Angela A. Kokkosis

The distribution and significance of varicosities in the saphenous trunks

OBJECTIVE The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes. METHODS This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented. RESULTS From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09). CONCLUSION A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression.

Experience of HeRO dialysis graft placement in a challenging population.

Objective: To assess the outcomes of the hemodialysis reliable outflow (HeRO) device in a subset of hemodialysis access-challenged patients with central venous obstruction. Methods: Retrospective analysis of a series of patients in 2 centers who underwent placement of the HeRO device between September 2009 and November 2010. Patients’ demographics, access history, HeRO patency, and number of reinterventions were analyzed. Results: Eleven patients underwent 12 HeRO implantations. The average duration of dialysis prior to HeRO placement was 5.55 ± 3.64 years. Primary and secondary patencies at 6 months and 1 year were 36.4% and 54.5% and 9.1% and 45.5%, respectively. Conclusions: In the end-stage renal disease population with central venous occlusive disease, the HeRO device offers the best long-term dialysis option when an arteriovenous fistula or graft is not possible. Close follow-up and subsequent aggressive interventions can prolong the use of the HeRO and avoid the last resort of dialysis catheters.

The perspective of the vascular surgery trainee on new ACGME regulations, fatigue, resident training, and patient safety.

Objective: To assess the opinions of vascular surgery trainees on the new Accreditation Council for Graduate Medical Education (ACGME) guidelines. Methods: A questionnaire was developed and electronically distributed to trainee members of the Society for Vascular Surgery. Results: Of 238 eligible vascular trainees, 38 (16%) participated. Respondents were predominantly 30 to 35 years of age (47%), male (69%), in 2-year fellowship (73%), and at large academic centers (61%). Trainees report occasionally working while fatigued (63%). Fellows were more likely to report for duty while fatigued (P = .012) than integrated vascular residents. Respondents thought further work-hour restrictions would not improve patient care or training (P < .05) and may not lead to more sleep or improved quality of life. Respondents reported that duty hours should vary by specialty (81%) and allow flexibility in the last years of training (P < .05). Conclusions: Vascular surgery trainees are concerned about further duty-hour restrictions on patient care, education, and training and fatigue mitigation has to be balanced against the need to adequately train vascular surgeons.

Pediatric nontraumatic myositis ossificans of the neck

Nontraumatic myositis ossificans circumscripta (MOC) is a rarely reported benign heterotopic ossification characterized by the aberrant formation of bone in extraskeletal soft tissues. Although a history of trauma can be elicited in 75% of MOC patients, the etiology is unclear in patients without inciting injury. MOC is associated with young male athletes, and is most often localized to the muscle groups of the extremities. Rare cases have been reported in children and adolescents of nontraumatic MOC in the neck. We present a 15-year-old adolescent with a rapidly growing, painful neck mass without traumatic stimulus.

Inflow stenosis as a contributing factor in the etiology of AV access-induced ischemic steal

Objective To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). Methods A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, pre-operative angiographic imaging and interventions performed were analyzed. Results A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). Conclusion In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete pre-operative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

Venous Outflow Obstruction With Retroperitoneal Kaposi's Sarcoma and Treatment With Inferior Vena Cava Stenting

A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposis sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent.

The Use of AngioVac for Symptomatic Aortic Thrombus Complicated by Mesenteric Ischemia

Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With the recent advancements of endovascular techniques, there is a trend to replace the traditional open surgery with an endovascular approach. We report a patient with paravisceral aortic thrombus involving the celiac artery and superior mesenteric artery (SMA). The patient was complaining of worsening abdominal pain, with clinical findings of leukocytosis, normal lactate, and diagnostic laparoscopy demonstrating a segment of threatened jejunum. We describe the novel use of vacuum-assisted suction filtration device in combination with over-the-wire thrombectomy and stenting to successfully restore blood flow within the SMA. The patient had resolution of her symptoms with improved blood flow to the bowel and no need for resection.

Investigation of venous ulcers

The evaluation of patients with venous ulceration primarily includes noninvasive methods to elucidate the distribution and extent of pathology. Duplex ultrasound is the first line of investigation, as it provides assessment of both reflux and obstruction conditions. In patients with iliofemoral pathology, axial imaging with computed tomography scan or magnetic resonance imaging should be performed. If the treatment of iliofemoral vein obstruction is warranted, then invasive assessment using venography and/or intravascular ultrasound should be used to guide the interventional procedure. Venous valve reflux can be identified and accurately characterized by duplex ultrasound, whereas the ultrasound assessment of functional abnormality associated with obstruction is less reliable. In patients with ulceration, the evaluation for and treatment of proximal venous obstruction has resulted in improved ulcer healing.

Vascular Surgery Training Paradigms in Asia, Europe, South America, the United Kingdom, and the United States

Around the world there are variations in the training pathway for vascular surgery. The time from high school graduation to the completion of vascular surgery training ranges from 11 to 15 years, and possibly more depending on research experience, other graduate degrees, or extracurricular experiences. This chapter gives a sampling of the similarities and differences across Asia, Europe, South America, the United Kingdom (UK) and the United States (US).

PC152. Risk Associated With Female Gender for More Advanced Peripheral Arterial Disease at Time of Femoropopliteal Bypass Remains Constant from 2003 to 2015

Objectives: Peripheral arterial disease (PAD) is estimated to affect 15% to 30% of the female U.S. population by 80 years of age. Women with PAD have different incidences of traditional modifiable risk factors as compared with men and are suspected to be underdiagnosed owing to atypical presentation, poor screening and an underappreciation of the prevalence of PAD in women. Additionally, women have faster functional decline as part of the natural course of their disease. For these reasons, we used the national Vascular Quality Initiative (VQI) database of femoropopliteal bypasses to identify non-mortality-related outcomes with female gender bias and to track gender attributable risk over time. Methods: Patients who underwent femoral-popliteal bypass, without prior open revascularization or amputation, and with occlusive pathology (n 1⁄4 7139) were selected for analysis. Seventy of 184 variables showed gender bias. Ambulatory status (AS), treatment indication (IND) and discharge location (DL) were selected for logistic regression. The cohort was further divided into four-time periods and risk associated with year of surgery among females was determined. Results: Females were more likely to have decreased ambulatory ability (HR, 1.48; P < .001), be treated for critical limb ischemia (CLI; HR, 1.60; P < .001) and be discharged to a nursing or rehabilitation facility (HR, 1.61; P < .001) at time of first bypass (Table). Over the four time periods assessed, the risk attributable to female gender for impaired AS, CLI as indication and skilled nursing facility as DL remained constant (HR, 1.27-1.58, 1.48-1.67 and 1.56-2.07, respectively; Fig). When year of surgery was used as a covariate for regression analysis, the year of intervention was not significantly associated with IND or DL. However, surgery year was significantly associated with decreased AS (HR, 1.039; P 1⁄4 .028; Table). Conclusions: Female gender remains associated with decreased ambulatory function and more advanced femoropopliteal disease at time of first bypass. Among females, the year of surgery was not significantly associated with IND or DL but did confer increased risk for difficulty ambulating. This suggests that associations between female gender, AS, IND, and DL have at best has remained constant. This study demonstrates that women with PAD continue to be treated at more