Systematic review and meta-analysis of management of incompetent perforators in patients with chronic venous insufficiency.

OBJECTIVE: Incompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurements, size, and the CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification. The objective of the present study was to systematically review and synthesize the current literature regarding the surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation, ultrasound-guided sclerotherapy, and radiofrequency ablation. METHODS: English-language literature reported before November 2021 was reviewed from the PubMed, EMBASE, and MEDLINE databases for primary studies reporting safety and efficacy outcomes in the surgical treatment of IPVs. Study quality and risk of bias were assessed using the Cochrane risk of bias tool for comparative studies and a modified version of the Newcastle-Ottawa scale for noncomparative studies. A random effects model was used to pool the effect sizes for efficacy outcomes of wound healing and freedom from wound recurrence. RESULTS: A total of 81 studies were included for qualitative synthesis, representing 7010 patients, with a mean age of 54.7 years. The overall evidence quality was low to intermediate, with a moderate to high risk of bias in the comparative studies. An 11.3% complication rate was found across the interventions, with no reported incidence of stroke or air embolism. Regarding efficacy, the pooled estimates for short-term (≤1 year) wound healing were 99.9% for ultrasound-guided sclerotherapy (95% confidence interval [CI], 0.81%-1%), 72.2% for open ligation (95% CI, 0.04%-0.94%), and 96.0% for SEPS (95% CI, 0.79%-0.99%). For short-term freedom from wound recurrence, the pooled estimate for SEPS was 91.0% (95% CI, 0.3%-0.99%). CONCLUSIONS: The current evidence regarding the treatment of IPVs is limited owing to the low adherence to reporting standards in the observational studies and the lack of randomization, blinding, and allocation concealment in the comparative studies. Additional comparative studies are needed to guide clinical decision-making regarding the invasive treatment options for IPVs.

Preprocedural Cross-Sectional Imaging Prior to Percutaneous Peripheral Arterial Disease Interventions.

Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.

Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition.

IMPORTANCE: Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated. OBJECTIVE: To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center. MAIN OUTCOMES AND MEASURES: Early mortality, perioperative morbidity, discharge disposition, and overall survival. RESULTS: A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively. CONCLUSIONS AND RELEVANCE: Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

Pancreatic endocrine tumors with major vascular abutment, involvement, or encasement and indication for resection.

BACKGROUND: Surgery for pancreatic endocrine tumors (PETs) with blood vessel involvement is controversial. HYPOTHESIS: Resection of PETs with major blood vessel involvement can be beneficial. DESIGN: The combined databases of the National Institutes of Health and Stanford University hospitals were queried. MAIN OUTCOME MEASURES: Operation, pathologic condition, complications, and disease-free and overall survival. RESULTS: Of 273 patients with PETs, 46 (17%) had preoperative computed tomography evidence of major vascular involvement. The mean size for the primary PET was 5.0 cm. The involved major vessel was as follows: portal vein (n = 20), superior mesenteric vein or superior mesenteric artery (n = 16), inferior vena cava (n = 4), splenic vein (n = 4), and heart (n = 2). Forty-two of 46 patients had a PET removed: 12 (27%) primary only, 30 (68%) with lymph nodes, and 18 (41%) with liver metastases. PETs were removed by either enucleation (n = 7) or resection (n = 35). Resections included distal or subtotal pancreatectomy in 23, Whipple in 10, and total in 2. Eighteen patients had concomitant liver resection: 10 wedge resection and 8 anatomic resections. Nine patients had vascular reconstruction: each had reconstruction of the superior mesenteric vein and portal vein, and 1 had concomitant reconstruction of the superior mesenteric artery. There were no deaths, but 12 patients had complications. Eighteen patients (41%) were immediately disease free, and 5 recurred with follow-up, leaving 13 (30%) disease-free long term. The 10-year overall survival was 60%. Functional tumors were associated with a better overall survival (P < .001), and liver metastases decreased overall survival (P < .001). CONCLUSION: These findings suggest that surgical resection of PETs with vascular abutment/invasion and nodal or distant metastases is indicated.