Thrombus Extension after Great Saphenous Vein Mechanochemical Ablation.

BACKGROUND: The objective of this study is to examine factors associated with thrombus extension after early experience with mechanochemical ablation, which combines mechanical damage to the venous endothelium with infusion of a sclerosant. METHODS: A retrospective review was performed of patients who underwent mechanochemical ablation to treat saphenous vein insufficiency in the thigh including the saphenofemoral junction. Data abstracted included patient demographics, procedural details, and postprocedural outcomes. Thrombus extension was determined by postprocedural duplex ultrasound and classified as flush closure with the femoral vein and any extension of thrombus into the femoral vein. RESULTS: Seventy-three patients met inclusion criteria. The mean age of the population was 60, 17.8% were female, and the mean body mass index (BMI) was 30.7. Seven (9.6%) patients who underwent mechanochemical ablation experienced saphenous vein closure flush with the femoral vein. Eleven (15%) patients experience extension of thrombus to less than 50% of the diameter of the femoral vein and one patient experienced complete thrombosis of the femoral vein. There was no significant difference in age, sex, or comprehensive classification system for chronic venous disorders between the group with thrombus extension and the group without, with the exception of BMI. The mean BMI in the group with thrombus extension was 26.8 vs. 32 in the group without (P = 0.02). There was no significant difference between the 2 groups in sclerosant volume used, distance between catheter tip and SFJ, and mean diameter of GSV in the thigh. CONCLUSIONS: In this cohort, the incidence of thrombus extension into the femoral vein with mechanochemical ablation was high relative to rates of thrombus extension associated with reported rates of thermal ablation. Further investigation with larger cohorts, and standardized reporting is required to characterize the true rate of thrombus extension after mechanochemical ablation and identify maneuvers which may prevent thrombus extension.

Preoperative Cardiac Stress Testing in the Southern California Vascular Outcomes Improvement Collaborative.

BACKGROUND: The objective of this study was to examine the use of preoperative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe). METHODS: A retrospective review was performed on data in all modules of the So Cal VOICe from September 2012 through May 2016. PCST was defined as stress echocardiogram or nuclear stress test. A new postoperative myocardial infarction (MI) was defined as troponin elevation and/or electrocardiogram/imaging changes with or without ischemic symptoms. Only elective cases in patients with asymptomatic cardiac status were included in the study. RESULTS: During the study period, 3,063 procedures meeting the inclusion criteria were performed in 7 registries: carotid endarterectomy (CEA), carotid artery stent, thoracic endovascular aneurysm repair, infrainguinal bypass (Infra), endovascular aneurysm repair (EVAR), suprainguinal bypass (Supra), and open abdominal aortic aneurysm repair (OAAA). PCST varied across registries from 17% in PVI to 62% in OAAA. PCST in CEA varied across 9 institutions from 10% to 79%. PCST in EVAR varied across 7 institutions from 14% to 83%. PCST in Infra varied across 4 institutions from 10% to 57%. Of the 12 patients across all registries who had a new MI, 6 had PCST, one of which was abnormal. CONCLUSIONS: The incidence of PCST varies widely across registries and institutions in the So Cal VOICe. Despite the wide variation, the incidence of new postoperative MI is exceptionally low. Further studies should evaluate the cost-effectiveness of the PCST practices and future quality improvement efforts should focus on standardization of indications for PCST.

Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative.

BACKGROUND: The objective of this study was to examine the variation in practice patterns and associated outcomes for carotid endarterectomy (CEA) within the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe), a regional quality group of the Vascular Quality Initiative. METHODS: All cases entered in the CEA registry by the So Cal VOICe were included in the study. RESULTS: From September 2010 through September 2015, 1,110 CEA cases were entered by 9 centers in the So Cal VOICe. Six hundred seventy-seven patients (61%) were male with mean age of 73 years. Nine hundred eighty-eight (89%) were hypertensive, 655 (59%) were prior or current smokers, 389 (35%) were diabetics, and 233 (21%) had coronary artery disease. Eight hundred twenty-one (74%) patients were asymptomatic (no history of ipsilateral neurologic event). The percentage of asymptomatic patients varied across the 9 centers from 57% to 91%. Preoperatively, 344 (31%) underwent cardiac stress test, center variation 13-75%, 500 (45%) underwent only duplex, center variation 11-72%. Intraoperatively, 600 (54%) underwent routine shunting, whereas 67 (6%) were shunted for an indication, and 444 (40%) were not shunted. Wound drainage was used in 422 (38%) cases, center variation 2-98%. Completion imaging by duplex and/or angiogram was performed in 766 (69%) cases, center variation 0-100%. Postoperatively, 11 (1%) patients had a new ipsilateral postoperative neurologic event, center variation 0-1.3%, 6 (0.5%) had a postoperative myocardial infarction, center variation 0-1.3%, and 8 (0.7%) required return to operating room for bleeding, center variation 0-1.3%. CONCLUSIONS: Despite wide variation in practice patterns surrounding CEA in the So Cal VOICe, postoperative complications were uniformly low. Further work will focus on identifying practices that can be modified to improve cost-effectiveness while maintaining excellent outcomes.