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Introduction:Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of chronic venous disease. Approximately 40% of patients with VLU present with the underlying deep venous disease (DVD). Although the data are scarce, these deep venous disease-related VLU (DRV) are thought to have higher recurrence rates and a substantial economic burden. The objective of this study was to assess the economic burden of DRV across Australia, France, Germany, Italy, Spain, the UK, and the USA.Methods:A comprehensive literature review was undertaken to identify publications documenting the incidence and prevalence of VLU and DRV, medical resource utilization, and associated costs of DRV. Findings from this literature review were used to estimate the economic burden of illness, including direct medical costs over a 12-month interval following initial presentation of a newly formed DRV.Results:Total annual incidence of new or recurrent DRV in Australia, France, Germany, Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000, 253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019. Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated annual direct medical costs for patients managed conservatively in these geographies total ~ $10.73 billion (USD) or $5527 per person per year.Conclusion:The availability of published data on the costs of VLU care varies widely across countries considered in this analysis. Although country-specific VLU practice patterns vary, there is a uniform pattern of high-cost care.

Describe the incidence and predictors of acute limb ischemia in patients with acute myocardial infarction complicated by cardiogenic shock.Patients with index hospitalizations for acute myocardial infarction complicated by cardiogenic shock from 2016 to 2019 in the U.S. National Readmission Database were identified. We evaluated the incidence of acute limn ischemia and its associated mortality, length of stay, and cost of hospitalization. We used multivariable logistic regression to determine independent predictors of acute limb ischemia in this population.A total of 84,615 patients had acute myocardial infarction complicated by cardiogenic shock and 1302 (1.54%) developed acute limb ischemia. The rates of acute limb ischemia increased from 1.29% in 2016 to 1.66% in 2019 (p=0.002). Utilization of microaxial mechanical circulatory support increased from 2.25% in 2016 to 13.36% in 2019 (p=0.0001). The major predictors of acute limb ischemia included peripheral arterial disease (OR, 7.34, 95% CI 6.12 to 8.81), veno-arterial extracorporeal membrane oxygenation (OR, 4.40, 95% CI of 3.19 to 6.07), and microaxial mechanical circulatory support (OR, 3.12, 95% CI of 2.74 to 3.55). Acute limb ischemia in patients with cardiogenic shock was associated higher mortality (39.20% vs 33.53%, p=0.0001).This nationwide observational study shows that acute limb ischemia is an important complication of acute myocardial infarction with cardiogenic shock. This complication is associated with higher mortality. In addition to peripheral artery disease the use of mechanical circulatory devices was associated with significantly higher rates of acute limb ischemia.

Visual or manual characterization and classification of atherosclerotic plaque lesions are tedious, error-prone, and time-consuming. The purpose of this study is to develop and design an automated carotid plaque characterization and classification system into binary classes, namely symptomatic and asymptomatic types via the deep learning (DL) framework implemented on a supercomputer. We hypothesize that on ultrasound images, symptomatic carotid plaques have (a) a low grayscale median because of a histologically large lipid core and relatively little collagen and calcium, and (b) a higher chaotic (heterogeneous) grayscale distribution due to the composition. The methodology consisted of building a DL model of Artificial Intelligence (called Atheromatic 2.0, AtheroPoint, CA, USA) that used a classic convolution neural network consisting of 13 layers and implemented on a supercomputer. The DL model used a cross-validation protocol for estimating the classification accuracy (ACC) and area-under-the-curve (AUC). A sample of 346 carotid ultrasound-based delineated plaques were used (196 symptomatic and 150 asymptomatic, mean age 69.9 ± 7.8 years, with 39% females). This was augmented using geometric transformation yielding 2312 plaques (1191 symptomatic and 1120 asymptomatic plaques). K10 (90% training and 10% testing) cross-validation DL protocol was implemented and showed an (i) accuracy and (ii) AUC without and with augmentation of 86.17%, 0.86 (p-value

Background: Iliofemoral venous obstruction is recognized with increasing frequency as the underlying cause of lower extremity symptoms including edema, pain, skin changes, and, in advanced cases, ulceration. This study sought to evaluate the safety and effectiveness of the Abre venous self-expanding stent system for the treatment of symptomatic iliofemoral venous outflow obstruction. Methods: The ABRE Study (A Multi-Center, Non-Randomized Study to Evaluate the Safety and Effectiveness of the Abre Venous Self-Expanding Stent System in Patients With Symptomatic Iliofemoral Venous Outflow Obstruction) is a single-arm, multicenter, prospective study that included 200 subjects from 24 global sites. The primary end points were 12-month primary patency and major adverse events within 30 days. Secondary end points included lesion and procedure success, primary-assisted and secondary patency, major adverse events, stent migration, stent fracture, and quality of life changes. End point-related adverse events and imaging studies were adjudicated by independent clinical events committee and core laboratories, respectively. Results: Venous obstruction cause was classified as acute deep vein thrombosis (16.5%, 33/200), post-thrombotic syndrome (47.5%, 95/200), or nonthrombotic iliac vein lesion (36.0%, 72/200). The common iliac and external iliac veins were stented in 96.0% (192/200), 80.5% (161/200) of subjects, respectively. Stent implant into the common femoral vein was required in 44.0% (88/200). Primary patency at 12 months was 88.0% (162/184). Four (2.0%) major adverse events occurred within 30 days. Twelve-month primary-assisted and secondary patency were 91.8% (169/184) and 92.9% (171/184), respectively. No stent fractures or migrations were reported. Mean target limb Villalta score decreased from 11.2±5.6 at baseline to 4.1±4.8 at 12 months, and the mean target limb revised Venous Clinical Severity Score decreased from 8.8±4.7 at baseline to 4.3±3.6 at 12 months. Clinically meaningful improvements in quality of life and venous functional assessment scores from baseline were demonstrated through 12 months in all measures. Conclusions: Symptomatic iliofemoral venous obstruction can be successfully treated with an Abre venous stent. Study outcomes demonstrated a high patency rate with a good safety profile. Patients demonstrated a significant reduction in clinical symptoms and improvement in quality of life that was maintained through 12-month follow-up. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03038438.

ImportanceThe post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40–50% of cases. There are limited evidence-based approaches for PTS clinical management.ObjectiveTo provide an expert consensus for PTS diagnosis, prevention, and treatment.Evidence-ReviewMEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms “post-thrombotic syndrome” and “post-phlebitic syndrome” used in titles and abstracts up to September 2020.Filters WereEnglish, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method.FindingsThe panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3–6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30–40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30–40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30–40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation.Conclusions and RelevanceThis position paper can help practicing clinicians in PTS management.

The aim of the present study was to report a large, single-center experience using the ClotTriever thrombectomy system (Inari Medical, Irvine, CA) for the management of acute iliofemoral (IF) deep vein thrombosis (DVT). One limitation of all endovascular devices for the treatment of acute IF-DVT has been the inability to completely remove all acute thrombus and the need for adjunctive thrombolysis with its attendant risk of bleeding complications.A single-center retrospective review of consecutive patients with acute IF-DVT treated with the ClotTriever thrombectomy system (Inari Medical) is reported. Procedural efficacy was evaluated by an independent core imaging laboratory (Syntactx, New York, NY). Both procedural and in-hospital safety were assessed during the index hospitalization. The treated vein patency was assessed using duplex ultrasound at 30 days after the procedure.A total of 96 patients were included in the present retrospective review, 40 of whom (40%) had contraindications to thrombolytic therapy. In terms of efficacy, 93 patients (97%) had ≥75% thrombus removal. During the index hospitalization, two patients (2%) had experienced a symptomatic pulmonary embolus. However, no mortality, major bleeding, or device-related complications had occurred in the study population. Of the 96 patients, 64 had undergone duplex ultrasound at 30 days after the procedure. Of the 64 patients, 62 had normal flow (97%), 53 (83%) had normal compressibility, and 11 (17%) had partial compressibility.The ClotTriever thrombectomy catheter was both safe and effective in our cohort of patients with acute IF-DVT outside a randomized clinical trial.

Both catheter-directed thrombolysis (CDT) and ultrasound-assisted thrombolysis (USAT) are novel treatment modalities for patients presenting with acute pulmonary embolism (PE). The objective of this study was to compare clinical and quality-of-life (QOL) outcomes for patients undergoing either treatment modality. We retrospectively studied 70 consecutive patients treated with either CDT or USAT over 3 years at a multicenter health system. The primary clinical efficacy endpoint was right ventricular systolic pressure (RVSP) reduction post-procedurally. Safety endpoints were mortality and bleeding incidents based on Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) criteria. Long-term QOL was assessed using the 36-Item Short-Form Health Survey (SF-36) via phone interview. Thirty-seven patients (53%) in our study underwent USAT and 33 (47%) patients were treated with conventional CDT. Among all patients studied, 96% had echocardiographic evidence for right ventricular strain on admission. Mean RVSP decreased by 18 ± 13 mmHg in the USAT group post-procedurally as compared to 14 ± 16 mmHg in the CDT group, without significant difference between groups ( p = 0.31). Rates of moderate and severe bleeding were largely identical between USAT and CDT groups (USAT: 3%; CDT: 0%; p = 0.09). There was no death in either group during admission. At long-term follow-up, there was no significant difference in QOL between both treatment modalities in all eight functional domains of SF-36. Our retrospective study demonstrated using USAT over conventional CDT for acute submassive or massive PE did not yield additional clinical, safety, or long-term QOL benefit.

Objective To evaluate the 36-month efficacy and safety of cyanoacrylate closure for the treatment of incompetent great saphenous veins in comparison with radiofrequency ablation. Methods In this multicenter, prospective, randomized controlled trial, 222 symptomatic subjects with incompetent great saphenous veins were assigned to either cyanoacrylate closure or radiofrequency ablation. The primary endpoint, complete closure of the target great saphenous vein, was determined using duplex ultrasound examination starting from three-month visit. Results At month 36, the great saphenous vein closure rates were 94.4% for the cyanoacrylate closure group and 91.9% for the radiofrequency ablation group. Stable improvement in symptoms and quality of life was observed in both groups. Adverse event rates between the 24- and 36-month visits were similar between the groups as were serious adverse events which were infrequent and judged unrelated to either the device or the procedure in both groups. Conclusions This trial continues to demonstrate the safety and efficacy of cyanoacrylate closure for the treatment of great saphenous vein incompetence with great saphenous vein closure rate at 36 months similar to that of radiofrequency ablation, indicating non-inferiority of cyanoacrylate closure to radiofrequency ablation. The improvement in quality of life outcomes were also sustained and similar between the two treatment groups.

Chronic kidney disease (CKD) and cardiovascular disease (CVD) together result in an enormous burden on global healthcare. The estimated glomerular filtration rate (eGFR) is a well-established biomarker of CKD and is associated with adverse cardiac events. This review highlights the link between eGFR reduction and that of atherosclerosis progression, which increases the risk of adverse cardiovascular events. In general, CVD risk assessments are performed using conventional risk prediction models. However, since these conventional models were developed for a specific cohort with a unique risk profile and further these models do not consider atherosclerotic plaque-based phenotypes, therefore, such models can either underestimate or overestimate the risk of CVD events. This review examined the approaches used for CVD risk assessments in CKD patients using the concept of integrated risk factors. An integrated risk factor approach is one that combines the effect of conventional risk predictors and non-invasive carotid ultrasound image-based phenotypes. Furthermore, this review provided insights into novel artificial intelligence methods, such as machine learning and deep learning algorithms, to carry out accurate and automated CVD risk assessments and survival analyses in patients with CKD.

Background Endovenous revascularization is the standard in the management of acute thrombotic, chronic post-thrombotic iliocaval or iliofemoral obstruction, and nonthrombotic iliac vein lesions. The purpose of this study is to describe our single-center experience of postprocedure anticoagulation and antiplatelet regimens used after endovenous revascularization for a variety of venous occlusive conditions. Methods We conducted a retrospective analysis of 100 consecutive patients who underwent endovenous stenting for iliocaval or iliofemoral obstruction from January 1, 2014, to April 30, 2018. Patients treated with direct oral anticoagulants, warfarin, or low-molecular-weight heparin (LMWH) with or without antiplatelet therapy were identified. Demographic, procedural, patency, and follow-up data were collected. Stent patency was evaluated using duplex Doppler ultrasound examination or contrast venography. Results Seventy-one of 100 patients were treated with direct oral anticoagulant therapy (DOAC). Sixteen (23%) were lost to follow-up, leaving 55 (77%) available for analysis. The mean follow-up was 14 months (range, 1-43 months) with 32 patients (58%) followed for 12 months or longer. Primary, primary-assisted, and secondary-assisted patency rates were 87%, 97%, and 98%, respectively, at 12 months. In the non-DOAC group (patients treated with warfarin or LMWH), these rates were 87%, 93%, and 95%, respectively, at 12 months. Antiplatelet therapy, including clopidogrel, aspirin, or both, was used in 53 of 55 patients in the DOAC cohort and 18 of 19 patients in the non-DOAC group. Conclusions Our-single center retrospective analysis demonstrates acceptable primary patency rates when using DOAC therapy compared with those treated with warfarin or LMWH.

Summary: Background: This study sought to compare effectiveness and safety of percutaneous mechanical thrombectomy (PMT) and thrombolysis alone (THR) in patients with acute or subacute iliofemoral deep vein thrombosis (IfDVT). Patients and methods: Observational and randomized trials, published between January 2001 to February 2019 were identified by searching MEDLINE. Studies on deep venous thrombosis (DVT) treated with either THR or PMT adjunctive to conventional anticoagulation and compressive intervention were included. Meta-analysis of proportions was conducted to assess effectiveness outcomes of successful lysis and primary patency, post-thrombotic syndrome (PTS), valvular reflux, recurrent DVT, as well as safety outcomes of major bleeding, hematuria, and pulmonary embolism. Results: Of 77 identified records, 17 studies including 1417 patients were eligible. Pooled proportion of successful lysis was similar between groups (THR: 95 % [I2 = 68.4 %], PMT 96 %, [I2 = 0 %]; Qbet [Cochran’s Q between groups] 0.3, p = 0.61). However, pooled proportion of 6-month primary patency was lower after THR than after PMT (68 % [I2 = 15.6 %] versus 94 %; Qbet 26.4, p 2 = 0 %] versus 1.0 % [I2 = 0 %]; Qbet 12.3, p 2 = 56 %] versus 91.3 % [I2 = 91.7 %]; Qbet 714, p bet 0.7, p = 0.39 and THR: 2 % versus PMT: 1 %; Qbet 1.1, p = 0.30, respectively). Conclusions: In patients with iliofemoral DVT, percutaneous mechanical thrombectomy was associated with a higher cumulative 6-month primary patency and a lower incidence of major bleeding compared to thrombolysis alone. Risk of hemolysis from mechanical thrombectomy needs further consideration.

Although acute intracranial hemorrhage (ICH) is a rare complication of catheter-directed thrombolysis (CDT), it remains a major concern associated with the use of CDT. The incidence and clinical predictors of developing ICH in the setting of CDT are not known.The National Inpatient Sample database was used to identify all patients with proximal lower extremity or caval deep vein thrombosis (DVT) from January 2005 to December 2013 in the United States. Multivariate logistic regression was performed to identify the clinical predictors of ICH between patients with DVT who had received anticoagulation therapy alone and those who had been treated with CDT plus anticoagulation therapy.Of 138,049 patients with proximal lower extremity or caval DVT, 7119 (5.2%) had received anticoagulation therapy and CDT. Of the patients treated with anticoagulation alone, ICH had occurred in 0.2% compared with 0.7% for those treated with CDT (P .01). The independent predictors of ICH in the CDT cohort were a history of stroke (odds ratio [OR], 19.4; 95% confidence interval [CI], 8.8-42.8; P .01), chronic kidney disease (OR, 2.2; 95% CI, 1.1-4.7; P = .03), age74 years (OR, 2.2; 95% CI, 1.2-4.3; P = .02), male sex (OR, 1.8; 95% CI, 1.01-3.3; P = .048). Of those patients treated with anticoagulation alone, the risk factors for the development of ICH were a history of stroke, hospital teaching status, and age74 years.The results from the present nationwide observational study showed that of patients with DVT treated with CDT, the independent predictors for developing ICH were a history of stroke, chronic kidney disease, male sex, and age 74 years.

Background Chronic venous insufficiency (CVI) is a widely prevalent condition. Saphenous venous reflux is the most common underlying pathology that leads to CVI. Endovenous thermal ablations (ETA) are the current gold standard. However, some patients present with some unique challenges making ETA less ideal. Nonthermal nontumescent therapies could be considered as alternative therapy in these patients. Methods We performed a retrospective review of treatment effects with United States Food and Drug Administration-approved polidocanol endovenous microfoam (PEM; Varithena® 1%) on venous symptomology in 10 (n = 10) C3-C6 patients with CVI and concomitant complex disease/pathology that limited the use of ETA. The pathology included risk of bruising or bleeding, severe lipodermatosclerosis, hidradenitis suppurativa, chronic fibrosis of the vein from prior superficial thrombosis, risk for nerve injury, and failed prior ETA. Before treatment, all patients underwent a venous incompetence study by duplex ultrasound (DUS). Preprocedure pain, symptoms, and Venous Clinical Severity Scores (VCSSs) were recorded. Clinical assessments and DUS were performed 4 days, 6 weeks, 6 months, and 1 year after treatment. Results DUS demonstrated reflux in the great saphenous vein (GSV), anterior accessory GSV, and/or the small saphenous vein. Pain scores and VCSS were reduced 4 days and 6 weeks after treatment. These lower scores were maintained for up to 1 year after treatment. Conclusions PEM use in C3-C6 patients resulted in successful improvement in VCSS, CVI symptoms, and wound healing among patients in whom ETA was not considered to be the optimal therapy.

Objective Although duplex ultrasound (DUS) imaging is the current gold standard in the diagnosis of femoropopliteal deep venous thrombosis, it is not an optimal diagnostic modality to diagnose iliocaval occlusion. Screening for iliocaval occlusion thus remains a challenge for clinicians because of the lack of a reliable noninvasive technique. This challenge results in most patients undergoing computed tomography venography or magnetic resonance venography or invasive venography and intravascular ultrasound imaging. This study reports a novel, yet simple, reproducible and intuitive, surface DUS finding of physiologic flow reversal within the superficial epigastric vein (SEV) as a sign of proximal iliocaval occlusion (ICO). Methods This was a retrospective study of 15 patients who were diagnosed with ICO based on the finding of SEV flow reversal on DUS imaging. Patient demographics, presenting CEAP C scores, ICO characteristics, correlation with advanced imaging, and short-term follow-up findings are reported. Results Physiologic reversal of the SEV resulted in confirmation of ICO in all patients who underwent advanced imaging, including computed tomography venography or traditional venogram along with intravascular ultrasound imaging. All patients who underwent follow-up DUS scans demonstrated normalization of the SEV flow after ICO recanalization. Conclusions ICO can result in deep venous thrombosis, post-thrombotic syndrome, and chronic venous insufficiency. Physiologic flow reversal in SEV is diagnostic of ICO. To the best of our knowledge, this is the first report of this novel DUS finding.

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p

Introduction: While traditional ambulatory phlebectomy (AP) is a safe and effective procedure, few adverse effects such as hematoma, bleeding, bruising and nerve injury have been reported. To improve AP and to reduce some of these adverse events, herein we report a novel technique – Foam Sclerotherapy Assisted Phlebectomy (SAP). Report: The details of the above technique, along with the potential advantages and limitations will be discussed. Discussion: Foam sclerotherapy and DUS act as valuable adjuncts to traditional AP. SAP increases precision and creates additional venospasm leading to reduced bruising, reduced nerve injury and sclerosis of residual vein segments. Keywords: Varicose veins, Sclerotherapy, Foam sclerotherapy, Phlebectomy, Venous insufficiency

Background Chronic venous disease (CVD) is a common vascular disorder with manifestations ranging from asymptomatic spider veins to venous ulcers. Elevated right atrial pressure, otherwise called central venous pressure (CVP), can also result in edema and hyperpigmentation similar to chronic venous insufficiency. Obstructive sleep apnea (OSA) is a known risk factor for elevation of CVP. Prevalence rates of elevated CVP or OSA are unknown in patients presenting with a diagnosis of CVD. Methods This is a single-center, retrospective, descriptive study of patients referred to our tertiary care center with a diagnosis of CVD. Each patient was evaluated by simultaneous venous duplex ultrasound (to assess venous reflux) and limited echocardiography of the right side of the heart (to assess elevated CVP). We assessed the prevalence and predictors of elevated CVP in this cohort using multivariate logistic regression. Results A total of 264 patients with CVD were evaluated, and of these, 22.7% had elevated CVP and 26.9% had OSA. There was no significant difference in the prevalence of OSA or elevated body mass index in the group with elevated CVP compared with patients with normal CVP. The predictors of elevated CVP were age >64.6 years (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.003-1.05; P = .026), diabetes mellitus (OR, 2.19; 95% CI, 1.05-4.5; P = .035), and right lower extremity Venous Clinical Severity Score of ≥8.5 (OR, 1.098; 95% CI, 1.011-1.193; P = .026). Other predictors included prior history of pulmonary embolism and renal insufficiency. Conclusions Compared with the general population, the prevalence of elevated CVP and OSA is significant in this cohort of patients. Age, diabetes, and right lower extremity chronic venous insufficiency symptoms seem to be predictors of elevated CVP. Larger, population-based prevalence studies are needed to confirm these findings.

Objective Several randomized controlled trials (RCTs) have compared different interventions for chronic venous insufficiency (CVI) management, but mixed comparison of these interventions is lacking. The aim of this network meta-analysis was to compare VenaSeal closure system (Medtronic, Minneapolis, Minn) with endovenous laser ablation (EVLA), radiofrequency ablation (RFA), mechanochemical ablation, sclerotherapy, and surgery for management of CVI to achieve anatomic success (complete closure of treated vein within 6 months after intervention) as the primary outcome and health-related quality of life (HRQoL; EuroQol-5 Dimension, Aberdeen Varicose Vein Questionnaire), Venous Clinical Severity Score (VCSS), pain scores, and adverse events as secondary outcomes. Methods A systematic review of journal databases was undertaken, and RCTs between January 1996 and September 2018 comparing different treatment options were included. Risk of bias and quality of publications were assessed using the Cochrane bias tool; Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study selection and reporting. Twenty RCTs comprising 4570 patients were analyzed. Data for anatomic success, VCSS, HRQoL, pain score, and adverse events were extracted and analyzed using mixed treatment comparison in a network meta-analysis. A Bayesian fixed or random effects model was selected for analysis. Rank probability graphs were generated for various treatments and corresponding ranks obtained to estimate their probability of being best. Relative treatment effects were calculated in terms of log odds ratios for anatomic success and adverse events. Mean difference was calculated for VCSS, HRQoL, and pain score. Results For the primary outcome measure (anatomic success), VenaSeal system had the highest probability of being ranked first (P = .980); RFA was ranked second (P = .365), EVLA third (P = .397), surgery fourth (P = .290), mechanochemical ablation fifth (P = .695), and sclerotherapy sixth (P = .982). For secondary outcome measures, VenaSeal system ranked third for VCSS (P = .332), fifth for EuroQol-5 Dimension (P = .420), and third for Aberdeen Varicose Vein Questionnaire (P = .300). Although, VenaSeal system was slightly inferior to some of the other interventions for HRQoL, the 95% credible interval of log odds ratio indicated insufficient evidence for any concrete conclusion to be drawn. VenaSeal system ranked first in reduction of postoperative pain score from baseline (P = .690) and was lowest in occurrence of adverse events (P = .650). Odds of occurrence of adverse events was 3.3 times in the sclerotherapy arm, 2.7 times in the EVLA arm, 1.6 times with surgery, and 1.1 times with RFA vs VenaSeal system arm. Conclusions VenaSeal system is a promising therapeutic option for anatomic success at 6 months, with fewer occurrences of adverse events (wound and groin infection, pulmonary embolism) in CVI patients compared with other interventions in this study. Additional economic analysis including cost-effectiveness analysis would provide interesting perspectives on real-world insights to patients, payers, and providers.

Background Venous thromboembolism (VTE) after coronary artery bypass graft (CABG) surgery may increase the postoperative morbidity and mortality. Therefore, we examined the current postoperative need for prophylactic antithrombotic therapy after CABG surgery. Methods This randomized, placebo-controlled, double-blind study was designed to compare the safety and efficacy of fondaparinux versus placebo in the prevention of VTE after CABG surgery. Between March 2010 and January 2013, 78 patients free from preoperative deep vein thrombosis (DVT) were enrolled, of whom 37 were randomly assigned to placebo and 41 to treatment with fondaparinux. The primary study end point was a composite, up to day 11, of ( a ) cumulative incidence of all VTE events, defined as symptomatic and asymptomatic DVT, and fatal and nonfatal pulmonary embolisms (efficacy end point), and ( b ) cumulative incidence of major hemorrhages (safety end point). Results A single asymptomatic DVT of a lower extremity was detected by duplex ultrasound at the time of discharge from the hospital in the placebo-treated group, and a single major postoperative hemorrhage occurred in the fondaparinux-treated group. Conclusions The incidence of postprocedural asymptomatic DVT in this sample of patients undergoing CABG surgery was low. The overall incidence of DVT in the control and investigational treatment groups was similar. Our results showed no benefit of prophylactic postoperative fondaparinux in this population. These findings are congruent with other published studies and provide additional support for recent recommendations not to routinely use anticoagulant prophylaxis after cardiac surgery.

Artificial Intelligence (AI), in general, refers to the machines (or computers) that mimic "cognitive" functions that we associate with our mind, such as "learning" and "solving problem". New biomarkers derived from medical imaging are being discovered and are then fused with non- imaging biomarkers (such as office, laboratory, physiological, genetic, epidemiological, and clinical-based biomarkers) in a big data framework, to develop AI systems. These systems can support risk prediction and monitoring. This perspective narrative shows the powerful methods of AI for tracking cardiovascular risks. We conclude that AI could potentially become an integral part of the COVID-19 disease management system. Countries, large and small, should join hands with the WHO in building biobanks for scientists around the world to build AIbased platforms for tracking the cardiovascular risk assessment during COVID-19 times and long-term follow-up of the survivors.

Purpose: To evaluate the 1- and 2-year patency and reintervention rates with the Zilver PTX drug-eluting stent (DES) in long complex femoropopliteal disease. Methods: A retrospective review was conducted of 89 consecutive patients (mean age 68.7±9.8 years; 86 men) with femoropopliteal occlusive disease (Rutherford category 2–6) treated with the Zilver PTX between December 2012 and December 2013. Mean lesion length for the entire cohort was 24.2±11.3 cm (median 24.0, range 4–48). The patient population was dichotomized into a short lesion (≤20 cm) group (n=41; mean lesion length 13.3±5.6 cm) and the full DES jacket (>20 cm) group (n=48; mean lesion length 33.0±6.5 cm). Primary endpoints were duplex-derived restenosis (peak systolic velocity ratio >2.5), clinically driven reintervention, and major amputation. Results: The incidence of restenosis was lower in the short lesion group at 1 year (19% vs 40% for the longer lesions, p=0.050) and 2 years (39% vs 54%, respectively; p=0.331). The short lesion group had significantly lower rates of reintervention at both 1 year (2% vs 21% in long lesions, p=0.009) and 2 years (12% vs 33%, p=0.019). Conclusion: Treatment of femoropopliteal lesions >20 cm with the Zilver PTX appears to be a clinically effective therapy for patients with symptomatic peripheral artery disease. However, there is an increase in restenosis and a need for reintervention that continues to progress up to 2 years.

Objective We previously reported 3-month and 12-month occlusion rates after treatment of clinically symptomatic saphenous vein reflux with either cyanoacrylate closure (CAC) using the VenaSeal Closure System (Medtronic, Dublin, Ireland) or radiofrequency ablation (RFA) in a randomized, multicenter, clinical trial, VenaSeal Sapheon Closure System vs Radiofrequency Ablation for Incompetent Great Saphenous Veins (VeClose). Herein we report the 24-month follow-up results of the VeClose trial. Methods There were 222 patients with symptomatic great saphenous vein (GSV) incompetence who were randomly assigned to receive either CAC (n = 108) or RFA (n = 114). Patients were not allowed to receive adjunctive treatment of tributary varicosities until after the 3-month visit. Duplex ultrasound of the target vein was performed at day 3 and months 1, 3, 6, 12, and 24 after treatment, and closure was assessed by ultrasound by the treating physician. Overall 24-month success rates were compared; in addition, time to first reopening of the target vein was evaluated using survival analysis. End points such as Venous Clinical Severity Score, EuroQoL-5 Dimension, and Aberdeen Varicose Vein Questionnaire were evaluated. Results Of 222 randomized patients, 171 completed the 24-month follow-up, which included 87 from the CAC group and 84 from the RFA group. The 24-month complete closure rate was 95.3% in the CAC group and 94.0% in the RFA group, demonstrating continued noninferiority of CAC compared with RFA (P = .0034). Symptoms and quality of life improved similarly in both groups. No clinically significant device- or procedure-related late adverse events occurred. Conclusions Both CAC and RFA were effective in closure of the target GSV, resulting in similar and significant improvements in the patient’s quality of life through 24 months. These results suggest that CAC of the GSV is safe and durable out to 2 years.

Venous duplex scanning can be divided into two different subcategories: (1) scanning to diagnose thrombus and (2) scanning to diagnose incompetence. Venous incompetence testing is used to assess th...

Venous disease is more common than arterial and lymphatic disease, resulting in significant patient morbidity and mortality. The primary diagnostic tool used to diagnose venous disease is duplex ul...

Minimally invasive endothermal treatments have replaced surgical ligation and stripping in the management of chronic venous insufficiency (CVI) and are now considered the standard of care. Newer techniques have emerged in the last few years in an attempt to further minimize the procedural discomfort associated with endothermal procedures. These new techniques are designed to avoid tumescent anesthesia (TA). These new non-thermal, tumescentless techniques are well tolerated and are shown to result in equivalent outcomes when compared to the thermal ablations. Since there is no data to support the argument that one of these therapies is truly superior to another, selection of a particular thermal or non-thermal technique is dependent on patient and physician preferences. Adoption of a particular non-thermal procedure is also dependent on other factors such as the learning curve, initial setup costs, overall cost-effectiveness and reimbursement. Once the reimbursement issues are resolved and durability is confirmed, these techniques have the potential to become the new standard of care for the management of CVI.

Cyanoacrylate closure (CAC) was shown in the recently published VenaSeal Sapheon Closure System vs Radiofrequency Ablation for Incompetent Great Saphenous Veins (VeClose) randomized clinical study to be an effective and noninferior option (in terms of both safety and effectiveness) to radiofrequency ablation (RFA) in the treatment of incompetent great saphenous veins. The objectives of this analysis were to report the efficacy and safety outcomes of the VeClose roll-in (training) group treated with CAC by physicians who had received device use training but had no prior treatment experience with the technique and to compare the outcomes with those from the randomized RFA and CAC groups.The first two subjects at each participating site (n = 20) were roll-in cases (ie, not randomized but instead treated with CAC) to ensure the physician's familiarity with the procedure. Subsequent eligible subjects were randomized to either CAC or RFA. After treatment, all subjects returned for assessment on day 3 and months 1, 3, 6, and 12. The study's primary end point was complete closure of the target vein at month 3. Secondary analyses included patient-reported intraprocedural pain and investigator-rated ecchymosis at day 3. Additional assessments included procedure time, quality of life surveys, and adverse events.Mean procedure time was longer in the roll-in group (31 minutes) compared with the randomized groups (24 minutes for CAC and 19 minutes for RFA; P .0001). Procedure time decreased in both the CAC and RFA groups over time, plateauing at about 22 minutes for CAC and 15 minutes for RFA. In the roll-in group, the 3-month complete occlusion rate was 100%. Reported intraprocedural pain ratings were similar between the roll-in and randomized groups. Other clinical assessments, including quality of life improvement and adverse events, were similar between the roll-in and randomized groups. Increasing procedure number did not affect clinical outcomes.The results from the VeClose study roll-in group demonstrate that despite the physician's lack of prior experience, initial treatment with CAC leads to comparable efficacy and safety results to RFA and is associated with a relatively short learning period.

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux, as well as venous obstruction. The most severe clinical manifestation of CVI is venous leg ulceration that can result in significant morbidity, including venous gangrene and amputation, albeit rare. Treatment modalities are aimed at reducing venous hypertension. Diuretic therapy, although widely used, only provides short-term improvement of the edema but provides no long-term benefit. Compression therapy is the cornerstone in the management of CVI. Compression can be achieved using compression bandaging, compression pumps, or graduated compression stockings. Topical steroid creams may reduce inflammation, venous eczema, and pain in the short term, but they can be detrimental in the long run. Apligraf (a living, bilayered, cell-based product) in conjunction with compression therapy was noted to be more effective in healing venous leg ulcerations, when compared with treatment with compression therapy and zinc paste. Endovascular and surgical techniques that minimize valvular reflux and relieve venous obstruction improve venous hemodynamics, promoting wound healing.

The incidence of vascular access site related complications ranges between 0.8 % to 1.8 % of diagnostic cardiac catheterization and up to 9 % of percutaneous coronary interventions (PCI) [1]. The femoral vessels at the groin are used as the access site for the majority of percutaneous coronary, peripheral arterial and venous, and electrophysiologic interventions. With emergence of endovascular abdominal aortic aneurysm repair (EVAR), thoracic endovascular aneurysm repair (TEVAR), and transcatheter aortic valve replacement (TAVR), larger access sheaths (up to 18Fr–24Fr) are required, which further increases the potential for access site complications. The true incidence of access site complications arising from non-coronary interventions is unknown; hence it is likely that the total incidence of vascular access site complications is greatly underestimated. Vascular closure devices (VCDs), radial artery access, fluoroscopic guidance, and ultrasound guidance have all been used with a hope to minimize these complications. Despite these attempts, vascular access complications have not been eliminated. Cardiovascular specialists must promptly identify these complications and manage them appropriately.

A 78-year-old man presented to our wound clinic with bilateral lower-extremity weeping ulcerations. He had been diagnosed with lymphedema 5 years previously after sigmoidectomy for obstructing adenocarcinoma. Intraoperatively, there was no evidence of gross adenopathy or metastasis. He declined further treatment or imaging at that time, and was noncompliant with lymphedema therapy. His medical history included worsening renal insufficiency and cardiac murmurs for which he declined workup. There was no history of thyroid disorder or recent travel abroad. Lower-extremity examination demonstrated stage III lymphedema of elephantine proportions …

Although compression therapy was initially described over 2,000 years ago (Felty and Rooke Semin Vasc Surg Mar 18:36-40, 1), several patients with edema do not receive appropriate compression therapy. Instead, most patients with edema are treated primarily with diuretics. Compression therapy is the cornerstone of treatment of venous edema and lymphatic disorders. Compression therapy decreases the foot and leg volume and reduces venous reflux and venous hypertension. Compression can be achieved by multiple different modalities, such as inelastic bandages; multilayered wraps; short, medium, and long stretch bandages; graduated compression stockings; and pneumatic compression devices. The major criticism of compression therapy is poor patient compliance. Compliance can be improved by selecting appropriate compression therapy tailored to the needs of the individual patient and by providing adequate patient education.

A 53-year-old man presented with sudden onset left-sided weakness. His medical history included hereditary hemorrhagic telangiectasia with recurrent epistaxis. On examination, he was hypoxemic at rest and had left-sided flaccid hemiparesis. He was noted to have multiple lower lip telangiectasias (Figure 1). Computed tomography of chest revealed bilateral segmental and subsegmental pulmonary emboli (Figure 2, arrows) and a left lower lobe arteriovenous malformation (AVM) (Figure 2, arrowhead). MRI of brain and …

Objectives To discuss the differential diagnosis of a case with leg swelling and pain with special emphasis on soft-tissue malignancy. Methods Symptomatic deep vein thrombosis (DVT) of lower limb was treated with standard anticoagulants. In view of persistent symptoms for three months, repeat duplex venography, magnetic resonance imaging (MRI) and biopsy were undertaken to uncover the underlying pathology. Results Imaging and biopsy revealed a 5 × 11 cm myxoid liposarcoma, adherent to the vein, that was the cause of her persistent symptoms despite anticoagulation, possibly by its local mass effect and also by its potential to create a thrombogenic milieu. Excision of the tumour led to symptom relief. A Medline search of English language papers was undertaken to review related literature. Conclusion The report highlights the importance of considering neo-plastic masses as differential in painful leg swelling. Diagnosis is made by a high index of suspicion in atypical cases and confirmed by follow-up duplex or MRI. Treatment involves surgical excision that provides symptom relief as well as avoids potential tumour extension.

Heparin-induced thrombocytopenia is an immune-mediated syndrome that results from unfractionated heparin or low molecular weight heparin exposure. It often remains unrecognized and undertreated and can cause limb and/or life-threatening thrombosis. The authors present 2 cases of thrombosis: one arterial and the other venous that occurred following endovascular abdominal aortic aneurysm repair. To the authors' knowledge, this is only the second report of arterial thrombosis and the first of deep vein thrombosis as a result of heparin-induced thrombocytopenia developing following endovascular abdominal aortic aneurysm repair. This underscores the importance of considering heparin-induced thrombocytopenia as a potential cause for postendovascular thrombotic complications in the patient who develops thrombocytopenia following this procedure.

An increased prevalence of coronary heart disease (CHD) has been well documented in the South Asian population living worldwide. The prevalence of certain traditional CHD risk factors, like diabetes mellitus and tobacco use, have been on the rise in this ethnic group and likely contribute to the increase in CHD prevalence. Still, a disproportionate excess of CHD exists, and this may be linked to novel CHD risk factors. We have reviewed the prevalence of CHD in South Asians and its association to both traditional and novel CHD risk factors. We present a literature review of traditional and novel CHD risk factors, and incorporate the results of a cross-sectional study investigating the prevalence of these factors in a South Asian population residing in the United States with no prior diagnosis of CHD. The total cholesterol (TC) (mean ± standard deviation) was 193.72 ± 33.76 mg/dL, high-density lipoprotein (HDL) was 42.20 ± 12.11 mg/dL, and low-density lipoprotein (LDL) was 124.88 ± 27.22 mg/dL. The mean triglyceride level was 166.60 mg/dL. The prevalence of elevated TC (200 mg/dL) was 41.3% and elevated LDL (130 mg/dL) 40.7%. There was a significant difference between men and women in the prevalence of reduced HDL (40 mg/dL) (67.3% vs. 49.4%), elevated triglycerides (130 mg/dL) (56.4 vs. 30.4%), and small-dense LDL particles (53.6% vs. 27.8%). Considerably higher prevalence of novel CHD risk factors has been noted in the South Asian population. The CHD risk may increase significantly when these novel factors co-exist with traditional CHD risk factors.

A 69-year-old female with a history of coronary artery disease, smoking, stenosis of the distal aorta, and squamous cell carcinoma of the tongue was referred for pre-operative cardiovascular clearance for jaw reconstruction surgery. She complained of lifestyle-limiting bilateral hip, buttock, thigh, and calf claudication, with an initial claudication distance of one-half city block and an absolute claudication distance of one city block. Her ankle brachial index (ABI) was noted to be 0.36 on the right leg and 0.43 on the left leg. Segmental pressures and pulse volume recordings suggested disease at the aortoiliac segment. A CT angiogram demonstrated aortic occlusion, collateralization between the internal mammary arteries (IMA) and inferior epigastric arteries (IEA), and reconstitution of the infra-inguinal vessels bilaterally (Panels A and B; CFA = common femoral artery). The patient underwent cardiac catheterization due to significant ischemia on a dipyridamole tomographic dual isotope scan. A selective angiogram of the IMAs confirmed the IMA-IEA collateralization along with antegrade flow within the IMA branches and retrograde flow (caudad) within the IEA branches bilaterally.

A 61-year-old Caucasian female with prior history of bilateral femoro-popliteal bypass grafts, chronic venous insufficiency and long-standing rheumatoid arthritis was admitted with painful bilateral lower extremity ulcerations. Presumptive diagnosis of infected venous or vasculitic ulcers was made and vascular medicine consultation was obtained. Anterolateral aspects of bilateral lower extremities were erythematous and revealed several tender ulcers with well-defined edges. The ulcer bases were composed of predominantly pale granulation tissue and serous discharge (Panel A). Ankle‐brachial index and toe pressures were normal at rest. Pertinent laboratory results included a rheumatoid factor of 392 IU/ml and a Westergren sedimentation rate of 115 mm/h. The serum cryoglobulins, C-ANCA, PANCA and complement levels (C3/C4) were within normal limits. An MRI did not suggest osteomyelitis. A wound biopsy was requested due to the atypical nature of the ulcers and revealed cutaneous large T-cell lymphoma. Panel B shows the microscopic appearance of the large T-cell lymphoma with angioinvasive features. Beneath an ulcerated epidermis, malignant lymphoid cells infiltrate the deep dermis and subcutis and invade small and medium-sized arterioles in the deep dermis (1: hematoxylin and eosin, 200). At higher magnification, the cells have a large cell morphology (2: hematoxylin and eosin, 400). Immunohistochemistry for the T-cell-associated antigen CD3 shows a brown colorimetric reaction decorating the cytoplasmic membranes of the neoplastic cells (3: anti-CD3, 400). CHOP chemotherapy was started but she died several months after the diagnosis. Malignant transformation of chronic ulcers is well documented, although uncommon. 1 Patients with rheumatoid arthritis frequently present with leg ulceration 2 and are at increased risk for lymphoma. 3