 2012 to 2017 and 2017 to 2021. Data were standardized to represent the average number of cases per trainee per year. RESULTS: Within the fellowship, we found a 362.37% increase in endovascular procedures (mean, 56.80 ± 32.57 vs 262.63 ± 9.91; P < .001), although there was only a 32.47% increase in open procedures (220.19 ± 4.55 vs 291.68 ± 8.20) between the first and last time intervals. There was a decrease in abdominal aneurysm repair (24.46 ± 7.30 vs 13.85 ± 0.58; P < .001) and visceral (6.41 ± 0.44 vs 5.80 ± 0.42; P = .039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18 ± 8.23 vs 382.20 ± 5.84; P < .001). Residents had greater total, open, and endovascular procedures per year than fellows (all P < .001). Chief residents had approximately one-half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04 ± 0.80 vs 12.40 ± 1.32; P = .007) and visceral (5.83 ± 0.41 vs 4.88 ± 0.46; P > .001) procedures than residents. Overall, 52% to 53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56 ± 12.10 vs 261.27 ± 10.13, 365.52 ± 17.23 vs 319.58 ± 6.62; both P < .001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. CONCLUSIONS: Vascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.

Systematic review of groin incision surgical site infection preventative measures in vascular surgery.

OBJECTIVE: Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention ,techniques including prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy, and adhesive drapes. METHODS: This review was conducted and reported in accordance with the PRISMA statement. A systematic review was conducted using the Google Scholar, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics. RESULTS: The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are as follows. We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin (Grade 2C). We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention (Grade 2C). Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use, we suggest closed-incision negative pressure wound therapy be used in groin surgical incisions at high risk for SSI (Grade 2B). Given the paucity of data regarding adhesive drapes, such as Ioban, no recommendation can be made regarding its use. CONCLUSIONS: This review highlights the effects of various preventative techniques and their potential benefit in the prevention of SSI in the groin. However, there is a glaring deficit in the available data, emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. The use of endovascular techniques continues to increase, thus limiting the number of open arterial procedures and the potential for further studies to be conducted. To provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.

Who are the Vascular Society Presidents?

BACKGROUND: We noted distinct differences between the demographics among the presidents of various vascular societies. To help characterize these among the present United States, Canadian, and European vascular societies, we queried the websites for the United States, Canadian, and European vascular societies in a systematic review for the names of their presidents since their respective inceptions. METHODS: Age and ethnicity were determined by a search on healthgrades.com, Google, and online obituaries. The year of ascendency to the presidency and the year of birth were used as identifying time points. RESULTS: There are significant differences between the ages of the presidents of the various vascular societies. While the presidents of Vascular and Endovascular Surgical Society were significantly younger than those of every other vascular society examined, Midwestern Vascular Surgical Society, Canadian Society for Vascular Surgery, and Society of Vascular Medicine were also significantly younger than the remainder of the societies examined (P < 0.0001). The presidents of the remaining societies were not significantly different in age from each other. When comparing the ages of the presidents in the first and last decades of each society, 2 were found to have significantly increased (Society of Vascular Medicine [P = 0.0029] and Vascular and Endovascular Surgical Society [P < 0.0001]), while 2 others were found to have significantly decreased (New England Society for Vascular Surgery [P = 0.0092] and Eastern Vascular Society [P = 0.0085]). Of the 532 total entries for these presidents examined over these 13 societies, 19 (3.6%) of these were filled by women and 37 (7%) with minorities. CONCLUSIONS: There was a great deal of variability in terms of age, gender, and minority representation of the presidents among the vascular societies examined. While the share of women and minorities to serve as presidents in vascular societies varied between societies, both groups were under-represented across the board. However, in recent years, the number of women and minorities elected as presidents of vascular societies has been trending upwards.

Adjunctive topical oxygen therapy for wound healing in patients with peripheral arterial disease.

INTRODUCTION: While the use of hyperbaric oxygen therapy has been supported by randomized prospective trials for the use of selective lower extremity wounds, it is associated with significant cost, inconvenience, and a small risk of pneumothorax, barotrauma to the tympanic membrane, and severe hypoglycemia. As topical oxygen therapy (tOT) avoids these issues and there is little literature examining its use for patients with peripheral arterial disease (PAD), we reviewed our experience with tOT as an adjunctive technique for wound healing with arterial wounds. METHODS: We reviewed our experience with tOT for lower extremity wounds over 8 years. PAD patients with non-healing ulcers were referred to tOT after having revascularization of the limb and/or debridement where appropriate. tOT was administered to affected areas 4 times a week with a local boot that delivered 100% oxygen to the wound at 1.03 atm for 90-min sessions. We had 28 patients with PAD, 57.1% male, and 36 individual wounds. Ages ranged from 37 to 93 (mean 62 ± 13.7). 82% had a history DM, 75% hypertension, and 60.7% hyperlipidemia. 78% had lower extremity arterial angioplasty and 11% had a LE bypass. The remainder had a debridement only and were not candidates for arterial revascularization. RESULTS: tOT duration ranged from 1 to 7 months (mean 3 ± 2). 29% stopped tOT before healing. 25% healed completely. One died during follow-up. Overall, 66% had reduction of the wound area ranging from 12% to 100%. None had major limb amputation. 18% underwent toe amputations. 25% of our patients were lost to follow-up. CONCLUSION: While these data are from a single-center and are single-armed, they represent the largest reported series of this therapy. This home-based therapy does show promise and warrants further investigation.

The Great Masquerader - TB Osteoarthritis.

OBJECTIVES: TB arthritis is a rarely reported entity in Western literature and its ability to masquerade as many other diseases makes it difficult to diagnose. We report an interesting case of TB arthritis of the ankle. METHODS: We present a 44 year-old diabetic Chinese male with a recent history of worsening pain, swelling, and redness in his left foot with an abscess and X-ray findings consistent with Charcot foot. RESULTS: At first, the presentation was believed to be Charcot's foot with MSSA osteomyelitis but after the wound culture and bone biopsy were both positive for Mycobacterium tuberculosis as well, the diagnosis of tuberculous arthritis was confirmed. CONCLUSIONS: While the prevalence of TB and other diseases is low in the majority of the United States, we still need to be aware of such diseases in populations with increasing migration and be cognizant of the potential impact of a patient's background on a diagnosis is critical to properly diagnosing and treating patients. Vascular surgeons may be seeing patients with abscesses of the lower extremities and may miss the diagnosis if cultures for TB are not sought.

Partial In-Stent Thrombosis After Iliac Vein Stenting in Non-Thrombotic Vein Lesions.

OBJECTIVE: Iliac vein stenting is a safe and efficacious procedure for the correction of iliac vein stenosis. One of its known major complications is complete iliac vein stent thrombosis. However, we have noticed in our practice that a number of patients developed only early partial in-stent (<60%) thrombosis, within the first 30 days. In order to try to learn more about these lesions, we reviewed the data for possible causes of these lesions. MATERIALS/METHODS: From September 2012 to August 2018, we obtained 3518 iliac vein venograms using intravascular ultrasound (IVUS) for patients with venous insufficiency who failed to respond to conservative therapy. Patients were followed up with transcutaneous duplex ultrasound (DUS) every 3 months for the first year and every 6 - 12 months thereafter. Patients were prescribed clopidogrel for 3 months or were told to continue their pre-existing anticoagulants. RESULTS: There were 2234 women and 1284 men who received an iliac vein stent. The mean age was 65.7 ±14 years. Mean follow-up for this cohort was 17 months. Of 74 patients developed a full thrombosis, 38 developed a partial venous thrombosis and 3406 developed no thrombosis. When comparing those who developed a partial thrombus versus those who developed no thrombus/full thrombus, overall age, laterality, CEAP, gender, and whether the patient received clopidogrel prior to the procedure and after the procedure were not found to be statistically significant factors. However, patients with an ASA score of 2 or 3,were found to be at a higher risk of developing a partial thrombus(P = 0.0223) compared to those who had an ASA score of 1 or 4. CEAP Scores and ASA class breakdown can be seen in Table 1 and Table 2, respectively. Of the 38 partial venous thrombosis that developed,18 completely resolved within the first 3 months after the procedure and 20 remained chronic past 3 months after the procedure. Patients with partial venous thrombosis were asymptomatic upon clinical presentation, and none developed post thrombotic syndrome (PTS) or pulmonary embolism (PE). Male gender was associated with partial thrombus resolution(P = 0.0036) CONCLUSIONS: Patients with ASA scores of 2 or 3, seemed to be at a higher risk of developing a partial thrombus when compared to patients with ASA score of 1 or 4. Male gender was associated with partial thrombus resolution. All other factors appear to not be statistically significant in impacting the development of a partial thrombus. This has been the first attempt to look at this new clinical entity.

Case report of superficial femoral artery and popliteal artery aneurysm repair using brachial vein.

BACKGROUND: Several veins have been well-recognized as acceptable conduits for infrainguinal bypass surgery when the ipsilateral greater saphenous vein is unavailable. However, there is a paucity of literature describing the brachial vein as an adequate alternative. In the absence of other viable autogenous conduits, we describe the use of a brachial vein as a successful alternative for lower extremity revascularization. METHODS: A 70-year-old man presented with a chief complaint of right calf pain. Duplex ultrasound imaging of his right lower extremity revealed right-sided 2.5 cm acutely thrombosed superficial femoral artery and popliteal artery aneurysms. The patient underwent a suction thrombectomy with tissue plasminogen activator using the Power Pulse feature and Solent catheter from the AngioJet® (Boston-Scientific, Marlborough, MA) system. To repair the thrombosed aneurysms, an open bypass was planned. Due to lack of viable alternative traditionally used venous conduits, a bypass was created using the patient's brachial vein. RESULTS: A bypass was created from the superficial femoral artery to the P2 segment of the popliteal artery using a non-reversed brachial vein with ligation of the side branches of the superficial femoral artery and popliteal artery aneurysm from within the sac lumen. Completion angiogram revealed runoff through the anterior tibial artery only. Follow-up imaging at three months demonstrated a patent brachial bypass. CONCLUSION: Brachial veins can be safely used as viable venous conduits for lower extremity bypass surgery and should therefore be considered as an alternative when more commonly used veins are unsuitable or unavailable. However, more research is needed to determine the potential opportunities and challenges this alternative may present.

Sphygmomanometer-induced hemostasis following iatrogenic guidewire perforation during lower extremity angioplasty.

OBJECTIVES: Iatrogenic guidewire perforation is a well-known complication of lower extremity angioplasty that is often benign or can be easily treated with endovascular techniques. However, perforations that occur in arterial side branches may be more challenging to manage. If bleeding persists, open surgery and fasciotomy may be required to evacuate the resulting hematoma and prevent compartment syndrome. These subsequent procedures increase morbidity and, if the angioplasty was performed in the outpatient setting, necessitate patient transfer to a hospital. To address these challenges, we describe a non-invasive hemostasis technique involving serial sphygmomanometer cuff inflations over the affected site in a series of five patients who experienced this complication at our office. METHODS: We retrospectively reviewed the medical records of consecutive patients undergoing lower extremity angioplasty that were found to have an arterial guidewire perforation on completion angiogram at our outpatient center between February 2012 and February 2017. Patients found to have iatrogenic guidewire perforations were administered intravenous protamine sulfate and were transferred to the surgical recovery room. Patients received ibuprofen or acetaminophen for pain management. A blood pressure cuff was placed around the site of perforation, and patients received serial cuff inflation cycles with repeated examinations of both limbs until patients reported cessation of pain and there were no signs of a developing hematoma. Patients were observed for two hours before they were discharged home. A follow-up duplex ultrasound examination was completed within one week of the intervention. RESULTS: Over the course of five years, 536 angioplasties were performed at our outpatient office. Five of these patients experienced iatrogenic guidewire perforation (0.93%). Perforations occurred in branches of the anterior or posterior tibial artery. All of these patients were successfully managed with the aforementioned hemostasis technique. None of these patients required transfer to a hospital for further management, and no complications were reported at follow-up. CONCLUSIONS: Complications of iatrogenic guidewire perforations in lower extremity arterial side branches can be safely and effectively managed by applying external compression around the affected site with an automatic blood pressure cuff.

Fast-track thrombolysis protocol for acute limb ischemia.

OBJECTIVE: Catheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. METHODS: A retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. RESULTS: Primary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. CONCLUSIONS: FTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions.

Physician impact on use of fluoroscopy during endovascular procedures to improve radiation safety.

OBJECTIVE: To determine whether differences exist in fluoroscopy time and radiation exposure during lower extremity endovascular procedures performed by fellowship trained vascular surgeons vs general surgeons, to minimize radiation exposure to operating room staff. METHODS: A retrospective review of all lower extremity endovascular procedures was performed from August 1, 2014, to January 29, 2016. The procedures were performed by the surgical department's four surgeons with endovascular privileges: two vascular surgeons and two general surgeons. Only procedures involving lower extremity arterial angiograms with balloon angioplasty, stenting, or atherectomy were included. The operative records were reviewed for each case. The total fluoroscopy time and total radiation dose for each procedure were recorded. Procedures were grouped according to the number of endovascular interventions as one to two interventions, three to four interventions, and five or more interventions performed. Statistical analysis was performed with a P value of less than .05 considered significant. RESULTS: About 271 lower extremity endovascular procedures were performed during the study period by 4 surgeons. The average age of the patient population was 70 years. The total number of procedures performed over the study period were 112, 45, 91, and 25 for surgeons 1 through 4, respectively. On average, 3.24 interventions were performed during each procedure. Vascular surgeons were found to have shorter fluoroscopy time for procedures involving one to two (7.8 vs 30.1; P < .01), three to four (9.3 vs 34.2; P < .01), and five or more (11.5 vs 51.9; P < .01) interventions. Vascular surgeons were also found to have less radiation exposure compared with general surgeons in procedures with one to two (1.69 vs 3.53; P = .001) and five or more (2.3 vs 5.4; P = .003) interventions. There was no significant difference in radiation exposure between vascular and general surgeons for procedures with three to four interventions (5.86 vs 5.59; P = .95). CONCLUSIONS: In this small series at our institution, lower extremity endovascular procedures performed by specialty trained vascular surgeons were associated with both decreased operative fluoroscopy time and decreased radiation exposure when compared with general surgeons.

Safety of vascular interventions performed in an office-based laboratory in patients with low/moderate procedural risk.

OBJECTIVE: An exponential increase in number of office-based laboratories (OBLs) has occurred in the United States, since the Center for Medicare and Medicaid Services increased reimbursement for outpatient vascular interventions in 2008. This dramatic shift to office-based procedures directed to the objective to assess safety of vascular procedures in OBLs. METHODS: A retrospective analysis was performed to include all procedures performed over a 4-year period at an accredited OBL. The procedures were categorized into groups for analysis; group I, venous procedures; group II, arterial; group III, arteriovenous; and group IV, inferior vena cava filter placement procedures. Local anesthesia, analgesics, and conscious sedation were used in all interventions, individualized to the patient and procedure performed. Arterial closures devices were used in all arterial interventions. Patient selection for procedure at OBL was highly selective to include only patients with low/moderate procedural risk. RESULTS: Nearly 6201 procedures were performed in 2779 patients from 2011 to 2015. The mean age of the study population was 66.5 ± 13.31 years. There were 1852 females (67%) and 928 males (33%). In group I, 5783 venous procedures were performed (3491 vein ablation, 2292 iliac vein stenting); with group II, 238 arterial procedures (125 femoral/popliteal, 71 infrapopliteal, iliac 42); group III, 129 arteriovenous accesses; and group IV, 51 inferior vena cava filter placements. The majority of procedures belonged to American Society of Anesthesiology class II with venous (61%) and arterial (74%) disease. A total of 5% patients were deemed American Society of Anesthesiology class IV (all on hemodialysis). There was no OBL mortality, major bleed, acute limb ischemia, myocardial infarction, stroke, or hospital transfer within 72 hours. Minor complications occurred in 14 patients (0.5%). Thirty-day mortality, unrelated to the procedure, was noted in 9 patients (0.32%). No statistically significant differences were noted in outcomes between the four groups. CONCLUSIONS: Our data suggest that it is safe to use OBL for minimally invasive, noncomplex vascular interventions in patients with a low to moderate cardiovascular procedural risk.

Malignant Transformation of Nonhealing Ulcer-Basal Cell Carcinoma.

We discuss the rare case of a 72-year-old female with a history of a nonhealing lower extremity ulcer that was biopsied, revealing malignant transformation to basal cell carcinoma (BCC). Although BCC is the most common malignancy worldwide, malignant transformation of nonhealing wounds is more often associated with squamous cell carcinoma. Current literature estimates the rate of BCC arising from venous stasis ulcer to occur between 1.5 and 15%. When diagnosed early, BCC can have cure rates of up to 95%. However, metastatic BCC has a median survival of roughly 8 months. We believe it is important to raise awareness of this rare, but often curable, clinical diagnosis to improve long-term outcomes.

Prinzmetal-Like Acute Limb Ischemia.

Vasospasm-induced acute limb ischemia (ALI), also known as vasospastic limb ischemia (VLI), is a rare, underreported vascular event. Unlike thrombotic and embolic occlusive etiologies, which often warrant revascularization, vasospasm is a transient phenomenon that may be successfully managed conservatively without surgical intervention. Thus, prompt recognition and accurate diagnosis of VLI is imperative to avoid unnecessary surgical or endovascular procedures. This diagnosis, however, can pose as a challenge for clinicians, as it can present with clinical signs and symptoms near-identical to the presentation of thrombotic-induced ALI. In this report, we present a patient that experienced 2 vasospasm-induced ischemic events; the patient developed Rutherford IIb acute limb-threatening ischemia following cardiac catheterization for myocardial infarction. Computer tomography angiography findings of her right leg revealed acute occlusion suggesting the need for immediate operative intervention for limb salvage. However, due to her critical state, she instead was managed with medical treatments. Despite no intervention, the patient had full resolution of her right leg symptoms. We present this case to highlight the unusual multifocality of vasospastic events and to increase awareness of the diagnostic challenges associated with VLI.

Dyeless iliac vein stenting.

OBJECTIVE: Iliac vein stenting is increasingly being explored for the treatment of chronic venous insufficiency. While venography is considered the gold standard for assessing iliac veins, some have proposed that intravascular ultrasound should be utilized instead due to its greater sensitivity at detecting stenotic lesions. Routinely, our service uses both intravascular ultrasound and venography, but we have noted that some patients cannot tolerate dye due to allergy, renal insufficiency, or deemed high-risk by the interventionalist due to uncontrolled medical co-morbidities. This study aimed to investigate whether forgoing dye had an impact on iliac vein stent thrombosis. METHODS: From 2012 to 2016, 1482 iliac vein procedures (91 intravascular ultrasound-only and 1391 intravascular ultrasound plus venography) were performed on 992 patients who failed conservative treatment for chronic venous insufficiency. Our mean patient age was 65.8 years (range 21-99; SD ± 14.3) with 347 male and 645 female patients. The clinical presenting symptoms per clinical-etiology-anatomy-pathophysiology classification for the intravascular ultrasound-only cohort were C1:0, C2:3, C3:31, C433, C5:5, C6:20 and for the intravascular ultrasound plus venography cohort were C1:0, C2:24, C3:566, C4:583, C5:30, C6:188. Stent thrombi that developed within or at 30 days of stenting were categorized as early and greater than 30 days as late. Transcutaneous duplex ultrasound classified stent thrombi as either partial or occlusive. Our average follow-up time was 19.4 months (0-42, SD ± 12.5). RESULTS: A total of 2.2% intravascular ultrasound-only patients versus 2.75% intravascular ultrasound plus venogram patients developed early stent thrombosis, p = 0.35. Early partial stent thrombosis occurred in 1.1% of the intravascular ultrasound-only group versus 2.6% of the intravascular ultrasound plus venogram group, p = 0.38. Early occlusive stent thromboses occurred in 1.1% of intravascular ultrasound-only patients and 0.15% of intravascular ultrasound plus venogram patients, p = 0.06. Late stent thromboses developed in 4% of patients in the intravascular ultrasound-only cohort and 4% in the intravascular ultrasound plus venogram cohort, p = 0.97. Late partial stent thromboses occurred in 2.7% of intravascular ultrasound-only patients versus 2.6% in intravascular ultrasound plus venogram patients, p = 0.99. Late occlusive stent thromboses occurred in 1.3% of intravascular ultrasound-only patients versus 1.4% of intravascular ultrasound plus venogram patients, p = 0.95. Moreover, the formation of any stent was 6.2% in the intravascular ultrasound-only versus 6.75% in the intravascular ultrasound plus venogram group, p = 0.55. CONCLUSION: Results of our study show no significant difference in stent thrombosis between the intravascular ultrasound-only and intravascular ultrasound plus venogram cohorts. This concludes that using intravascular ultrasound alone is safe for iliac vein stenting.

Iliac Vein Stent Placement and the Iliocaval Confluence.

OBJECTIVE: Prior literature has recommended routine iliac vein stent extension into the inferior vena cava (IVC) to assure adequate outflow for iliac vein stenting procedures. Our bias was that only the lesion should be stented without routine stent extension up to the IVC. We report our experience with this limited stenting technique. METHODS: From 2012 to 2015, 844 patients (1,216 limbs) underwent iliac vein stenting for nonthrombotic iliac vein lesions (NIVLs). All limbs were evaluated in accordance with the presenting sign of the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) score, and duplex scans and intravascular ultrasound (IVUS) showing more than 50% cross-sectional area or diameter reduction. All study patients had failed 3 months of conservative management. The procedures of iliac vein stenting were all office based. Two techniques were compared: (1) placement of the iliac vein stent to cover the lesion and terminating cephalad into the IVC if the lesion involved the common iliac vein and (2) placement of the iliac vein stent to cover the lesion only and not passing the iliocaval confluence if the lesion only involved the external iliac vein. Complications were assessed during 30-day follow-up using the duplex scan technique to look for thrombosis. RESULTS: Of the total 844 patients, 543 (64%) were women. The average age was 66 (±14.2) years (range, 21-99 years). The stent was placed in the left lower limb in 474 patients and bilaterally in 370 patients. The presenting sign in accordance with the CEAP classification was C3 = 626, C4 = 404, C5 = 44, and C6 = 141. The average iliac vein stenosis by IVUS was 62% (±12% standard deviation [SD]). We had 715 patients with the iliac vein stent extending into the IVC, and of these, 8 patients had thrombosis within 30 days after the procedure. On the other hand, 501 patients had the iliac vein stent without crossing the iliocaval confluence, and of these, 4 patients had thrombosis within 30 days of the procedure. There was no difference between these 2 groups in regard to gender (P = 0.1) or age (P = 0.3). Laterality was statistically different (P < 0.0001) with more stents to be extended into the IVC if the lesion is in the left lower limb. Comparing these 2 groups in regard to 30-day thrombosis as a complication was not statistically significant (P = 0.6). There was no statistical difference between the 2 groups in regard to the presenting sign CEAP (P = 0.6). CONCLUSIONS: These results question the need for routine iliac vein stent extension into the IVC in patients with NIVLs. We were not able to demonstrate a significant risk of thrombosis with just placing the stent to cover the lesion only with short-term follow-up.

Compartment Syndrome of the Leg after Intraosseous (IO) Needle Insertion.

Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case of an 87-year-old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.

Radiofrequency Ablation Increases the Incidence of Endothermal Heat-Induced Thrombosis.

BACKGROUND: Endovenous thermal ablation has become the procedure of choice in the treatment of superficial venous reflux disease. The current armamentarium of devices and techniques aimed at the elimination of saphenous reflux offers surgeons and interventionalists a variety of treatment options; however, there is a lack of data comparing the safety of these products. The most concerning complication after endovenous thermal ablation is endothermal heat-induced thrombosis (EHIT) due to the risk of progression to deep venous thrombosis. This study aimed to compare the incidence rate of EHIT between radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). METHODS: This was a single-center, office-based, retrospective study over the course of 5 years, in which 3,218 consecutive patients underwent 10,029 endovenous saphenous ablations. The patient cohort was 66.2% female, with an average age of 61.9 years. At the time of each individual intervention, 24, 212, 3,620, 4,806, 200, and 1,167 patients had Clinical-Etiology-Anatomy-Pathophysiology disease 1, 2, 3, 4, 5, and 6, respectively. RESULTS: There was a total of 3,983 EVLT and 6,091 RFA procedures. The most common vessel treated was the great saphenous vein, 63.6% of the time, followed by the small saphenous vein (25.6%), accessory saphenous vein (6.1%), and perforator vein (4.6%). There were 186 cases of EHIT, with 137 (73.6%) identified as type 1 as per the Kabnick classification. Endovenous ablation performed via RFA resulted in significantly more cases of EHIT than of EVLT (109 vs. 77; P = 0.034; odds ratio = 1.52), which was confirmed by a multivariate analysis. CONCLUSIONS: In the largest single-center study of endovenous saphenous ablations to date, RFA was shown to pose a significantly higher risk of EHIT than of EVLT.

Noninfectious aortitis: A case report.

INTRODUCTION: Noninfectious aortitis has been increasingly reported worldwide with a growing prevalence in western medicine. Attributed to our increasingly diverse population, western surgeons must be vigilant to promptly differentiate these cases from its more common infectious counterpart in order to ensure subsequent appropriate management of these patients. METHODS: We present a case report of a 71-year-old Indo-Caribbean male who presented with nonspecific abdominal and back pain, found to have aortitis of a noninfectious etiology.Results and conclusion: While our patient's process was ultimately managed without surgical intervention, the varied clinical presentation along with the lack of specific laboratory markers pose a challenge for surgeons to appropriately diagnose and manage aortitis. Appropriate diagnostic imaging, the utilization of a multidisciplinary team, and close patient monitoring are key components for effective management of this increasingly prevalent disease process.

Celiac Artery Vasculitis.

Isolated celiac artery vasculitis is an uncommon disease rarely reported in the Western literature. In this case report, we describe a 52-year-old Chinese male presenting with abdominal pain who was diagnosed with nonspecific celiac artery vasculitis and was successfully treated with a short course of oral corticosteroids.

Superior Mesenteric Artery Thrombosis after Necrotizing Pancreatitis.

Vascular complications secondary to acute pancreatitis carry a high morbidity and mortality, often because of their hemorrhagic or thrombotic effects. When thrombosis presents, it is typically localized to the splanchnic venous system. In this report, we present a case of acute superior mesenteric artery thrombosis secondary to necrotizing pancreatitis after a laparoscopic cholecystectomy. The patient was successfully treated with catheter-directed thrombolysis and mechanical thrombectomy.