Urological complications caused by inferior vena cava filters: a systematic review

INTRODUCTION

Inferior vena cava (IVC) filters act in preventing pulmonary embolisms (PE). Various complications have been reported with their use. However, a credible urological complication rate, filter characteristics, and clinical presentation has yet to be summarized. Thus, we reported these complications in the form of a systematic review.

EVIDENCE ACQUISITION

A search strategy was designed using PubMed, MEDLINE, and EMBASE on February 10th, 2022. The design of this search strategy did not include any language restrictions. The key words (and wildcard terms) used in the search strategy were urolog*, ureter*, bladder, kidney coupled with filter, inferior vena cava, and cava*. Inclusion criteria were: patients older than 18, with previous IVC filter placement, and urologic complication reported. Exclusion criteria were: patients younger than 18, no IVC filter placement, and no urologic complication reported. Other case series and reviews were excluded to avoid patient duplication.

EVIDENCE SYNTHESIS

Thirty-five articles were selected for full-text screening. Thirty-seven patient cases were reviewed, and the median age was 53 (range: 21-92 years old). Abdominal and or flank pain was reported in 16 (43%) patients, hematuria was seen in eight (22%) and two (5%) patients died due to acute renal failure resulting from the urologic complications of the IVC filter. Indications for IVC filter placement were recurrent pulmonary embolism (PE), contraindication to or noncompliance with anticoagulant therapy. The IVC filters were infrarenal in 29 (78.4%) patients, suprarenal in five (13.5%) patients, not reported in two patients, and misplaced into the right ovarian vein in one patient. Three or more imaging modalities were obtained in 19 patients (51%) for planning. IVC filter removal was not performed in 17 (45.9%) patients, endovascular retrieval occurred in nine (24.3%) patients, and open removal was performed in seven (18.9%) patients, and tissue interposition was performed in two (5.4%) patients. One patient did not have the management reported.

CONCLUSIONS

Urological complications caused by IVC filters although rare, are likely underreported, require extensive workup, and pose surgical challenges. Due to their complex management, filter retrieval should be planned for as soon as feasible, and plans should be made as early as during the IVC filter implant. For those that do develop complications, clinical judgement must be exercised in management, and open surgical, endovascular or even conservative management strategies can be viable options and should be discussed in a multidisciplinary setting.

The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs).

METHODS

A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS).

RESULTS

Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF.

CONCLUSIONS

Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.

Impact of COVID-19 on patients undergoing scheduled procedures for chronic venous disease

OBJECTIVE

The COVID-19 pandemic has drastically altered the medical landscape. Various strategies have been employed to preserve hospital beds, personal protective equipment, and other resources to accommodate the surges of COVID-19 positive patients, hospital overcapacities, and staffing shortages. This has had a dramatic effect on vascular surgical practice. The objective of this study is to analyze the impact of the COVID-19 pandemic on surgical delays and adverse outcomes for patients with chronic venous disease scheduled to undergo elective operations.

METHODS

The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March 2020 to evaluate the outcomes of patients with vascular disease whose operations were delayed. Modules were developed by vascular surgeon working groups and tested before implementation. A data analysis of outcomes of patients with chronic venous disease whose surgeries were postponed during the COVID-19 pandemic from March 2020 through February 2021 was performed for this study.

RESULTS

A total of 150 patients from 12 institutions in the United States were included in the study. Indications for venous intervention were: 85.3% varicose veins, 10.7% varicose veins with venous ulceration, and 4.0% lipodermatosclerosis. One hundred two surgeries had successfully been completed at the time of data entry. The average length of the delay was 91 days, with a median of 78 days. Delays for venous ulceration procedures ranged from 38 to 208 days. No patients required an emergent intervention due to their venous disease, and no patients experienced major adverse events following their delayed surgeries.

CONCLUSIONS

Interventions may be safely delayed for patients with venous disease requiring elective surgical intervention during the COVID-19 pandemic. This finding supports the American College of Surgeons' recommendations for the management of elective vascular surgical procedures. Office-based labs may be safe locations for continued treatment when resources are limited. Although the interventions can be safely postponed, the negative impact on quality of life warrants further investigation.

Vacuum-assisted closure therapy for the management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Vacuum-assisted closure (VAC) therapy has become a popular treatment option for wound healing. The aim of this meta-analysis was to assess the use of VAC therapy as a bridge before the definitive treatment for the management of deep sternal wound complications.

METHODS

A systematic literature review and meta-analysis were performed in PubMed and Embase. Outcomes of interest included mortality, treatment failure, length of hospital stay (LOS), length of intensive care unit (ICU) stay and cost of treatment.

RESULTS

Twenty-two studies involving 1980 patients were included in the quantitative synthesis of this meta-analysis. Patients treated with VAC had significantly lower overall mortality [1738 patients; Risk ratio [RR] = 0.36 (95% confidence interval [CI]: 0.25, 0.51)], treatment failure [1210 patients; RR = 0.26 (95% CI: 0.19, 0.37)], LOS [498 patients; (standard mean difference = -0.44 (95% CI: -0.81, -0.07)] and ICU stay [309 patients; (standard mean difference = -0.34 (95% CI: -0.67, -0.01)] compared to that of non-VAC patients. VAC therapy was associated with reduced cost of treatment per patient compared with that of non-VAC therapies (reductions of 3600 USD, 6000 USD and 8983 USD in the reported studies).

CONCLUSIONS

VAC therapy as an adjunct in the definitive treatment of patients with deep sternal wound complications was associated with lower mortality, treatment failure, LOS, ICU stay and cost of treatment when compared with a non-VAC approach. Randomised controlled trials would be essential to confirm these findings.

Morbidity and Long-Term Patient-Reported Outcomes Following Advanced Carotid Body Tumor Resection

BACKGROUND

The reported risk of a cranial nerve (CN) injury is up to 1 in 4 patients in large registries of carotid body tumor (CBT) resection. Functional outcome for this population is unknown.

METHODS

We evaluated consecutive patients who underwent CBT resection from November 2013 through October 2020. Demographics, intraoperative details, complications, and outcomes were recorded from the medical record. Permanent CN nerve injury was defined as deficits lasting >6 months. Frequency statistics, averages, chi-squared test, and multiple logistic regression were completed for primary end points of complications and disease-free survival. Patient-reported outcomes were gathered via telephone survey of patients conducted in September 2021.

RESULTS

Fifty-one patients presented with CBTs and the following Shamblin classes: I (n = 7; 14%), II (n = 36; 69%), and III (n = 9; 17%). Head and neck oncology and vascular surgery jointly did 52% of CBT resections, including 6 of 9 Shamblin III cases. Eight patients (15.3%, all Shamblin II or III) suffered a total of 12 CN injuries - 8 CN XII (5 temporary and 3 permanent), 3 CN X (all permanent), and 1 CN XI (permanent). Seven of the CN injury subgroup had preoperative embolization and 5 were joint oncology/vascular cases. In addition, 4 separate carotid injuries required repair. Notably, all patients had disease-free survival postoperatively at a mean follow-up of 6 months. Patient-reported outcomes obtained in 70.6% of patients 1 year or more from index operation demonstrated that two-thirds of patients live without any permanent functional deficits, and the majority of those with continued deficits rate the symptoms as daily but mild in severity.

CONCLUSIONS

In a series of complex CBT patients treated with preoperative embolization capabilities and multidisciplinary surgical approach, disease-free survival was achieved in all patients despite a high rate of iatrogenic CN injuries, most commonly CN XII. Patient-reported outcomes survey results indicate that injuries identified on clinical exam underreport patients' true postoperative CN deficits - especially branches of CN X. This data support the practice of aggressive primary resection of CBTs while providing guidance for expected functional outcomes due to CN injury risk.

Endovascular experience at an academic office-based procedure center

OBJECTIVE

The number of office-based procedure centers with the capability of performing a wide range of endovascular procedures has substantially increased over the past decade. This shift in practice settings has occurred faster in the private sector as compared to the academic environment. The purpose of our study was to evaluate the clinical outcomes of endovascular procedures performed at a dedicated academic outpatient procedural center.

METHODS

We reviewed the clinical data of 400 patients who underwent 499 endovascular procedures in a university-based, academic outpatient procedure center between November 2013 and December 2016. Outcomes analyzed included procedure-related complications, limb loss, mortality, and emergency department visits or hospital admissions that occurred within 30 days following the procedure.

RESULTS

The 400 patients had a mean age of 65 ± 13 years with slightly more females (51%; n = 203) as compared to males (49%; n = 197). Most patients (71%; 284) were Caucasian while 80 (20%) were African-Americans. Associated comorbidities included hypertension (86%), diabetes mellitus (51%), chronic kidney disease (42%), and obesity (mean body mass index of 29 ± 6). Based on anesthetic risk, most were ASA class 3 (81%), while ASA 1 and 2 comprised 17% and ASA 4 only 2%. Medicare beneficiaries accounted for 254 (64%) of our patients. Pre-operative studies included mainly duplex ultrasound (62%) and other noninvasive arterial studies (57%).The mean procedural time was 58 min (range, 7 to 200) with an overall technical success rate of 97%. There were no deaths. Complications developed in 10 patients following the 483 procedures (2.1%) being hospitalized with four of them transferred directly to the emergency room. The reasons for these hospitalizations included acute limb ischemia, arterial pseudoaneurysm, deep vein thrombosis, congestive heart failure, myocardial infarction, and lower extremity pain not vascular in origin. Financial reimbursement at the office-based center was higher than that seen with hospital-based procedures.

CONCLUSIONS

Endovascular procedures performed in an academic office-based procedure center are safe and associated with good clinical outcomes. A small minority of patients have subsequent ER visits or hospital admissions. Academic institutions should consider adding an office-based procedure center based on today's competitive healthcare market.

Atherectomy to treat femoropopliteal atherosclerotic disease

Atherectomy as an endovascular modality to treat peripheral arterial disease has gained traction over the past 10 years. Unlike most other available technologies, atherectomy works by physically debulking atherosclerotic plaque via a variety of mechanisms being the femoropopliteal segment the most targeted one. The aims of this review were to detail the types of atherectomy available, existing evidence available for atherectomy use in the femoropopliteal segment as compared to other interventions, critical appraisal of its current use and the possible influences on its indication. Future steps regarding atherectomy usage and data presentation are also described.

Nutcracker phenomenon secondary to superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome, compression of the duodenum due to a decreased angle between the aorta and SMA, has a wide range of clinical presentations making it difficult to diagnose. Compression of the left renal vein is known as Nutcracker syndrome. We present the case of a 26-year-old male with a delayed diagnosis of SMA syndrome and Nutcracker phenomenon due to the patient's history of chronic pancreatitis. As a result of his obstruction and aspiration pneumonia, he was diagnosed with septic shock. The patient was treated for septic shock and maintained on an enteric diet with improvement in the body mass index and complete resolution of SMA syndrome symptoms.

Embolic protection devices for carotid artery stenting: A network meta-analysis

OBJECTIVES

Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications.

METHODS

A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups.

CONCLUSIONS

PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment

BACKGROUND

Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology.

METHODS

In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved.

RESULTS

The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment.

CONCLUSION

This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.

Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair

BACKGROUND

Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair.

METHODS

All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits.

RESULTS

Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9 years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68 days in the endovascular and 107 ± 79 days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22 months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28 days) and 7 days (ranging, 3-18 days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30 days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found.

CONCLUSIONS

Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.

A Systematic Review and Meta-analysis on the Efficacy and Safety of Direct Oral Anticoagulants in Patients with Peripheral Artery Disease

BACKGROUND-OBJECTIVE

PAD is a significant cause of morbidity and mortality affecting over 200 million people worldwide. Current guidelines recommend at least a single antiplatelet or anticoagulant agent in symptomatic PAD and lifelong antithrombotic treatment after a revascularization procedure. The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of direct oral anticoagulants (DOACs) in patients with peripheral artery disease (PAD). PAD is a significant cause of morbidity and mortality affecting over 200 million people worldwide.

METHODS

The present systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Risk ratios (RR) were calculated using the random effects model.

RESULTS

Overall, ten studies were included in this systematic review and meta-analysis. In four studies, 14,257 patients with PAD were enrolled and they were assigned to receive either aspirin (ASA)+/- clopidogrel (N=5,894) or DOAC+/- anti-platelet (e.g., ASA, clopidogrel) (N=8,363). Non DOAC users were found to have higher reintervention rates (RR 1.12; 95% CI 1.01-1.24; p=0.025) compared to DOAC users. No statistically significant difference was observed between the two groups, in terms of major bleeding (RR 0.78; 95% CI 0.50-1.23; p=0.285), all-cause mortality (RR 0.98; 95% CI: 0.83-1.16; p=0.818) and cardiovascular mortality (RR: 0.99; 95% CI: 0.73-1.333; p=0.946) mortality. In addition, two real-world studies comparing DOAC with warfarin showed decreased rates of major cardiovascular events in the DOAC group.

CONCLUSIONS

DOAC use alone or combined with an anti-platelet agent could be associated with lower re-intervention rates, without increasing the risk for adverse bleeding events. However, this study failed to detect any difference in terms of all-cause mortality, MACEs and MALEs between DOAC users and DOAC naïve patients. Future studies are needed to better determine the efficacy and safety of DOACs in patients with PAD.

Trends of core versus subspecialty operative procedures completed in general surgery residency training programs

INTRODUCTION

General surgery residency involves performing subspecialty procedures in addition to the core general procedures. However, the proportion of core general surgery versus subspecialty procedures during training is variable and its temporal changes are unknown. The goal of our study was to assess the current trends in core general surgery and subspecialty procedure distributions during general surgery residency training.

METHODS

Data were collected from the ACGME core general surgery national resident available report case logs from 2007 to 2019. Descriptive and time series analyses were used to compare proportions of average procedures performed per resident in the core general surgery category versus the subspecialty category. F-tests were conducted to show whether the slopes of the trend lines were significantly non-zero.

RESULTS

The mean of total procedures completed for major credit by the average general surgery resident increased from 910.1 (SD=30.31) in 2007 to 1070.5 (SD=37.59) in 2019. Over that same period, the number of general, cardiothoracic, plastic and urology surgery procedures increased by 24.9%, 9.8%, 76.6% and 19.3%, respectively. Conversely, vascular and paediatric surgery procedures decreased by 7.6% and 30.7%, respectively. The neurological surgery procedures remain stable at 1.1 procedures per resident per year. A significant positive correlation in the trend reflecting total (p<0.0001), general (p<0.0001) and plastic (p<0.0016) surgery procedures and the negative correlation in the trend lines for vascular (p<0.0006) and paediatric (p<0.0001) surgery procedures were also noted.

CONCLUSIONS

Trends in overall surgical case volume performed by general surgery residents over the last 12 years have shown a steady increase in operative training opportunity despite the increasing number of subspecialty training programmes and fellowships. Further research to identify areas for improvement and to study the diversity of operative procedures, and their outcomes is warranted in the years to come.

Critical Appraisal of the Contemporary Use of Atherectomy to Treat Femoral-Popliteal Atherosclerotic Disease

OBJECTIVE

Atherectomy has become increasingly used as an endovascular treatment of lower extremity atherosclerotic disease in the United States. Concerns and controversies about its indication and outcomes exist. The goal of this systematic review and meta-analysis was to investigate the outcomes and complications related to atherectomy to treat femoropopliteal atherosclerotic disease.

METHODS

A systematic review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was performed. Four major scientific repositories, MEDLINE, EMBASE, The Cochrane Library, and Thompson Web of Sciences were queried from their inception to April 5, 2020. Data was reviewed and entered in a dedicated dataset by the investigators. Outcomes included patency rates, clinical and hemodynamic improvement, and morbidity and mortality associated with atherectomy interventions.

RESULTS

Twenty-four studies encompassing 1900 patients met inclusion criteria for this study. 74.3% of patients presented with Rutherford class (RC) 1-3 and 25.7% presented with RC class 4-6. 1445 patients underwent atherectomy, and 455 patients were treated without atherectomy. Atherectomy patients underwent directional atherectomy (DA, n = 851), rotational atherectomy (RA, n = 851), laser atherectomy (LA, n = 201), and orbital atherectomy (OA, n = 78). The majority of patients additionally received adjunct treatments which were variable across studies and included a combination of stenting, balloon angioplasty (BA), or drug coated balloon (DCB) angioplasty. Technical success was achieved in 92.3% of cases. Distal embolization, vessel perforation, and dissection occurred in 3.4%, 1.9%, and 4% of cases respectively. Initial patency was 95.4% and at 12-month median follow up primary patency was 72.6%. ABI improved from pre-operative mean of 0.6 to post-operative mean of 0.84. Incidence of major amputation and mortality over the follow up period was 2.2% and 3.4% respectively.

CONCLUSIONS

This review of the published data suggests that femoropopliteal atherectomy can be completed safely while modestly improving ABIs and maintaining one-year patency in nearly three out of four patients; however, this is based on heterogeneous studies that skew generalizable conclusions about atherectomy's efficacy. Atherectomy places a high cost burden on the healthcare system and is utilized in the United States at a higher rate than in other countries. Our review of the literature does not demonstrate clear atherectomy superiority to alternatives that would warrant pervasive and increasing use of this costly technology. Future work should focus on developing high quality randomized controlled trials to determine specific patient and lesion characteristics in which atherectomy can add value.

Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis

PURPOSE

The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies.

MATERIALS AND METHODS

A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality.

RESULTS

Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004).

CONCLUSION

Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.

A systematic review and meta-analysis of outcomes after acute limb ischemia in patients with cancer

BACKGROUND

Cancer results in a hypercoagulable state that is associated with both venous and arterial thromboses. However, little is known about the effects of acute limb ischemia (ALI) in this cohort of patients. In the present systematic review and meta-analysis, we analyzed the available clinical data on cancer and its association with ALI and evaluated the outcomes in these patients after a diagnosis of ALI.

METHODS

Three databases, including PubMed, EMBASE, and the Cochrane Library, were queried. Studies that met the inclusion criteria were included regardless of the publication year, language, sample size, or follow-up length. All the steps of the meta-analysis were conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) and MOOSE (meta-analysis of observational studies in epidemiology) guidelines.

RESULTS

Seven studies from 6222 references with a total of 2899 patients were included. Of the 2899 patients, 1195 (41%) had had a diagnosis of ALI before their cancer diagnosis, and 1704 (59%) had presented with ALI after a cancer diagnosis. Nearly three quarters of ALI events were among patients with cancer of the skin and soft tissue (19%), genitourinary (18%), lung (17%), and gastrointestinal (16%) systems. ALI recurrence was similar between the two groups, and major amputation was more likely in patients with a diagnosis of ALI after a cancer diagnosis (7.4% vs 4.6%; P < .01). The incidence of mortality at 1 year was significantly greater for patients with established cancer who had presented with ALI compared with the patients who had presented with ALI before a cancer diagnosis (50.6% vs 29.9%; P < .01). After adjusting for study variability using the random effects model, the mortality at 1 year for all patients was 52.3% (95% confidence interval, 37.7%-66.5%). No significant heterogeneity (P = .73) was found between the two groups of patients, which varied by the timing of the ALI diagnosis in relation to the cancer diagnosis.

CONCLUSIONS

The 1-year mortality after the development of ALI in patients with cancer was >50%. For patients presenting with ALI of unclear etiology, the presence of an underlying cancer should be considered.

Feasibility and acceptability of virtual mock oral examinations for senior vascular surgery trainees and implications for the certifying exam

Objectives

The COVID-19 pandemic resulted in the cancellation of in-person testing across the country. We sought to understand the feasibility of conducting virtual oral examinations as well as solicit opinions of vascular surgery program directors (PD) regarding the use of virtual platforms to conduct both low stakes mock oral examinations with their trainees and potentially “real” high stakes certifying examinations (CE) moving forward.

Methods

Forty-four senior vascular surgery trainees from 17 institutions took part in a virtual mock oral examination conducted by 38 practicing vascular surgeons via Zoom. Each examination lasted 30 minutes with four clinical scenarios. An anonymous survey pertaining to the conduct of the examination and opinions on feasibility of using virtual examinations for the vascular surgery CE was sent to all examiners and examinees. A similar survey was sent to all vascular surgery program directors.

Results

The overall pass rate was 82% (36/44 participants) with no correlation with training paradigm. 32/44 (73%) of trainees, 29/38 (76%) of examiners and 49/103 (48%) of PDs completed the surveys. Examinees and examiners thought the experience was beneficial and PDs also thought the experience would be beneficial for their trainees. While the majority of trainees and examiners believed they were able to communicate and express (or evaluate) knowledge and confidence as easily virtually as in person, PDs were less likely to agree confidence could be assessed virtually. The majority of respondents thought the CE of the Vascular Surgery Board of the American Board of Surgery could be offered virtually, although no groups thought virtual exams were superior to in person exams. While cost benefit was perceived in virtual examinations, the security of the examination was a concern.

Conclusions

Performing virtual mock oral examinations for vascular surgery trainees is feasible. Both vascular surgery trainees as well as PDs feel that virtual CEs should be considered by the Vascular Surgery Board.

A network meta-analysis of direct factor Xa inhibitors for the treatment of cancer-associated venous thromboembolism

INTRODUCTION

Treatment of cancer-associated venous thromboembolism (CAVTE) remains challenging. The aim of this study was to assess the outcomes of direct acting oral anticoagulants (DOAs) for the treatment of CAVTE.

MATERIALS AND METHODS

A network meta-analysis of randomized clinical trials comparing DOAs (Apixaban, Rivaroxaban, and Edoxaban) versus Dalteparin for the treatment of CAVTE was performed. Outcomes of interest included, VTE recurrence, all-cause mortality, event-free survival, major bleeding, and clinically relevant non-major bleeding (CRNMB). Analysis was based on a random effects model and Bayesian Markov-chain Monte Carlo method was used for indirect comparisons.

RESULTS

Four RCTs involving 2894 patients were included. Overall certainty of evidence was moderate regarding all outcomes. DOAs exhibited lower risk of VTE (RR 0.62; 95% CI 0.44, 0.87; P = 0.007), similar risk of major bleeding (RR 1.33; 95% CI 0.84, 2.11; P = 0.23), and higher risk of CRNMB (RR 1.66, 95% CI 1.08, 2.56; P = 0.02), compared with Dalteparin. Risk of all-cause mortality and event-free survival were similar between groups with RR 0.99 (95% CI 0.84, 1.16) and RR 1.03 (95% CI 0.94, 1.13), respectively. Apixaban ranked first for recurrent VTE (42.4%) and major bleeding (62.3%) and Dalteparin ranked first for CRNMB (54.7%). Rivaroxaban ranked best considering all-cause mortality (58.7%); Apixaban ranked best for event-free survival (83.6%).

CONCLUSIONS

DOAs presented a reduced risk of recurrent VTE with similar risk of major bleeding compared to Dalteparin. However, a higher risk of CRNMB is expected when this cohort of patients are treated with DOAs instead of Dalteparin.

Actions to enhance interactive learning in surgery

Introduction

Many educational institutions and academic organizations provide concise and highly organized educational material for the trainees and training programs, while others do not. The role of interactive technology-enhanced learning in surgical education is not entirely explored and disseminated despite common knowledge of such interactive educational technology. Utilizing such technology in the place of textbooks could replace a peer trainee and a teacher examiner.

Evidence

Maximizing involvement, participation, and interactivity from both surgical trainees and their faculty has been shown to improve the quality and outcomes of surgical education. Given that there is an increasing trend towards shifting from traditional unidirectional teaching to learner-centered interactive teaching. Improving the educational activities setting from the traditional – didactic unidirectional lecture to multi-directional, interactive, engaging, and stimulating activity can enhance learners' educational outcomes. With the advent of educational technology, interactive and shared learning became more feasible and creative. Various educational technology platforms, instructional designs, and tools serve different educational purposes guided by educational activity's objective. Educational systems have integrated numerous widely technologies such as smartphones, tablets, and cloud-based services that greatly facilitate instructional strategies and teaching methods. Many institutions and programs have embraced the new technologies to enhance the overall learning process. Educational technology offers new concepts and applications in learning beyond faster communication or storage of digital resources. Furthermore, active and interactive learning in surgical education has been found to carry a strong and implied impact depending on how it is structured. To enhance and promote interactive surgical education on a broad scale, the following initiatives will be reviewed; interactive adult learning worldwide, wide sharing of knowledge and skills, and use of educational technology where it is pertinent.

Conclusion

Residents and surgical training programs need assistance with the process of learning amid ongoing technological innovations. This guidance would leverage the training programs' educational efforts toward effective surgery training. Interactive educational learning technology is expected to fulfill this need by promoting knowledge sharing, skills learning to enhance educational outcomes.

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With the widespread use of educational technologies, there is less emphases on interactive learning in surgery.

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Interactive learning in surgical education carries a substantial educational impact depending on how it is structured.

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Initiatives are proposed to enhance interactive surgical education.

The impact of the COVID-19 pandemic on vascular surgery practice in the United States

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to widespread postponement and cancelation of elective surgeries in the United States. We designed and administered a global survey to examine the impact of COVID-19 on vascular surgeons. We describe the impact of the pandemic on the practices of vascular surgeons in the United States.

METHODS

The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons is an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force disseminated April 14 to 24, 2020. This analysis focuses on pattern changes in vascular surgery practices in the United States including the inpatient setting, ambulatory, and vascular laboratory setting. Specific questions regarding occupational exposure to COVID-19, adequacy of personal protective equipment, elective surgical practice, changes in call schedule, and redeployment to nonvascular surgery duties were also included in the survey. Regional variation was assessed. The survey data were collected using REDCap and analyzed using descriptive statistics.

RESULTS

A total of 535 vascular surgeons responded to the survey from 45 states. Most of the respondents were male (73.1%), white (70.7%), practiced in urban settings (81.7%), and in teaching hospitals (66.8%). Almost one-half were in hospitals with more than 400 beds (46.4%). There was no regional variation in the presence of preoperative COVID-19 testing, COVID-19 OR protocols, adherence to national surgical standards, or the availability of personal protective equipment. The overwhelming majority of respondents (91.7%) noted elective surgery cancellation, with the Northeast and Southeast regions having the most case cancellations 94.2% and 95.8%, respectively. The Northeast region reported the highest percentage of operations or procedures on patients with COVID-19, which was either identified at the time of the surgery or later in the hospital course (82.7%). Ambulatory visits were performed via telehealth (81.3%), with 71.1% having restricted hours. More than one-half of office-based laboratories (OBLs) were closed, although there was regional variation with more than 80% in the Midwest being closed. Cases performed in OBLs focused on critical limb ischemia (42.9%) and dialysis access maintenance (39.9%). Call schedules modifications were common, although the number of call days remained the same (45.8%).

CONCLUSIONS

Vascular surgeons in the United States report substantial impact on their practices during the COVID-19 pandemic, and regional variations are demonstrated, particularly in OBL use, intensive care bed availability, and COVID-19 exposure at work.

Global vascular surgeons' experience, stressors, and coping during the coronavirus disease 2019 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges for health care systems globally. We designed and administered a global survey to examine the effects of COVID-19 on vascular surgeons and explore the COVID-19-related stressors faced, coping strategies used, and support structures available.

METHODS

The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons was an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force. The survey analysis evaluated the effects of COVID-19-related stressors on vascular surgeons measured using the Generalized Anxiety Disorder 7-item scale. The 28-item Brief Coping Orientation to Problems Experienced inventory was used to assess the active and avoidant coping strategies. Survey data were collected using REDCap (Research Electronic Data Capture) from April 14, 2020 to April 24, 2020 inclusive. Additional qualitative data were collected using open-ended questions. Univariable and multivariable analyses of the factors associated with the anxiety levels and qualitative analysis were performed.

RESULTS

A total of 1609 survey responses (70.5% male; 82.5% vascular surgeons in practice) from 58 countries (43.4% from United States; 43.4% from Brazil) were eligible for analysis. Some degree of anxiety was reported by 54.5% of the respondents, and 23.3% reported moderate or severe anxiety. Most respondents (∼60%) reported using active coping strategies and the avoidant coping strategy of "self-distraction," and 20% used other avoidant coping strategies. Multivariable analysis identified the following factors as significantly associated with increased self-reported anxiety levels: staying in a separate room at home or staying at the hospital or a hotel after work (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.08-1.79), donning and doffing personal protective equipment (OR, 1.81; 95% CI, 1.41-2.33), worry about potential adverse patient outcomes due to care delay (OR, 1.47; 95% CI, 1.16-1.87), and financial concerns (OR, 1.90; 95% CI, 1.49-2.42). The factors significantly associated with decreased self-reported anxiety levels were hospital support (OR, 0.83; 95% CI, 0.76-0.91) and the use of positive reframing as an active coping strategy (OR, 0.88; 95% CI, 0.81-0.95).

CONCLUSIONS

Vascular surgeons globally have been experiencing multiple COVID-19-related stressors during this devastating crisis. These findings have highlighted the continued need for hospital systems to support their vascular surgeons and the importance of national societies to continue to invest in peer-support programs as paramount to promoting the well-being of vascular surgeons during and after the COVID-19 pandemic.

Sharp Recanalization with the Upstream GoBack Catheter for Chronic Occlusive Ilio-Caval Thrombosis

Recanalization of chronic iliofemoral deep vein thrombosis is indicated to reduce symptoms and improve quality of life. However, recanalization is dependent on the ability to cross chronic obstructions. We present a case of chronically thrombosed inferior vena cava and common iliac veins that failed conventional crossing techniques but were successfully recanalized using the recently approved Upstream GoBack Crossing Catheter.

The Impact of the COVID-19 Pandemic on Vascular Surgery Trainees in the United States

BACKGROUND

The impact of the coronavirus disease 19 (COVID-19) pandemic on health care workers has been substantial. However, the impact on vascular surgery (VS) trainees has not yet been determined. The goals of our study were to gauge the impact of COVID-19 on VS trainees' personal and professional life and to assess stressors, coping, and support structures involved in these trainees' response to the COVID-19 pandemic.

METHODS

This was an anonymous online survey administered in April 12-24, 2020 during the surge phase of the global COVID-19 pandemic. It is a subset analysis of the cross-sectional Society for Vascular Surgery Wellness Committee Pandemic Practice, Anxiety, Coping, and Support Survey. The cohort surveyed was VS trainees, integrated residents and fellows, in the United States of America. Assessment of the personal impact of the pandemic on VS trainees and the coping strategies used by them was based on the validated Generalized Anxiety Disorder 7-item (GAD-7) scale and the validated 28-time Brief Coping Orientation to Problems Experienced inventory.

RESULTS

A total of 145 VS trainees responded to the survey, with a 23% response rate (145/638). Significant changes were made to the clinical responsibilities of VS trainees, with 111 (91%) reporting cancellation of elective procedures, 101 (82%) with call schedule changes, 34 (24%) with duties other than related to VS, and 29 (24%) participation in outpatient care delivery. Over one-third (52/144) reported they had performed a procedure on a patient with confirmed COVID-19; 37 (25.7%) reported they were unaware of the COVID-19 status at the time. The majority continued to work after exposure (29/34, 78%). Major stressors included concerns about professional development, infection risk to family/friends, and impact of care delay on patients. The median score for GAD-7 was 4 (interquartile range 1-8), which corresponds to no or low self-reported anxiety levels. VS trainees employed mostly active coping and rarely avoidant coping mechanisms, and the majority were aware and used social media and online support systems. No significant difference was observed between integrated residents and fellows, or by gender.

CONCLUSIONS

The pandemic has had significant impact on VS trainees. Trainees reported significant changes to clinical responsibilities, exposure to COVID-19, and pandemic-related stressors but demonstrated healthy coping mechanisms with low self-reported anxiety levels. The VS community should maintain awareness of the impact of the pandemic on the professional and personal development of surgeons in training. We recommend adaptive evolution in training to accommodate the changing learning environment for trainees.

Brazilian vascular surgeons experience during the coronavirus (COVID-19) pandemic

Background

The COVID-19 pandemic has made a significant impact on all spheres of society. The objective of this study was to examine the impact of COVID-19 on the practices, finances, and social aspects of Brazilian vascular surgeons’ lives.

Methods

This is a descriptive analysis of the responses from Brazilian vascular surgeons to the cross-sectional anonymous Society for Vascular Surgery Wellness Task Force Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons disseminated 14–24 April 2020. Survey dissemination in Brazil occurred mainly via the Brazilian Society of Angiology and Vascular Surgery (SBACV) and social media. The survey evaluated the impact of the COVID-19 pandemic on vascular surgeons’ lives by assessing COVID-19-related stressors, anxiety using theGeneral Anxiety Disorder (GAD)-7 scale, and coping strategies using the Brief Coping Orientation to Problems Experienced (Brief-COPE) inventory.

Results

A total of 452 responses were recorded from Brazil, with 335 (74%) respondents completing the entire survey. The majority of respondents were males (N = 301, 67%) and practiced in an urban hospitals. The majority of respondents considered themselves at high risk to be infected with COVID-19 (N = 251, 55.8%), and just over half the respondents noted that they had adequate PPE at their primary hospital (N = 171, 54%). One hundred and nine (35%) surgeons confirmed that their hospitals followed professional surgical society guidelines for prioritizing surgeries during the pandemic. At the time of the survey, only 33 (10%) surgeons stated they have pre-operative testing of patients for COVID-19 available at their hospital. Academic vascular surgeons reported being redeployed more often to help with other non-vascular duties compared to community-based or solo practitioners (43% vs. 30% vs. 21% respectively, P = .01). Severe anxiety due to pandemic-related financial concerns was similar in those surgeons practicing solo compared to those in community- or academic-based/group practice (46% vs. 38% vs. 22%; P = .54). The respondents reported their anxiety levels as mild based on the stressors investigated instead of moderate-severe (54% vs. 46%; P = .04). Social media was utilized heavily during the pandemic, with video gatherings being the most commonly used tool (76%). Self-distraction (60%) and situational acceptance (81%) were the most frequently reported coping mechanisms used among Brazilian vascular surgeons.

Conclusion

The COVID pandemic has greatly affected healthcare providers around the world. At the time of this survey, Brazilian vascular surgeons are reporting low anxiety levels during this time and are using mostly active coping mechanisms.

The utilization of intravascular lithotripsy to facilitate transcarotid artery revascularization

Carotid artery disease and stroke account for the second cause of mortality in worldwide. Recently, transcarotid artery stenting (TCAR) has emerged as a treatment modality that carries a very low stroke rate. However, there are limitations to TCAR, such as heavily calcified plaques that might preclude optimal stent expansion. We describe a successful transcarotid artery stenting with flow reversal performed in an independent and active nonagenarian with focal, circumferentially calcified carotid artery plaque, for which intravascular lithotripsy was utilized.

Percutaneous Endovascular Repair of a Ruptured Extent III Thoracoabdominal Aortic Aneurysm with Bilateral Large Common Iliac Aneurysms and Aortocaval Fistula

Ruptured thoracoabdominal aneurysms (rTAAAs) are rare and carry a significant rate of morbidity and mortality. Aortocaval fistula secondary to rTAAA is even more infrequent. We describe an urgent and staged endovascular treatment of a ruptured extent III thoracoabdominal aortic aneurysm with an aortocaval fistula by performing vena cava stenting to treat aortocaval fistula as a damage control maneuver prior to transfer and subsequent TAAA repair with a physician-modified endograft at a quaternary level hospital.

Rescue of proximal failure of endovascular abdominal aortic aneurysm repair with standard and fenestrated grafts

BACKGROUND

This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center.

METHODS

All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively.

RESULTS

Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively.

CONCLUSIONS

Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.

Concomitant Staple Aneurysmorrhaphy and Flow-Calibrated Arteriovenous Fistula Banding Over a Coronary Dilator to Treat Hand Steal Syndrome

BACKGROUND

True venous aneurysm formation can occur in patients with arteriovenous fistulas (AVFs) for hemodialysis but association with steal syndrome is uncommon.

METHODS

To describe a case of a patient on chronic hemodialysis through a right brachiocephalic fistula, who presents with associated steal syndrome and true arteriovenous access aneurysm.

RESULTS

A 34-year-old female with true AVF aneurysm presented with hand steal syndrome confirmed by noninvasive studies. The patient underwent a successful vein aneurysmorrhaphy with a commercially available stapler device and duplex ultrasound flow-calibrated banding. At 1-year follow-up, she remains pain free and the fistula remains functional with no recurrence of venous aneurysmal degeneration.

CONCLUSION

The use of a commercially available surgical stapler devices along with flow-calibrated banding guided by duplex ultrasound over a coronary dilator during the same operation is an elegant, efficacious, and a durable alternative for patients with hand steal syndrome and concomitant AVF aneurysms.

Morbidity and mortality after thermal venous ablations

BACKGROUND

The treatment of saphenous vein reflux has evolved over the years with the development of thermal ablation techniques. This study was designed to analyze the complications of endovenous ablation (EVA) using data from an open, voluntary national database.

METHODS

We analyzed 349 adverse events of endovenous laser (EVLT) and radiofrequency ablation (RFA) reported in the Manufacturer and User Facility Device Experience (MAUDE) database from January 2000 to June 2012. Outcomes of interest were pulmonary embolism (PE), deep vein thrombosis (DVT), death, and device failures (i.e. broken laser tip, broken sheath).

RESULTS

Two hundred and three (58%) reports were patient-related injuries and the other 146 (42%) device-related failures. More complications were related to RFA compared to EVLT (216 vs. 133 procedures). Thirty (8%) non-fatal PEs and 123 (35%) DVTs were described. There were 7 (2%) periprocedural deaths, all from PE. Of the 135 device failure reports, 41(30%) required surgical intervention. Despite an increasing number of procedures, reported events peaked around 2008 and stabilized since then. Over the past 5 years, the incidence of adverse events reported for EVLT and RFA were 1 and 2 per 10,000 procedures. The complication ratio over the years was <1:2500 for DVT, <1:10,000 for PE, <1:50,000 for death.

CONCLUSION

EVA has gained high acceptance worldwide but the risks tend to be overlooked. Despite a very low complication rate, mortality has been reported. The complications found in MAUDE represent only a fraction as the majority of the practitioners are not aware of this database. Further investigation by a large national registry is warranted to better define the real magnitude of EVA complications.

Surgical treatment of varicose veins and venous malformations in Klippel–Trenaunay syndrome

Background

Klippel–Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy.

Methods

The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan–Meier method and Log-rank statistics were used where appropriate.

Results

Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7–55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P < 0.001).

Conclusions

In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome.

Outcomes of blunt thoracic aortic injury in adolescents

BACKGROUND

Blunt traumatic aortic injury (BTAI) is of very rare occurrence in adolescents. The purpose of our study was to assess the clinical presentation and treatment outcomes of BTAI in this subset of patients.

METHODS

We reviewed prospective data of 18 patients who were 20 years or younger with BTAI among 28,000 trauma patients from January 1993 to December 2011. Outcomes of interest were the trends on the type of repair (nonoperative [NOP], open repair [OR], or endovascular treatment [ET]) and the impact of concomitant injuries using the Injury Severity Score (ISS) on early morbidity and mortality.

RESULTS

Thirteen (72%) patients with BTAI were male with a cohort median age of 16 ± 3 years. The mechanism of trauma was car accident in 12 patients, pedestrian struck by car in 5, and motorcycle crash in 1. The total ISS was 46.2 ± 15.3 being the highest score of the thoracic component (4.6 ± 0.6) followed by the head score (4 ± 1.2). Two (11%) patients were pronounced dead in the emergency department and other 2 succumbed within 24 hr from admission. Of those 14 (78%) patients who survived longer than 24 hr, the ISS was significantly lower compared with those pronounced dead earlier (37.8 ± 10.7 vs. 59.6 ± 11.6; P = 0.0009). Ten patients (71%) underwent OR, 3 (17%) ET, and other 2 (28%) patients were treated nonoperatively. The ISS was similar among all 3 treatment groups (OR: 33 ± 8 vs. ET: 53 ± 9 vs. NOP: 51 ± 6; P = nonsignificant). No paraplegia or renal failure was noted in either ET or OR group. In-hospital and overall mortality were 21% and 39%. Of those who survived hospitalization, 8 (73%) patients were discharged home and 3 (27%) to a rehabilitation center.

CONCLUSIONS

The incidence of BTAI is very low in adolescents. Mortality rate is considerable even in young patients and it is associated with high ISS and degree of aortic wall disruption. Young patients with BTAI who survive hospitalization have a lower ISS and are often discharged home rather than to a rehabilitation facility.

Outcomes of endoscopically harvested saphenous vein for lower extremity bypass

OJECTIVES

The purpose of this study was to evaluate the outcomes of endoscopically harvested saphenous vein (EHSV) for lower extremity bypass (LEB) surgery.

METHODS

Data from 91 consecutive patients who underwent LEB using EHSV between February 2003 and November 2012 were analyzed. Outcomes of interest were wound infection, patency, re-intervention and limb loss.

RESULTS

Fifty-eight (64%) and 33 (36%) patients underwent femoropopliteal (FP) and femorotibial (FT) bypass using EHSV. Three (3%) patients had superficial and 1 (1%) deep wound infection. Primary and primary assisted patency at 5 years was 68% and 71% in the FP group and 56% and 65% in the FT group. Six (6%) patients underwent major amputation. No predicting factors for wound infection or graft patency were found.

CONCLUSIONS

EHSV carries a low incidence of perioperative wound complication and has a reasonable mid-to-long-term patency regardless of the length of vein harvested.

The natural history and treatment outcomes of symptomatic ovarian vein thrombosis

BACKGROUND

Information on ovarian vein thrombosis (OVT) is limited to some retrospective studies. The purpose of this prospective study was to evaluate the natural history and treatment outcomes of OVT.

METHODS

Patients with documented symptomatic OVT who were treated with anticoagulation and had at least 3 months of follow-up were included. Outcomes of interest were recanalization rates, pain resolution, pelvic congestion syndrome, recurrent deep venous thrombosis (DVT), and mortality. All patients underwent clinical examination and duplex ultrasound; computed tomography venography was selectively performed.

RESULTS

There were 23 women with a mean age of 44 years (range, 23-68 years). Fifteen (65%) right, 5 (22%) left, and 3 (23%) bilateral OVTs were detected. The median follow-up was 27 months (range, 3 months-7 years). The most common presentation was abdominal pain in nine patients (39%), followed by flank pain in six (26%). Two patients (9%) presented with dyspnea due to pulmonary embolism. The most prevalent condition was the puerperium (n = 9; 39%). Complete recanalization occurred in 16 veins (61%), partial recanalization in four veins (15%), and occlusion in six veins (24%) while patients were receiving anticoagulation. Four patients (17%) had lower extremity DVT during follow-up after the interruption of anticoagulation. Three patients (13%) developed pelvic congestion syndrome. All four deaths (17%) were due to cancer-related complications.

CONCLUSIONS

Symptomatic OVT is rare. Patients fare well with anticoagulation; complete recanalization occurs in about two thirds of the patients. Recurrent DVT is found in lower extremity veins after the interruption of anticoagulation in 17% of patients; mortality was seen only in cancer patients.

Recanalization rates after acute deep vein thrombosis: a single-center experience using a newly proposed vein diameter variation index

BACKGROUND

Duplex ultrasound scanning (DUS) is the method of choice for diagnosis of deep vein thrombosis (DVT). However, only a few studies have performed prospective serial DUS after an acute episode of DVT to assess its evolution. This study aimed to report our experience using DUS combined with a thrombosis score (TS) and a newly proposed vein diameter variation index (VDVI) to evaluate the rate of resolution of DVT by assessing and quantifying the early stages of vein recanalization in proximal vein segments within 6 months after an episode of acute lower extremity DVT.

METHODS

Twelve patients with first episode of acute lower extremity DVT confirmed by DUS as occurring in ≤10 days after the onset of venous thrombosis symptoms were followed up prospectively for 6 months. TS and VDVI were calculated at 1, 3, and 6 months to assess vein recanalization. Intra-thrombus arteriovenous fistula formation was also investigated and related to the recanalization process.

RESULTS

Seven (58%) women were included, with a total cohort median age of 53.5 ± 19 years. The left lower extremity was affected in 7 (58%) patients. DVT was diagnosed in 55 proximal vein segments. All patients had proximal DVT, with involvement of the external iliac, femoral, and popliteal veins. After 6 months, there was a significant decrease in TS and increase in VDVI (P < 0.001) in all proximal vein segments assessed, indicating thrombus regression. The more distal the DVT was, the faster was the VDVI increase, with most popliteal veins being recanalized at 3 months (P < 0.001). Intra-thrombus arteriovenous fistula was identified in 50% of patients at 1 month while on anticoagulation.

CONCLUSIONS

The combined use of two different DUS-based assessment tools, TS and the proposed VDVI, provided an effective method to prospectively assess vein recanalization rates after an episode of acute lower extremity DVT in this series of patients and may allow a correct evaluation of DVT and its resolution or progression.