A single-center experience of anterior accessory saphenous vein endothermal ablation demonstrates safety and efficacy.

OBJECTIVE: Endothermal ablation is well-established for the treatment of the great and small saphenous veins. Data are lacking for treatment of the anterior accessory saphenous vein (AASV). The purpose of this study was to evaluate the safety and efficacy of AASV treatment using endothermal ablation. METHODS: This retrospective review included 314 limbs at a single academic institution from 2016 to 2018 using the institutional Vascular Quality Initiative database. All limbs had documented AASV reflux. Baseline characteristics were evaluated including age; sex; ethnicity; clinical, etiology, anatomy, pathophysiology classification; Venous Clinical Severity Score (VCSS); and vein diameter. Outcomes relating to procedure safety and efficacy included treatment modality and length, successful ablation on postoperative imaging, postprocedural clinical outcomes, incidence of endothermal heat-induced thrombosis (EHIT), and any postprocedural complication. RESULTS: A total of 314 consecutive limbs were identified from 2016 to 2018. The preprocedure VCSS scores were available for 312 limbs and averaged 6.13 ± 3.33. A history of varicose veins were reported in all limbs with 49.4% (n = 155) having previously undergone a procedure. The most common presenting symptom was mild edema in 52.5% (n = 165). Vein diameter and assessment of reflux were obtained by venous duplex ultrasound (DUS) examination. The largest AASV diameter was available for 304 limbs, averaging 7.93 ± 2.69 mm. Treatment modalities included radiofrequency ablation (RFA) in 59.2% (n = 186), endovenous laser ablation (EVLA) in 37.9% (n = 119), and isolated microphlebectomy in 2.9% (n = 9). In all, 38.5% (n = 121) of limbs underwent concomitant microphlebectomy at the time of EVLA. The total treatment length was obtained in 297 limbs, averaging 23.0 cm ± 12.0. Postoperatively, 94.6% of limbs (n = 297) were prescribed compression stockings. Postoperative DUS examination was performed in 312 limbs, revealing successful ablation in 96.5% (n = 303) with 2 limbs (0.6%) developing an EHIT, both treated with therapeutic enoxaparin for 1 week. Repeat DUS examination revealed thrombus resolution in one limb; the other patient was lost to follow-up. VCSS scores after the procedure were available for 145 limbs and averaged 4.45 ± 2.31. This was a statistically significant decrease from preprocedure VCSS scores (P < .01). Average duration of follow-up was 2.2 years, with two limbs lost to follow-up. Of the nine limbs (3.5%) whose initial procedure failed, five (56%) were treated using RFA and four (44%) were treated using EVLA. There were no other postoperative complications. CONCLUSIONS: Our experience over a 3-year period for treating the AASV shows it to be safe and effective in a broad range of disease severity with an improvement in VCSS and a low incidence of EHIT. Additionally, RFA and EVLA exhibit similar treatment efficacy. Long-term follow-up data are needed.

Outcomes of translumbar embolization of type II endoleaks following endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Presence of an endoleak can compromise aneurysm exclusion after endovascular abdominal aortic aneurysm repair (EVAR). Type II endoleaks (T2Es) are most common and may cause sac expansion. We report outcomes of translumbar embolization (TLE) of T2Es following EVAR. METHODS: We conducted a retrospective chart review of patients with T2E after EVAR treated with TLE from 2011 to 2018 at a single academic institution. Treatment indications were the presence of persistent T2E and aneurysm growth ≥5 mm. Sac stabilization was defined as growth ≤5 mm throughout the follow-up period. RESULTS: Thirty consecutive patients were identified. The majority were men (n = 24), with a mean age of 74.3 years (95% confidence interval [CI], 70.9-77.6 years). The most common comorbidities were hypertension (83.3%) and coronary artery disease (54.0%). The mean maximal sac diameter at T2E discovery was 5.8 cm (95% CI, 5.4-6.2 cm). The mean time to intervention from endoleak discovery was 33.7 ± 28 months with a mean growth of 0.84 cm (95% CI, 0.48-1.2 cm) during that time period. The mean follow-up time after TLE was 19.1 months (95% CI, 11.1-27.2 months). Twenty-eight patients were treated with cyanoacrylate glue (CyG) alone, and two were treated with CyG plus coil embolization (CE). There was immediate complete endoleak resolution as assessed intraoperatively, and sac stabilization in 15 cases (50.0%). Eleven patients (36.7%) had evidence of persistent T2E on initial imaging after the embolization procedure; additional follow-up revealed eventual sac stabilization at a mean of 21.3 ± 7.2 months, and therefore, these patients did not require further intervention. In the remaining four cases (13.3%), there was persistent T2E after the initial TLE, requiring a second intervention. Repeat TLE stabilized growth in three of these four patients after a mean of 17.6 ± 12.9 months. One patient required open sacotomy and ligation of lumbar vessels due to continued persistence of the T2E and continued aneurysm growth. There were no ischemic complications related to the embolization procedures. Factors associated with persistent endoleak after initial embolization were larger aneurysm diameter at the time of initial endoleak identification (P < .001) and the use of antiplatelet agents (P < .02). The use of anticoagulation was not a significant risk factor for endoleak recurrence or aneurysm growth after TLE. CONCLUSIONS: TLE of T2E is a safe and effective treatment option for T2E with aneurysm growth following EVAR. Patients taking antiplatelet medication and those with larger aneurysms at the time of endoleak identification appear to be at increased risk for persistent endoleak and need for subsequent procedures following initial TLE. These patients may require more intensive monitoring and follow-up.

Case Series of Concomitant Klippel-Trenaunay Syndrome and May-Thurner Syndrome.

Klippel-Trenaunay syndrome is a rare vascular disorder which includes leg swelling, or lower extremity deep venous reflux/thrombosis as a presenting symptom. May-Thurner syndrome is also a rare pathology involving compression of the left common iliac vein, usually by the right common iliac artery. The incidence of concomitant occurrence of these entities is unknown and not well reported. This case series describes 3 patients who underwent evaluation of symptomatic left lower extremity venous disease. All 3 suffered symptomatic Klippel-Trenaunay initially, and were subsequently diagnosed with concomitant May-Thurner Syndrome. They were successfully treated with left common iliac vein stents with symptomatic improvement.

Use of Gore C-TAG with active control to treat a complex infrarenal abdominal aortic aneurysm.

Complex abdominal aortic aneurysms (AAAs) can preclude the use of endovascular aortic repair. In patients unable to undergo open surgical repair (OSR), the use of endografts outside the instructions for use might be the only option. We present the case of a woman with a highly angulated infrarenal AAA neck who was unsuitable for OSR and was successfully treated using a Gore C-TAG conformable thoracic stent graft (W.L. Gore and Associates, Inc, Flagstaff, Ariz) with active control, Medtronic Heli-FX EndoAnchors (Medtronic Vascular, Minneapolis, Minn), and a bifurcated Gore Excluder endoprosthesis W.L. Gore and Associates). The repair was successful without evidence of an endoleak. Using a thoracic endograft outside of the instructions for use to treat infrarenal AAAs might be feasible for patients unable to undergo OSR.

Lower extremity compartment syndrome after elective percutaneous fenestrated endovascular repair of an abdominal aortic aneurysm.

Ischemic complications after fenestrated endovascular aortic aneurysm repair (FEVAR) can result in significant morbidity and mortality. We present a case of a 65-year-old man who underwent a FEVAR complicated by bilateral lower extremity compartment syndrome requiring four-compartment fasciotomies. This ischemic complication was likely caused by sheath occlusion because the patient had no evidence of arterial injury or distal plaque embolization. This case highlights the importance of careful postoperative monitoring after FEVAR, because the larger sheaths required can be occlusive and result in lower extremity ischemia, even for relatively short cases.