Update on venous procedures performed in the office setting.

Treatment for chronic venous disease has evolved from hospital-based surgical procedures to minimally invasive office-based office procedures that provide shorter recovery periods, less postprocedural discomfort, and quicker return to normal activities. A specialty venous clinic, separate from the arterial practice, with a specialized professional health care team, provides a comfortable setting in which patients can have access to the most up-to-date treatment options. Sclerotherapy treatment for telangectasias, reticular veins, tributary varicosities, insufficient truncal veins, and incompetent perforating veins is a common therapy that is well suited for the office setting. Most office-based minimally invasive venous procedures require little or no sedation. Tumescent anesthesia is safe and effective for ambulatory phlebectomy and endovenous ablation procedures. A calm, inviting atmosphere, confident and professional health care team, and prompt access to care will improve patient satisfaction and result in a successful, growing venous practice.

Diagnosis and management of venous ulcers.

Venous ulceration of the lower extremities is a common and often disabling condition. Venous ulcers are the result of a chronic inflammatory condition caused by persistent venous hypertension. Therapy is directed at counteracting the chronic inflammation in the tissues and at decreasing ambulatory venous hypertension in the area. Compression therapy helps decrease the venous hypertension and aids healing. Topical agents may be used to help decrease the bacterial load in the wound, provide a moist healing environment for dry wounds, or absorb the exudate in wounds with a lot of drainage. Pharmacological adjuncts, such as pentoxifylline or flavanoids, may help counteract the chronic inflammation in the ulcerated area. Interventions to decrease the ambulatory venous hypertension can help patients with either active or healed ulcers. Ablation of incompetent superficial truncal veins and/or perforating veins using radiofrequency ablation, endovenous laser ablation, or foam sclerotherapy can speed ulcer healing and prevent recurrence.

Endovascular aortic repair or minimal incision aortic surgery: Which procedure to choose for treatment of high-risk aneurysms?

BACKGROUND: This study evaluates use of endovascular aortic repair (EVAR) and minimal incision aortic surgery (MIAS) for treatment of high-risk patients with infrarenal aneurysms. METHODS: A retrospective review of patients treated with EVAR or MIAS between 2000 and 2002 was performed. High-risk criteria included age older than 80 years, creatinine level greater than 3.0 mg/dL, recent myocardial infarction, congestive heart failure, severe chronic obstructive pulmonary disease, hostile abdomen, or morbid obesity (body mass index greater than 30). Patient demographics, duration of stay, morbidity, and mortality were compared. Exclusionary criteria for EVAR treatment included neck less than 1.5 cm or greater than 26 mm in diameter, densely calcified iliac arteries less than 6 mm, or creatinine level greater than 3.0 mg/dL. Exclusionary criteria for MIAS included pararenal abdominal aortic aneurysm, aneurysm greater than 10 cm, and morbid obesity. RESULTS: Eighty-four patients were treated (61 EVAR, 23 MIAS). Average age for EVAR was 74 years and 72 years for MIAS. Average aneurysm size was 6 cm for both. American Society of Anesthesiologists score was 3.1 for EVAR and 3.0 for MIAS patients. Thirty-two of 61 EVAR patients (52%) had 2 risk factors, and 12 of 61 (20%) had 3 risk factors. Seven of 23 MIAS patients (30%) had 2 risk factors, and 7 had more than 3 risk factors (30%). There were 2 EVAR deaths (3%) from multiorgan failure and 1 MIAS death (4%) from myocardial infarction. Average duration of stay was 5.1 days for both EVAR and MIAS. Thirty-day morbidity was 18% for EVAR and 17% for MIAS patients. CONCLUSIONS: EVAR and MIAS are comparable for the treatment of high-risk aneurysm patients.

Current management of varicose veins.

Problematic varicose veins are estimated to occur in up to 30 million Americans and may be symptomatic and/or unsightly. The majority of symptomatic varicose veins occur in the lower extremities and can result in significant circulatory disease. This problem is more common in women as a result of pregnancy and child bearing. Cosmetic treatment for varicosities is best achieved with a variety of sclerosing procedures.

Minimal incision aortic surgery (MIAS).

This study evaluates the clinical and economic impact of using less extensive minimal invasive aortic surgery (MIAS) for elective treatment of infrarenal aortic aneurysms (AAA) and aortoiliac occlusive disease (AIOD) in two independent surgical departments. Surgeons from two institutions conducted a prospective consecutive, nonrandomized analysis of MIAS electively performed in 80 patients. MIAS outcomes were compared with 80 consecutive elective standard open aortic procedures (40 from each institution), which were performed during the same time period. Cost analyses for MIAS and standard open repair were performed at each institution. Our results indicated that MIAS is as safe as standard open repair, is more cost-effective, and has significantly shorter hospital stays than with standard open repair.

Is coil embolization of hypogastric artery necessary during endovascular treatment of aortoiliac aneurysms?

The aim of this study was to evaluate the safety and efficacy of stent graft coverage of hypogastric artery in the management of aortoiliac aneurysms. Between January 2000 and December 2002, 98 patients underwent endovascular repair of aortoiliac aneurysms (EVAR). Of these, 24 (24.5%) required occlusion of one hypogastric artery to facilitate the endovascular repair. Based on the method of hypogastric artery occlusion, patients were divided in to two groups. Group A (13/24 = 54%) underwent standard coil embolization followed by hypogastric artery orifice coverage whereas group B (11/24 = 46) underwent hypogastric artery orifice coverage without coil embolization. Post-EVAR computed tomographic angiography (CTA) was used to determine occurrence of endoleaks from the hypogastric artery orifice and patency of superior gluteal artery in both groups. These findings were further correlated with presence or absence of gluteal claudication. There was no difference in age (p < 0.38) or iliac aneurysm size (p < 0.3). In group A (13 patients), occlusion of superior gluteal artery was seen in 6 (46%). Four of six (66%) patients developed severe gluteal claudication. Patients in group A were likely to require more than one intervention (p < 0.00036). No patients in group B developed occlusion of the superior gluteal artery (p < 0.04) or gluteal claudication (p < 0.046). No endoleaks were seen from the origins of hypogastric artery in either group. The follow-up period ranged from 2 to 35 months. Hypogastric artery orifice coverage without coil embolization effectively prevented retrograde endoleak without the occurrence of disabling gluteal claudication. Coil embolization of the hypogastric artery may be unnecessary during treatment of aortoiliac aneurysm.