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The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Reduced surgical site infection (SSI) rates have been reported with use of closed incision negative pressure therapy (ciNPT) in high-risk patients.A deep learning-based, risk-based prediction model was developed from a large national database of 72,435 patients who received infrainguinal vascular surgeries involving upper thigh/groin incisions. Patient demographics, histories, laboratory values, and other variables were inputs to the multilayered, adaptive model. The model was then retrospectively applied to a prospectively tracked single hospital data set of 370 similar patients undergoing vascular surgery, with ciNPT or control dressings applied over the closed incision at the surgeon's discretion. Objective predictive risk scores were generated for each patient and used to categorize patients as "high" or "low" predicted risk for SSI.Actual institutional cohort SSI rates were 10/148 (6.8%) and 28/134 (20.9%) for high-risk ciNPT versus control, respectively (P 0.001), and 3/31 (9.7%) and 5/57 (8.8%) for low-risk ciNPT versus control, respectively (P = 0.99). Application of the model to the institutional cohort suggested that 205/370 (55.4%) patients were matched with their appropriate intervention over closed surgical incision (high risk with ciNPT or low risk with control), and 165/370 (44.6%) were inappropriately matched. With the model applied to the cohort, the predicted SSI rate with perfect utilization would be 27/370 (7.3%), versus 12.4% actual rate, with estimated cost savings of $231-$458 per patient.Compared with a subjective practice strategy, an objective risk-based strategy using prediction software may be associated with superior results in optimizing SSI rates and costs after vascular surgery.

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

To compare outcomes after conversion of arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling owing to ipsilateral central vein stenosis.This single-center retrospective study comprised 48 patients (19 men, mean age 58 y) with arm swelling ipsilateral to AV access and central vein stenosis over a 13-year period who had clinical follow-up and without prior central stents. Twenty-one patients underwent placement of a HeRO graft with anastomosis of the HeRO graft to the existing graft or fistula, and 27 patients underwent central venous stent deployment. Symptomatic improvement in arm swelling and access patency rates after intervention were ascertained from medical records.Improvement in swelling within 1 month after HeRO conversion and stent deployment was found in 95% and 89%, respectively (P = .62). Swelling eventually recurred in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P.001). Primary access patency was statistically significantly longer after HeRO conversions than stent deployments, with 6- and 12-month primary patency rates of 89% and 72% vs 47% and 11% (P.001). HeRO conversions also resulted in longer 6- and 12-month secondary access patency rates (95% and 95% vs 79% and 58%, P = .006). Mean number of interventions per 1,000 access days to maintain secondary patency was 2.7 for the HeRO group vs 6.3 for the stent group.Although stent deployment and HeRO graft conversion are effective for alleviating arm swelling in the short term in patients receiving hemodialysis with clinically significant arm swelling and functioning AV access, the HeRO graft has more durable results.

Vascular : : official journal of the International Society for Vascular Surgery, International Society of Vascular Specialists, International Society for Cardiovascular Surgery (2020). doi:10.1177/1708538119890960, Published by Sage, London [u.a.]

Endovascular stenting of the deep venous system is increasingly used to treat stenotic and occluded veins. This article reviews the efficacy and safety of venous stenting for lower extremity occlusive disease.The Ovid portal was used to search the MEDLINE database for English-language randomized controlled trials and case series published between January 1, 2005, and December 31, 2018, involving venous stenting for lower extremity and inferior venacaval occlusive and compressive disease. Studies were eligible for inclusion if they contained at least 30 patients with at least 6 months of follow-up. Clinical outcomes, long-term patency, complications, and postoperative anticoagulation regimens were reviewed. Also included are nationally presented trial results of dedicated venous stents that may not have been formally published yet.Relevant studies were too heterogeneous for a formal meta-analysis to be performed. We analyzed 3812 stented limbs from 23 published studies and two national presentations. Dedicated venous stents were used in 740 patients, and standard stents were used in 3072 patients. The overall major complication rate was 1%. Median symptomatic improvement and ulcer healing were seen in 79% and 71% of the standard stented limbs, respectively. For standard stents, the median primary, assisted primary, and secondary patency rates were 71%, 89%, and 91%, respectively, with a median study follow-up of 23.5 months. Dedicated venous stents had an overall primary patency of 78.8% at 12 months, with lower patency (73%) seen in post-thrombotic vs compressive (96%) disease.Whereas the quality of evidence remains weak, iliocaval venous stenting appears to be a safe and effective treatment of chronic venous disease. In early results, dedicated venous stents appear safe and demonstrate results that are as good as or better than those of historically used devices.

BACKGROUND: No independent comparisons, with midterm follow-up, of standard arteriovenous grafts (SAVGs) and immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare “real-world” performance of SAVGs and IAAVGs. METHODS: Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April 2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based on the type of graft implanted. Patients’ comorbidities, graft configuration, operative characteristics, and follow-up were collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft-related complications, time to first cannulation, time to tunneled catheter removal, catheter-related complications, and overall survival. Patency was determined from the time of the index procedure; χ(2), Kaplan-Meier, and Cox regression analyses were used, with the P value set as significant at < .05. RESULTS: There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients’ characteristics were similar between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs6.8%; P < .04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P = .4) and 18 months (SAVG, 29.0%; IAAVG, 43.7%; P = .4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P = .73) and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P = .73). Overall survival was 48% at 24 months. IAAVG patients required fewer overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs; P = .025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P = .74) or graft infection (SAVG, 19.0%; IAAVG, 12.0%; P = .276). Seventy-five percent of all grafts were successfully cannulated, with shorter median time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1–19 days) compared with the SAVG group (31 days; IQR, 26–47 days; P < .01). Of all pre-existing catheters, 65.75% were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR, 22–50 days) vs 49 days (IQR, 39–67 days) in the SAVG group (P < .01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P < .045). CONCLUSIONS: IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary procedures were performed in IAAVGs.

Background No independent reviews, with midterm follow-up, of current experience with immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this project was to assess the real-world performance of 2 different IAAVGs over a 2-year period at a large tertiary referral center. Methods Between January 2014 and April 2016, all consecutive patients who underwent placement of Acuseal (Gore) or Flixine (Maquet) IAAVGs were identified for retrospective analysis from the electronic medical record and Vascular Quality Initiative database. Primary, primary-assisted and secondary patency rates, time to first cannulation, time to tunneled catheter removal, and overall survival were recorded. Results Forty-three patients were identified to have undergone placement of IAAVG, 31 Acuseal (72%), and 12 Flixine (28%). Of the Acuseal cohort, 7 were implanted with outflow through a HeRO catheter system (Merit Medical). Mean follow-up time was 8.4 months. Overall survival was 57.4% at 18 months. Overall primary, primary assisted, and secondary patency at 18 months were 33.36%, 34.31%, and 51.03%, respectively. Eighty three percent of grafts were successfully cannulated, and 78% of preexisting catheters were removed. Mean time to successful graft cannulation and catheter removal were 14.85 and 32.26 days, respectively. Conclusions Real-world experience with novel arteriovenous access grafts is consistent with results from industry-sponsored studies. Early cannulation of immediate-access grafts can be successfully performed in a wide variety of patients. However, prolonged catheter dwell times persist despite increased rates of successful early-graft cannulation. Further study of methods for promoting catheter removal in this patient population is warranted.

Venous disease is common in women. We know, for instance, that women more often present with complaints of venous symptoms than men, that pregnancy predisposes women to deep venous thrombosis (DVT) and venous thrombotic events (VTEs), and that women are more likely to have syndromes that are secondary to venous compression. Knowledge of venous disease and associated therapies in women has certainly improved over the past few decades. Yet there still remains a lot that we do not know. This chapter aims to discuss some of the common venous disease pathologies in women, shed some light on these unanswered questions, and highlight potential areas for future study.

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Immediate-access arteriovenous grafts (IAAVGs), or early cannulation arteriovenous grafts (AVGs), are more expensive than standard grafts (sAVGs) but can be used immediately after placement, reducing the need for a tunneled dialysis catheter (TDC). We hypothesized that a decrease in TDC-related complications would make IAAVGs a cost-effective alternative to sAVGs.We constructed a Markov state-transition model in which patients initially received either an IAAVG or an sAVG and a TDC until graft usability; patients were followed through multiple subsequent access procedures for a 60-month time horizon. The model simulated mortality and typical graft- and TDC-related complications, with parameter estimates including probabilities, costs, and utilities derived from previous literature. A key parameter was median time to TDC removal after graft placement, which was studied under both real-world (7 days for IAAVG and 70 days for sAVG) and ideal (no TDC placed with IAAVG and 1 month for sAVG) conditions. Costs were based on current Medicare reimbursement rates and reflect a payer perspective. Both microsimulation (10,000 trials) and probabilistic sensitivity analysis (10,000 samples) were performed. The willingness-to-pay threshold was set at $100,000 per quality-adjusted life-year (QALY).IAAVG placement is a dominant strategy under both real-world ($1201.16 less expensive and 0.03 QALY more effective) and ideal ($1457.97 less expensive and 0.03 QALY more effective) conditions. Under real-world parameters, the result was most sensitive to the time to TDC removal; IAAVGs are cost-effective if a TDC is maintained for ≥23 days after sAVG placement. The mean catheter time was lower with IAAVG (3.9 vs 8.7 months; P .0001), as was the mean number of access-related infections (0.55 vs 0.74; P .0001). Median survival in the model was 29 months. Overall mortality was similar between groups (76.3% vs 76.7% at 5 years; P = .33), but access-related mortality trended toward improvement with IAAVG (6.1% vs 6.8% at 5 years; P = .052).The Markov decision analysis model supported our hypothesis that IAAVGs come with added initial cost but are ultimately cost-saving and more effective. This apparent benefit is due to our prediction that a decreased number of catheter days per patient would lead to a decreased number of access-related infections.

Perforating veins may play a role in the development of chronic venous insufficiency and ulceration. There is renewed interest in minimally invasive treatments vs historic surgical options. Current indications for treatment, technical success, and evidence for clinical efficacy are summarized. Existing recommendations include perforator closure in Clinical, Etiology, Anatomy, and Pathophysiology class 5 or class 6 disease through percutaneous thermal ablation, subfascial endoscopic perforator surgery, open surgery, or sclerotherapy. Closure rates for percutaneous thermal ablation are reported as 60% to 80% initially. More recanalization and de novo perforator formation have been reported than after thermal saphenous closure. Ultrasound-guided foam sclerotherapy has shown promise in perforator closure and wound healing, but with variable success rates. Regardless of method used, successful closure of perforators appears predictive of wound healing with minimal morbidity. However, the power and design of all studies supporting this are far from robust, and more work is needed.

Background Venous ulcers are painful, recurrent, and difficult to heal. Electronic medical records (EMRs) are often not optimized to track wounds. Specialized wound care programs may not interface with office-based records, creating a need to standardize the process of venous ulcer measurement and dressing documentation within existing systems. This work describes the creation of an EMR protocol to track venous ulcer size, to standardize dressings, to address related health issues, and to improve education of the patient. We hypothesized that the institution of an EMR protocol to track clinical features of venous ulcer patients, including wound size and health status, would facilitate wound healing. Methods We performed a retrospective review of a prospective database from September 2014 to May 2017. Modifications to the EMR included the formation of a venous ulcer patient list, a dressing tracker, calculation of total ulcer area, graphing of ulcer size over time, and images of the wound area. Patient education materials were created through the EMR and loaded into an automatic end-visit printout that emphasized smoking cessation, weight loss, and consultation with specialty services as necessary. Quarterly meetings with the supervising physician were established to review each patient's wound progress and to target areas of improvement. Results During the study period, 204 patients with chronic C5 and C6 disease were observed. Before the start of the project, the healing rate was 53.3%. Wound healing rates improved from 59.5% (quarter 1) to 77.94% (quarter 8). In the quarter before the project started, there were no patients who had quit or cut down on smoking or smokeless tobacco, no patients who were referred for weight loss consultation, and nine who were already patients of bariatric surgery. During the study period, 29% of patients quit smoking, 19% decreased smoking, and 20% cut down smokeless tobacco use. There were 54 patients who underwent advanced arterial evaluation; 175 patients underwent sclerotherapy and 137 patients had endovenous thermal ablation to treat axial reflux in the affected limb. The EMR modification project took 13 months to craft and to implement, with approximately 8 hours of meeting time from the surgical team. Conclusions A comprehensive care model for venous ulcer patients through EMR modification improved overall patient care, increased communication between providers, and facilitated ulcer healing. EMR modification can be introduced with an acceptable time investment on the part of both the provider and the institutional information technology team.

Open saphenous removal, phlebectomy, and venous ligation were historic mainstays of surgical treatment of venous disease. Duplex ultrasound has become standard to diagnose venous insufficiency. Percutaneous modalities have allowed treatments to include thermal and nonthermal endovenous ablation. These treatments vary in preoperative planning, procedural steps, and postprocedural care, but all are safe and effective. An individualized approach should be taken in determining which modality is offered to each patient. Endovenous options, which often are minimally invasive and safely performed in an outpatient setting, allow access to effective treatments with low risk and discomfort.

Since their introduction in 1973, inferior vena cava filters have evolved concurrent with advancing technology, and, therefore, their use has expanded due to broader indications for insertion. This paper focuses on the challenges and future directions of this trend, including a closer look at complications, retrieval rates, and cost-effectiveness.

Postoperative infections can complicate patient care and increase health care costs. A vascular preventative bundle was implemented at a large teaching/research intensive hospital to decrease surgical site infections (SSIs) with vascular surgery patients. The aim of this study was to measure fidelity to the bundle and determine if implementation of the vascular SSI bundle reduced the rate of SSIs. Three periods of data were collected, and they are identified as preimplementation (period 1), early implementation (period 2), and postimplementation (period 3). There were 711 patients for all three periods, approximately equally distributed in the periods. The use of preoperative hair clippings, chlorhexidine (CHG) wipes, and appropriate antibiotics showed the greatest improvement from preimplementation to early implementation. All three measures showed significant improvements in fidelity. For appropriate antibiotics, the fidelity was the highest and showed the largest improvement compared to the other measures. The performance of clippings preoperatively and using CHG wipes improved significantly. Evidence-based interventions have been recommended to support the implementation and sustainability of the bundle. The infection rate between preop and postperiod was not statistically different.

Central venous stenosis or occlusion is a common phenomenon that plagues patients on hemodialysis. The incidence of symptomatic central venous stenosis is estimated to be up to 20 % of hemodialysis patients. This chapter discusses central venous stenosis and the management of this disease.

The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, Minn) has provided an innovative means to obtain hemodialysis access for patients with severe central venous occlusive disease. The outcomes of this novel treatment modality in a difficult population have yet to be clearly established.A retrospective review of HeRO graft placement from June 2010 to January 2012 was performed. Patient hemodialysis access history, clinical complexity, complications, and outcomes were analyzed. Categoric data were described with counts and proportions, and continuous data with means, ranges and, when appropriate, standard deviations. Patency rates were analyzed using life-table analysis, and patency rate comparisons were made with a two-group proportion comparison calculator.HeRO graft placement was attempted 21 times in 19 patients (52% women), with 18 of 21 (86%) placed successfully. All but one was placed in the upper extremity. Mean follow-up after successful placement has been 7 months (range, 0-23 months). The primary indication for all HeRO graft placements except one was central vein occlusion(s) and need for arteriovenous access. Patients averaged 2.0 previous (failed) accesses and multiple catheters. Four HeRO grafts (24%), all in women, required ligation and removal for severe steal symptoms in the immediate postoperative period (P.01 vs men). Three HeROs were placed above fistulas for rescue. All thrombosed4 months, although the fistulas remained open. An infection rate of 0.5 bacteremic events per 1000 HeRO-days was observed. At a mean follow-up of 7 months, primary patency was 28% and secondary patency was 44%. The observed 12-month primary and secondary patency rates were 11% and 32%, respectively. Secondary patency was maintained in four patients for a mean duration of 10 months (range, 6-18 months), with an average of 4.0 ± 2.2 thrombectomies per catheter.HeRO graft placement, when used as a last-resort measure, has been able to provide upper extremity access in patients who otherwise would not have this option. There is a high complication rate, however, including a very high incidence of steal in women. HeRO grafts should continue to be used as a last resort.

Pathologic perforating veins have become an interest to the venous specialist caring for patients with CEAP 4 to 6 disease. Historically, open perforator ligation and then subdermal endoscopic perforator ligation was described. These methods had clear shortcomings. More recently, thermal ablation techniques, including radiofrequency ablation and laser ablation, have been described. Ultrasound-guided sclerotherapy has also been used as a possible means to treat pathologic perforator veins. This report describes and summarizes the updated techniques to treat perforating veins in a challenging patient population.

Objective The objective of this review was to create an evidence summary of the available literature comparing saphenous vein ablation and concomitant phlebectomy vs ablation with staged phlebectomy. Methods A review of the literature for ambulatory patients treated for venous insufficiency with saphenous ablation and phlebectomy was conducted. A literature search was performed using MEDLINE, Cochrane Library, Google Scholar, and PubMed with the keywords phlebectomy, endovenous ablation, staged procedures, vein stripping, superficial venous disease, and powered phlebectomy. All studies that described a single approach, systematic reviews, case series (N Results Eight clinical comparative studies of combined saphenous ablation and phlebectomy vs staged procedures were found: three randomized prospective studies, two prospective comparisons, and three retrospective reviews. Conclusions Combined treatment of saphenous incompetence and symptomatic varicosities results in better short-term and better to equivalent long-term patient outcomes.

IntroductionIschemic steal syndrome (ISS) associated with arteriovenous (AV) access is rare but can result in severe complications. Multiple techniques have been described to treat ISS with varying degrees of success. This study compares the management and success associated with these techniques.MethodsPatients with ISS between June 2003 and June of 2008 at the University of Pittsburgh Medical Center were retrospectively reviewed. Demographics, type of AV access, management technique, and success of intervention were recorded. Success was defined as resolution of ISS symptoms while preserving access function. One hundred consecutive AV access procedures were reviewed for comparison. Data were analyzed using χ2 test, Fisher's exact test, and Student's t test. The study was approved by our institutional review board.ResultsA total of 114 patients with ISS had a mean age of 65 years (range, 20-90 years), were predominantly female (66%), diabetic (61%), and with a brachial origin fistula (69%). Risk factors for ISS included coronary artery disease (CAD; P < .001), hypertension (P < .001), and tobacco use (P = .048). Women were noted to have a brachial origin access more frequently than men (odds ratio [OR], 3.1; P = .009). Forty-four patients with mild steal were observed. Seventy patients underwent 87 procedures. Procedures performed included ligation (n = 27), banding (n = 22), distal revascularization and interval ligation (DRIL; n = 21), improvement of proximal inflow (n = 9), revision using distal inflow (RUDI; n = 4), and proximalization of arterial inflow (PAI; n = 3). Early procedures (

Introduction La traitement endoveineuse par laser (TEVL) est une alternative admise pour l’ablation de veines axiales dans le cadre des incontinences veineuses symptomatiques, mais son efficacite et le taux de complications pour les veines de calibre large (≥1 cm) font encore debat. De plus, son role dans le traitement des veines saphenes externes (VSE) et des veines accessoires anterieures (VAA) n’a pas ete valide. Methode Il s’agit d’une etude retrospective des patients ayant beneficie d’une TEVL au niveau de veines saphenes internes (VSI), de VSE, ou de VAA entre Aout 2007 et Mai 2009. Au total, 885 membres inferieurs ont ete revus. 153 patients ont ete exclus en raison d’informations incompletes. Le sexe, l’âge, la taille de la veine, les details peroperatoires, les donnees de l’echodoppler, et les donnees du suivi ont ete collectes. Les veines mesurant Resultats Un total de 732 ablations a ete revu chez 175 hommes et 557 femmes (76,1%). Le suivi moyen avec echodoppler a ete de 3 semaines, et tous les patients ont beneficie d’au moins un echodoppler postoperatoire. Au total, 565 (77,3%) VSI, 113 (15,5%) VSE, et 53 (7,3%) VAA ont ete traitees. 88 ablations ont ete realisees sur des veines mesurant ≥1 cm, soit 12% de l’ensemble des veines traitees. Au total, 82 VSI, trois VSE, et trois VAA mesuraient>1 cm, et les VSI comprenaient plus de 93,2% des veines de calibre traitees( p ≤ 0,001 vs. cohorte entiere). Une ulceration active etait presente pour 4,9% des petites veines et 9,1% des veines larges traitees ( p = 0,11). Une moyenne de 2,983 J (etendue: 250-7,922) a ete utilisee pour les ablations, les veines mesurant ≥1 cm ayant ete traite avec des niveaux energetiques significativement plus eleves (3,733 vs. 2,876 J, p p = 0,91). Cela a inclus des echecs pour 3,4% des petites veines et pour 4,5% des veines larges ( p = 0,59). De plus, deux thromboses veineuses profondes (0,4%) sont survenues, chacune d’entre elles apres ablation de VSI. La complication la plus frequente a ete l’echec de fermeture, qui est survenue dans 1,6% des cas de VSI, dans 8,8% des cas de VSE, et dans 13,2% des cas de VAA ( p p ≤ 0,001) et des taux moindre de complications ( p = 0,005) en comparaison aux VSE et VAA. Conclusions Les taux de complications et d’echec de fermeture ne sont pas significativement differents pour les veines de calibre ≥1 cm et les veines de plus petit calibre. Bien que des niveaux d’energie plus eleves soient utilises pour les veines de grand calibre, le taux de complications n’en est pas pour autant plus eleve, ce qui suggere l’efficacite et l’innocuite de la TEVL pour la fermeture des veines de calibre large. Des taux d’echec et de complications plus eleves ont ete observes lors du traitement des VSE et VAA par rapport aux VSI.

The proximal cephalic vein that enters the axillary vein (cephalic arch) is a common site of stenosis in patients with upper extremity arteriovenous fistulas for hemodialysis (HD). In this study, we present the outcomes of a series of cephalic vein transposition, to determine its utility in the setting of refractory arch stenosis.We conducted a retrospective review of patients undergoing cephalic vein transposition to manage refractory cephalic arch stenosis from January 1, 2008 to August 31, 2015. Demographics, past medical history, access history of the patients as well as procedural details of the surgery to the stenotic segment, patency of the access, and the need for subsequent interventions were recorded.Twenty-three patients underwent a cephalic vein transposition during the study period. The patients undergoing cephalic transposition had their current access for an average of 3.0 ± 2.6 years and had an average of 2.3 ± 0.9 interventions on the access prior to the surgery. Complications from the surgery were uncommon (8.7%) and no patient required a temporary tunneled dialysis catheter. The re-intervention rate was 0.2 ± 0.2 interventions per patient per year. At two years, primary patency was 70.9% and cumulative patency was 94.7% for the patients with cephalic transposition.Cephalic vein transposition is safe and effective treatment for cephalic arch stenosis without interrupting utilization of the access. The surgical approach to stenosis of the proximal cephalic vein is effective, requires minimal re-interventions, and should be considered for isolated, refractory cephalic arch stenosis in mature arteriovenous fistulas.

BackgroundOpen and endovascular thoracic aneurysm repairs are associated with significant complications including paraplegia, stroke, vascular insufficiency, and death. Predictors of adverse outcomes are not well-defined in this patient population.MethodsThe database of the GORE TAG (W.L. Gore, Flagstaff, Ariz) Pivotal Trial comparing the TAG endograft to open repair was interrogated. Univariate (UVA) and multivariate analyses (MVA) of demographic, clinical, anatomic, and procedural variables were conducted to discover possible predictors of serious adverse events for the whole group and for the TAG and open cohort groups separately. Early adverse outcomes occurred within 30 days or the initial hospitalization. P value of ≤ .05 was significant.ResultsA total of 140 TAG and 94 open descending thoracic aneurysm (DTA) patients were analyzed, consisting of 128 men and 106 women. Perioperative deaths were 9/94 for open surgery and 3/140 for TAG patients, with 10/12 (7 open, 3 TAG) deaths occurring in men. Two female deaths were both after open surgery. Multivariate analysis showed predictors of death for all patients were symptomatic aneurysms and male gender. Analysis of a combined morbidity/mortality endpoint (stroke/paralysis/MI/death) showed elevated creatinine predicted these events for the whole group. Open surgery (P < .001) and increasing aneurysm diameter (P < .001) predicted an increased likelihood of any major adverse event. Open surgery was significantly associated with an increased risk of paraplegia (P = .002). Vascular complications were more frequent in the TAG (19%) than in open DTA patients (9%) (P = .038). Female gender (P = .01) predicted vascular complications within the endovascular group. For all analyses, long procedure times were correlated with adverse events. Women were noted to have longer procedure times for both TAG and open repairs.ConclusionElevated creatinine levels and symptomatic aneurysms predict morbidity and mortality, respectively, regardless of repair type. Male gender predicted death after open surgery, and since most deaths (9 of 12) were in this group, male gender predicted death overall, despite women's more difficult endovascular TAA repairs as evidenced by longer procedure times and higher vascular complication rates. All major adverse events and paraplegia were more common for open surgery patients.

ObjectiveThe purpose of this study is to evaluate contemporary results of ruptured aortoiliac aneurysms (RAAA) and identify the role of surgeons' annual aortic volume and other prognostic indicators for early outcome.MethodsA retrospective review identified 213 consecutive patients who presented with an atherosclerotic RAAA without thoracic extension over 6.5 years ending in June 2007. Excluded were 31 ruptures treated by endovascular repair (EVAR) or following previous EVAR, also excluded were two chronic asymptomatic hemodynamically stable ruptures. Ten patients were not treated due to either patient's refusal or prohibitive surgical risk. Demographic, preoperative, intraoperative, and postoperative variables were collected. Log rank test and Cox proportional hazard model analyses were utilized to identify factors contributing to mortality and morbidity in these patients. Survival rates were estimated by Kaplan-Meier method.ResultsOne hundred thirty-one males and 39 females with a mean age of 74.5 ± 8.1 years underwent consecutive RAAA repairs. The operative mortality rate was 38.2% (65/170), including 29 intraoperative deaths. Using multivariate analysis, surgeon's average annual AAA volume (20 average annual AAA cases/y) had a higher 30-day survival rates (78.4% vs 57.9%, P = .024). Octogenarians had a lower 30-day survival rate of 49.0% vs 70.5% (P = .012). Patients who developed postoperative intestinal ischemia had a lower 30-day survival rate compared with patients without (48.1% vs 15.3%, P = .002). Increased intraoperative fluid and blood product usage was associated with bowel ischemia (P < .05).ConclusionsRAAA remains a highly lethal problem. The improved early outcomes of surgeons with high-volume AAA have strong implications for training, emergency staffing needs and alternative treatment strategies.

Background The use of a distal filter cerebral protection device with carotid artery stenting is commonplace. There is little evidence, however, that filters are effective in preventing embolic lesions. This study examined the incidence of embolic phenomenon during carotid artery stenting with and without filter use. Methods This was a prospective, randomized, single-center study of carotid artery stenting with or without a distal cerebral protection filter. A 1:1 scheme was used to randomize 36 carotid artery stenting procedures in 35 patients. Diffusion-weighted magnetic resonance imaging (DW MRI) 24 hours after stenting was used to assess the occurrence of new embolic lesions. Blinded observers calculated lesion number and volume. Results The mean age was 78.6 ± 7.0 in the cerebral protection group compared with 74.1 ± 8.7 in the no cerebral protection group ( P = .92). Despite similar average age, the percentage of octogenarians was higher in the cerebral protection group (61.1% vs 22.2%; P = .04). Two procedures in the cerebral protection group were not successful. One was completed without protection because of inability to track the filter, and the second was aborted because of severe tortuosity with a later carotid endarterectomy. New MRI lesions were noted in 72% of the cerebral protection group compared with 44% in the no cerebral protection group ( P = .09). The average number of lesions in these patients was 6.1 and 6.2, respectively, with mean DW MRI lesion size of 16.63 mm 3 vs 15.61 mm 3 ( P = .79 and .49, respectively). Four strokes occurred (11%), two in each group, in patients aged 75, 80, 82, and 84 years. The only major stroke occurred in the no cerebral protection group. Conclusions The use of filters during carotid artery stenting provided no demonstrable reduction of microemboli, as expected. Routine use of cerebral protection filters should undergo a more critical assessment before mandatory universal adoption.

Background Traumatic transection of the thoracic aorta is a highly morbid injury. Treatment may be delayed while attention focuses on concomitant injuries. Thoracic endovascular aortic repair (TEVAR) is effective but remains controversial in these often-young patients. We reviewed our experience in acute and subacute treatment of these injuries with TEVAR. Methods A retrospective analysis of five men and five women who underwent TEVAR for aortic transection from 1999 to 2007 was conducted. Procedures were performed with standard endovascular techniques. Follow-up included computed tomography at 1 month and yearly thereafter. Results Mean age was 44 years (range, 20 to 84 years). Motor vehicle accidents accounted for 7 injuries, a snowmobile accident for 1, skydiving for 1, and balloon angioplasty of a coarctation for 1. Average diameter of the proximal landing zone was 25 mm (range, 23 to 29 mm). Mean external iliac size was 10 mm (range, 7 to 15 mm), and no conduits were required. Immediate technical success was 90%, with no 30-day mortality. Seven patients underwent repair acutely (≤24 hours) and three patients subacutely (range, 4 days to 2 months) for pseudoaneurysm. Four patients had procedures for concomitant injuries before their transection was repaired (3 laparotomies and a fixation for open fracture). One endoleak was noted, which resolved by the 1-month follow-up. The lone device-related complication was an endograft collapse at 5 months managed by repeat endografting, which was complicated by aortoesophageal fistula requiring esophagectomy and open reconstruction. No iliac injuries occurred. At 20-months of mean follow-up (range, 2 to 70 months), all patients are alive and well. Conclusions TEVAR for traumatic aortic transection is feasible, with good initial success. Repair can be delayed in selected cases. Continued surveillance is necessary to ensure good long-term outcomes in these young patients. Care must be taken when performing TEVAR for this off-label indication because these devices are designed for the larger aortic diameters of aneurysm patients.

Objective Perforator vein closure for the treatment of advanced chronic venous insufficiency has been shown to be effective using radiofrequency ablation (RFA), endovenous laser ablation (EVLA), or ultrasound-guided foam sclerotherapy (UGFS). The objective of the study was to compare these three modalities and attempt to identify factors that might predict treatment failure. Methods A retrospective review of a prospectively managed database of perforator vein treatments performed at a three centers within a single institution from February 2013 to July 2014. The modality for perforator closure was left to the discretion of the treating physician. A Duplex scan was performed at 2 weeks after the procedure. Standard statistical methods were used to compare subgroup characteristics. Univariate and multivariate analyses were performed using SAS v9.3. Results We performed 296 perforator ablations on 112 patients. Superficial venous reflux was appropriately treated before perforator ablation. Of the 296 procedures, 62 (21%) underwent EVLA, 93 (31%) RFA, and 141 (48%) UGFS. The indications for intervention in most patients were C5 and C6 disease (67%). At 2 weeks, closure rates were significantly lower for UGFS (57%) compared with RFA (73%; P = .05) but failed to reach significance compared with EVLA (61%; P = .09). When patients were first treated with UGFS and closure failed, thermal ablation was then successful in 85% (P = .03) of EVLA and 89% (P = .003) of RFAs as a secondary procedure, compared with initial closure rates. Systemic anticoagulation, perforator size, and presence of deep vein reflux did not affect closure rates for any modality. Factors that were predictive of failure were body mass index >50 with closure rates of only 37% for all modalities. There were five postprocedure deep venous thromboses found (5%). One patient had an isolated gastrocnemius thrombus after undergoing UGFS and the other four had focal tibial vein thrombosis without extension into the popliteal vein. Conclusions In this study we compared EVLA, RFA, and UGFS for the treatment of incompetent perforating veins. RFA was found to be the most reliable means of perforator closure and was significantly better than UGFS. Morbid obesity (body mass index >50) predicted failure of perforator closure in all groups. Failure of UGFS as an initial treatment led to increased perforator closure when thermal ablation was used as a secondary technique.

Current guidelines suggest that arteriovenous fistula (AVF) is associated with survival advantage over arteriovenous graft (AVG). However, AVFs often require months to become functional, increasing tunneled dialysis catheter (TDC) use, which can erode the benefit of an AVF. We sought to compare survival in patients with end-stage renal disease after creation of an AVF or AVG in patients starting hemodialysis (HD) with a TDC and to identify patient populations that may benefit from preferential use of AVG over AVF.Using U.S. Renal Data System databases, we identified incident HD patients in 2005 through 2008 and observed them through 2008. Initial access type and clinical variables including albumin levels were assessed using U.S. Renal Data System data collection forms. Attempts at AVF and AVG creation in patients who started HD through a TDC were identified by Current Procedural Terminology codes. We accounted for the effect of changes in access type by truncating follow-up when an additional AVF or AVG was performed. Survival curves were then constructed, and log-rank tests were used for pairwise survival comparisons, stratified by age. Multivariate analysis was performed with Cox proportional hazards regressions; variables were chosen using stepwise elimination. An interaction of access type and albumin level was detected, and Cox models using differing thresholds for albumin level were constructed. The primary outcome was survival.Among the 138,245 patients who started with a TDC and had complete records amenable for analysis, 22.8% underwent AVF creation (mean age ± standard deviation, 68.9 ± 12.5 years; 27.8% mortality at 1 year) and 7.6% underwent AVG placement (70.2 ± 12.0 years; 28.2% mortality) within 3 months of HD initiation; 69.6% remained with a TDC (63.2 ± 15.4 years; 33.8% mortality). In adjusted Cox proportional hazards regression, AVF creation is equivalent to AVG placement in terms of survival (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.93-1.02; P = .349). AVG placement is superior to continued TDC use (HR, 1.54; 95% CI, 1.48-1.61; P.001). In patients older than 80 years with albumin levels4.0 g/dL, AVF creation is associated with higher mortality hazard compared with AVG creation (HR, 1.22; 95% CI, 1.04-1.43; P = .013).For patients who start HD through a TDC, placement of an AVF and AVG is associated with similar mortality hazard. Further study is necessary to determine the ideal access for patients in whom the survival advantage of an AVF over an AVG is uncertain.

Arteriovenous fistulas (AVFs) are associated with improved long-term outcomes but longer maturation times and higher primary failure rates compared with arteriovenous grafts (AVGs). The Fistula First Breakthrough Initiative has recently emphasized tunneled dialysis catheter (TDC) avoidance. We sought to characterize the relationship of AVFs and AVGs to the use of TDCs as well as secondary procedures.Using the United States Renal Data System (USRDS) database, we identified incident hemodialysis (HD) patients in 2005 that started HD with a TDC and survived at least 1 year. We then monitored them through 2008. Access creation, TDC removal, TDC placement, and secondary procedures were identified by Current Procedural Terminology codes (American Medical Association, Chicago, Ill). Multivariate logistic regression was used to identify risk factors for the primary end points.In 2005, HD was initiated in 56,495 patients, 74% with a TDC. Of these, 6286 had an access procedure ≤3 months and 1 year of follow-up (AVF, 4634; AVG, 1652). Mean age was 67.7 years (AVF, 67.3; AVG, 68.7 years; P.001), 53.3% were men (AVF, 58.1%; AVG, 40.5%; P.001), and 33.8% were obese (AVF, 33.6%; AVG, 34.4%; P = not significant). AVG placement was associated with a higher TDC removal at 1 (7.9% vs 3.1%; P.001), 3 (47.8% vs 17.8%; P.001), and 6 (60.6% vs 47.2%; P.001) months. There was no difference at 9 months (AVG, 64.9% vs AVF, 62.3%; P = .06). The median time to TDC removal was lower in the AVG group (70 days vs 155 days; P.001). Multivariable model found AVFs were associated with decreased odds of TDC removal at 3 (odds ratio, 0.22; P.001) and 6 months (odds ratio, 0.54; P.001). AVGs required more secondary procedures than AVFs at all time points up to 1 year and specifically had increased thrombectomy procedures (39.8% vs 11.5%; P.001).In patients starting dialysis with a TDC, AVGs are associated with increased TDC removal and fewer catheter days compared with AVFs at up to 6 months. However, AVGs require more secondary procedures at all time points up to 1 year.

Dialysis access-related ischemic steal syndrome is a well-recognized dialysis access complication. When severe, manifestations include rest pain, hand dysfunction, and tissue loss. Dialysis access attempts on the affected extremity are usually abandoned after a diagnosis of steal syndrome, and patients are often left catheter-dependent. Prophylactic distal revascularization with interval ligation has been described in patients at high-risk for steal syndrome. We present our experience with prophylactic distal revascularization with interval ligation performed simultaneously with arteriovenous fistula creation to prevent the recurrence in five patients and review the current body of literature supporting its use.