Utilization of and Outcomes Associated with Intravascular Ultrasound during Deep Venous Stent Placement among Medicare Beneficiaries.

PURPOSE: To evaluate temporal trends, practice variation, and associated outcomes with the use of intravascular ultrasound (US) during deep venous stent placement among Medicare beneficiaries. MATERIALS AND METHODS: All lower extremity deep venous stent placement procedures performed between January 1, 2017, and December 31, 2019 among Medicare beneficiaries were included. Temporal trends in intravascular US use were stratified by procedural setting and physician specialty. The primary outcome was a composite of 12-month all-cause mortality, all-cause hospitalization, or repeat target vessel intervention. The secondary outcome was a composite of 12-month stent thrombosis, embolization, or restenosis. RESULTS: Among the 20,984 deep venous interventions performed during the study period, 15,184 (72.4%) utilized intravascular US. Moderate growth in intravascular US use was observed during the study period in all clinical settings. There was a variation in the use of intravascular US among all operators (median, 77.3% of cases; interquartile range, 20.0%-99.2%). In weighted analyses, intravascular US use during deep venous stent placement was associated with a lower risk of both the primary (adjusted hazard ratio, 0.72; 95% confidence interval [CI], 0.69-0.76; P < .001) and secondary (adjusted hazard ratio, 0.32; 95% CI, 0.27-0.39; P < .001) composite end points. CONCLUSIONS: Intravascular US is frequently used during deep venous stent placement among Medicare beneficiaries, with further increase in use from 2017 to 2019. The utilization of intravascular US as part of a procedural strategy was associated with a lower cumulative incidence of adverse outcomes after the procedure, including venous stent thrombosis and embolization.

Triage of patients with venous and lymphatic diseases during the COVID-19 pandemic - The Venous and Lymphatic Triage and Acuity Scale (VELTAS) : A consensus document of the International Union of Phlebology (UIP), Australasian College of Phlebology (ACP), American Vein and Lymphatic Society (AVLS), American Venous Forum (AVF), European College of Phlebology (ECoP), European Venous Forum (EVF), Interventional Radiology Society of Australasia (IRSA), Latin American Venous Forum, Pan-American Society of Phlebology and Lymphology and the Venous Association of India (VAI) This consensus document has been co-published in Phlebology [DOI: 10.1177/0268355520930884] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.05.002]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/).

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program.

BACKGROUND: The benefit for carotid endarterectomy (CEA) to prevent a potential stroke has been shown to be less beneficial for women compared with men and the risk of carotid stenting (CAS) is higher in women than men. We hypothesized that a community-based Washington state registry data would also reveal increased morbidity and mortality for women undergoing carotid interventions. METHODS: Deidentified data for CEA and CAS between 2010 and 2015 were obtained from 19 hospitals participating in the Washington State Vascular-Interventional Surgical Care and Outcomes Assessment Program. Data analysis compared in-hospital composite outcome of stroke and mortality from CEA and CAS between women and men. RESULTS: Over the study period, 3704 individuals underwent CEA (n = 2759; 49.5% symptomatic) and CAS (n = 945; 60.9% symptomatic). Women accounted for 39.5% of the cohort. Women were slightly younger than men (70.0 ± 10.2 vs 71.0 ± 9.6 years respectively; P < .01), less likely to be smokers (70.1% vs 75.6%; P < .01), and less likely to have a diagnosis of coronary artery disease (32.9% vs 46.5%; P < .01). Fewer women underwent CEA for symptomatic carotid disease (46.1% vs 51.8%; P < .01). There were no statistically significant differences in the postoperative in-hospital stroke and mortality among women and men undergoing CEA (asymptomatic, 0.8% vs 1.4% [P = .36]; symptomatic, 1.8% vs 2.2% [P = .58]) and CAS (asymptomatic, 1.4% vs 2.2% [P = .56]; symptomatic, 4.6% vs 2.5% [P = .18]). Hospital duration of stay and discharge disposition were similar for women and men. A subanalysis of the octogenarian cohort undergoing CAS demonstrated a substantial increase in-hospital stroke and mortality among women and men (11.6% [CAS] vs 2.2% [CEA]; P = .024). CONCLUSIONS: In the Washington state Vascular-Interventional Surgical Care and Outcomes Assessment Program registry, hospital composite outcome of stroke and mortality following carotid interventions from 2010 to 2015 were noted to be similar for women and men. The notable exception to this finding was observed in subcohort of women undergoing CAS for symptomatic carotid disease at age 80 years or older. These findings should be taken into account when risk stratifying patients for carotid interventions.

The evidence supporting treatment of reflux and obstruction in chronic venous disease.

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.

Influence of Gender on Abdominal Aortic Aneurysm Repair in the Community.

BACKGROUND: Women have been shown to experience inferior outcomes following intact and ruptured abdominal aortic aneurysm (AAA) treatment in endovascular aneurysm repair (EVAR) and open surgical repair (OSR) groups. The goal of our study was to compare gender-specific presentation, management, and early outcomes after AAA repair using a statewide registry. METHODS: We utilized the Washington State's Vascular Interventional Surgical Care and Outcomes Assessment Program registry data collected in 19 hospitals from July 2010 to September 2013. Demographics, presentation, procedural data, and outcomes in elective and emergent AAA repair groups were analyzed. RESULTS: We identified 1,231 patients (19.6% women) who underwent intact (86.4%) or ruptured AAA (13.6%) repairs. Nine thousand seventy-two (79.0%) patients had EVAR and 259 (21.0%) had OSR. Men and women were of equivalent age and had similar comorbidities, except that women had less coronary artery disease (P < 0.01) and were more likely to suffer from chronic obstructive pulmonary disease (P = 0.05). Women had smaller aneurysm diameters (5.8 ± 1.1 vs. 6.2 ± 1.8 cm, P < 0.01) at the time of presentation and men had slightly higher incidence of rupture at larger aneurysm size. Men were more likely to undergo EVAR, with significant differences in elective (82.1% vs. 74.1%, P = 0.01), but not ruptured repair. Women had significantly higher mortality rates following elective EVAR (3.1% vs. 0.6%, P = 0.01), but not after ruptured or elective open repair. Following elective EVAR, women were less likely to be discharged to home after longer hospital stays (3 vs. 2 days, P < 0.01). CONCLUSIONS: Despite presentation at a similar age, with a smaller aneurysm diameter, and similar medical comorbidities, women experience substantially worse hospital outcomes primarily driven by elective endovascular procedures. Utilization of endovascular techniques in women still remains lower compared with men. Improvement of elective outcomes in women will likely depend on technical advancements in repair techniques and management strategies that may differ between genders.

What is effective care for varicose veins?

Varicose veins affect one-quarter to one-third of Western adult populations and consume an increasing amount of health care resources. Much of this increased utilization has been driven by the advent of minimally invasive technology including endovenous thermal ablation, foam sclerotherapy, and more recently mechanicochemical and cyanoacrylate glue ablation. This has largely been driven by patient and physician preferences in the absence of robust evidence that one therapy is truly superior to another. This partially arises from misunderstandings about appropriate outcomes measures and what truly constitutes effective treatment of varicose veins. Technical outcomes, such as saphenous closure rates, have frequently been used as surrogates for effective treatment but are poorly correlated with symptom improvement, quality of life, and risk of recurrence. Although there does appear to be a trend towards higher recurrence with ultrasound-guided foam sclerotherapy, the data are occasionally conflicting and there does not appear to be substantial differences between the various modalities. Similarly, there do not appear to be major differences in late quality of life measures between these treatment options. As long-term differences in recurrence and quality of life are small, overall cost effectiveness is driven primarily by initial treatment costs and ultrasound-guided foam sclerotherapy is the most cost-effective strategy in many models. However, there continues to be substantial uncertainty surrounding cost estimates and other factors of importance to the patient may ultimately drive treatment decisions. The benefits of some adjuncts to the treatment of axial superficial reflux, such as the concurrent versus staged management of tributary varicosities, remain ill-defined while that of others, such as routine post-procedural ultrasound surveillance and compression, need critical re-evaluation.

Venous ulcer care: which dressings are cost effective?

Healed or open venous ulcers may be present in up to 1% of Western populations and consume a large amount of healthcare resources. These ulcers are characterized by a chronic inflammatory environment with impaired healing and often require months for closure. The average monthly cost of care for an open ulcer has been estimated to be $4095. The fundamental tenets of ulcer care include adequate compression and maintaining a moist wound environment with an appropriate primary dressing. A number of specialized products including semi-occlusive/occlusive, antimicrobial, and advanced wound matrix dressings are now available. However, there is little data from appropriate clinical studies to suggest significantly improved outcomes with any of these dressings. Data regarding their cost-effectiveness is also limited, often conflicting, and subject to bias. At present, there is little solid evidence to guide the choice of primary dressings and a patient-centered approach focusing on characteristics of both the patient and their ulcer, while paying attention to costs, may be most appropriate.

A comparison of Villalta-Prandoni scale and venous clinical severity score in the assessment of post thrombotic syndrome.

BACKGROUND: Post-thrombotic syndrome (PTS) is the most important late complication of acute deep venous thrombosis (DVT), with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Although several instruments are available for evaluation of the severity of PTS, including the Villalta-Prandoni scale (VPS) and Venous Clinical Severity Score (VCSS), no studies have yet compared the 2 instruments. The purpose of this study is to compare the 2 instruments as part of a larger randomized controlled study that assessed the impact of graduated compressive stockings in the prevention of PTS. METHODS: Sixty-nine consecutive patients with acute DVT documented by duplex ultrasonography were randomized to treatment with 30-40 mm Hg graduated compressive stockings (GCS) or no stockings. Patients were followed clinically at months 1, 3, 6, 12, 18, and 24 after the diagnosis of DVT. PTS as defined by the VPS and VCSS were assessed at these follow-up visits. Based upon the VPS, PTS was scored as absent (score <3 or 3 without objective criteria), mild to moderate (score ≥3 with 1 objective criteria), or severe (score ≥4). For the VCSS, PTS was considered to be absent (score ≤3), mild to moderate (score 4-7), or severe (score ≥8). The 2 instruments were compared for mild to moderate and severe disease using the Pearson chi-squared test and gamma statistic. RESULTS: Good correlation was detected in the ability of VPS and VCSS instruments to detect mild to moderate disease (gamma statistic = 0.71-0.98; P < 0.05). For severe disease, a statistically significant correlation was not found in the ability of the 2 instruments to detect disease (gamma statistic = 0.5-0.98; P > 0.05), especially at 12 and 24 months. CONCLUSION: Both VPS and the VCSS scoring systems are important tools in the identification and follow-up of PTS. There exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.

A systematic review of lower extremity arterial revascularization economic analyses.

OBJECTIVE: Economic evaluation remains an understudied aspect of lower extremity vascular reconstructions. This study reviewed the economic-based literature with respect to open and endovascular treatment of peripheral arterial disease. METHODS: This systematic review included economic analyses of open and endovascular treatment of lower extremity peripheral arterial disease, including claudication and critical limb ischemia. Studies were categorized as model-based, cost-consequences, or econometric cost-analyses. Clinical, financial, and time-based outcomes were examined. RESULTS: From a candidate list of 1351 studies, 19 were appropriate for the review, comprising 3 model-based, 12 cost-consequence, and 4 cost-analyses. Because of the small numbers, claudication and critical limb ischemia studies were analyzed together. There was a trend favoring initial cost-savings with endovascular therapy. Whether this benefit is sustained over time is unknown. We were prevented from drawing cost-efficacy inferences because of a noted lack of standardized patient-centric outcomes, longitudinal data, and reintervention data. CONCLUSIONS: The existing lower extremity arterial revascularization economic literature is inadequate for drawing cost-efficacy conclusions and cannot inform guidelines for open vs endovascular treatment. Overcoming this limitation will require the inclusion of cost (initial and reintervention) and patient-centric outcomes in future studies evaluating lower extremity revascularization technologies. All journals, particularly vascular journals, should enforce standard reporting guidelines of effectiveness and economic studies to enable appropriate comparative and cost-effectiveness analyses.

Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad Hoc Outcomes Working Group.

In response to the need for a disease severity measurement, the American Venous Forum committee on outcomes assessment developed the Venous Severity Scoring system in 2000. There are three components of this scoring system, the Venous Disability Score, the Venous Segmental Disease Score, and the Venous Clinical Severity Score (VCSS). The VCSS was developed from elements of the CEAP classification (clinical grade, etiology, anatomy, pathophysiology), which is the worldwide standard for describing the clinical features of chronic venous disease. However, as a descriptive instrument, the CEAP classification responds poorly to change. The VCSS was subsequently developed as an evaluative instrument that would be responsive to changes in disease severity over time and in response to treatment. Based on initial experiences with the VCSS, an international ad hoc working group of the American Venous Forum was charged with updating the instrument. This revision of the VCSS is focused on clarifying ambiguities, updating terminology, and simplifying application. The specific language of proven quality-of-life instruments was used to better address the issues of patients at the lower end of the venous disease spectrum. Periodic review and revision are necessary for generating more universal applicability and for comparing treatment outcomes in a meaningful way.

A survey of physicians' knowledge and management of venous thromboembolism.

A review of all patients diagnosed with venous thromboembolism (VTE) at an academic medical center from 1996 to 1998 revealed a wide variation in management and subsequent patient outcomes and a 30% increase in utilization of the vascular laboratory from the previous 2-year period. The purpose of this study was to determine physicians' knowledge and management strategies before the implementation of integrated care pathways for VTE. Mail surveys were sent to 650 physicians covering 3 academic medical centers. The disciplines targeted were from those physicians who had previously referred patients for any VTE screening examination. One-hundred and twenty-eight physicians (20%) completed the survey. Only 12% of the physicians were able to correctly identify all of the veins routinely imaged as either deep or superficial veins. Fifty-nine percent of the physicians incorrectly identified the superficial femoral vein of the thigh as a superficial vein, and 23% believed the popliteal vein to be a superficial vein. Only 17% of the respondents correctly classified the tibial-peroneal veins as deep veins. Approximately 70% of the physicians stated that they would not treat symptomatic isolated calf vein thrombosis, and, of those, only 42% said that they would obtain serial duplex scans to monitor for proximal propagation. Physicians underestimated the charges for all diagnostic screening tests, and only 14% were able to correctly identify the range of charges for a venous duplex scan. This survey of physicians demonstrated a lack of basic knowledge regarding lower extremity venous anatomy, charges for the different diagnostic tests used to diagnose VTE, and, most importantly, current treatment standards for VTE.