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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.

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.

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.

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.

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 (

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.

Background The life expectancy of patients with oxygen-dependent chronic obstructive pulmonary disease (COPD) is significantly reduced, but the risk of any intervention is considered prohibitive. However, severe COPD may increase the risk of abdominal aortic aneurysm (AAA) rupture. We reviewed our experience with AAA repair in oxygen-dependent patients to determine whether operative risk and expected long-term survival justify surgical intervention. Methods A retrospective review of 44 consecutive patients with oxygen-dependent COPD undergoing AAA repair over an 8-year period was performed. Information was recorded for survival, length of follow-up, patient age, medical comorbidities, pulmonary function tests, and operative approach. Survival data were analyzed by Kaplan-Meier curves and compared with published cohorts of oxygen-dependent patients and the natural history of untreated aneurysms. Results Twenty-four patients underwent endovascular aneurysm repair (EVAR), and 20 underwent open procedures (14 retroperitoneal and 6 transabdominal). The mean AAA diameter was 6.1 cm (range, 5-9.5 cm). The mean age was 71.4 years, and 82% of patients were male. Operative mortality was 0%. The mean length of stay was 11.2 days for open procedures and 4.3 days for EVAR (significantly longer than that for standard-risk patients). The mean survival time was 37.9 months (range, 2-91 months). Preoperative medical comorbidities, type of repair, and pulmonary function tests were not predictive of survival. Postoperative morbidity was significantly higher with open repair. Long term survival was comparable to historical series of the natural history of O2 dependent patients without AAA but better than untreated 6 cm AAA cohorts. At 42 months, almost 50% of patients in our study group were still alive, compared to 20% survival at 34 months for those with untreated 6 cm AAAs. Conclusions It is reasonable to continue to offer AAA repair to home oxygen–dependent COPD patients who are ambulatory and medically optimized and who are without untreated coronary artery disease. Although EVAR may be the most suitable treatment for oxygen-dependent COPD patients, our results show that even open repair may be safely performed in this population, with acceptable results.

Objectives Behavior of the abdominal aortic aneurysm (AAA) sac after endovascular abdominal aortic aneurysm repair (EVAR) is graft-dependent. The Excluder endograft has been associated with less sac regression than some other stent grafts. Long-term follow-up has not been reported. Methods Between May 1999 and July 2002, 50 patients underwent EVAR with the Excluder bifurcated endoprosthesis. These patients were followed up prospectively with computed tomography (CT) at 1, 6, and 12 months and yearly thereafter. One immediate conversion to open surgery and three deaths occurred within 6 months. One additional patient was lost to follow-up. The remaining 45 patients, 35 men and 10 women, were followed up for at least 1 year, and form the basis for this report. Their mean age was 73 ± 5.5 years. The minor axis diameter at the largest area of the AAA on CT examination was compared with the baseline measurement at 1 month and to the smallest size previously recorded during follow-up. Change in sac size of 5 mm or greater was considered significant. Mean follow-up was 2.7 ± 1.2 years (range, 1-4 years). Nominal variables were compared with the χ 2 test, and continuous variables with the Student t test. Results A significant decrease in average AAA sac diameter was observed at 6-month, 1-year, and 2-year follow-up. These differences were lost by the 3-year evaluation, because of delayed sac growth (n = 9) and re-expansion of once shrunken aneurysms (n = 3). The probability of freedom from sac growth or re-expansion at 4 years was only 43%. At last follow-up, sac expansion occurred in the absence of active endoleak in nine patients. Type II endoleak was associated with sac expansion in three patients ( P = .003), resulting in one conversion to open surgery after the 4-year follow-up. No graft migrations, AAA ruptures, or aneurysm-related deaths were noted. Conclusions Late aneurysm sac growth or re-expansion after EVAR with the Excluder device is common, even in the absence of endoleak. Although the incidence of important clinical sequelae is low at this point, the incidence of aneurysm expansion should be taken into consideration during the risk-benefit assessment before EVAR repair with the Excluder device.

Dialysis access-associated steal syndrome (DASS) complicates arteriovenous access surgery. We describe a 10-year experience with the surgical management of DASS.DASS operations were retrospectively reviewed from July 2003 to July 2013 from a single academic institution. Demographics, symptoms, surgical details, and outcomes were collected.A total of 201 patients had 218 episodes of DASS. Mean age was 65 years, and 62% were women. DASS was caused by 175 arteriovenous fistulas (80%), 41 upper extremity prosthetic grafts (19%), and two thigh grafts (1%); 87% were brachial artery based. A portion (22%) were referred for DASS from outside practices. All patients had grade 2 (48%) or grade 3 (52%) DASS; 92% (185) were available for follow-up, with a median time to first follow-up of 23 days. Surgical procedures included ligation (73), distal revascularization with interval ligation (DRIL) (59), revision using distal inflow (RUDI) (21), banding (38), proximalization of arterial inflow (12), and distal radial artery ligation (13). There were no differences in preoperative comorbidities between treatment groups. The 30-day complications included continued steal, thrombosis, bleeding, infection, and mortality. Ligation and DRIL were performed most often for grade 3 steal. Ligation and banding were performed most acutely (median time to intervention after access creation of 39 and 24 days vs DRIL and RUDI at 97 and 100 days). Fistula preservation was 0% for ligation, 100% for DRIL, 95% for RUDI, and 89% for banding (P.01). Improvement of symptoms ranged from 75% (banding) to 98% (DRIL) (P = .005). Women were less likely to have DRIL but more likely to have ligation (P = .001). Complications were highest in the banding (49%) and RUDI (37%) groups. Average mortality was 3.5%, with no significant differences among groups. During the study period, 3287 access procedures were performed, and access volume steadily increased (2003-2008, 1312 access creations; 2008-2013, 1975). Percentage of fistulas (79% vs 86%), incidence of steal (4% vs 6%), and percentage of DRILs (25% vs 28%) were consistent across the two study periods.DRIL and ligation were performed in patients with the most severe symptoms. Compared with ligation, DRIL has equal symptom resolution, no increase in complications, and fistula preservation. Compared with banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the preferred procedure for management of DASS in patients with a functioning autologous fistula who can tolerate a major operation.

mortality (adjusted hazard ratio [HR], 1.03; P < .001). Compared with patients with IHC (N 1⁄4 419,009), overall risk-adjusted mortality was lowest in patients with AVF (N 1⁄4 71,328; HR, 0.65; P < .001), followed by AVG (N 1⁄4 17,544; HR, 0.83; P < .001). AVF was superior to IHC and AVG for all age groups (P < .001; Fig 1). However, there was a significant change in the relative efficacy of AVG at age 45 based on spline modeling: there were no differences comparing AVG to IHC for patients aged 18 to 44 years (adjusted HR, 0.90; P 1⁄4 .12), but AVG was superior to IHC for patients aged $45 years (adjusted HR, 0.82; P < .001). Conclusions: Contrary to previous reports, our data suggest that AVF is superior to AVG and IHC regardless of patient age, including in octogenarians. In contrast, the mortality benefit of AVG over IHC may not apply to younger age groups. All patients aged

Catheter-directed thrombolysis (CDT) with adjunctive mechanical techniques, when successful, is reported to alleviate symptoms of acute iliofemoral deep venous thrombosis (IFDVT) and to lower the occurrence of the post-thrombotic syndrome (PTS). This study aimed to determine longer term outcomes of catheter-based interventions for IFDVT and to identify predictors of immediate and mid-long-term failures that would guide optimal patient selection.Consecutive patients who underwent CDT or pharmacomechanical thrombolysis for IFDVT between May 2007 and March 2013 were identified from a prospectively maintained database. Assessment of predictors of immediate periprocedural failure was based on the degree of clot lysis (≤ 50% vs50%) and 30-day recurrence of DVT. Long-term anatomic and clinical failures and outcomes were assessed by ultrasound imaging of the lysed segments and Villalta score (≥ 5 vs5). Survival analysis was used to assess primary patency and PTS morbidity. Multivariate binary logistic and Cox regression models were used to determine predictors of anatomic and clinical failures.During the study period, 93 patients (118 limbs; mean age, 49.4 ± 16.2 years; 47 women) with symptoms averaging 11.1 ± 9.6 days in duration were treated with various combinations of CDT or pharmacomechanical thrombolysis; in 52 (56%), at least one iliocaval stent was deployed. Immediate treatment failure was seen in 11 patients (12%) predicted by the preoperative indication "phlegmasia" (odds ratio, 3.12; P = .042) and recent surgery (odds ratio, 19.6; P = .018). At a mean ultrasonographic follow-up of 16 ± 14 months (range, 1-65 months), six more patients sustained a rethrombosis, accounting for an overall 3-year primary patency of 72.1%. In the long-term model, loss of primary patency was associated with recent surgery (hazard ratio [HR], 4.04; P = .023), malignant disease (HR, 6.75; P = .016), and incomplete thrombolysis (≤ 50%) (HR, 5.83; P.001). By stratification of PTS on the basis of postprocedure failures, at 2 years PTS occurred in 50.6% of patients and in 16.3% of patients without failure (P.001).Thrombolysis for symptomatic IFDVT can achieve high rates of thrombus resolution and reduce long-term PTS morbidity on careful patient selection. Improved anatomic and clinical outcomes are associated with the completeness of thrombolysis.

ObjectiveRefluxing perforators contribute to venous ulceration. We sought to describe patient characteristics and procedural factors that (1) impact rates of incompetent perforator vein (IPV) thrombosis with ultrasound-guided sclerotherapy (UGS) and (2) impact the healing of venous ulcers (CEAP 6) without axial reflux.MethodsA retrospective review of UGS of IPV injections from January 2010 to November 2012 identified 73 treated venous ulcers in 62 patients. Patients had no other superficial or axial reflux and were treated with standard wound care and compression. Ultrasound imaging was used to screen for refluxing perforators near ulcer(s). These were injected with sodium tetradecyl sulfate or polidocanol foam and assessed for thrombosis at 2 weeks. Demographic data, comorbidities, treatment details, and outcomes were analyzed. Univariate and multivariable modeling was performed to determine covariates predicting IPV thrombosis and ulcer healing.ResultsThere were 62 patients (55% male; average age, 57.1 years) with active ulcers for an average of 28 months with compression therapy before perforator treatment, and 36% had a history of deep venous thrombosis and 30% had deep venous reflux. At a mean follow-up of 30.2 months, ulcers healed in 32 patients (52%) and did not heal in 30 patients (48%). Ulcers were treated with 189 injections, with an average thrombosis rate of 54%. Of 73 ulcers, 43 ulcers (59%) healed, and 30 (41%) did not heal. The IPV thrombosis rate was 69% in patients whose ulcers healed vs 38% in patients whose ulcers did not heal (P < .001). Multivariate models demonstrated male gender (P = .03) and warfarin use (P = .01) negatively predicted thrombosis of IPVs. A multivariate model for ulcer healing found complete IPV thrombosis was a positive predictor (P = .02), whereas a large initial ulcer area was a negative predictor (P = .08). Increased age was associated with fewer ulcer recurrences (P = .05). Predictors of increased ulcer recurrences were hypertension (P = .04) and increased follow-up time (P = .02). Calf vein thrombosis occurred after 3% (six of 189) of injections.ConclusionsThrombosis of IPVs with UGS increases venous ulcer healing in a difficult patient population. Complete closure of all IPVs in an ulcerated limb was the only predictor of ulcer healing. Men and patients taking warfarin have decreased rates of IPV thrombosis with UGS.

ObjectiveAlthough the optimal treatment of carotid stenosis remains unclear, available data suggest that women have higher risk of adverse events after carotid revascularization. We used data from the Society for Vascular Surgery Vascular Registry to determine the effect of gender on outcomes after carotid endarterectomy (CEA) and carotid artery stenting (CAS).MethodsThere were 9865 patients (40.6% women) who underwent CEA (n = 6492) and CAS (n = 3373). The primary end point was a composite of death, stroke, and myocardial infarction at 30 days.ResultsThere was no difference in age and ethnicity between genders, but men were more likely to be symptomatic (41.6% vs 38.6%; P < .003). There was a higher prevalence of hypertension and chronic obstructive pulmonary disease in women, whereas men had a higher prevalence of coronary artery disease, history of myocardial infarction, and smoking history. For disease etiology in CAS, restenosis was more common in women (28.7% vs 19.7%; P < .0001), and radiation was higher in men (6.2% vs 2.6%; P < .0001). Comparing by gender, there were no statistically significant differences in the primary end point for CEA (women, 4.07%; men, 4.06%) or CAS (women, 6.69%; men, 6.80%). There remains no difference after stratification by symptomatology and multivariate risk adjustment.ConclusionsIn this large, real-world analysis, women and men demonstrated similar results after CEA or CAS. These data suggest that, contrary to previous reports, women do not have a higher risk of adverse events after carotid revascularization.

ObjectiveTo identify patient-related and device-specific predictors of challenging and failed inferior vena cava (IVC) filter retrievals.MethodsRetrospective single center review of consecutive retrievable IVC filters placed between 2004 and 2009. Retrieval was defined as challenging when it was unsuccessful owing to reported technical failure or when adjunctive endovascular maneuvers or access sites were recruited. Data regarding patient- and filter-specific information were collected. Logistic regression models were used to identify predictors of the reported outcomes. Statistical significance was set at p 50 days and >90 days, respectively, and when the filter hook apposes the caval wall. Filter tilt increases retrieval difficulty but not failure rates.

Background: Endovascular interventions for May Thurner Syndrome (MTS) have become first line therapy, often performed in a young patient population despite the lack of robust supportive data. This paper reports on long term outcomes from a large series of patients treated for de-novo or posthrombotic presentation. Methods: A retrospective review of MTS patients stented between 2006 and 2010 at two institutions. Patients who presented with acute iliofemoral DVT were treated with either catheter directed thrombolysis (CDT) and/or pharmacomechanical thrombolysis (PMT) and identified as having a venous stenosis by venogram. Patients who presented with leg pain or swelling but no DVT and evidence of MTS on duplex were evaluated by venography. IVUS was selectively utilized. Stenting of the iliocaval junction was performed in all patients with a 50% diameter stenosis on venogram, or a 70% area stenosis on IVUS.