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Objective Chronic venous insufficiency (CVI) has an increased prevalence among obese individuals with body mass indices (BMI) over 30. A safe, efficacious, and evidence-based recommended treatment for CVI due to superficial venous reflux (SVR) in great saphenous veins (GSVs), small saphenous veins (SSVs), accessory saphenous veins (ASVs), and reflux in the perforator veins (PVs) is endovenous thermal ablation (EVTA). We sought to identify if BMI is an independent risk factor for recanalization after EVTA. Methods All patients with CVI were initially managed conservatively, and those with pathologic SVR refractory to compression therapy were offered EVTAs depending on the site of reflux. Sonographic confirmation of SVR was defined as >500 milliseconds of reflux in the GSVs, SSVs, and ASVs and a diameter >4 mm. PV reflux was confirmed as >350 milliseconds of reflux and a diameter >2.5 mm. All patients received a follow-up duplex ultrasound 1 week after the procedure, every 3 months for the first year, and every 6 months thereafter. Multivariate analysis with logistic regression was performed regarding patients' age, ablation modality (laser vs radiofrequency ablation), vein location and laterality, BMI, and recanalization. Results From 2013 to 2018, 9739 endovenous ablations were performed on 3070 patients. Endovenous laser was used in 3862 procedures and radiofrequency ablation in 5831 procedures. Veins treated with EVTA were distributed as follows: 6182 GSVs, 2509 SSVs, 597 ASVs, and 451 PVs. The mean patient age was 61.1 years (15-99, standard deviation [SD] ±15.6) with a mean BMI of 31.2 kg/m2 (13.7-69.5, SD ±7.3). A total of 68.4% patients were women and 31.4% men. The mean follow-up was 25.8 months (0-65.9, SD ±12.9). Multivariate statistical analysis with logistic regression was used to determine potential statistical significance between BMI and vein recanalization after EVTA. Overall, obese patients experienced more recanalizations than nonobese patients (P = .032), with an average BMI of 33 kg/m2 for recanalizations. PVs were statistically more likely to recanalize than any other vein (P = .0001). A secondary analysis was performed with the exclusion of PVs, due to their five times increased risk of recanalization, and showed no significant difference of recanalization across all BMI subgroups (P = .127). Conclusions BMI does not predict recanalization risk after EVTA, except for ablations performed on PVs.

To determine whether differences exist in fluoroscopy time and radiation exposure during lower extremity endovascular procedures performed by fellowship trained vascular surgeons vs general surgeons, to minimize radiation exposure to operating room staff.A retrospective review of all lower extremity endovascular procedures was performed from August 1, 2014, to January 29, 2016. The procedures were performed by the surgical department's four surgeons with endovascular privileges: two vascular surgeons and two general surgeons. Only procedures involving lower extremity arterial angiograms with balloon angioplasty, stenting, or atherectomy were included. The operative records were reviewed for each case. The total fluoroscopy time and total radiation dose for each procedure were recorded. Procedures were grouped according to the number of endovascular interventions as one to two interventions, three to four interventions, and five or more interventions performed. Statistical analysis was performed with a P value of less than .05 considered significant.About 271 lower extremity endovascular procedures were performed during the study period by 4 surgeons. The average age of the patient population was 70 years. The total number of procedures performed over the study period were 112, 45, 91, and 25 for surgeons 1 through 4, respectively. On average, 3.24 interventions were performed during each procedure. Vascular surgeons were found to have shorter fluoroscopy time for procedures involving one to two (7.8 vs 30.1; P .01), three to four (9.3 vs 34.2; P .01), and five or more (11.5 vs 51.9; P .01) interventions. Vascular surgeons were also found to have less radiation exposure compared with general surgeons in procedures with one to two (1.69 vs 3.53; P = .001) and five or more (2.3 vs 5.4; P = .003) interventions. There was no significant difference in radiation exposure between vascular and general surgeons for procedures with three to four interventions (5.86 vs 5.59; P = .95).In this small series at our institution, lower extremity endovascular procedures performed by specialty trained vascular surgeons were associated with both decreased operative fluoroscopy time and decreased radiation exposure when compared with general surgeons.

ImportanceA transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS).ObjectiveTo quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach.Design, Setting, and ParticipantsThis retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022.ExposuresMonth and year of surgery as well as patient risk status.Main Outcomes and MeasuresNumber and proportion of carotid revascularization procedures by operative approach.ResultsA total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P P P Conclusions and RelevanceResults of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.

Introduction: Inhibitors of programmed cell death receptor (PD-1) and its ligand (PD-L1), such as nivolumab and pembrolizumab, confer anti-autoimmune activities and are therefore approved for anti-cancer therapy. Their mode of action removes autoimmunity checkpoints, thus increasing the risk of immune-related adverse events. Case Presentation: This report describes a clinical case of life-threatening diabetic ketoacidosis (DKA) in a patient after long-term nivolumab administration to treat primary central nervous system lymphoma (PCNSL). The patient presented to the emergency department (ED) with symptoms of fatigue, along with nausea and vomiting for two days; laboratory testing revealed significant hyperglycemia (glucose 673 mg/dL), elevated anion gap (>27), metabolic acidosis, ketonemia, glucosuria and ketonuria, findings of which were consistent with DKA. Given no personal history of diabetes mellitus or other autoimmune conditions and additional tests ruling out alternative causes, the patient was suspected of having newly-onset DKA secondary to nivolumab treatment. Management & Outcome: The patient was treated with fluids, electrolytes replenishments and insulin drip, which closed the anion gap and normalized electrolytes. She was transitioned to subcutaneous insulin. The patient recovered well and was discharged on Metformin and longacting insulin, with close follow-up with endocrinology and oncology. Discussion: Autoimmune endocrinopathies induced by checkpoint inhibitors for cancer treatment have been reported in the past. Newly-onset hyperglycemia and DKA are common autoimmunemediated side effects of checkpoint inhibitor uses in patients without prior history of diabetes mellitus. Clinicians should be aware to prevent this potentially life-threatening condition.

Objectives: Iliac vein stenting is a relatively new procedure in the treatment of chronic venous insufficiency. Research has shown that it is a safe and effective form of treatment, however, one of the well-known risks is in-stent thrombosis. We hypothesize that a single 75 mg dose of Clopidogrel the night prior to the procedures along with a 3-month regimen post-op would decrease the 30-day thrombosis rate. Methods: A retrospective study was performed on 3,518 patients from September 2012 to August 2018 who received an iliofemoral stent. Patients were broken down into 2 main groups: those given Clopidogrel post-stent and those given Clopidogrel both pre- and post-stent. In our practice, we prescribe a 3-month course of Clopidogrel after iliac vein stenting. Patients were also checked for any anticoagulant medications pre- and/or post-stent. The 30-day thrombosis rates were recorded for each patient. Results: 1,205 patients received Clopidogrel pre-procedurally and post-procedurally, 1,941 patients received Clopidogrel only post-procedurally. 372 patients were excluded from the study because they were on other anti-coagulant medications. Mean follow-up for this cohort was 17 months. 112 total patients developed some degree of 30 day in-stent thrombosis (3.6%). 74 patients developed a complete thrombosis of the stent and 38 developed a partial (≤60% occlusion) thrombosis. Of the 1,205 patients who were on clopidogrel pre-stenting, 28 had a complete thrombosis and 10 had a partial in-stent thrombosis. Of the 1,941 patients on Clopidogrel only post-stenting, 46 had a complete thrombosis and 28 had a partial in-stent thrombosis. Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day any degree of thrombosis rates (complete and partial thrombosis) (p = .33). Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day complete thrombosis rates (p = .93). Conclusions: There appears to be no statistical difference in 30-day thrombosis rates between those receiving Clopidogrel the night prior vs. those who do not receive Clopidogrel the night prior. Therefore, we conclude that it is not necessary to give this single dose the night prior to iliac vein stenting procedures.

Objectives The COVID-19 pandemic has had major implications for the United States healthcare system. This survey study sought to identify practice changes, understand current personal protection equipment (PPE) use, and determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers versus low case numbers. Methods A fourteen-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons’ current practice was sent to 365 vascular surgeons across the country via REDCap from 4/14/2020 to 4/21/2020 with responses closed on 4/23/2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania and California) differed from those with lower case numbers (all other states). Results A total of 121 vascular surgeon responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between high case and low COVID case states (p=0.285). High case states were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case types did not differ. Most attendings work with residents (90.8%) and limited their exposure to procedures on suspected/confirmed COVID-19 cases (56.0%). Thirty-eight percent of attendings have been redeployed within the hospital to a vascular access service, and/or other service outside of vascular surgery. This was more frequent in high case volume states compared to low case volume states (p=0.039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons feel that they do not have adequate PPE to perform clinical their duties. Conclusion The initial response to the COVID-19 pandemic has resulted in reduced elective cases with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty, however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey., ARTICLE HIGHLIGHTS: Type of research: Nationwide survey of attending vascular surgeons Key Finding: Most of the 121 vascular attendings who responded are limiting resident involvement in COVID-19 positive cases, 38% of attendings have been redeployed to services other than traditional vascular surgery, such as the ICU and vascular access service, and 71% are reusing personal protective equipment (PPE). Twenty-one percent of vascular surgeons do not feel they have adequate access to PPE. Take Home Message: There have been major changes to vascular surgery practice during the COVID-19 pandemic.

Objective Whereas the commonly described manifestations of venous insufficiency include telangiectasia, varicose veins (VVs), edema, skin changes, and ulcers, we have noted some patients who present with external hemorrhage from lower extremity VVs. Because there are few recent data examining this entity, we herein describe our experience. Methods During 29 months, we had 32 patients present with hemorrhage from lower extremity VVs. There were 15 men and 17 women with a mean age of 60.2 years (range, 38-89 years; standard deviation [SD], ±14.9 years). Interestingly, 16 of these patients presented after coming into contact with warm water; 28 patients, 19 patients, and 1 patient presented with reflux >500 milliseconds in the great, small, and accessory saphenous veins, respectively. Eight patients and six patients had reflux >1 second in the femoral and popliteal veins, respectively. Results All patients were treated with weekly Unna boots. Mean ulcer healing time was 2.12 weeks (range, 1-8 weeks; SD, ± 2.15 weeks). Patients with VV hemorrhage after contact with warm water had a mean healing time of 1.75 weeks, whereas those who bled without such exposure took an average of 3.5 weeks (P = .0426). Twenty patients underwent at least one endovenous thermal ablation procedure, with the average patient in the cohort receiving 2.16 procedures (range, 0-9; SD, ± 2.37). There was no significant difference between laterality, age, or sex between patients who bled after warm water contact and those who bled spontaneously. The ulcers recurred in three of the patients, and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2 months (range, 26 months; SD, ± 8.9 months), and we noted no recurrent bleeding episodes. Conclusions Spontaneous hemorrhage of VVs, although relatively under-reported, is not a rare occurrence. Risk factors are unknown; however, half of our patient cohort reported VV hemorrhage during or directly after coming into contact with warm water. Furthermore, these patients demonstrated a significantly shorter wound healing time compared with the rest of the cohort. Basic first aid, wound care, and hemostasis control education should be provided to all patients with VVs. Further investigation surrounding the risk factors associated with VV hemorrhage is warranted.

Background Endovenous thermal ablation has become the procedure of choice in the treatment of superficial venous reflux disease. The current armamentarium of devices and techniques aimed at the elimination of saphenous reflux offers surgeons and interventionalists a variety of treatment options; however, there is a lack of data comparing the safety of these products. The most concerning complication after endovenous thermal ablation is endothermal heat-induced thrombosis (EHIT) due to the risk of progression to deep venous thrombosis. This study aimed to compare the incidence rate of EHIT between radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Methods This was a single-center, office-based, retrospective study over the course of 5 years, in which 3,218 consecutive patients underwent 10,029 endovenous saphenous ablations. The patient cohort was 66.2% female, with an average age of 61.9 years. At the time of each individual intervention, 24, 212, 3,620, 4,806, 200, and 1,167 patients had Clinical-Etiology-Anatomy-Pathophysiology disease 1, 2, 3, 4, 5, and 6, respectively. Results There was a total of 3,983 EVLT and 6,091 RFA procedures. The most common vessel treated was the great saphenous vein, 63.6% of the time, followed by the small saphenous vein (25.6%), accessory saphenous vein (6.1%), and perforator vein (4.6%). There were 186 cases of EHIT, with 137 (73.6%) identified as type 1 as per the Kabnick classification. Endovenous ablation performed via RFA resulted in significantly more cases of EHIT than of EVLT (109 vs. 77; P = 0.034; odds ratio = 1.52), which was confirmed by a multivariate analysis. Conclusions In the largest single-center study of endovenous saphenous ablations to date, RFA was shown to pose a significantly higher risk of EHIT than of EVLT.

Age ≥80 years is known to be an independent risk factor for periprocedural stroke after transfemoral carotid artery stenting (TF-CAS) but not after carotid endarterectomy (CEA). The objective of the present study was to compare the perioperative outcomes for CEA, TF-CAS, and transcarotid artery revascularization (TCAR) among octogenarian patients (aged ≥80 years) overall and stratified by symptom status and degree of stenosis.All patients aged ≥80 years with 50% to 99% carotid artery stenosis who had undergone CEA, TF-CAS, or TCAR in the Vascular Quality Initiative (2005-2020) were included. We compared the perioperative (30-day) incidence of ipsilateral stroke or death for CEA vs TF-CAS vs TCAR using analysis of variance and multivariable logistic regression models. The results were confirmed in a sensitivity analysis stratified by symptom status and degree of stenosis.Overall, 28,571 carotid revascularization procedures were performed in patients aged ≥80 years: CEA, n = 20,912 (73.2%), TF-CAS, n = 3628 (12.7%), and TCAR, n = 4031 (14.1%). The median age was 83 years (interquartile range, 81.0-86.0 years); 49.8% of the patients were symptomatic (51.9% CEA, 46.2% TF-CAS, 42.4% TCAR); and 60.7% had high-grade stenosis (59.0% CEA, 65.2% TF-CAS, 65.4% TCAR). Perioperative stroke/death occurred most frequently following TF-CAS (6.6%), followed by TCAR (3.1%) and CEA (2.5%; P .001). After adjusting for baseline differences between groups, the odds ratio (OR) for stroke/death was greater for TF-CAS vs CEA (adjusted OR [aOR], 3.35; 95% confidence interval [CI], 2.65-4.23), followed by TCAR vs CEA (aOR 1.49, 95% CI 1.18-1.87). The risk of perioperative stroke/death remained significantly greater for TF-CAS compared with CEA regardless of symptom status and degree of stenosis (P .05 for all). In contrast, the risk of stroke/death was higher for TCAR vs CEA for asymptomatic patients (aOR, 2.04; 95% CI, 1.41-2.94) and those with high-grade stenosis (aOR, 1.49; 95% CI, 1.11-2.05) but similar for patients with symptomatic and moderate-grade disease (P.05 for both). The risk of myocardial infarction was lower with TCAR (aOR, 0.59; 95% CI, 0.40-0.87) and TF-CAS (aOR, 0.56; 95% CI, 0.40-0.87) compared with CEA overall.Overall, TCAR and CEA can be safely offered to older adults, in particular, symptomatic patients and those with moderate-grade stenosis. TF-CAS should be avoided in older patients when possible.

Objective Endothermal ablation as endothermal laser ablation (EVLA) or Radiofrequency ablation (RFA) is being progressively more employed for small saphenous vein (SSV) insufficiency treatment. Prior studies have shown recurrence rates of 0% to 10% in incompetent small saphenous veins (ISSVs). The objective of this study is to determine the efficacy of redo venous ablations for symptomatic recanalized SSVs and to predict factors related with recanalization. Methods A retrospective analysis of 2,566 procedures in 1,752 patients with CVI due to ISSVs from 2012 to 2018 was performed, using individual chart review for data extraction. All 2,566 procedures were performed using endothermal ablation in patients who failed initial conservative management. Postoperative duplex ultrasound scans were performed within 3 to 7 days. We defined a successful obliteration as a lack of color flow by postoperative duplex scan. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel at follow-up. We conducted follow-ups every 3 months in the first year, followed by every 6 months subsequently. Results Among the 2,566 procedures, redo ablation was performed in 91 ISSVs (86 patients), including 58 women and 28 men. 54 procedures were performed on the left lower extremity, 37 were performed on the right lower extremity. The average Body Mass Index (BMI) was 32.2 ± 7.66. The mean age was 62.4 ± 15.10 years. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classes of the patients were: C1, 0; C2, 0; C3, 29; C4, 43; C5, 1; and C6, 18. The mean maximum diameter of the targeted veins, for the redo procedures, was 4.51± 1.33 mm. Forty procedures were performed using EVLA, 51 were performed using RFA. Initial technical success was 98.9%. Redo procedures had an early closure of 96.7%. At follow up after a mean duration of 24.9 ± 14.9 months, closure was 96.5%. No correlation was found between successful obliteration in the redo procedure and age, gender, CEAP, laterality, EVLA vs. RFA, BMI, or vein diameter. Conclusions Rates of successful closure for ISSVs on initial and redo procedures are comparable. The data validate the potential usefulness of performing redo SSV ablations.

Since the onset of the COVID-19 pandemic, a concentrated research effort has been undertaken to elucidate risk factors underlying viral infection, severe illness, and death. Recent studies have investigated the association between blood type and COVID-19 infection. This article aims to comprehensively review current literature and better understand the impact of blood type on viral susceptibility and outcomes.

Objective Iliac vein stenting of nonthrombotic iliac vein lesions is an evolving treatment course for management of chronic venous insufficiency. To characterize these lesions, we examined our experience treating these lesions with balloon venoplasty before stenting. Methods A retrospective analysis was performed to study all patients who underwent venograms with venoplasty and stenting of iliac veins from February 2013 to July 2016. All patients included in the study were treated with a trial conservative management for 3 consecutive months before venogram and, if indicated, venoplasty was performed. If a greater than 50% reduction in cross-sectional area or diameter was observed on intravascular ultrasound examination, the stenotic area was treated with balloon angioplasty, sized to nonstenotic distal vein segment (range, 10 × 40 mm to 16 × 60 mm). Intravascular ultrasound examination was also used to measure the area of stenotic iliofemoral veins before and after balloon angioplasty. Results A total of 1021 venograms with venoplasty and stenting of iliac veins were performed in 713 patients from February 2013 to July 2016. The mean age of the study population age was 64.88 years (range, 21-99 years; standard deviation [SD], 14.57), with 451 female and 262 male patients. Before angioplasty, the mean cross-sectional stenotic area was 67.97 mm2 (range, 6-318 mm2; SD, 34.87). After balloon angioplasty, the mean stenotic area increased to 78.80 (range, 6-334 mm2; SD, 44.50; P 10% of baseline before venoplasty); group B, decreased ( Conclusions Our data show there is a highly variable response after venoplasty of stenotic area of nonthrombotic iliac vein lesions. Balloon venoplasty showed greater improvement in improving the area of stenotic left-sided lesions. However, stenting of the lesions should be performed routinely owing to recoil and spasm in lesions.

Objectives Drug-eluting stents (DES) have been promoted as an alternative to the traditional non-drug eluting stents (nDES), and offer the potential for improved patency rates. However, DES are more expensive than nDES, and results comparing these stents outside of clinical trials have been limited. Materials and methods A retrospective review was performed on all in patient infrainguinal lower extremity endovascular procedures between January 2014 and September 2016, which involved stent implantation. Procedures involving the common femoral artery, superficial femoral artery, and above knee popliteal artery were included. Procedures involving iliac, below knee popliteal, tibial, peroneal, and pedal arteries were excluded. The type of stent, number of stents, length of each stent, and location of stent were recorded for each procedure. Data on each patients Trans-Atlantic Inter Society Consensus II class were collected. End-points included stent thrombosis, restenosis, re-intervention, and limb loss. Post-operative arterial duplexes were obtained every three months to determine stent patency during follow-up visits. In-stent stenosis was defined as >60% narrowing on arterial duplex. Thrombosis was defined as in-stent occlusion, and limb loss involved only major amputations in the treated extremity. Bivariate analysis and Students two-sample T-test were used to analyze the data. IBM-SPSS – 22 was used for all analyses. Results Two hundred and twelve patients underwent at total of 252 procedures during the study period. Of this group, 191 procedures met inclusion criteria. There were 21 lesions that were treated with both nDES and DES and they were excluded from further analysis. The average patient age was 73.2 ± 11.6 years; 68.6% had hypertension, and 58.1% had diabetes. Mean follow-up was 7.18 ± 7.96 months. The most common indication for intervention was claudication (53%), followed by critical limb threatening ischemia (47%); 124 procedures involved only nDES (Lifestent®)(Bard, Tempe, AZ), 46 procedures involved only DES (Zilver®) (Cook, Bloomington, IN). Comparison of nDES and DES showed the overall rate of thrombosis (11.1% vs. 16.7%, p = 0.81), overall rates of re-stenosis (48.2% vs. 46%, p = 1.0), re-intervention (13.7% vs. 14.3%, p = 1.0), and limb loss (9.7% vs. 0.0%, p = 0.38) was equivalent between the groups. The six-month primary patency rate for nDES and DES (41.9% vs. 40.0%, p = 1.0) was also equivalent. On average, the average lengths of nDES were longer than DES (19.2 ± 14.3 cm vs.11.4 ± 5.7 cm) ( p Conclusions In this retrospective analysis from one institution, the use of an nDES or DES did not result in a statistically significant difference in the rate of thrombosis, re-stenosis, ipsilateral re-intervention, or ipsilateral amputation over a two-year period when involving the CFA, SFA, and above knee popliteal artery.

Objective Iliac vein stenting is increasingly being explored for the treatment of chronic venous insufficiency. While venography is considered the gold standard for assessing iliac veins, some have proposed that intravascular ultrasound should be utilized instead due to its greater sensitivity at detecting stenotic lesions. Routinely, our service uses both intravascular ultrasound and venography, but we have noted that some patients cannot tolerate dye due to allergy, renal insufficiency, or deemed high-risk by the interventionalist due to uncontrolled medical co-morbidities. This study aimed to investigate whether forgoing dye had an impact on iliac vein stent thrombosis. Methods From 2012 to 2016, 1482 iliac vein procedures (91 intravascular ultrasound-only and 1391 intravascular ultrasound plus venography) were performed on 992 patients who failed conservative treatment for chronic venous insufficiency. Our mean patient age was 65.8 years (range 21–99; SD ± 14.3) with 347 male and 645 female patients. The clinical presenting symptoms per clinical–etiology–anatomy–pathophysiology classification for the intravascular ultrasound-only cohort were C1:0, C2:3, C3:31, C433, C5:5, C6:20 and for the intravascular ultrasound plus venography cohort were C1:0, C2:24, C3:566, C4:583, C5:30, C6:188. Stent thrombi that developed within or at 30 days of stenting were categorized as early and greater than 30 days as late. Transcutaneous duplex ultrasound classified stent thrombi as either partial or occlusive. Our average follow-up time was 19.4 months (0–42, SD ± 12.5). Results A total of 2.2% intravascular ultrasound-only patients versus 2.75% intravascular ultrasound plus venogram patients developed early stent thrombosis, p = 0.35. Early partial stent thrombosis occurred in 1.1% of the intravascular ultrasound-only group versus 2.6% of the intravascular ultrasound plus venogram group, p = 0.38. Early occlusive stent thromboses occurred in 1.1% of intravascular ultrasound-only patients and 0.15% of intravascular ultrasound plus venogram patients, p = 0.06. Late stent thromboses developed in 4% of patients in the intravascular ultrasound-only cohort and 4% in the intravascular ultrasound plus venogram cohort, p = 0.97. Late partial stent thromboses occurred in 2.7% of intravascular ultrasound-only patients versus 2.6% in intravascular ultrasound plus venogram patients, p = 0.99. Late occlusive stent thromboses occurred in 1.3% of intravascular ultrasound-only patients versus 1.4% of intravascular ultrasound plus venogram patients, p = 0.95. Moreover, the formation of any stent was 6.2% in the intravascular ultrasound-only versus 6.75% in the intravascular ultrasound plus venogram group, p = 0.55. Conclusion Results of our study show no significant difference in stent thrombosis between the intravascular ultrasound-only and intravascular ultrasound plus venogram cohorts. This concludes that using intravascular ultrasound alone is safe for iliac vein stenting.

Objective: It has been a widely accepted practice that a previous placed pacemaker, automatic implantable cardioverter defibrillators, or central line can be a contraindication to placing a hemodialysis catheter in the ipsilateral jugular vein. Fear of dislodging pacing wires, tunneling close to the battery site or causing venous obstruction has been a concern for surgeons and interventionalists alike. We suggest that this phobia may be unfounded. Methods: A retrospective review was conducted of patients in whom hemodialysis catheters were placed over a period of 10 years. For each hemodialysis catheter that was placed, perioperative chest X-ray performed was used to evaluate for pre-existing pacemakers and central lines. The position and laterality of placement of the hemodialysis catheter along with presence of arteriovenous fistula with functional capacity for access were noted. Results: A total of 600 hemodialysis catheters were placed in patients over the period of 10 years. The mean age of the patients was 73.6 ± 12 years with a median age of 76 years. We found 20 pacemakers or automatic implantable cardioverter defibrillators and 19 central lines on the same side of the neck as the hemodialysis catheter that was placed in the ipsilateral jugular vein. No patient exhibited malfunction or dislodgment of the central line, the pacemaker, or automatic implantable cardioverter defibrillator or evidence of upper extremity venous obstruction based upon signs symptoms or duplex exams. Conclusion: Based on our experience, we suggest that placement of hemodialysis catheter in the internal jugular vein ipsilateral to the pre-existing catheter/leads is safe and spares the contralateral limb for arteriovenous fistula creation.

Objective Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive “back-up plan.” Methods This is a retrospective analysis of data collected from March 2014 to January 2018 of 18 patients who underwent TEVAR at a tertiary care facility with a level I trauma center. There were 11 males and 7 females with an average age of 68.8 years old (range 19–97; SD ± 19.52). The average body mass index (BMI) was 24.7 kg/m2 (range 16.8–35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2). Results The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3–6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3–166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support. Conclusion These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.

Vasospasm-induced acute limb ischemia (ALI), also known as vasospastic limb ischemia (VLI), is a rare, underreported vascular event. Unlike thrombotic and embolic occlusive etiologies, which often warrant revascularization, vasospasm is a transient phenomenon that may be successfully managed conservatively without surgical intervention. Thus, prompt recognition and accurate diagnosis of VLI is imperative to avoid unnecessary surgical or endovascular procedures. This diagnosis, however, can pose as a challenge for clinicians, as it can present with clinical signs and symptoms near-identical to the presentation of thrombotic-induced ALI. In this report, we present a patient that experienced 2 vasospasm-induced ischemic events; the patient developed Rutherford IIb acute limb-threatening ischemia following cardiac catheterization for myocardial infarction. Computer tomography angiography findings of her right leg revealed acute occlusion suggesting the need for immediate operative intervention for limb salvage. However, due to her critical state, she instead was managed with medical treatments. Despite no intervention, the patient had full resolution of her right leg symptoms. We present this case to highlight the unusual multifocality of vasospastic events and to increase awareness of the diagnostic challenges associated with VLI.

Background Ureteral arterial fistulas are rare but potentially life threatening. We present a female who developed a ureteral arterial fistula following a right robotic nephrectomy. After several endovascular interventions to control the bleeding had failed, we approached the fistula through the right ureteral stump with coil embolization. Methods Coil embolization of the right ureteral stump was performed. We utilized a 6Fr × 45 cm sheath inserted through one of the cystoscope channels to cannulate the right ureteral orifice. We then performed a retrograde ureterogram. After, we were able to visualize full length of the ureter, ahd we began placing several 10–12 mm Nester coils to pack the ureter and tamponade the fistula for hemostasis. After the ureter was packed, we injected 1 g of Vancomycin into the ureter. The sheath and cytoscope were removed and the patient did well and was sent to the recovery room. Results Postoperatively, the patient had no complaints of hematuria and her hemoglobin level remained unchanged. She was observed for a few days prior to being discharged to home. The patient’s follow-up at six months revealed resolution of her hematuria. Conclusion Ureteral arterial fistula is a potentially life-threatening condition. Endovascular stenting has provided a safe, reliable alternative to open surgery. However, when endovascular options are not satisfactory, coil embolization of the ureteral stump may serve as a safe and effective alternative treatment for these cases.

Objective Catheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. Methods A retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. Results Primary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. Conclusions FTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions.

Objective True profunda femoris artery aneurysm (TPFAA) is rare. Most cases of profunda femoris artery aneurysm are classified as pseudoaneurysms. TPFAAs are mostly asymptomatic, but some are manifested with pain, swelling, paresthesia, gait and movement disturbances, thrombosis, and rupture. There is a paucity of evidence on the effectiveness of diagnostic and therapeutic measures for management of TPFAA. The aim of this paper was to systematically review the incidence, diagnosis, and management of TPFAA. Methods A comprehensive systematic review on the diagnosis and management of TPFAAs was conducted by a search through PubMed, Cochrane, Embase, and Google Scholar databases to identify and to evaluate publications on TPFAA since 2012. Only publications on TPFAA were included in this review. Results A total of 19 publications published from 2012 were included in the review. The studies were 18 case reports and a cadaver study reporting 27 TPFAAs in 26 patients with a mean age of 69.6 years. Rupture was reported in 18.5% of the cases (n = 5); the conventional clinical presentation of unruptured TPFAA was reported in 48% of cases (n = 13), with 40.9% of unruptured aneurysms being asymptomatic (n = 9). Computed tomography angiography was used as a diagnostic tool in 85.2% of the cases (n = 23); Doppler ultrasound was applied in 33.3% of cases (n = 9). The common therapeutic approaches were resection and revascularization (n = 13 [48.1%]) and ligation or resection without reconstruction (n = 6 [22.2%]). Cumulative analysis for cases reported before and after 2012 yielded similar results. Conclusions Review of the current literature supports that computed tomography angiography and Doppler ultrasound are the mainstay diagnostic approaches for TPFAA. Surgical repair through ligation, resection, and revascularization remains the most common and effective therapeutic procedure. Endovascular embolization is recommended for aneurysms when surgery is not tenable because of the patient's comorbidities and the aneurysm's anatomy.

Objective Lower extremity endovenous ablation has become the primary treatment modality for symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) has been reported as one of the primary complications of these venous ablative procedures. Our aim was to determine how long EHITs take to resolve and the factors affecting this length of time. Methods A retrospective analysis was performed of 10,029 consecutive procedures from March 2012 to September 2018 performed on 3218 patients who underwent endovenous ablation for lower extremity venous reflux. There were 6091 procedures performed with radiofrequency ablation (RFA) and 3938 with endovenous laser ablation (EVLA). Postprocedural venous duplex ultrasound was performed to evaluate for EHIT and recanalization at 3 to 7 days, every 3 months for the first year, and every 6 to 12 months thereafter. JMP version 14 (SAS Institute, Cary, NC) was used for all statistical analysis. Results EHIT was found to have developed in 186 patients; 109 patients had been treated with RFA and 77 with EVLA. The average age of the patients receiving EVLA in whom EHIT developed was 59.97 ± 11.61 years. The patients who received RFA and in whom EHIT developed had an average age of 73.4 ± 9.64 years. The average time of resolution for the EVLA group was 75 ± 71.97 days. The average resolution time for the RFA group was 139.8 ± 232.52 days. There were no statistical differences between EHIT resolution times and age, sex, body mass index, clinical class, laterality, type of vein treated, or whether the patient was taking clopidogrel preoperatively or postoperatively. A statistical difference was found between EHIT resolution time and whether the patient was treated with EVLA or RFA (P = .0332). Conclusions Our study seems to suggest that EHIT resolution times may be related to the difference in treatment modality between EVLA and RFA. The data suggest that EHIT resolves more quickly with the use of EVLA than with RFA.

Objective Iliac vein stenting has been an evolving treatment option in the management of CVI secondary to iliac vein obstruction. Historically, treatment of CVI has been focused on the elimination of saphenous vein disease; however, the effect of reduction of iliac vein obstruction on superficial venous reflux remains largely unknown. This study aimed to identify the effect of iliac vein stenting on saphenous vein reflux. Methods In this retrospective study spanning course of five years, we performed 2681 venograms with venoplasties and stenting of the iliac veins. Pre-operative and post-operative venous mapping was performed via duplex ultrasonography. Patients who received any lower extremity vascular intervention between “pre-” and “post-stenting” duplex ultrasonography examination, other than iliac vein stenting, were excluded from analysis. Results One thousand six hundred forty-five patients, of which 63.2% were female, underwent iliac vein stenting; 1033 patients received bilateral intervention, whereas 356 and 259 patients received unilateral left and right stenting, respectively. The average age of the patient cohort was 66 (range 22–100; SD ± 13.9). The distribution CEAP scores of each limb at the time of intervention were: C2 (1%), C3 (25%), C4 (51%), C5 (5%), and C6 (18%). Bilateral iliac vein stenting significantly reduced reflux in the bilateral great saphenous and small saphenous veins by 363.8 ms ( p Conclusion Bilateral iliac vein stenting decreased great saphenous vein and small saphenous vein reflux. Unilateral stenting did not demonstrate a significant reduction in saphenous reflux. Bilateral reduction in stenosis of the iliac veins may influence superficial venous reflux.

Objective Deep venous arterialization (DVA) is a technique aimed at providing an option for chronic limb-threatening ischemia patients with no options except amputation. In patients with no outflow distal targets permitting bypass, DVA involves creating a connection between a proximal arterial inflow and a distal venous outflow in conjunction with disruption of the vein valves in the foot. This permits blood flow to reach the foot and potentially to resolve rest pain or to assist in healing of a chronic wound. We aimed to provide an up-to-date review of DVA indications; to describe the open, percutaneous, and hybrid technique; to detail outcomes of each of the available techniques; and to relay the postoperative considerations for the DVA approach. Methods A literature review of relevant articles containing all permutations of the terms “deep venous arterialization” and “distal venous arterialization” was undertaken with the MEDLINE, Cochrane, and PubMed databases to find cases of open, percutaneous, and hybrid DVA in the peer-reviewed literature. The free text and Medical Subject Headings search terms included were “ischemia,” “lower extremity,” “venous arterialization,” “arteriovenous reversal,” and “lower limb salvage.” Studies were primarily retrospective case series but did include two studies with matched controls. Recorded primary outcomes were patency, limb salvage, wound healing, amputation, and resolution of rest pain, with secondary outcomes of complication and overall mortality. Studies were excluded if there was insufficient discussion of technical details (graft type, target vein) or lack of reported outcome measure. Results Studies that met inclusion criteria (12 open, 3 percutaneous, 2 hybrid) were identified, reviewed, and summarized to compare technique, patient selection, and outcomes between open, percutaneous, and hybrid DVA. For open procedures, 1-year primary patency ranged from 44.4% to 87.5%; secondary patency was less reported but ranged from 55.6% at 1 year to 72% at 25-month follow-up. Limb salvage rates ranged from 25% to 100%, wound healing occurred in 28.6% to 100% of cases, and rest pain resolved in 11.9% to 100% across cohorts. For the endovascular approach, primary patency ranged from 28.6% to 40% at 6-month and 10-month follow-up. Limb salvage rates ranged from 60% to 71%, with rates of major amputation ranging from 20% to 28.5%. Conclusions This review provides an up-to-date review of DVA indications, description of various DVA techniques, patient selection associated with each approach, and outcomes for each technique.

OBJECTIVE: Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs. METHODS: All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUS > 90 days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs. RESULTS: One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96; ± 9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with a > 90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid–subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (p > 0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; p = 0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (p > 0.05). Post-operative DUS was performed at 17.0 and 12.9 days in the eversion and patch CEA cohorts, respectively (p = 0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (p > 0.05). CONCLUSION: Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.

Objective Catheter-directed thrombolysis in the treatment of acute iliofemoral deep venous thrombosis (IFDVT) often requires more than one interventional session to yield successful outcomes. Catheter-directed thrombolysis is generally expensive, requiring prolonged hospital stay that may be associated with increased local and systemic hemorrhagic complications. We developed the fast-track thrombolysis protocol (FTTP) to address these issues. The goal of FTTP is to restore patency during the initial session of thrombolysis, thereby minimizing costs and complications associated with prolonged thrombolysis. Methods A retrospective analysis of 38 patients treated for acute IFDVT using FTTP at our institution from January 2014 to February 2019 was performed. The protocol includes periadventitial injection of lidocaine at the venipuncture site under ultrasound guidance, contrast venography of the entire target segment, pharmacomechanical rheolytic thrombectomy of the occluded venous segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and, if indicated, venous stent placement in areas of significant (≥50%) stenosis refractory to thrombolysis and balloon angioplasty. Once the thrombus was cleared, patients were prescribed oral antithrombotic therapy. Results Thirty-eight primary FTTPs (45 total interventions) were performed in 38 patients. The median age was 66 years (range, 39-93 years); 60.5% were female. Initial venous access was most often obtained through the popliteal vein, followed by the femoral and great saphenous veins. The mean operative time was 122 minutes (range, 59-249 minutes), and the median volume of tissue plasminogen activator infused was 10 mg (range, 4-20 mg). The median cost per procedure, including devices and medication, was $5374.45. Median postoperative length of stay was 1 day (range, 1-45 days). Successful single-session FTTP, as determined by completion venography, was accomplished in 81.5% (n = 31/38) of cases. The remaining seven cases (18.5%) required one additional session. Of the 38 patients, 30 (79%) required iliac vein stenting. Periprocedural complications consisted of one patient with retroperitoneal hemorrhage that was managed conservatively. No patients experienced rethrombosis within 30 days of FTTP. During the 5-year study period, there were no cases of pulmonary embolism, significant local or systemic hemorrhage, limb loss, or mortality. Conclusions FTTP, as presented herein, appears to be a safe, effective, and cost-effective technique in the resolution of acute IFDVT.

Endovenous ablation of the lower extremity veins has become the primary treatment of symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) and recanalization are two well-known complications of these venous ablative procedures. Because the elderly represent the fastest growing demographic, our goal was to look at whether there is a difference of these complications and age distribution in octogenarians, nonagenarians, and centenarians vs the younger population.A retrospective study was conducted of 10,029 procedures that were performed from March 2012 to September 2018 on 8273 veins across 3218 patients who underwent endovenous ablation for lower extremity venous reflux; 6091 procedures were performed with radiofrequency ablation, and 3938 were performed with endovenous laser ablation. We reviewed charts of all patients who underwent radiofrequency ablation or endovenous laser treatment during this time. Postprocedural venous duplex ultrasound was performed at 3 to 7 days to check for EHIT and recanalization, every 3 months for the first year, and every 6 to 12 months thereafter. The χAges ranged from 15 years to 103 years. The average age of the patients was 61.9 ± 15.2 years. Average overall follow-up for all age groups was 25.8 ± 12.9 months. Of the 3218 patients, 2700 were younger than 80 years, 380 were between 80 and 89 years, 132 were between 90 and 99 years, and 6 were 100 years or older. Of the 10,029 procedures, 8730 were performed on patients younger than 80 years; 1124, on patients 80 to 89 years; 159, on patients 90 to 99 years; and 16, on patients 100 years or older. There were 111 patients who had bilateral procedures in the accessory saphenous vein, 1878 patients who had bilateral procedures in the great saphenous vein, 99 patients who had bilateral procedures in the perforator vein, and 760 patients who had bilateral procedures in the small saphenous vein. There were statistically significant increases in EHIT rates between octogenarians and those in the age group 80 years (P = .047); between nonagenarians and those in the age group 80 years (P = .04); and between the combined group of octogenarians, nonagenarians, and centenarians and the age group 80 years (P = .012). No statistical difference was found in rates of EHIT between octogenarians and nonagenarians (P = .5). Overall age is a risk factor for the development of EHIT (odds ratio, 1.03; 95% confidence interval, 1.02-1.04; P .00001). There were statistically significant increases in recanalization rates between octogenarians and those in the age group 80 years (P = .000013); between nonagenarians and those in the age group 80 years (P = .00022); and between the combined group of octogenarians, nonagenarians, and centenarians and the age group 80 years (P .00001). No statistical difference was found in rates of recanalization between octogenarians and nonagenarians (P = .48). Statistical analysis of centenarians alone was not done because of zero patients available in the EHIT or recanalization category. Overall age was found to be a risk factor for recanalization (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P .00002).Whereas there is a relatively higher chance of EHIT and recanalization in the age group80 years, our study shows that the majority of EHITs were class 1 and class 2. According to our study, venous ablation is safe and effective across all age groups, and age alone should not be used to deny patients venous ablations.

Objective An exponential increase in number of office-based laboratories (OBLs) has occurred in the United States, since the Center for Medicare and Medicaid Services increased reimbursement for outpatient vascular interventions in 2008. This dramatic shift to office-based procedures directed to the objective to assess safety of vascular procedures in OBLs. Methods A retrospective analysis was performed to include all procedures performed over a 4-year period at an accredited OBL. The procedures were categorized into groups for analysis; group I, venous procedures; group II, arterial; group III, arteriovenous; and group IV, inferior vena cava filter placement procedures. Local anesthesia, analgesics, and conscious sedation were used in all interventions, individualized to the patient and procedure performed. Arterial closures devices were used in all arterial interventions. Patient selection for procedure at OBL was highly selective to include only patients with low/moderate procedural risk. Results Nearly 6201 procedures were performed in 2779 patients from 2011 to 2015. The mean age of the study population was 66.5 ± 13.31 years. There were 1852 females (67%) and 928 males (33%). In group I, 5783 venous procedures were performed (3491 vein ablation, 2292 iliac vein stenting); with group II, 238 arterial procedures (125 femoral/popliteal, 71 infrapopliteal, iliac 42); group III, 129 arteriovenous accesses; and group IV, 51 inferior vena cava filter placements. The majority of procedures belonged to American Society of Anesthesiology class II with venous (61%) and arterial (74%) disease. A total of 5% patients were deemed American Society of Anesthesiology class IV (all on hemodialysis). There was no OBL mortality, major bleed, acute limb ischemia, myocardial infarction, stroke, or hospital transfer within 72 hours. Minor complications occurred in 14 patients (0.5%). Thirty-day mortality, unrelated to the procedure, was noted in 9 patients (0.32%). No statistically significant differences were noted in outcomes between the four groups. Conclusions Our data suggest that it is safe to use OBL for minimally invasive, noncomplex vascular interventions in patients with a low to moderate cardiovascular procedural risk.

Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case of an 87-year-old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.

Background Although arteriovenous fistulae (AVFs) are the preferred mode of hemodialysis access because of their high patency rates, they are associated with an appreciable rate of nonmaturation. Balloon-assisted maturation (BAM) has been described to treat this issue. BAM is defined as repeated sequential graduated dilatation of the outflow vein. This study aims to evaluate the short-term complications of using the radial artery as an access for BAM procedures and fisutloplasties. Transradial access was used preferentially with multiple lesions in the AVF that were difficult to access with a single venous puncture. Methods Data were collected over 3 years on 44 office-based duplex-guided transradial access BAM procedures in 27 patients of whom 19 were men. BAM with ultrasound guidance was performed in 324 cases using a venous puncture during this period. The indication for the procedures was a failure of AVF maturation, and 5 cases were with short segment thrombectomy. All procedures were performed with local anesthesia only. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex-guided. The radial artery was punctured with ultrasound guidance and a 4–5 French low-profile sheath was placed. After crossing the lesion(s), 5,000 units of heparin was given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. Vascular injuries were classified based on the postprocedural duplex assessment. All patients had follow-up duplex scans within a week. Results The average age was 79 years (±14 SD, range 39–99 years). The types of AVF were 35 radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The number of sites of lesions was 17 on the venous outflow, 7 perianastomotic, and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. The balloon size ranged from 3–6 mm (28 patients) and 7–12 mm (16 patients). The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma (2), and intimal flap (3). Extravasation was controlled with duplex-guided compression. There were no radial artery thromboses, and all the AVFs were patent on completion duplex and follow-up duplex. Conclusions These data suggest that the radial artery could be used as a safe access route for BAM procedures with relatively low rates of complication. This approach can be considered as an adjunct in the armamentarium for angioplasty of AVF.

Prior literature has recommended routine iliac vein stent extension into the inferior vena cava (IVC) to assure adequate outflow for iliac vein stenting procedures. Our bias was that only the lesion should be stented without routine stent extension up to the IVC. We report our experience with this limited stenting technique.From 2012 to 2015, 844 patients (1,216 limbs) underwent iliac vein stenting for nonthrombotic iliac vein lesions (NIVLs). All limbs were evaluated in accordance with the presenting sign of the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) score, and duplex scans and intravascular ultrasound (IVUS) showing more than 50% cross-sectional area or diameter reduction. All study patients had failed 3 months of conservative management. The procedures of iliac vein stenting were all office based. Two techniques were compared: (1) placement of the iliac vein stent to cover the lesion and terminating cephalad into the IVC if the lesion involved the common iliac vein and (2) placement of the iliac vein stent to cover the lesion only and not passing the iliocaval confluence if the lesion only involved the external iliac vein. Complications were assessed during 30-day follow-up using the duplex scan technique to look for thrombosis.Of the total 844 patients, 543 (64%) were women. The average age was 66 (±14.2) years (range, 21-99 years). The stent was placed in the left lower limb in 474 patients and bilaterally in 370 patients. The presenting sign in accordance with the CEAP classification was C3 = 626, C4 = 404, C5 = 44, and C6 = 141. The average iliac vein stenosis by IVUS was 62% (±12% standard deviation [SD]). We had 715 patients with the iliac vein stent extending into the IVC, and of these, 8 patients had thrombosis within 30 days after the procedure. On the other hand, 501 patients had the iliac vein stent without crossing the iliocaval confluence, and of these, 4 patients had thrombosis within 30 days of the procedure. There was no difference between these 2 groups in regard to gender (P = 0.1) or age (P = 0.3). Laterality was statistically different (P 0.0001) with more stents to be extended into the IVC if the lesion is in the left lower limb. Comparing these 2 groups in regard to 30-day thrombosis as a complication was not statistically significant (P = 0.6). There was no statistical difference between the 2 groups in regard to the presenting sign CEAP (P = 0.6).These results question the need for routine iliac vein stent extension into the IVC in patients with NIVLs. We were not able to demonstrate a significant risk of thrombosis with just placing the stent to cover the lesion only with short-term follow-up.