Venous thrombosis following endovenous laser ablation with and without thromboprophylaxis.

OBJECTIVE: Venous thromboembolism (VTE) occurs infrequently after endovenous laser ablation (EVLA). The purpose of this study was to assess the incidence of VTE after EVLA with and without pharmacologic prophylaxis. METHODS: From October 2019 to March 2020, a series of consecutive patients from the prospectively maintained VEINOVA (vein occlusion with various techniques) registry was retrospectively analyzed. All the patients underwent EVLA with and without postoperative thromboprophylaxis. A 1470-nm laser wavelength with a radial fiber was used for EVLA. Concomitant phlebectomy or sclerotherapy of insufficient tributaries was allowed. Perivenous tumescence was applied with 1% Rapidocaine (lidocaine hydrochloride monohydrate; Sintetica SA). Ablation of varicose veins was performed by continuously drawing back the laser fiber at a power of 10 W, aiming for a linear endovenous energy delivery of 60 to 90 J/cm. Compression stockings were applied postoperatively, and the patients were advised to wear them for 1 week. Duplex ultrasound was performed at the 1- and 4-week follow-up visits to determine the occlusion rate and the occurrence of EHIT and VTE. RESULTS: Overall, 249 patients were identified from the registry. Of the 249 patients, 26 were omitted because of treatment of recurrent varicose veins. Finally, 223 consecutive patients with 223 legs and 227 saphenous veins (159 great saphenous veins, 49 small saphenous veins, and 19 anterior accessory saphenous veins) were included in the final analysis. Their mean age was 58.1 ± 13.8 years, and 167 patients (73.1%) were women. The clinical CEAP (clinical, etiology, anatomy, pathophysiology) classification was C2 for 11 legs (4.9%), C3 for 123 legs (55.2%), C4a or C4b for 86 legs (38.6%), and C5 to C6 for 3 legs (1.4%). Thromboprophylaxis was given to 132 patients (59.2%) for 3 days (rivaroxaban 10 mg once daily to 130 patients [98.5%] and low-molecular-weight heparin to 2 patients [1.5%]). No thromboprophylaxis was administered to 91 patients (40.8%) after EVLA. The average treatment length was 34.2 ± 19.3 cm and the average diameter was 5.0 ± 1.3 mm. At 1 week of follow-up, no thrombotic event had occurred in either group. At 4 weeks of follow-up, one case of EHIT class 2 (1.1%) and one case of pulmonary embolism (1.1%) had occurred in the group without thromboprophylaxis. In the thromboprophylaxis group, one deep vein thrombosis (0.8%) event had occurred (adjusted P = .135). At 1 and 4 weeks of follow-up, the treated varicose veins remained occluded in both groups. CONCLUSIONS: Endovenous ablation of truncal varicose veins appears to be safe with a low thrombotic event rate with or without pharmacologic thromboprophylaxis. However, more data are needed before a final recommendation regarding the best thromboprophylaxis treatment option can be given.

Safety, feasibility, and early efficacy of the water-specific 1940-nm laser wavelength for ablation of saphenous incompetence.

Objective: The aim of the present study was to evaluate the safety, feasibility, and early efficacy of saphenous vein ablation using a water-specific 1940-nm diode laser wavelength using low linear endovenous energy density. Methods: We retrospectively analyzed a series of patients who had undergone endovenous laser ablation (EVLA) between July 2020 and October 2021 from the multicenter, prospectively maintained VEINOVA (vein occlusion with various techniques) registry. EVLA was performed using a water-specific 1940-nm radial laser fiber. In the same session, all insufficient tributaries were treated by phlebectomy or sclerotherapy. Tumescent anesthesia was injected into the perivenous space. The vein diameter, energy delivered, and linear endovenous density were reviewed at baseline. The incidence of venous thromboembolism, endovenous heat-induced thrombosis (EHIT), burns, phlebitis, paresthesia, and occlusion were reviewed at 2 days and 6 weeks of follow-up. We used descriptive statistics to describe the results. Results: Overall, 229 patients were identified. Of the 229 patients, 34 were excluded because of treatment of recurrent varicose veins at a previously operated site (residual or neovascularization). Finally, 108 patients with varicose veins and 87 with recurrent varicose veins (new varicose veins in an untreated area) due to disease progression were included in the present analysis. A total of 256 native saphenous veins (163 great saphenous veins, 53 small saphenous veins, and 40 accessory saphenous veins) in 224 legs had undergone EVLA. The mean patient age was 58.3 ± 16.5 years. Of the 195 patients, 134 (68.7%) were women and 61 (31.3%) were men. Nearly one half of the patients had a history of saphenous vein surgery (44.6%). The CEAP (clinical, etiology, anatomy, pathophysiology) class was C2 in 31 legs (13.8%), C3 in 108 (48.2%), C4a to C4c in 72 (32.1%), and C5 or C6 in 13 legs (5.8%). The treatment length was 34.8 ± 18.3 cm. The mean diameter was 5.0 ± 1.2 mm. The average linear endovenous density was 34.8 ± 9.2 J/cm. Concomitant miniphlebectomy was performed in 163 patients (83.6%) and concomitant sclerotherapy in 35 patients (18%). At 2 days and 6 weeks of follow-up, the occlusion rate of the treated truncal veins was 99.6% and 99.6%, respectively, with only one truncal vein (0.4%) with partial recanalization at 2 days and 6 weeks of follow-up. No cases of proximal deep vein thrombosis, pulmonary embolism, or EHIT had occurred at follow-up. Only one patient (0.5%) had developed calf deep vein thrombosis at 6 weeks of follow-up. The incidence of postoperative ecchymosis was rare (1.5%) and had resolved at 6 weeks of follow-up. Conclusions: EVLA of incompetent saphenous veins using the water-specific 1940-nm diode laser wavelength is feasible and appears to be safe and efficient with a high occlusion rate, minimal side effects, and a zero rate of EHIT.

Safety and efficacy of endovenous thermal ablation for treatment of symptomatic varicose veins during summertime.

Background: Traditionally, varicose vein treatment is predominately performed during the colder seasons. However, data whether higher outdoor temperatures affect the outcome and/or complication rate of endovenous thermal ablation (ETA) for treatment of symptomatic varicose veins are missing. Patients and methods: In this observational study, the medical records of all patients who had ETA of the great saphenous vein (GSV), accessory saphenous vein (ASV), or small saphenous vein (SSV) between September 2017 and October 2020 were reviewed. Results: In total 846 ETA interventions in 679 patients with 1239 treated truncal veins and an average length of 69 cm phlebectomy were included. The highest temperature recorded on and within the first 14 days after treatment was on average 19.0°C (SD±7.2°C) with a minimum and maximum of -1°C and 35.9°C. Interventions were categorized according to the recorded temperature (<25°C n=584; 25-29.9°C n=191; and ≥30°C n=71). The occlusion rates were excellent (99-100%) across groups. Despite a significantly higher proportion of patients with obesity, personal history of superficial vein thrombosis and length of phlebectomies in the high temperature groups, no significant difference regarding days of work loss, patients' satisfaction or complications including bleeding or thromboembolic events was observed. Infections were rare (0.8%), but more frequently observed in the 25-29.9°C group (2.6%; p=0.058). No infection was observed in the ≥30°C group and pain 6 weeks after the intervention was even lower (VAS 0.5±1.0 and 0.5±1.2 vs. 0.0±0.1, p=0.008). Conclusions: Given the minimal invasive nature of ETA, our results can reassure clinicians and patients that ETA varicose vein treatment is possible and safe throughout the year, even on hot summer days. A non-significant trend to more infections was observed but was not associated with other adverse outcomes such as prolonged analgetics intake or inability to work.

Association of Intima-Media Thickness Measured at the Common Carotid Artery With Incident Carotid Plaque: Individual Participant Data Meta-Analysis of 20 Prospective Studies.

Background The association between common carotid artery intima-media thickness (CCA-IMT) and incident carotid plaque has not been characterized fully. We therefore aimed to precisely quantify the relationship between CCA-IMT and carotid plaque development. Methods and Results We undertook an individual participant data meta-analysis of 20 prospective studies from the Proof-ATHERO (Prospective Studies of Atherosclerosis) consortium that recorded baseline CCA-IMT and incident carotid plaque involving 21 494 individuals without a history of cardiovascular disease and without preexisting carotid plaque at baseline. Mean baseline age was 56 years (SD, 9 years), 55% were women, and mean baseline CCA-IMT was 0.71 mm (SD, 0.17 mm). Over a median follow-up of 5.9 years (5th-95th percentile, 1.9-19.0 years), 8278 individuals developed first-ever carotid plaque. We combined study-specific odds ratios (ORs) for incident carotid plaque using random-effects meta-analysis. Baseline CCA-IMT was approximately log-linearly associated with the odds of developing carotid plaque. The age-, sex-, and trial arm-adjusted OR for carotid plaque per SD higher baseline CCA-IMT was 1.40 (95% CI, 1.31-1.50; I2=63.9%). The corresponding OR that was further adjusted for ethnicity, smoking, diabetes, body mass index, systolic blood pressure, low- and high-density lipoprotein cholesterol, and lipid-lowering and antihypertensive medication was 1.34 (95% CI, 1.24-1.45; I2=59.4%; 14 studies; 16 297 participants; 6381 incident plaques). We observed no significant effect modification across clinically relevant subgroups. Sensitivity analysis restricted to studies defining plaque as focal thickening yielded a comparable OR (1.38 [95% CI, 1.29-1.47]; I2=57.1%; 14 studies; 17 352 participants; 6991 incident plaques). Conclusions Our large-scale individual participant data meta-analysis demonstrated that CCA-IMT is associated with the long-term risk of developing first-ever carotid plaque, independent of traditional cardiovascular risk factors.

Combining Proximal Foam Sclerotherapy and Distal Endovenous Laser Ablation for Recurrent Varicose Vein Treatment.

BACKGROUND: Recurrent varicose veins with neovascularization are a common clinical problem. Although endovenous laser ablation (EVLA) has become the standard treatment modality to treat truncal veins, additional sclerotherapy is required to treat newly formed tortuous veins. A novel laser fiber with an injection channel (nLF) allows for such simultaneous proximal sclerotherapy and offers a potentially more effective treatment option. OBJECTIVE: The aim of this study was to present our experience using the nLF for combined EVLA and sclerotherapy treatment of symptomatic recurrent varicose veins. MATERIALS AND METHODS: A retrospective single-center cohort study analyzed the outcomes of all patients with symptomatic recurrent varicose veins, treated with an nLF between September 2020 and August 2022. RESULTS: In total, 28 combined EVLA/sclerotherapy procedures performed with the nLF in 26 patients were analyzed. In all cases, neovascularizations were treated by sclerotherapy through the nLF catheter, followed by laser ablation of the remaining truncal veins. All follow-up ultrasound examinations showed persistent complete occlusion of the treated truncal veins and neovascularizations. No clinically relevant complications were observed. CONCLUSION: Combining proximal foam sclerotherapy and distal EVLA using an nLF for the treatment of symptomatic recurrent varicose veins is safe and effective.

Thromboprophylaxis practice after outpatient endovenous thermal ablation.

OBJECTIVE: The use of endovenous thermal ablation (ETA) for the treatment of truncal varicose veins has been increasing worldwide; however, uncertainty remains regarding the need for thromboprophylaxis and follow-up of patients undergoing this minimally invasive procedure. A nationwide survey of among physicians performing ETA was conducted to assess the thromboprophylaxis practice and follow-up protocols after ETA in Switzerland. METHODS: A questionnaire was sent to all ETA-certified physicians (n = 193) in Switzerland. The survey covered procedure type, thromboprophylaxis (including pharmacologic and compression therapy), duplex ultrasound follow-up examinations, and the management of endovenous heat-induced thrombosis (EHIT). RESULTS: Overall, 121 responses were received, for a response rate of 62.7%. Of the 121 respondents, 71 were vascular medicine specialists (58.7%) and 46 were general or vascular surgeons (38.0%), representing the two largest groups of specialists, followed by 2 dermatologists (1.7%) and 2 interventional radiologists (1.7%). Pharmacologic thromboprophylaxis after ETA was always used by 86 physicians (71.1%), nearly always by 8 (6.6%), frequently used by 5 (4.1%), rarely used by 21 (17.4%), and never by 1 physician (0.8%). A direct oral anticoagulant drug was the preferred type of thromboprophylaxis used by 92 physicians (77.3%). The first dose of thromboprophylaxis was mostly administered immediately after intervention by 53 physicians (53.7%). The duration of postablation thromboprophylaxis ranged from 1 to 21 days, with 7 to 10 days used by 57 physicians. Compression therapy was used by all physicians, with large variation in duration ranging from 1 to 42 days after a single ETA session and after ETA with concomitant phlebectomy. Postablation duplex ultrasonography was performed routinely by 120 respondents (99.2%), and 84 respondents (69.4%) performed two to three duplex ultrasound scans. Management of EHIT depended on the EHIT class and differed widely among the physicians. CONCLUSIONS: Our nationwide survey on thromboprophylaxis practices after ETA of truncal varicose veins in Switzerland showed that most physicians use pharmacologic thromboprophylaxis, with a direct oral anticoagulant drug the preferred agent. However, the timing of the first dose and the duration of thromboprophylaxis varied widely among the respondents, reflecting the uncertainty in this domain owing to the absence of high-quality evidence-based guidelines.

Feasibility and safety of flush endovenous laser ablation of the great saphenous vein up to the saphenofemoral junction.

OBJECTIVE: The optimal ablation distance from the catheter tip to the common femoral vein during endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a matter of debate. In this study, we evaluated the feasibility and safety of flush ablation (fEVLA) of the GSV. METHODS: This single-center, retrospective analysis of prospectively collected data included all consecutive fEVLA interventions of the GSV between September 2017 and October 2018. Interventions were performed with a 1470-nm radially emitting fiber. Primary end points were technical feasibility of fEVLA and endovenous heat-induced thrombosis (EHIT) class 2 to class 4. Secondary end points were procedure-related complications; anatomic success at week 6; and flush occlusion at day 1, day 10, and week 6. RESULTS: A total of 135 consecutive intended fEVLA procedures were performed in 113 patients (86 female, 27 male). The average body mass index was 24.9 ± 4.3 kg/m2. The Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class for these patients was C2 in 78 (57.8%), C3 in 48 (35.6%), C4 in 8 (5.9%), and C5 in 1 (0.7%). The GSV diameter at the saphenofemoral junction was 9.4 ± 2.7 mm with a maximum of 16 mm. In 126 cases (93.3%), concomitant treatment of tributaries with phlebectomy or foam sclerotherapy was performed. In 127 cases (94.1%), fEVLA was technically feasible; in 8 cases (5.9%), appropriate catheter tip placement was not possible. In these cases, "standard" GSV ablation 10 to 20 mm distal to the saphenofemoral junction was performed. In the remaining 127 cases, one (0.8%) EHIT class 2 and one (0.8%) EHIT class 3 developed at day 10. After a 2- to 3-week course of anticoagulation with rivaroxaban, these EHIT cases resolved without sequelae. Furthermore, one (0.8%) superficial vein thrombosis and one (0.8%) calf vein thrombosis at the site of phlebectomy were observed. No local groin complication occurred. Flush occlusion was observed in 94.5%, 95.3%, and 88.2% of the cases at day 1, day 10, and week 6, respectively. Multivariate regression analysis revealed no significant association between flush ablation at day 1 and age, body mass index, CEAP class, fiber type, maximum vein diameter, or applied joules per centimeter. CONCLUSIONS: The results of this study suggest that fEVLA of the GSV using a radial emitting laser is feasible and seems to be safe.

Perforator vein endovenous heat induced thrombosis after laser ablation of the great saphenous vein.

Endovenous heat induced thrombosis at the sapheno-femoral or sapheno-popliteal junction is a well-known complication after superficial truncal vein endovenous laser ablation (EVLA). This report describes a rare thigh perforator vein thrombus propagation into the femoral vein after EVLA of the great saphenous vein.

Duration of pharmacological thromboprophylaxis after outpatient endovenous laser ablation: a propensity score-matched analysis.

AIM OF THE STUDY: The objective of this study was to identify the optimal duration of pharmacological thromboprophylaxis after outpatient endovenous laser ablation (EVLA). METHODS: In this multicentre retrospective study in a university hospital, regional hospital and private practices, we collected the demographic, procedural and outcome data of all consecutive patients with varicose veins class C2 to C6 undergoing outpatient EVLA of truncal and accessory veins between February 2009 and December 2015. The cumulative primary efficacy endpoint consisted of endovenous heat-induced thrombosis (EHIT) class 2–4, deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosed with duplex ultrasound or computed tomography angiography after 1 and 4 weeks of follow-up. Cumulative secondary endpoints were complete ablation of the treated veins and major bleeding, skin burns and infection. RESULTS: A total of 864 patients were treated with EVLA as an outpatient procedure. Of those, 35 patients were omitted because of therapeutic anticoagulation or dual antiplatelet therapy. Another 36 cases were excluded as the patients received pharmacological thromboprophylaxis for 5 days. A total of 793 were included in the final analysis. Of those, 225 patients (28.4%) received fondaparinux 2.5 mg s.c. for 3 days, 166 patients (20.9%) received rivaroxaban 10 mg p.o. for 3 days and 402 patients (50.7%) received rivaroxaban 10 mg for 10 days. The incidence of EHIT class 2–4 was 0.8% (n = 6) in total, 1.3% (n = 6) in group 1 (treated for 3 days) and 0.3% (n = 1) in group 2 (treated for 10 days) (odds ratio [OR] 0.19, confidence interval [CI] 0.02–1.66, p = 0.133). The cumulative primary composite endpoint at 4-week follow-up was 1.1% (n = 9) and was 2.1% (n = 8) in group 1 and 0.3% (n = 1) in group 2 (OR 0.0.12, CI 0.01–0.96, p = 0.046). Propensity score-matched analysis revealed no significant difference in the composite primary endpoint (CI −0.074 to 0.26). Complete occlusion rate was 99.2% in group 1 and 98.8% in group 2 (OR 0.61, CI 0.15–2.59, p = 0.506). No PE or major bleeding events occurred in either group. Propensity score-matched analysis showed no significant difference in the secondary endpoints. CONCLUSION: Using propensity score-matched analysis we showed that pharmacological thromboprophylaxis after EVLA seems to be equally effective with 3 days or 10 days of treatment with a similar success rate and safety profile. Undoubtedly, a large randomised control trial, ideally including a group without pharmacological thromboprophylaxis, is needed to draw more definitive conclusions on the optimal duration of pharmacological post-EVLA thromboprophylaxis.

Safety and efficacy of outpatient endovenous laser ablation in patients 75 years and older: a propensity score-matched analysis.

AIMS OF THE STUDY: The purpose of this study was to evaluate the safety and efficacy of endovenous laser ablation (EVLA) in patients 75 years and older in an outpatient setting. METHODS: In this multicentre retrospective study, we collected the demographic, procedural and outcome data of all consecutive patients with varicose veins class C2 to C6 undergoing EVLA of truncal and accessory saphenous veins. The primary efficacy endpoint was complete ablation of the treated veins diagnosed with duplex ultrasound at 4-week follow up. The primary safety endpoint was endothermal heat-induced thrombosis (EHIT) and deep vein thrombosis (DVT) at 4-week follow up as diagnosed by duplex ultrasound. A secondary endpoint was minor or major bleeding. RESULTS: Between February 2009 and December 2015, a total of 829 patients were treated with EVLA of the truncal and accessory saphenous veins. Among them, 747 were <75 years old (group 1) and 82 were ≥75 years old (group 2). The primary efficacy outcome was reached in 739 patients (98.9%) in group 1 and in 80 patients (97.6%) in group 2 (odd ratio [OR] 0.43, confidence interval [CI] 0.09–2.07; p = 0.295). The number of patients with EHIT type 2 and DVT were 4 (0.5%) and 2 (0.3%), respectively, in group 1, and 2 (2.4%) and 1 (1.2%), respectively, in group 2 (OR 4.64, CI 0.83–25.75; p = 0.079 and OR 4.59, CI 0.41–51.27; p = 0.215, respectively). Minor bleeding events occurred in 36 patients (4.8%) in group 1 and 7 patients (8.9%) in group 2 (OR 1.84, CI 0.79-4.29; p = 0.155). No major bleeding occurred in either group. Propensity score-matched analysis revealed no significant difference in efficacy and safety outcomes. CONCLUSION: EVLA performed as an outpatient procedure seems to be effective and safe in the elderly population as compared to the younger age group.

Rivaroxaban for thrombosis prophylaxis in endovenous laser ablation with and without phlebectomy.

OBJECTIVE: Endovenous heat-induced thrombosis (EHIT) is a well-described complication of endovenous laser ablation (EVLA). We report our centers' experience on the efficacy (EHIT level ≥2 according to the Kabnick classification) and safety (observed major and minor bleeding events) of rivaroxaban for EHIT prophylaxis in EVLA with and without concomitant phlebectomy. METHODS: Demographic, procedural, and outcome data of all patients with EVLA of the great, accessory, or small saphenous vein and EHIT prophylaxis with 10 mg/d rivaroxaban between 2012 and 2014 were reviewed and analyzed in this investigator-initiated multicenter retrospective observational single-arm study. RESULTS: During a median (interquartile range) follow-up duration of 51 (41-68) days, complete vein occlusion was achieved in 98.4% of 438 EVLA procedures in 306 patients. One patient had an EHIT level 2 (0.2%; 95% confidence interval, 0.006%-1.3%). No major bleedings (0%; 95% confidence interval, 0.0%-0.8%) and six minor bleedings (1.4%; 95% confidence interval, 0.5%-3%) were observed. CONCLUSIONS: Rivaroxaban (10 mg/d) for 5 to 10 days seems to be an efficacious and safe alternative for EHIT prophylaxis in EVLA with or without phlebectomy.

Varicosities of the lower extremity, new approaches: cosmetic or therapeutic needs?

Varicose veins of the lower extremity (VVLE) are a frequently encountered vascular disorder in the general population. The general view that VVLE are a non-serious disease with primarily aesthetic impact is a common misconception, as the disease can have a significant negative impact on generic and disease-specific quality of life. Further, VVLE may be associated with potentially threatening clinical conditions, such as chronic venous ulceration, venous thromboembolism and haemorrhage from ruptured varicose veins. In the case of symptomatic varicose veins, in the presence of advanced lower limb skin changes or when venous complications occur, a referral for dedicated evaluation by the vascular medicine specialist is recommended. The initial diagnostic test of choice to detect the extent of the varicose disease and to plan treatment is duplex ultrasound. Traditionally, compression therapy, surgical high ligation and stripping of the truncal veins have been considered standard of care for VVLE. Driven by the aim to reduce surgical trauma and improve the long-term effectiveness, minimally invasive treatment options have been developed in the last two decades, namely endovascular vein ablation techniques (EVA). Endovenous laser ablation and radiofrequency ablation have been established as first-line treatments for varicose veins associated with axial reflux on the basis of the most recent international guidelines. For practical purposes and depending on the concrete clinical situation, the various EVA and surgical techniques are often combined, leading to multimodal varicose vein therapy management. Knowledge of the different techniques is of utmost importance for the vascular medicine specialist. The purpose of this article is to provide an overview of the new EVA techniques and to elucidate the different therapeutic strategies for VVLE.

[Well-Tried and New Ones ­ Update Varicose Vein Treatment 2016]. / Altbewährtes und Neues - Update Krampfaderbehandlung 2016.

Venous leg symptoms are frequent, but their relevance is frequently underestimated. With the introduction of effective, minimal-invasive endovenous treatment modalities the treatment of varicose veins has recently made major advances. The basis of every treatment decision is a competent anamnesis, clinical investigation and duplex scan. Outpatient varicose vein treatment using endovenous methods has been proofed to be at least as effective as traditional varicose vein surgery but is associated with fewer adverse events. Accordingly, the endovenous methods are exspected to replace surgery as goldstandard treatment and endovenous thermal vein ablation (Laser/Radiofrequency) is accepted by the Swiss Federal Office of Public Health for general reimbursment since 1st january 2016. All currently available methods have their advantages and limitations, the individual selection based on the present symptoms, anatomic findings and patients' preferences is fundamental for an optimal treatment result and maximized patient satisfaction.

Contrast-enhanced ultrasound after endovascular aortic repair-current status and future perspectives.

An increasing number of patients with abdominal aortic aneurysms (AAAs) are undergoing endovascular aortic repair (EVAR) instead of open surgery. These patients require lifelong surveillance, and the follow-up imaging modality of choice has been traditionally computed tomography angiography (CTA). Repetitive CTA imaging is associated with cumulative radiation exposure and requires the administration of multiple doses of nephrotoxic contrast agents. Contrast-enhanced ultrasound (CEUS) has emerged as an alternative strategy in the follow-up of patients with EVAR and demonstrates high sensitivity and specificity for detection of endoleaks. In fact, a series of studies have shown that CEUS is at least performing equal to computed tomography for the detection and classification of endoleaks. This article summarizes current evidence of CEUS after EVAR and demonstrates its usefulness via various patient cases.

Radioprotective lightweight caps in the interventional cardiology setting: a randomised controlled trial (PROTECT).

AIMS: The aim of this study was to test the radioprotection efficacy and comfort of newer bilayer barium sulphate-bismuth oxide composite (XPF) caps in an interventional cardiology setting. METHODS AND RESULTS: Operators were randomly assigned to wear standard fabric (n=59), 0.3 mm (n=74), or 0.5 mm (n=64) lead-equivalent XPF caps. Radiation doses were measured by using dosimeters placed outside and underneath the caps. Wearing comfort was assessed at the end of each measurement on a visual analogue scale (VAS) (0-100, with 100 indicating optimal comfort). Procedural data did not differ between the XPF and standard groups. Mean standard, XPF 0.3 mm, and XPF 0.5 mm cap weights were 12.5 g, 118.4 g, and 123.7 g, respectively. VAS comfort ratings of the standard and XPF caps did not differ significantly (p=0.272). The mean radiation protection was 12.0%, 95% CI: 4.9-19.1% (standard caps, n=35), 91.5%, 95% CI: 87.4-95.6% (XPF 0.3 mm caps, n=45) and 97.1%, 95% CI: 92.5-100% (XPF 0.5 mm caps, n=44) (p≤0.001 for all group comparisons). Using the XPF caps, a cumulative total radiation dose reduction by almost factor 10 was evident (272 procedures, 22,310 µSv outside the XPF caps, 2,770 µSv inside the caps). CONCLUSIONS: Lightweight XPF caps show comparable comfort to standard fabric caps, but provide substantial radiation protection during fluoroscopy-guided cardiac interventions.

Lightweight bilayer barium sulfate-bismuth oxide composite thyroid collars for superior radiation protection in fluoroscopy-guided interventions: a prospective randomized controlled trial.

PURPOSE: To test whether newer bilayer barium sulfate-bismuth oxide composite (XPF) thyroid collars (TCs) provide superior radiation protection and comfort during fluoroscopy-guided interventions compared with standard 0.5-mm lead-equivalent TCs. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained for this HIPAA-compliant study, and 144 fluoroscopy-guided vascular interventions were included at one center between October 2011 and July 2012, with up to two operators randomly assigned to wear XPF (n = 135) or standard 0.5-mm lead-equivalent (n = 121) TCs. Radiation doses were measured by using dosimeters placed outside and underneath the TCs. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100, with 100 indicating optimal comfort). Adjusted differences in comfort and radiation dose reductions were calculated by using a mixed logistic regression model and the common method of inverse variance weighting, respectively. RESULTS: Patient (height, weight, and body mass index) and procedure (type and duration of intervention, operator, fluoroscopy time, dose-area product, and air kerma) data did not differ between the XPF and standard groups. Comfort was assessed in all 256 measurements. On average, the XPF TCs were 47.6% lighter than the standard TCs (mean weight ± standard deviation, 133 g ± 14 vs 254 g ± 44; P < .001) and had a significantly higher likelihood of a high level of comfort (visual analog scale >90; odds ratio, 7.6; 95% confidence interval: 3.0, 19.2; P < .001). Radiation dose reduction provided by the TCs was analyzed in 117 data sets (60 in the XPF group, 57 in the standard group). The mean radiation dose reductions (ie, radiation protection) provided by XPF and standard TCs were 90.7% and 72.4%, with an adjusted mean difference of 17.9% (95% confidence interval: 7.7%, 28.1%; P < .001) favoring XPF. CONCLUSION: XPF TCs are a lightweight alternative to standard 0.5-mm lead-equivalent TCs and provide superior radiation protection during fluoroscopy-guided interventions.

Prospective comparison of palpation versus ultrasound-guided radial access for cardiac catheterization.

BACKGROUND: Radial access is increasingly used for both diagnostic and interventional cardiac procedures. Prospective data comparing ultrasound- versus palpation-guided radial catheterization are largely lacking. METHODS: In this prospective, single-center study, a total of 183 consecutive patients scheduled for transradial cardiac catheterization by an experienced interventionalist were assigned 1:1 to either palpation- or ultrasound-guided radial access. Demographic and procedure parameters were prospectively recorded. RESULTS: Baseline demographic and clinical parameters did not differ significantly between the ultrasound group (n = 92) and palpation group (n = 91). The initial radial catheterization success rate (87% vs 86.8%; P=.999) and time to access (47 seconds [interquartile range (IQR), 20-90 seconds] versus 31 seconds [IQR, 20-75 seconds]; P=.179) did not differ between the ultrasound and palpation groups, respectively. Pulse quality (absent, weak, strong) was independently associated with access failure in both groups (P<.001). Obesity was associated with access failure in the palpation group (P=.005), but not in the ultrasound group (P=.544). In 3/12 cases (25%) in the ultrasound group and 2/6 cases (33%) in the palpation group, the operator was able to establish radial access using the alternative method (P=.710). If palpation-guided radial access failed, an additional ultrasound-guided attempt before crossover to femoral access was associated with a shorter overall time to access (525 seconds [IQR, 462-567 seconds] versus 744 seconds [IQR, 722-788 seconds]; P=.016). CONCLUSIONS: Ultrasound-guided radial access seems to provide no substantial additional benefit over palpation-guided access alone. Attempting the alternative guiding methods to establish radial access before crossover to femoral access seems to be a reasonable approach.

Evaluation of novel disposable, light-weight radiation protection devices in an interventional radiology setting: a randomized controlled trial.

OBJECTIVE: Radiation exposure to interventionalists is increasing. The currently available standard radiation protection devices are heavy and do not protect the head of the operator. The aim of this study was to evaluate the effectiveness and comfort of caps and thyroid collars made of a disposable, light-weight, lead-free material (XPF) for occupational radiation protection in a clinical setting. SUBJECTS AND METHODS: Up to two interventional operators were randomized to wear a XPF or standard 0.5-mm lead-equivalent thyroid collars in 60 consecutive endovascular procedures requiring fluoroscopy. Simultaneously a XPF cap was worn by all operators. Radiation doses were measured using dosimeters placed outside and underneath the caps and thyroid collars. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100 [100 = optimal]). RESULTS: Patient and procedure data did not differ between the XPF and standard protection groups. The cumulative radiation dose measured outside the cap was 15,700 µSv and outside the thyroid collars 21,240 µSv. Measured radiation attenuation provided by the XPF caps (n = 70), XPF thyroid collars (n = 40), and standard thyroid collars (n = 38) was 85.4% ± 25.6%, 79.7% ± 25.8% and 71.9% ± 34.2%, respectively (mean difference XPF vs standard thyroid collars, 7.8% [95% CI, -5.9% to 21.6%]; p = 0.258). The median XPF cap weight was 144 g (interquartile range, 128-170 g), and the XPF thyroid collars were 27% lighter than the standard thyroid collars (p < 0.0001). Operators rated the comfort of all devices as high (mean scores for XPF caps and XPF thyroid collars 83.4 ± 12.7 (SD) and 88.5 ± 14.6, respectively; mean scores for standard thyroid collars 89.6 ± 9.9) (p = 0.648). CONCLUSION: Light-weight disposable caps and thyroid collars made of XPF were assessed as being comfortable to wear, and they provide radiation protection similar to that of standard 0.5-mm lead-equivalent thyroid collars.

Direct percutaneous sac injection for postoperative endoleak treatment after endovascular aortic aneurysm repair.

BACKGROUND: This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). METHODS: Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ± 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. RESULTS: DPSI using thrombin (n = 16), coils (n = 7), gelfoam (n = 6), or glue (n = 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P = .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P = .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P = .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. CONCLUSIONS: This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail.

Transapical endovascular aortic repair to treat complex aortic pathologies.

Clinical condition, hostile anatomy, and previous heart/aortic surgery may preclude standard open surgery and standard endovascular interventions in patients with complex aortic pathologies. We report our initial experience using the transapical endovascular approach to treat a type IA endoleak after transfemoral endovascular graft repair for a contained rupture of a penetrating descending aortic ulcer; an ascending aortic anastomotic pseudoaneurysm after open surgical repair of an ascending aortic dissection; and a type A aortic dissection after minimally invasive mitral valve repair. There were no neurologic or cardiovascular complications, and the 30-day mortality was 0%.