Contraindications to tissue plasminogen activator thrombolysis for acute lower extremity ischemia.

OBJECTIVE: Previous randomized prospective trials have demonstrated the effectiveness of transcatheter tissue plasminogen activator (tPA) thrombolysis in treating acute limb ischemia (ALI) compared to conventional surgery. These pivotal trials have also highlighted contraindications for these procedures. Given recent advancements in techniques and technology, our aim is to reassess the relevance of these contraindications in contemporary practice. METHODS: A retrospective chart analysis was performed utilizing the inpatient medical records of consecutive individuals who underwent tPA treatment for acute limb ischemia (ALI) from September 2016 to April 2022. Inclusion criteria encompassed patients aged 18 and above displaying clinical symptoms and imaging evidence of ALI within 14 days. All patients received tPA with suction thrombectomy following the fast-track thrombolysis protocol. In cases where a persistent thrombus or stenosis was detected, catheter-directed thrombolysis was considered overnight, and patients underwent angiography and reassessment in the operating room subsequently. RESULTS: Patients were classified into two groups based on the STILE trial's established contraindications for endovascular treatment in acute limb ischemia (ALI). If a patient had any of these contraindications, they were placed in the contraindicated group. This resulted in 24 patients (32%) in the contraindicated group and 52 patients (68%) in the non-contraindicated group. No statistically significant demographic variations were observed between these groups. Contraindications in our study included uncontrolled hypertension (12/24, 50%), recent invasive procedures (7/27, 29%), history of cerebrovascular accident (CVA) within 6 months (3/24, 12%), and intracranial malformation/neoplasms (2/24, 8%). Three patients within the non-contraindicated group experienced bleeding complications: two with puncture site bleeds and one with nasal bleeding. In contrast, one patient in the contraindicated group had transient postoperative hematuria. There were no significant differences in bleeding complications observed between the two groups (p = .771). Additionally, no amputations were observed within our population. CONCLUSIONS: In light of our study results and advancements in endovascular therapies, we can now safely and efficiently treat patients who were previously considered contraindicated for such treatments. It is essential to individualize treatments and carefully balance the risks and benefits of endovascular versus open surgical revascularization for these patients. Additionally, we believe that the nearly 30-year-old guidelines for endovascular therapies need to be revisited and updated to align with modern technology.

Indications, technical aspects, and outcomes of stent placement in chronic iliofemoral venous obstruction.

BACKGROUND: Iliofemoral venous stent placement (IVS) has evolved to a well-established endovascular treatment modality for chronic iliofemoral venous obstruction (CIVO). Dedicated venous stents gained approval from the US Food and Drug Administration in 2019 and solidified IVS as a defined intervention with clear indications, contraindications, risks, benefits, and procedural management principles. This review focuses on the indications, technical aspects and outcomes of stenting for CIVO. Other aspects pertaining to IVS are covered in other articles that are a part of this series. METHODS: This study conducted a literature search limited to English articles. Three search strategies were used, and references were managed in Covidence software. Four investigators screened and evaluated articles independently, excluding meta-analyses, clinical trial protocols, and nonrelevant studies. Eligible studies, focused on clinical outcomes and stent patencies, underwent thorough review. RESULTS: The literature search yielded 1704 studies, with 147 meeting eligibility criteria after screening and evaluation. Exclusions were based on duplicates, irrelevant content, and noniliac vein stent placement. CONCLUSIONS: Successful IVS for CIVO relies on meticulous patient selection, consistent use of intravascular ultrasound examination during procedures and attention to the technical details of IVS.

A comparison of below-knee vs above-knee endovenous ablation of varicose veins.

OBJECTIVE: Varicose veins have a significant impact on quality of life and can commonly occur in the thigh and calves. However, there has been no large-scale investigation examining the relationship between anatomic distribution and outcomes after varicose vein treatment. This study sought to compare below-the-knee (BTK) and above-the-knee (ATK) varicose vein treatment outcomes. METHODS: Employing the Vascular Quality Initiative Varicose Vein Registry, 13,731 patients undergoing varicose vein ablation for either BTK or ATK lesions were identified. Outcomes were assessed using patient-reported outcomes (PROs) and the Venous Clinical Severity Score (VCSS). Continuous variables were compared using the t-test, and categorical variables were analyzed using the χ2 test. Multivariable logistic regression was used to estimate the odds of improvement after intervention. The multivariable model controlled for age, gender, race, preoperative VCSS composite score, and history of deep vein thrombosis. RESULTS: Patients who received below-knee treatment had a lower preoperative VCSS composite (7.0 ± 3.3 vs 7.7 ± 3.3; P < .001) and lower PROs composite scores (11.1 ± 6.4 vs 13.0 ± 6.6; P < .001) compared with those of patients receiving above-knee treatment. However, on follow-up, patients receiving below-knee intervention had a higher postoperative VCSS composite score (4.4 ± 3.3 vs 3.9 ± 3.5; P < .001) and PROs composite score (6.1 ± 4.4 vs 5.8 ± 4.5; P = .007), the latter approaching statistical significance. Patients receiving above-knee interventions also demonstrated more improvement in both composite VCSS (3.8 ± 4.0 vs 2.9 ± 3.7; P < .001) and PROs (7.1 ± 6.8 vs 4.8 ± 6.6; P < .001). Multivariable logistic regression analysis similarly revealed that patients receiving above-knee treatment had significantly higher odds of improvement in VCSS composite in both the unadjusted (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.28-1.65; P < .001 and adjusted (OR, 1.31; 95% CI, 1.14-1.50; P < .001) models. Patients receiving above-knee treatment also had a significantly higher odds of reporting improvement in PROs composite in both the unadjusted (OR, 1.85; 95% CI, 1.64-2.11; P < .001) and adjusted (OR, 1.65; 95% CI, 1.45-1.88; P < .001) models. CONCLUSIONS: Treatment region has a significant association with PROs and VCSS composite scores after varicose vein interventions. Preoperatively, there were significant differences in the composite scores of VCSS and PROs with patients receiving BTK treatment exhibiting less severe symptoms. Yet, the association appeared to reverse postoperatively, with those receiving BTK treatments exhibiting worse PROs, worse VCSS composites scores, and less improvement in VCSS composite scores. Therefore, BTK interventions pose a unique challenge compared with ATK interventions in ensuring commensurate clinical improvement after treatment.

Body Mass Index Impacts Indication But Not Outcomes of Thoracic Endovascular Aortic Repair.

BACKGROUND: There are limited studies looking at thoracic endovascular aortic repair (TEVAR) outcomes in obese and overweight patients. Our objective was to determine the rate of complications, reintervention, and short-term mortality in normal weight, overweight, and obese patients undergoing TEVAR. METHODS: Patients undergoing TEVAR at a large tertiary hospital from October 2007 to January 2020 were analyzed. Patients were stratified into 3 cohorts based on body mass index (BMI): normal (18.5-25 kg/m2), overweight (25-30 kg/m2), and obese (>30 kg/m2). Primary outcomes were 30-day and 1-year survival. Intraoperative, in-hospital, and postdischarge complications were assessed as secondary outcomes using the Clavian-Dindo classification system. In addition, reinterventions associated with the index TEVAR procedure as a secondary outcome. RESULTS: Among 204 patients fitting the study criteria, we identified 65 with normal BMI, 78 overweight, and 61 obese patients. Obese patients were younger than the overweight and normal BMI patients (mean age 62.2 vs. 66.7 vs. 70.7, respectively, P = 0.003). In terms of TEVAR indication, the obese cohort had the highest percentage of patients with type B aortic dissection (36.4%), while the normal BMI cohort had the higher proportion of patients undergoing TEVAR for isolated thoracic aortic aneurysm (63.9%). Intraoperative complications did not significantly differ between cohorts. Postoperatively, in-hospital complications, postdischarge complications and 30-day return to the operative room did not differ significantly between study cohorts. Odds of reintervention did not differ significantly between cohorts, both on univariate and multivariate analysis. Log-rank test of Kaplan Meier analysis revealed no difference in reintervention-free survival (P = 0.22). Thirty-day mortality and 1-year overall survival were similar across cohorts. Both univariate and multivariate logarithmic regression revealed no difference in likelihood of 30-day mortality between the obese and normal cohort. CONCLUSIONS: There were no measurable differences in complications, reinterventions, or mortality, suggesting that vascular surgeons can perform TEVAR across a spectrum of BMI without compromising outcomes.

Diabetes, Hypertension, and Smoking Do Not Affect Outcomes of Iliofemoral Vein Stenting for Chronic Proximal Venous Outflow Obstruction.

BACKGROUND: Diabetes, hypertension, and smoking are well-recognized risk factors for peripheral artery disease (PAD), but little is known of their impact on chronic venous insufficiency (CVI). This study evaluates these factors in patients undergoing iliac vein stenting (IVS) for CVI. METHODS: A registry of 708 patients who underwent IVS from August 2011 to June 2021 was retrospectively analyzed. Symptoms were quantified using venous clinical severity score (VCSS) and CEAP classification. Both major and minor reinterventions were recorded. Logistic regression models were used to determine the unadjusted and adjusted odds ratio of any reintervention. Log-rank test was used to assess differences in reintervention-free survival. RESULTS: The prevalence of hypertension was 51.1% (N = 362), diabetes was 23.0% (N = 163), and smoking was 22.2% (N = 157). Patients with diabetes (3.6 vs. 3.4; P = 0.062), hypertension (3.6 vs. 3.3; P < 0.001), and smoking (3.7 vs. 3.4; P = 0.003) had higher CEAP scores than those without these comorbidities. Improvement in VCSS composite scores showed no differences postoperatively (diabetes: P = 0.513; hypertension: P = 0.053; smoking: P = 0.608), at 1-year follow-up (diabetes: P = 0.666; hypertension: P = 0.681; smoking: P = 0.745), or at 5-year follow-up (diabetes: P = 0.525; hypertension: P = 0.953; smoking: P = 0.146). Diabetes (P = 0.454), smoking (P = 0.355), and hypertension (P = 0.727) were not associated with increased odds of major reintervention. Log-rank test similarly showed no differences in reintervention-free survival for major or minor reoperations between those with and without diabetes (P = 0.79), hypertension (P = 0.14), and smoking (P = 0.80). CONCLUSIONS: Diabetes, hypertension, and smoking were prevalent among CVI patients, but unlike in PAD patients, they had little to no impact on long-term outcomes or reinterventions after IVS.

Identifying venous clinical severity score thresholds for Clinical-Etiology-Anatomy-Pathophysiology classifications of venous edema and higher.

OBJECTIVE: Venous Clinical Severity Score (VCSS) is a widely used standard for assessing and grading the severity of chronic venous disease (CVD). Prior research highlighted its high validity in detecting and quantifying venous disease. However, there is little, if any, known about the precise thresholds at which VCSS discriminates important stages of deep venous disease. This study sought to elucidate the diagnostic accuracy, thresholds, and correlation at which VCSS detects salient CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classes in deep venous disease progression. METHODS: A registry of 840 patients who presented with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions from August 2011 to June 2021 was retrospectively analyzed. VCSS and CEAP classifications were used to evaluate preoperative symptoms. VCSS was compared to CEAP classes to determine the precise VCSS composite values at which the instrument was able to detect CEAP C3 and higher, C4 and higher, and C5 and higher. Receiver operative characteristic (ROC) curve and area under the curve (AUC) were used to evaluate VCSS for its ability to discriminate disease at these stages of CEAP classification. Spearman's rank coefficient was used to determine the correlation between CEAP VCSS composite as well as individual VCSS components (pain, varicose vein, edema, pigmentation, inflammation, induration, ulcer number, ulcer size, ulcer duration, compression). RESULTS: VCSS composite was able to detect venous edema (C3) and higher at a sensitivity of 68.9% and a specificity of 54.8% at an optimized threshold of 8.5 (AUC = 0.648; 95% C.I. = 0.575-0.721). To detect changes in skin and subcutaneous tissue from CVD (C4) and higher, an optimal threshold of 11.5 was found with a sensitivity of 51.7% and specificity of 76.5% (AUC = 0.694; 95% C.I. = 0.656-0.731). Healed venous ulcer (C4) and higher was detectable at an optimized threshold of 13.5 at a sensitivity of 67.7% and a specificity of 88.9% (AUC = 0.819; 95% C.I. = 0.766-0.873). The correlation between VCSS composites and CEAP was weak (ρ = 0.372; p < .001). Attributes of VCSS that reflect more severe venous disease correlated more closely with CEAP classes, namely pigmentation (ρ = 0.444; p < .001), inflammation (ρ = 0.348; p < .001), induration (ρ = 0.352; p < .001), number of active ulcers (ρ = 0.497; p < .001), active ulcer size (ρ = 0.485; p < .001), and ulcer duration (ρ = 0.497; p < .001). The correlation between CEAP class and the other four components of VCSS were not statistically significant. CONCLUSION: VCSS composite thresholds of 8.5, 11.5, and 13.5 are threshold values for detecting CEAP classification C3 and higher, C4 and higher, and C5 and higher, respectively. Consistent with prior work, VCSS appears to have a better ability to discriminate CVD at more severe CEAP classifications. In this registry, the correlation between VCSS and CEAP was found to be weak while components of VCSS that suggest more advanced disease exhibited the strongest correlation with CEAP.

Clinician Perspectives for Mental Health Delivery Following COVID-19 in Carceral Settings: A Pilot Study.

We aimed to understand clinician perspectives on mental healthcare delivery during COVID-19 and the utility of tele-mental health services in carceral settings. A survey was administered in November 2022 through the American College of Correctional Physicians listserv. A nationwide sample of 55 respondents included 78.2% male (n = 43) and 21.8% female (n = 12), 49.1% active clinicians (n = 27) and 50.9% medical directors (n = 28), with a median of 12 and mean of 14.5 years working in carceral settings. Most agreed that mental telehealth services could serve as a stopgap amid infection prevention measures and resource-limited settings with an increasing role moving forward (80.0%, n = 44) but may not be sufficient to replace in-person services completely. Access to mental healthcare is vital in helping achieve optimal health during incarceration. Most clinicians in a nationwide survey report an essential role of mental telehealth in the future, although they vary in beliefs on the present implementation. Future efforts should further identify facilitators and barriers and bolster delivery models, particularly via e-health.

Women are Not at Higher Risk for Reintervention or Major Amputation after Lower Extremity Atherectomy for Peripheral Artery Disease.

BACKGROUND: Our objective was to compare short-term and long-term differences in reintervention-free and major amputation-free survival between female and male patients undergoing lower extremity atherectomy for peripheral artery disease. METHODS: We analyzed lower extremity atherectomy procedures performed on 294 patients between January 2014 and September 2019. Reintervention was defined as either open bypass or endovascular procedure to the same region following the index operation. Kaplan-Meier (KM) survival analysis was performed to compare reintervention-free and major amputation-free survival between sexes. Multivariate logistic regression analyses were performed to determine the adjusted odds of reintervention and major amputation based on sex. We conducted subgroup analyses by anatomic region (femoropopliteal vs. tibial), indication (claudication vs. chronic limb-threatening ischemia (CLTI)), and balloon type (drug-coated balloon (DCB) versus plain balloon angioplasty (POBA)) across sexes. RESULTS: Of the 294 patients, 125 (42.5%) were female. Compared to men, women receiving atherectomy were more likely to be Black (28.0% vs. 16.6%; P = 0.018), a nonsmoker (44.8% vs. 21.3%; P < 0.001), and present with CLTI (55.2% vs. 43.2%; P = 0.042). There were no differences in atherectomy region, lesion type, or balloon type between sexes. KM analysis showed similar 4-year reintervention-free survival (68.8% vs. 75.1%; P = 0.88) and major amputation-free survival (97.6% vs. 97.6%; P = 0.41) between sexes. Women and men had similar reintervention-free survival when grouped by femoropopliteal (67.9% vs. 70.8%; P = 0.69) or tibial (76.2% vs. 83.9%; P = 0.68) atherectomy region. Indication (claudication versus CLTI) did not affect reintervention-free survival in either women (64.5% vs. 69.6%; P = 0.28) or men (68.5% vs. 76.7%; P = 0.84). KM curves for DCB versus POBA were also similar between sexes and showed an early benefit in reintervention rate favoring DCB, which dissipated in both women (65.4% vs. 72.7%; P = 0.61) and men (75.5% vs. 78.4%; P = 0.18) by 3 years. CONCLUSIONS: Compared to men, women demonstrate commensurate benefit from atherectomy for lower extremity revascularization. There were no differences seen in long-term reintervention or major amputation between sexes.

Venous Clinical Severity Score has a suboptimal ability to detect improvement after iliac vein stenting across three years of follow-up.

OBJECTIVE: Venous Clinical Severity Score (VCSS) is currently the gold standard for measuring the severity of chronic venous disease, especially in patients with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions. Change in VCSS composite scores is often used to quantitatively measure the degree of clinical improvement after venous interventions. This study sought to assess the discriminative ability, sensitivity, and specificity of change in VCSS composites for detecting clinical improvement after iliac venous stenting. METHODS: A registry of 433 patients who underwent iliofemoral vein stenting for chronic PVOO from August 2011 to June 2021 was retrospectively analyzed. These 433 patients had follow-up exceeding 1 year after the index procedure. Change in VCSS composite and clinical assessment scores (CAS) were used to quantify improvement after venous interventions. CAS is an assessment by the operating surgeon based on patient self-reporting to assess the degree of improvement at each clinic visit compared with before the index procedure longitudinally across the treatment course of a patient. Patients are rated as worse (-1), no change (0), mildly improved (+1), significantly improved (+2), and asymptomatic/complete resolution (+3) at every follow-up visit as compared with their disease severity prior to the procedure based on patient self-report. This study defined improvement as CAS >0 and no improvement as CAS ≤0. VCSS was then compared with CAS. Receiver operative characteristic curve and area under the curve (AUC) were used to evaluate change in VCSS composite for its ability to discriminate between improvement and no improvement after intervention at each year of follow-up. RESULTS: Change in VCSS was a suboptimal measure for discriminating clinical improvement (1-year AUC, 0.764; 2-year AUC, 0.753; 3-year AUC, 0.715). Across all three time points, a change in VCSS threshold of +2.5 maximized the sensitivity and specificity of the instrument to detect clinical improvement. At 1 year, change in VCSS at this threshold was able to detect clinical improvement at a sensitivity of 74.9% and specificity of 70.0%. At 2 years, VCSS change had a sensitivity of 70.7% and specificity of 66.7%. At 3 years of follow-up, VCSS change had a sensitivity of 76.2% and specificity of 58.1%. CONCLUSIONS: Across 3 years, change in VCSS exhibited a suboptimal ability to detect clinical improvement in patients undergoing iliac vein stenting for chronic PVOO with considerable sensitivity but variable specificity at a threshold of 2.5.

Gender Differences in Iliofemoral Vein Stenting for Chronic Venous Insufficiency.

INTRODUCTION: Little is known about gender's role in chronic venous insufficiency (CVI). The aim of this study was to evaluate the impact of gender on outcomes of iliac vein stenting(IVS) for CVI. METHODS: 866 patients who underwent vein stenting for CVI at one institution from August 2011 to June 2021 were analyzed via retrospective review. Patients were followed up to 5 years after initial stent placement. Presenting symptoms were quantified using Venous Clinical Severity Score(VCSS), Clinical Assessment Score(CAS), and Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class. Reoperations after initial IVS were recorded. Major reoperations were defined as iliac interventions using venography. Minor reoperations were defined as thermal ablation. Multivariate logistic regression models were used determine odds of any and major reintervention. RESULTS: Compared to females, males pre-operatively presented with a higher mean CEAP class (3.6 vs .3.3; P < .001), VCSS composite (11.3 vs .9.9; P < .001), and smoking history (134 vs .49; P < .001). The 2 groups were similar in age (P = .125), BMI(P = .898), previous DVT (P = .085), diabetes (P = .386), hypertension (P = 1.0), and CAD (P = .499). Multivariate analyses revealed no association between gender and any reintervention (OR, 1.02; 95%CI, .71-1.46; P = .935) or gender and major reintervention (OR, 1.39; 95% CI, .86-2.23 P = .177). There were no differences in number of stents placed (P = .736) or symptomatic improvement at 1 month (P = .951), 3 months (P = .233), 6 months(P = .068), and greater than 1 year (P = .287). At the 1 year follow-up, the male cohort had higher CAS values than females P = .034). Males had larger reduction in composite VCSS than women at 1 year (5.1 vs. 3.8; P = .003) and 3 years (5.3 vs .3.7; P = .031) of follow-up and similar levels of improvement in post-op (4.0 vs .3.5; P = .059), 2 years (4.3 vs .3.8; P = .295), 4-years (5.1 vs .4.6; P = .529), 5 years (5.6 vs .4.2; P = .174), and 6 years (5.93vs.3.3 P = .089). CONCLUSIONS: In a single site study of IVS in patients with CVI, males tended to present worse symptoms than females. After surgery, however, both cohorts showed improvement, and both seemed to improve to the same degree of residual symptoms.

Sentiment Analysis of Online Patient-Written Reviews of Vascular Surgeons.

BACKGROUND: Online patient reviews influence a patient's choice of a vascular surgeon. The aim of this study is to examine underlying factors that contribute to positive and negative patient reviews by leveraging sentiment analysis and machine learning methods. METHODS: The Society of Vascular Surgeons publicly accessible member directory was queried and cross-referenced with a popular patient-maintained physician review website, healthgrades.com. Sentiment analysis and machine learning methods were used to analyze several parameters. Demographics (gender, age, and state of practice), star rating (of 5 stars), and written reviews were obtained for corresponding vascular surgeons. A sentiment analysis model was applied to patient-written reviews and validated against the star ratings. Student's t-test or one-way analysis of variance assessed demographic relationships with reviews. Word frequency assessments and multivariable logistic regression analyses were conducted to identify common and determinative components of written reviews. RESULTS: A total of 1,799 vascular surgeons had public profiles with reviews. Female gender of surgeon was associated with lower star ratings (male = 4.19, female = 3.95, P < 0.01) and average sentiment score (male = 0.50, female = 0.40, P < 0.01). Younger physician age was associated with higher star rating (P = 0.02) but not average sentiment score (P = 0.12). In the Best reviews, the most commonly used one-words were Care (N = 999), Caring (N = 767), and Kind (N = 479), while the most commonly used two-word pairs were Saved/Life (N = 189), Feel/Comfortable (N = 106), and Kind/Caring (N = 104). For the Worst reviews, the most commonly used one-words were Pain (N = 254) and Rude (N = 148), while the most commonly used two-word pairs were No/One (N = 27), Waste/Time (N = 25), and Severe/Pain (N = 18). In a multiple logistic regression, satisfactory reviews were associated with words such as Confident (odds ratio [OR] = 8.93), Pain-free (OR = 4.72), Listens (OR = 2.55), and Bedside Manner (OR = 1.70), while unsatisfactory reviews were associated with words such as Rude (OR = 0.01), Arrogant (OR = 0.09), Infection (OR = 0.20), and Wait (OR = 0.48). CONCLUSIONS: Female surgeons received significantly worse reviews and younger surgeons tended to receive better reviews. The positivity and negativity of reviews were largely related to words associated with the patient-doctor experience and pain. Vascular surgeons should focus on these 2 areas to improve patient experiences and their own reviews.

Race differences in iliofemoral vein stenting for chronic venous insufficiency.

INTRODUCTION: Major disparities in outcomes by race are present throughout vascular surgery, yet little has been published on iliac vein stent outcomes by race. This retrospective study assessed iliac vein stent outcomes by patient race. METHODS: Patients who underwent iliac vein stenting at a single institution for chronic venous insufficiency (CVI) from 2011 to 2021 were reviewed. Demographic, preoperative, perioperative, and postoperative data were collected. Self-reported race groups included Asian, Black, Hispanic, and White. Univariate differences were analyzed using χ2 tests for categorical variables and 1-way ANOVA for continuous variables. Outcomes included change in Venous Clinical Severity Score (VCSS) at interval timepoints relative to a preoperative baseline and reinterventions. Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) of any minor and major reintervention. Multivariate regression models controlled for demographic and comorbidity characteristics. RESULTS: A total of 827 patients were included. Asian patients were younger and had a greater proportion of male patients, lower Body mass index (BMI), less smoking history, and fewer comorbidities. White patients were more likely to have a history of deep vein thrombosis (DVT). White patients presented with the most severe CVI symptoms as defined by both Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification and preoperative VCSS composite scores. There were no differences in acute DVT, number of stents deployed, and bilateral versus unilateral stent placement. Black patients had the longest average days of follow-up, followed sequentially by Hispanic, White, and Asian. Black patients had the most reinterventions, while Asian patients had the fewest. Asian patients were less likely to have a major reintervention. No differences in VCSS composite or change in VCSS were observed. CONCLUSIONS: In patients with CVI, Asian patients presented younger and healthier, while White patients presented with the most severe symptoms. No differences were observed in VCSS outcomes, though Black patients had the most reinterventions.

Iliac vein stenting outcomes for patients with superficial venous insufficiency concurrent with deep venous disease.

OBJECTIVE: Many patients will present with chronic proximal venous outflow obstruction (PVOO) and superficial venous insufficiency (SVI) at the time of iliac vein stenting. In the present study, we aimed to determine whether differences in outcomes were present for patients receiving an iliac vein stent according to whether concurrent SVI was present. METHODS: A registry of 553 patients who had undergone iliac vein stent placement for chronic PVOO from 2011 to 2021 was retrospectively analyzed. Two groups of patients were followed for ≤6 years after initial vein stent placement: group 1 (n = 178; 32.2%) had not had SVI before or after stent placement and group 2 (n = 375; 67.8%) had had SVI at initial iliac vein stent procedure. The patients' symptoms were evaluated using the venous clinical severity score (VCSS). Postoperative procedures after initial stent placement were recorded. Postoperative procedures included any operation performed after the index iliac vein stent procedure. Endovenous thermal ablation was classified as a minor postoperative procedure, and any intervention with venography was classified as a major postoperative reintervention. Multivariate regression models were used to determine the odds of a major reintervention or minor procedure postoperatively. RESULTS: Across the two groups, the mean age (group 1, 65.3 years; group 2, 59.9 years; P < .001), body mass index (27.6 vs 26.1 kg/m2; P = .004), diabetes (32.6% vs 17.6%; P < .001), arterial hypertension (68.5% vs 42.1%; P < .001), and coronary artery disease (16.9% vs 9.6%; P = .048) differed significantly. The time to follow-up was similar between the two groups (P = .915). Longitudinally, both groups had had similar improvements in the composite VCSSs. After multivariable adjustment, group 2 was more likely than group 1 (odds ratio, 5.26; 95% confidence interval, 3.33-8.59; P < .001) to have required a postoperative minor procedure, but not a major reintervention. Group 2 had also averaged a shorter interval from the index procedure to a postoperative procedure than group 1 (525.7 days vs 258.1 days; P < .001). CONCLUSIONS: Compared with patients without SVI, those with SVI and chronic PVOO were younger, had had fewer comorbidities, and fared similarly in the change in the composite VCSSs but were more likely to have required a minor procedure and less likely to have required a major reintervention after the index iliac vein stent procedure.

Medical students' knowledge of race-related history reveals areas for improvement in achieving health equity.

BACKGROUND: Medical schools have increasingly integrated social justice, anti-racism, and health equity training into their curricula. Yet, no research examines whether medical students understand the complex history of racial injustice. We sought to investigate the relationship between medical students' historical knowledge and their perceptions regarding health equity. METHODS: Medical students at one large urban medical school self-rated their familiarity and importance of various racially-significant historical events and persons, as well as their agreement with statements regarding health equity, education, and preparedness to act. Descriptive and multivariate analyses were conducted in R. RESULTS: Of 166 (RR=31.3%) participants, 96% agreed that understanding historical context is necessary in medicine; yet 65% of students could not describe the historical significance of racial events or persons. Only 57% felt that they understood this context, and the same percentage felt other medical students did not. A minority of students felt empowered (40%) or prepared (31%) to take action when they witness racial injustice in healthcare. Multiracial identity was significantly associated with increased knowledge of African American history (p<0.01), and a humanities background was significantly associated with increased knowledge of Latin American history (p=0.017). There was a positive, significant relationship between advocacy statements, such as "I have taken action" (p<0.001) and "I know the roots of racism" (p<0.001) with mean familiarity of historical events. CONCLUSIONS: This study demonstrates that while students agree that racism has no place in healthcare, there remains a paucity of knowledge regarding many events and figures in the history of American race relations and civil rights, with implications for future physicians' patient care and health equity efforts.

Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations.

OBJECTIVE: An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-). METHODS: A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs. RESULTS: A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years. CONCLUSIONS: Patients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

Symptom Relief and Reintervention after Iliac Vein Stenting Stratified by CEAP Clinical Classification.

BACKGROUND: This study sought to evaluate long-term symptom relief and reintervention rates after iliac vein stenting (IVS) in patients with chronic venous outflow obstruction. METHODS: A single-institution database of patients undergoing IVS from August 2011 to June 2021 was analyzed. Patients were stratified into three cohorts based on the clinical component of the clinical, etiology, anatomical, and pathophysiology (CEAP) classification: C3, C4, and C5/6. Symptoms were quantified using the venous clinical severity score (VCSS). Reintervention was defined as any procedure using venography. Edema, pigmentation, and ulceration progression-free survival as well as reintervention-free survival were assessed with Kaplan Meier analysis. RESULTS: Among 737 total patients, there were 435 C3, 206 C4, and 96 C5/6 patients. The C5/6 cohort had the highest percentage of patients undergo reoperation (36.4%). C5/6 patients yielded the poorest ulceration progression-free survival (P < 0.001) while C3 patients had the poorest skin pigmentation progression-free survival (P = 0.009). On adjusted analysis there was no significant difference in odds of reintervention between study cohorts. Mean composite VCSS scores were significantly different at each yearly post-operative follow-up visit up to 6 years. CONCLUSIONS: The present study is one of the largest investigations of long-term outcomes in IVS patients. Most patients with long-term follow-up experienced an improvement in their composite VCSS. CEAP clinical classification at the time of IVS had a significant influence on the likelihood and quantity of reintervention.

Collapsed endograft and lower limb ischemia from type B dissection repaired with thoracic endovascular aortic graft and iliac stenting: A case report and review of the literature.

The collapse of an abdominal aortic endograft is a rare event. We present the case of a 60-year-old man with an abdominal endograft who came to the emergency department with chest, back, abdominal, and lower extremity pain in addition to a cool left foot. On imaging, he was found to have a type B aortic dissection and a collapsed abdominal endograft. Subsequently, the patient was taken to the operating room and treated with a thoracic endovascular aortic repair, abdominal aortic cuff, and an iliac stent. Our study details this case and thoroughly reviews similar cases in the literature.

Embolic Protection Devices are Not Associated with Improved Outcomes of Atherectomy for Lower Extremity Revascularization.

BACKGROUND: Atherectomy is associated with a risk of distal embolization, but the role of embolic protection devices (EPDs) during atherectomy is not well-defined. This study examines the utilization and impact of EPD on the outcomes of atherectomy during peripheral vascular interventions (PVIs). METHODS: The annual trend in utilization of EPD during atherectomy in the Vascular Quality Initiative PVI files (2010-2018) was derived. Patients with concomitant open surgery, acute limb ischemia, emergent-status, concomitant thrombolysis, missing indication, missing EPD use, and missing long-term follow-up data were excluded. The characteristics of patients undergoing atherectomy with and without EPD were compared. Propensity matching based on age, gender, race, chronic obstructive pulmonary disease, coronary artery disease, end-stage renal disease, prior PVI, indication, urgent-status, TransAtlantic interSociety Consensus classification, and anatomical location of lesion was performed. The perioperative and 1-year outcomes of the matched groups were compared. RESULTS: EPD was used in 23.3% of atherectomy procedures (n = 5,013/21,500). The utilization of EPD with atherectomy increased from 8.8% to 22.7% (P = 0.003) during the study period. Patients undergoing atherectomy without EPD were more likely to have ESRD (7.8% vs. 5.2%; P < 0.001), tissue loss (31% vs. 23.1; P < 0.001), tibial intervention (39.6% vs. 23.3%; P < 0.001), higher number of arteries treated (1.78 ± 0.92 vs. 1.68 ± 0.93; P = 0.001), and longer length of lesion (21.15 ± 21.14 vs. 19 ± 20.27 cm; P = 0.004). Conversely, patients undergoing atherectomy with EPD were more likely to be White (81.1% vs. 74%; P < 0.001), have a history of smoking (80.6% vs. 74.5%; P < 0.001), chronic obstructive pulmonary disease (24.8% vs. 21.6%; P < 0.037), coronary artery disease (38.5% vs. 33.2%; P = 0.002), prior percutaneous coronary intervention (24.3% vs. 19.9%, P = 0.005), prior coronary artery bypass grafting (32.3% vs. 24.9%; P < 0.001), and prior PVI (49.2% vs. 45.1%; P = 0.023). After propensity matching, there were 1,007 patients in each group with no significant difference in baseline characteristics. There was no significant difference in short-term outcomes including the rate of distal embolization, technical success, dissection, perforation, discharge to home, and 30-day mortality. The use of EPD was, however, associated with longer fluoroscopy time. At 1-year, there was also no difference in primary patency, ipsilateral minor or major amputation, ankle brachial index improvement, reintervention, or mortality rate between patients who underwent atherectomy with and without EPD. CONCLUSIONS: EPD has been increasingly used in conjunction with atherectomy especially in patients with claudication and femoropopliteal disease. However, the use of EPD during atherectomy does not seem to impact the outcomes. Further research is needed to justify the additional cost and fluoroscopy time associated with the use of EPD during atherectomy.

Endovascular Intervention for May-Thurner Syndrome in a Pregnant Patient with a Patent Foramen Ovale and Paradoxical Embolism.

May-Thurner syndrome (MTS) is a known structural risk factor for deep vein thrombosis (DVT) and embolism. In patients with a patent foramen ovale (PFO), emboli originating from the deep veins are able to paradoxically reach the systemic circulation via the PFO, consequently resulting in transient ischemic attacks (TIA) or stroke.We report the case of a 31-year-old pregnant woman, with a recent history of TIA, who presented with chronic bilateral numbness, pain, and swelling in the lower extremities. On imaging, she was found to have a PFO and MTS. Her pregnancy was subsequently terminated. This decision was made independently by the patient. Her care team did not advise her to terminate her pregnancy as there was no specific medical reason to do so. However, the patient was in significant physical pain and distress and ultimately was not comfortable continuing with the pregnancy. This highlights the complex, multifactorial decision-making process that pregnant patients with comorbid health conditions undertake. The patient then underwent transcatheter PFO closure and stents were placed bilaterally in the left and right common iliac veins. Following the stent procedure, lower extremity symptoms swiftly resolved, allowing the patient to significantly improve her ability to ambulate. There have been no signs of TIA since her procedures, and her venous symptoms have been stable.In patients with TIA or stroke from a paradoxical embolism, MTS should be considered as a potential etiology. Endovascular intervention to treat the underlying MTS should also be considered to decrease the risk of recurrent DVT and embolism.