Factors associated with recanalization and reintervention following below knee polidocanol endovenous microfoam ablation for great saphenous and small saphenous veins.

BACKGROUND: Polidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost one decade with specific advantages for below knee (BK) truncal veins where thermal ablation poses a risk of injury to adjacent nerves. The current literature of the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients. METHODS: We performed a retrospective study of a prospectively maintained database of patients from a single institution who underwent 1% PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasound (DU) within 7 days after injection, every 3 to 6 months for 1 year, and every 6 to 12 months thereafter. Patients with symptomatic recanalization underwent reintervention. The 26 patients lost to follow-up without DU after ablation were excluded. The factors associated with recanalization and reintervention were examined by multivariate and nonparametric analyses. RESULTS: Between March 2018 and July 2023, 411 patients (166 male, 245 female) with 573 treated limbs (284 right, 289 left) met the study criteria. Of the 573 included limbs, 457 (79.8%) had undergone prior above knee saphenous ablations. A total of 554 BK GSV and 42 SSV ablations were performed. The most recent DU was performed at a mean of 231 ± 329 days. The overall recanalization rate was 10.6% (55 GSVs and 8 SSVs) at a mean follow-up of 104 ± 180 days. Comparing the closed and recanalized veins, we found no significant difference in age (P = .90), treated laterality (P = .14), patient body mass index (P = .59), preprocedural CEAP (clinical-etiology-anatomy-pathophysiology) score (P = .79), recanalization rate in GSVs vs SSVs (P = .06), or administered PEM volume (P = .24). The recanalized veins had significantly larger preprocedural diameters than the veins that remained closed (recanalized, 4.9 mm; closed, 4.3 mm; P = .001). Men had higher incidence of recanalization than women (men, 14.2%; women, 8%; P = .015). Anticoagulation use was associated with recanalization (odds ratio, 1.96; 95% confidence interval, 1.1-3.6; P = .03). Early recanalization at the first DU accounted for 31 failures (49.2%) and had a significantly lower administered PEM volume compared with later recanalization (early, 4 mL; late, 5 mL; P = .025). There were no significant differences between the 33 recanalized patients requiring reintervention (52.4%) and the 30 who did not. Twenty-four reinterventions were performed with PEM, 100% of which remained closed at a median of 160 days (interquartile range, 257 days). CONCLUSIONS: PEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 89% at a mean of 231 days and shows promise as salvage therapy. Most cases of recanalization were noted in the early postprocedure period and were associated with a lower PEM volume. A larger vein diameter, male sex, and anticoagulation use are associated with higher rates of recanalization.

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.

Value and limitations of postoperative duplex scans after endovenous thermal ablation.

BACKGROUND: Endovenous thermal ablation (EVTA) of the lower extremity veins has risen to become the main treatment modality for symptomatic venous reflux disease. One of the main reported side effects of EVTA is recanalization. As of today, there is no clear protocol as to when follow-up duplex ultrasound scans should be performed. However, the standard for postoperative duplex after truncal ablation is within 1 week of the procedure. Our aim is to try to find whether there is a particular time period when postoperative duplex ultrasound scans should be performed to allow us to best diagnose recanalization. METHODS: We retrospectively analyzed 9799 procedures in 3237 patients with chronic venous insufficiency owing to great, small, and anterior accessory saphenous vein insufficiency from 2012 to 2018. We excluded 466 perforator veins. All 9799 procedures were performed using EVTA in patients who failed to respond to conservative management initially. Postoperative duplex ultrasound scans were performed within 1 week (3-7 days postoperatively). We defined a successful obliteration as lack of color flow on postoperative scan. We defined symptomatic recanalization as presence of reflux on duplex ultrasound examination in the targeted vessel at follow-up with symptom recurrence. Follow-ups were performed every 3 months in the first year and every 6 months thereafter. RESULTS: Patient ages ranged from 15 to 99 years. The median patient age at the time of the procedures was 63 years (interquartile range [IQR], 51-73 years). The median overall follow-up was 25 months (IQR, 4-56 months). The Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class of all the procedures were: C1, 21; C2, 208; C3, 3585; C4, 4680; C5, 188; and C6, 1117. There were 145 redo procedures performed after symptomatic recanalization was diagnosed in patients. CEAP class of the redo patients were: C1, 0; C2, 2; C3, 49; C4, 70; C5, 5; and C6, 19. CONCLUSIONS: Most patients underwent a redo procedure performed within the first year after the initial procedure. Conversely, there was great variability as to when redo procedures were performed. Because there is no defined pattern as to when these symptomatic occurrences arise, it may not be required to perform postoperative duplex ultrasound scans after EVTA routinely, but instead when a patient comes back with symptoms such as swelling.

The Progressive Veterinary Practice.

Veterinary practices must be forward-thinking to effectively serve today's pet owners and move into the future. The progressive practice considers every aspect of a pet owner's journey, from searching for a veterinarian to paying their invoice, and seeks ways to improve their experience. Many tools and methods can be used to reach these goals, while also improving efficiency and veterinary team well-being. Digital tools and artificial intelligence in particular provide significant advances that allow veterinary practices to better serve and build relationships with their clients and patients.

Seasonal variation in swelling of lower extremity edema in patients with chronic venous insufficiency.

OBJECTIVE: We had observed that some patients with chronic venous insufficiency (CVI) had reported their lower extremity edema was worse during warmer weather. Limited research is available regarding the seasonal variation in lower extremity edema. Patients with CVI were questioned to determine whether they had experienced significant seasonal variation in their lower extremity edema and which factors might be associated with such variation. METHODS: Consecutive patients with lower extremity edema were asked whether the edema was worse in the summer or warmer weather. Data was collected between June 2017 and August 2020. A total of 1683 patients (age range, 16-102 years; mean ± standard deviation, 62 ± 14.3 years). Of the 1683 patients, 1157 were female (mean age, 62 ± 14.13 years) and 526 were male (mean age, 62.5 ± 13.82 years). Data were also collected on the presenting symptoms, degree of venous reflux of the great saphenous vein (GSV) reported from the most recent duplex ultrasound, and the season at the time of questioning. For statistical analysis, χ2 goodness-of-fit tests and one-way analysis of variance tests were used. RESULTS: Of the 1683 patients, 56.6% had reported worsening of their lower extremity edema during warmer weather, including 62.7% of the female patients and 37.3% of the male patients. The female patients had reported significantly more worsening of their lower extremity edema (P = 7.06e-18). Female patient age was associated with whether they had experienced worsening (P = .02), with more younger patients reporting worsening. Male patient age was not associated with whether they had reported worsening (P = .97). No significant differences were found in the degree of presenting symptoms between those who had and had not reported worsening (P = .58). Also, no significant differences were found in the degree of venous reflux between the right (P = .61) and left (P = .89) GSV between those who had and had not reported worsening. The season in which the patients had presented during the study period was associated with whether they had reported worsening edema. The patients who had been questioned in the winter (December, January, February) and summer (June, July, August) had reported more worsening of their edema in the warmer months (P = .008 and P = .0002, respectively). The patients who had been questioned in the spring (March, April, May) and fall (September, October, November) had not reported significantly more worsening of their edema in the warmer months (P = .167 and P = .119, respectively). CONCLUSIONS: Of the 1683 patients surveyed, 56.6% had reported worsened edema in the warmer weather. The women (especially the younger women) in the present study had experienced significant worsening, although the men had not. The degree of GSV venous reflux and severity of the presenting symptoms of the patients was not associated with whether worse edema had been reported. However, the season in which the patients had been questioned was associated with the report of worsening edema. The patients questioned in the coldest and warmest months had reported significantly more worsening. The patients questioned in the milder months had not reported significantly more worsening. These findings suggest that a sex and age bias exists in the seasonal variation of lower extremity edema in patients with CVI.

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.

Early Results With a New Endovenous Radiofrequency Ablation Catheter, Venclose®.

OBJECTIVES: Endovenous Radio-frequency Ablation (RFA) has become a common treatment for chronic venous insufficiency. The Medtronic® Closurefast catheter was previously the only RFA catheter approved for use in this procedure. In 2018 VenClose® Company's new device was approved. As there has been little literature on this new device, we examined our results with this new alternative. METHODS: Patients with symptomatic venous insufficiency had their lower extremities mapped via ultrasound. If superficial reflux (>.5 s) was found the patients were recommended a 6-week conservative course of compression stockings, elevation, and NSAIDs. If conservative treatment failed, the patient was scheduled for an RFA. The procedure was done at the outpatient clinic, instructions were given to return for follow-up in 3-5 days, and every 3 months thereafter for the first year. 1032 procedures were performed over 14 months. RESULTS: We had 503 patients, 69% female, mean age 54 ± 12. Under the CEAP system, clinical manifestation portion, the majority of our limbs were class C3 and class C4. The majority of veins closed were GSV above knee and SSV. Follow-up duration ranged from 1 to 276 days (Mean (M) = 10 SD: 20 days). Our success rate was 99.32% at initial follow-up. We observed EHITs in 12 cases (1.16%), 8 of which were class I, 2 of which were class II, and 2 of which were class III. We noted SVTs of proximal varicose veins in 40 cases (3.88%) and SVT of distal GSV in 4 cases (.38%). There were 4 (.38%) cases of DVT, 3 in calf muscular veins (.29%), and one in a perforator vein (.09%). We observed two cases of puncture abscess (.193%), 8 cases of infection at the puncture site (.77%), with 8 infections occurring at locations other than the puncture site and not as a result of the procedure. CONCLUSION: These preliminary results indicate that this new machine and catheter are promising with low rates of EHIT, recanalizations, and other complications. It is important to research this catheter and further studies should continue to follow up to examine recanalization rates over a more long-term follow-up.

Correlation of body mass index with recanalization risk after endovenous thermal ablation.

OBJECTIVE: Chronic venous insufficiency (CVI) has an increased prevalence among obese individuals with body mass indices (BMI) over 30. A safe, efficacious, and evidence-based recommended treatment for CVI due to superficial venous reflux (SVR) in great saphenous veins (GSVs), small saphenous veins (SSVs), accessory saphenous veins (ASVs), and reflux in the perforator veins (PVs) is endovenous thermal ablation (EVTA). We sought to identify if BMI is an independent risk factor for recanalization after EVTA. METHODS: All patients with CVI were initially managed conservatively, and those with pathologic SVR refractory to compression therapy were offered EVTAs depending on the site of reflux. Sonographic confirmation of SVR was defined as >500 milliseconds of reflux in the GSVs, SSVs, and ASVs and a diameter >4 mm. PV reflux was confirmed as >350 milliseconds of reflux and a diameter >2.5 mm. All patients received a follow-up duplex ultrasound 1 week after the procedure, every 3 months for the first year, and every 6 months thereafter. Multivariate analysis with logistic regression was performed regarding patients' age, ablation modality (laser vs radiofrequency ablation), vein location and laterality, BMI, and recanalization. RESULTS: From 2013 to 2018, 9739 endovenous ablations were performed on 3070 patients. Endovenous laser was used in 3862 procedures and radiofrequency ablation in 5831 procedures. Veins treated with EVTA were distributed as follows: 6182 GSVs, 2509 SSVs, 597 ASVs, and 451 PVs. The mean patient age was 61.1 years (15-99, standard deviation [SD] ±15.6) with a mean BMI of 31.2 kg/m2 (13.7-69.5, SD ±7.3). A total of 68.4% patients were women and 31.4% men. The mean follow-up was 25.8 months (0-65.9, SD ±12.9). Multivariate statistical analysis with logistic regression was used to determine potential statistical significance between BMI and vein recanalization after EVTA. Overall, obese patients experienced more recanalizations than nonobese patients (P = .032), with an average BMI of 33 kg/m2 for recanalizations. PVs were statistically more likely to recanalize than any other vein (P = .0001). A secondary analysis was performed with the exclusion of PVs, due to their five times increased risk of recanalization, and showed no significant difference of recanalization across all BMI subgroups (P = .127). CONCLUSIONS: BMI does not predict recanalization risk after EVTA, except for ablations performed on PVs.

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.

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.

Success rate and factors predictive of redo endothermal ablation of small saphenous veins.

OBJECTIVE: Endothermal ablation, such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), has been increasingly used for treatment of small saphenous vein (SSV) insufficiency. Prior studies have shown recurrence rates of 0% to 10% in incompetent SSVs (ISSVs). The objective of the present study was to determine the efficacy of redo venous ablation for symptomatic recanalized SSVs and to predict the factors related to recanalization. METHODS: A retrospective analysis of 2566 procedures in 1752 patients with chronic venous insufficiency due to ISSVs from 2012 to 2018 was performed, using individual medical record review for data extraction. All 2566 procedures were performed using endothermal ablation for patients in whom initial conservative management had failed. Postoperative duplex ultrasound scans were performed within 3 to 7 days after treatment. We defined successful obliteration as a lack of color flow using postoperative duplex ultrasound. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel during follow-up. We conducted follow-up examinations every 3 months during the first year and every 6 months subsequently. RESULTS: Of the 2566 procedures, redo ablation was performed in 91 ISSVs for 86 patients, including 58 women and 28 men. Of the 91 procedures, 54 were performed on the left lower extremity and 37 on the right lower extremity. The mean body mass index was 32.2 ± 7.66 kg/m2. The mean age was 62.4 ± 15.10 years. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class was C1, C2, C3, C4, C5, and C6 for 0, 0, 29, 43, 1, and 18 patients, respectively. The mean maximum diameter of the targeted veins for the redo procedures was 4.51 ± 1.33 mm. Of the 91 procedures, 40 were performed using EVLA and 51 were performed using RFA. The initial technical success was 98.9%. The redo procedures showed an early closure of 96.7%. At a mean follow-up duration of 24.9 ± 14.9 months, the closure rate was 96.5%. No correlation was found between successful obliteration with the redo procedure and age, gender, CEAP class, laterality, EVLA vs RFA, body mass index, or vein diameter. CONCLUSIONS: The rates of successful closure for ISSVs with initial and redo procedures were comparable. These data have validated the potential usefulness of performing redo SSV ablation.

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.

Effect of Pre-Procedure Clopidogrel With Iliac Vein Stenting in Non-Thrombotic Vein Lesions.

OBJECTIVES: Iliac vein stenting is a relatively new procedure in the treatment of chronic venous insufficiency. Research has shown that it is a safe and effective form of treatment, however, one of the well-known risks is in-stent thrombosis. We hypothesize that a single 75 mg dose of Clopidogrel the night prior to the procedures along with a 3-month regimen post-op would decrease the 30-day thrombosis rate. METHODS: A retrospective study was performed on 3,518 patients from September 2012 to August 2018 who received an iliofemoral stent. Patients were broken down into 2 main groups: those given Clopidogrel post-stent and those given Clopidogrel both pre- and post-stent. In our practice, we prescribe a 3-month course of Clopidogrel after iliac vein stenting. Patients were also checked for any anticoagulant medications pre- and/or post-stent. The 30-day thrombosis rates were recorded for each patient. RESULTS: 1,205 patients received Clopidogrel pre-procedurally and post-procedurally, 1,941 patients received Clopidogrel only post-procedurally. 372 patients were excluded from the study because they were on other anti-coagulant medications. Mean follow-up for this cohort was 17 months. 112 total patients developed some degree of 30 day in-stent thrombosis (3.6%). 74 patients developed a complete thrombosis of the stent and 38 developed a partial (≤60% occlusion) thrombosis. Of the 1,205 patients who were on clopidogrel pre-stenting, 28 had a complete thrombosis and 10 had a partial in-stent thrombosis. Of the 1,941 patients on Clopidogrel only post-stenting, 46 had a complete thrombosis and 28 had a partial in-stent thrombosis. Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day any degree of thrombosis rates (complete and partial thrombosis) (p = .33). Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day complete thrombosis rates (p = .93). CONCLUSIONS: There appears to be no statistical difference in 30-day thrombosis rates between those receiving Clopidogrel the night prior vs. those who do not receive Clopidogrel the night prior. Therefore, we conclude that it is not necessary to give this single dose the night prior to iliac vein stenting procedures.

Partial subclavian artery coverage in TEVAR patients for acute type B aortic dissections: an alternative solution.

BACKGROUND: Acute type B aortic dissection with origin of the left subclavian artery (LSA) is generally managed with endovascular therapy for acute coverage of the LSA with: 1) no revascularization; 2) revascularization with open methods; or 3) endovascular revascularization. To identify an alternative solution, we critically evaluated a small cohort of patients who had partial coverage of their LSA. METHODS: Three thoracic endovascular repairs were performed from January-March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative management. Indications included acute type B dissection with lower extremity ischemia, ruptured dissection, and persistent symptoms of dissection after medical therapy. RESULTS: Technical success was achieved in all three patients, and all procedures were performed percutaneously. The mean distance between the ostium of the LSA and the entry point of dissection was 11.1±3.4 mm. Within the 30-day postoperative period, there were no deaths, aortic ruptures, myocardial infarctions, or conversions to open repair. Freedom from re-intervention was noted in all 3 patients. There was no spinal cord ischemia. CONCLUSIONS: There is no strong evidence to support the current optimal approach for treatment of the thoracic aorta. Partial coverage of LSA in patients with <2 cm seal zones may be considered as an alternative. However, due to our small sample size, limited follow-up, and lack of comparison cohort, further investigation is necessary.

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.

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.

Resolution times of endovenous heat-induced thrombosis.

OBJECTIVE: Lower extremity endovenous ablation has become the primary treatment modality for symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) has been reported as one of the primary complications of these venous ablative procedures. Our aim was to determine how long EHITs take to resolve and the factors affecting this length of time. METHODS: A retrospective analysis was performed of 10,029 consecutive procedures from March 2012 to September 2018 performed on 3218 patients who underwent endovenous ablation for lower extremity venous reflux. There were 6091 procedures performed with radiofrequency ablation (RFA) and 3938 with endovenous laser ablation (EVLA). Postprocedural venous duplex ultrasound was performed to evaluate for EHIT and recanalization at 3 to 7 days, every 3 months for the first year, and every 6 to 12 months thereafter. JMP version 14 (SAS Institute, Cary, NC) was used for all statistical analysis. RESULTS: EHIT was found to have developed in 186 patients; 109 patients had been treated with RFA and 77 with EVLA. The average age of the patients receiving EVLA in whom EHIT developed was 59.97 ± 11.61 years. The patients who received RFA and in whom EHIT developed had an average age of 73.4 ± 9.64 years. The average time of resolution for the EVLA group was 75 ± 71.97 days. The average resolution time for the RFA group was 139.8 ± 232.52 days. There were no statistical differences between EHIT resolution times and age, sex, body mass index, clinical class, laterality, type of vein treated, or whether the patient was taking clopidogrel preoperatively or postoperatively. A statistical difference was found between EHIT resolution time and whether the patient was treated with EVLA or RFA (P = .0332). CONCLUSIONS: Our study seems to suggest that EHIT resolution times may be related to the difference in treatment modality between EVLA and RFA. The data suggest that EHIT resolves more quickly with the use of EVLA than with RFA.