Alok Tiwari

COMMON FACIAL VEIN: AN ALTERNATIVE PATCH MATERIAL IN CAROTID ANGIOPLASTY

Patch angioplasty is a popular adjunct to carotid endarterectomy to facilitate arteriotomy closure. The long saphenous vein is the common autogenous patch in use. We tested the feasibility of using the ipsilateral common facial vein (CFV), which is usually sacrificed during exposure of the carotid bifurcation. A consecutive series of 17 patients undergoing carotid endarterectomy was examined to show the use of CFV patch in arteriotomy closure in 18 procedures. During exposure of the carotid bifurcation, the facial vein was harvested and distended with heparinized saline to assess the size of the vein. If the vein had an adequate diameter, it was everted and used as a double‐layered patch. Patients were followed up postoperatively with serial duplex scanning at 3, 6 and 12u2003months, and yearly thereafter. The median (range) age of the patients in the series was 66u2003years (52–72u2003years). Of the 18 CFV harvested, 2 were rejected because of small calibre. The median (range) length of the vein harvested was 5u2003cm (4–6u2003cm). The average diameter of harvested vein was 5u2003mm. The median (range) time taken for harvesting, distending and everting the vein was 10u2003min (8–12u2003min). There were no perioperative deaths or strokes. There was no significant re‐stenosis during the follow up of 24u2003months (18–36u2003months), with a mean peak velocity of 0.86u2003m/s (0.58–1.29u2003). The use of everted CFV patch in carotid angioplasty is safe, quick, convenient and durable, whereas saphenous veins are spared and lower limb incisions avoided.

Use of inferior vena cava filters in a tertiary referral centre in Australia.

Introduction:u2002 To investigate the use of inferior vena cava (IVC) filters in a tertiary referral centre, looking at indication, types of filters and, with temporary/optional filters, removal rates.

Stenting as a bail-out option after failed percutaneous transluminal angioplasty in infrainguinal vein bypass grafts.

Objectives To study the safety and efficacy of bare and covered stents in infrainguinal vein grafts after failure of PTA for treating graft stenoses. Methods An analysis of a prospective database of all patients who underwent stenting of infrainguinal vein bypass grafts at this institution between 1 January 2008 and 31 December 2012 was carried out. The main outcome considered was primary patency, which was reported at 1, 6 and 12 months. Results A total of 18 patients with a mean age of 73 years (range: 56 to 86) were included. The indications for stent placement were significant recoil (7, 39%), graft rupture (6, 33%), residual vein cusps (3, 17%) and aneurysmal degeneration (2, 11%). There was a high overall technical success rate of 94% (17/18) and arrest of haemorrhage was achieved in all cases of graft rupture. The primary patency at 1, 6 and 12 months was 89%, 71% and 59%, respectively. Conclusion The use of bare and covered stents in infrainguinal vein grafts appears safe and effective. They are an excellent bail-out option for the treatment of graft rupture and give acceptable short-term results.

Factors Affecting Medium-Term Outcomes After Crural Angioplasty in Critically Ischemic Legs

Objectives: To study factors affecting patency and medium-term outcomes after crural angioplasty. Materials and Methods: All crural angioplasties between March 2003 and September 2010 were reviewed from a prospective database to analyze primary patency, amputation-free survival, and limb salvage. Results: Five hundred and twenty-seven limbs in 478 patients (58.7% male, mean age 73.9 ± 0.53 years) were treated. In all, 49.1% were diabetic patients and 7.4% were dialysis dependent. Primary patency was 65.5%, 57.8%, 48.5%, and 32.9% at 1, 6, 12, and 36 months, respectively. Amputation-free survival was 75.2% at 1 year and 59.0% at 3 years. Limb salvage at 3 years was 92.7%. Rutherford categories 5 and 6 had a consistent adverse effect on patency. This led to an adverse amputation-free survival and limb salvage at 3 years. Conclusion: Crural angioplasty is an effective treatment for limb salvage. Its outcomes are adversely affected by diabetes, renal disease, coronary disease, and worsening Rutherford grade.

Common femoral vein canal lipoma causing chronic unilateral lower limb swelling.

A 64-year-old woman presented to vascular clinic with a 2-year history of right ankle swelling, associated with pain on walking. Initial venous duplex imaging showed no obvious cause. Further imaging showed a lipoma compressing the common femoral vein. We consider the relative merits of the imaging modalities of the groin and the literature available on lipomas causing compression.

Endovascular Treatment of a Fishy Ulcer Caused by a Traumatic Arteriovenous Fistula

Arteriovenous fistula secondary to trauma is an uncommon cause of leg ulcers. In this article, an unusual case of a nonhealing leg ulcer caused by a stingray is described. This case highlights the difficulty in diagnosing and treating nonhealing ulcers secondary to arteriovenous fistula.

Efficacy of topical local anaesthesia to reduce perioperative pain for endovenous laser ablation of varicose veins: a double-blind randomized controlled trial

Objectives: Tumescent local anaesthesia via multiple injections in the perivenous space leads to intraoperative and postoperative pain during endovenous laser ablation (EVLA). We considered whether the application of topical local anaesthesia reduces pain caused by these injections. Methods: Eligible patients undergoing local anaesthetic EVLA were recruited and randomized to either application of topical local anaesthesia or water-based gel (placebo) to the inner thigh over the marked great saphenous vein. Varicose vein severity was classified using the American venous forum clinical etiological anatomical pathological (CEAP) classification score for chronic venous disorders and the Aberdeen varicose vein questionnaire (AVVQ) score. Visual analogue pain scores attributable to the varicose veins or tumescent injections were recorded before the procedure, immediately postprocedure and prior to discharge. Secondary outcome measures were extra analgesia requirement during or immediately postoperatively. Analysis was performed using the unpaired Student’s t test and Wilcoxon signed-rank test. Results: A total of 52 patients underwent the procedure. Eight patients were excluded from analysis due to failure to complete the procedure or incomplete data. In the remaining 44 patients (24 local anaesthesia, 20 placebo), no statistical difference was noted in age, gender distribution or the severity of varicose veins assessed preoperatively by the clinician (CEAP classification score, median = 2 in both groups) and patient (AVVQ, mean placebo = 21.59, local anaesthesia = 17.53, p = 0.264) between the two groups. There was no statistical difference in pain scores between the placebo and topical local anaesthetic group at baseline (23.0 versus 20.44, p = 0.57), immediately postoperatively (23.35 versus. 19.75, p = 0.44) or predischarge (20.9 versus 13.75, p = 0.68). Conclusions: Topical local anaesthesia is of no benefit in EVLA of varicose vein to reduce patient experience of perioperative pain.

Modification of a bifurcated stent graft for aortouniiliac endovascular aneurysm repair in a renal transplant patient.

Introduction. We describe a case of aortouniiliac (AUI) endovascular aortic aneurysm repair (EVAR) using combined iliac limb and bifurcated body stent graft modular system. Case report. This technique is demonstrated in a 58-year-old man with a 6-cm abdominal aortic aneurysm suitable for EVAR. The patient has a functioning cadaveric renal transplant anastamosed to the mid right external iliac artery, an occluded left iliac system and stenosed right iliac system. The renal allograft was protected with minimal passage across the transplant artery origin using this modified approach. The patient was successfully treated with a bifurcated main body deployed within a contralateral limb endoprosthesis. Subsequent scans confirmed no endoleaks or stent migration. Conclusions. The AUI conversion from existing Gore excluder stent graft system is safe and should be considered when faced with challenging anatomy of a pelvic renal transplant, slender access, and contralateral iliac occlusion.

Results of the EVRA trial will be a game-changer for the management of every venous ulcer

The prevalence of venous leg ulceration (VLU) in the adult population is up to 3% with higher prevalence seen with increasing age and female gender. Active ulceration has a profound detrimental effect upon the quality of life and is associated with significant pain and mobility restriction limiting a patient’s physical and social roles. Mean lifetime with a venous ulcer is between 5–10 years. 1–3% of the western healthcare budget is spent on managing this condition because of its chronic and relapsing nature. The gold standard of care until now for VLU has been compression bandaging with initial ulcer healing rates in excess of 70% at six months, but subsequently 25% of these ulcers recur by one year. The Effect of Surgery and Compression on Healing And Recurrence (ESCHAR) trial from the late 1990s showed that ulcer recurrence was significantly reduced for patients who had superficial venous surgery in combination with compression therapy compared to those who had compression alone (31% vs. 56% leg ulcer recurrence at four years) but did not show improved ulcer healing rate. A number of factors may have reduced the benefit of surgery on overall time to achieve ulcer healing in this landmark trial. One perception was the lack of statistical power in which participants with healed rather than open active ulcers predominated. The analysis was performed on an intention to treat principle and 19% of those randomized to the surgery arm did not receive an intervention, because a lot of patients with venous ulcer disease were elderly with significant co-morbidities and were deemed not fit for a general anaesthetic. In those who underwent surgery, the majority did not have their superficial venous reflux eliminated, and perforator disease was not primarily treated because of the limitations of open surgery. Furthermore, surgery was delayed on average for 7 weeks out of the 24-week ulcer healing phase of the study. This led to a widely held view until now that superficial venous surgery can be deferred until the leg ulcer had healed and on the grounds of increased risk of wound infection, although the ESCHAR trial only showed a 2% wound infection rate in those treated with surgery. The recent publication of the primary results of the Early Venous Reflux Ablation (EVRA) multicentre trial has changed the VLU landscape and will renew the interest for early ablation of superficial venous reflux for CEAP 6 disease. The world of VLU enthusiasts has finally gained significant Level 1 evidence that has the potential to change the clinical practice worldwide. EVRA was a non-commercial study conducted at 20 National Health Service (NHS) hospitals across the UK and randomised 450 patients with active venous ulceration of less than six months duration to two groups; the first to receive therapeutic compression therapy and early endovenous ablation of their superficial venous reflux within two weeks of randomisation and the other group to receive compression alone. This group received deferred endovenous intervention once the ulcer was healed. Those who had early endovenous intervention as an adjunct to compression therapy demonstrated faster healing time, rate of ulcer healing at six months, median ulcer-free time and decreased recurrence of their VLU. The investigators are to be congratulated on a monumental effort over the past five years, culminating in a landmark trial in vascular surgery, which will likely be a game changer and have a global impact as to how venous ulcers should now be treated – patients should have an expedited vascular assessment and offered early intervention to ablate their superficial venous reflux. Patient and care provider education is now essential. This is borne out by the fact

Reporting outcomes of new and old endovenous technologies using a standardized dataset – Now is the time for change

The management of varicose veins has undergone an industrial revolution over the past decade but the optimal treatment modality remains debatable. The initial ‘gold standard’ of high ligation, stripping and avulsions has been gradually replaced by endothermal ablation and ultrasound-guided foam sclerotherapy (USGFS), with the outcome of these procedures now having more than 10-year follow-up data showing at least comparable results to open surgery but improvement in many other parameters. The results of foam sclerotherapy have been inferior to both endovenous laser and radiofrequency ablation in terms of anatomical and clinical recurrence such that modifications of the technique, including catheter-directed foam sclerotherapy and use of a more stable form of foam (Varithena , BTG International, UK), are increasingly being utilised with some success. There has therefore been an impetus for the development of newer techniques to further enhance the patient’s peri-operative experience and avoid the need for tumescent anaesthesia and thermal ablation of the so-called non-thermal, non-tumescent (NTNT) technologies. These include mechano-chemical ablation with ClariVein (Vascular Insights, MA, USA) and cyanoacrylate glue embolization (VenaSeal, Medtronic Ltd, Galway, Ireland). These relatively new techniques have shown promising results but without long-term data. At present, all these novel devices are difficult to compare due to the heterogeneous reporting of outcome measures as highlighted by several NTNT reviews and metanalyses published recently. This may be due to selective reporting of positive results especially with new technologies where there are pressures to show that the new treatment actually works! There have been many reports highlighting the need for standardised reporting of outcomes in endovenous surgery including publications from the society of vascular surgery (SVS) and European Society of Vascular Surgery (ESVS). Most reported studies use a combination of outcome data, mainly immediate and medium-term truncal ablation, as confirmed by duplex ultrasound and changes in patient symptoms and quality of life, utilising a validated venous questionnaire such as the revised Venous Clinical Severity Score (rVCSS) and Aberdeen Varicose Vein Questionnaire. Not all studies report on significant complications such as deep vein thrombosis (DVT) rate or, in cases of endovenous ablation, endothermal heat-induced thrombosis (EHIT). Other confounding factors are the timing of the adjunctive treatments and how pain is quantified peri-operatively. Reporting on procedural complications such as phlebitis and skin pigmentation is also variable and clinical measures of time off work and return to normal daily activities are not routinely described. This was previously highlighted by Thakur et al., but subsequent studies looking at newer venous ablative devices have failed to take heed of these problems. The authors argue that there is now a need for standardisation of the main outcome measures of the differing venous ablative procedures so that the various techniques can be compared equitably. This should follow the guidelines from the various vascular societies as mentioned above and should be ‘policed’ by the editors of journals to ensure that they are followed. If there are missing datasets, then the reasons for this