Jennifer Heller

Thromboembolism in plastic surgery.

Learning Objectives: After studying this article, the participant should be able to: 1. Appreciate the pathophysiology of deep venous thrombosis and pulmonary embolus. 2. Identify patients at risk for deep venous thrombosis and pulmonary embolus before and after surgery. 3. Recognize modalities for diagnosis and treatment of deep venous thrombosis and pulmonary embolus. 4. Recognize what precautions to take to avoid deep venous thrombosis and pulmonary embolus in plastic surgery patients. Thromboembolism is a dreaded complication of surgery in multiple disciplines, including plastic surgery, and deep venous thrombosis and pulmonary embolus cause significant morbidity, even death. This article provides methods for understanding and preventing deep venous thrombosis and pulmonary embolus in plastic surgery.

Variability in the Management of Superficial Venous Thrombophlebitis across Practitioners Based in North America and the Global Community

Introduction. This study aimed to compare management patterns of patients with SVT among healthcare practitioners based in North America versus those in the global community. Methods. A 17-question, multiple choice survey with questions regarding SVT diagnosis and management strategies was provided to practitioners who attended the American Venous Forum (AVF) meeting in 2011. Results. There were 487 practitioners surveyed with 365 classified as North American (US or Canada) and 122 (56 Europe, 25 Asia, 11 South America, and 7 Africa) representing the global community. The key difference seen between the groups was in the initial imaging study used in patients presenting with SVT (P = 0.046) and physicians in the US ordered fewer bilateral duplex ultrasounds and more unilateral duplex ultrasounds (49.6% versus 58.2%, 39.7% versus 34.4%). In the US cohort, phlebologists and vascular surgeons constituted 82% (n = 300) of the specialties surveyed. In the global community, SVT was managed by phlebologists or vascular surgeons 44% (n = 54) of the time. Surgical management was highly variable between groups. Conclusion. There is currently no consensus between or among practitioners in North America or globally as to the surgical management of SVT, duration of follow-up, and anticoagulation parameters.

Heterogeneity in venous disease practice patterns amongst primary healthcare practitioners.

Introduction This study aimed to describe the practice patterns of primary healthcare practitioners who diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, and referral patterns. Methods A survey was distributed at the August 2011 Primary Care Medical Conference (Pri-Med) in Baltimore, Maryland. Pri-med is a medical education company that caters to the continued professional development needs of a variety of physicians. Results A total of 305 surveys were completed. Of the respondents, 91% were physicians and 9% were advanced level practitioners. In all, 93% prescribed compression stockings as first-line treatment. Heterogeneous referral patterns were reported with 81% referring to vascular surgery, 25% to a vein clinic, 10% to interventional radiology, and 3% to interventional cardiology. Up to 35% responded that they met resistance (did not have their referral accepted) when attempting referral to a vascular surgery colleague. There was substantial variation when asked about the treatment of deep vein thrombosis with 88% starting anticoagulation therapy, 54% prescribing compression stockings, 40% doing a thrombophilia workup, and 25% referring for lytic therapy. Conclusion Diagnosis and management aptitude of venous disease is highly variable. Further grassroots education is required to improve diagnosis and treatment in patients with chronic venous disease.

Variability in the Management of Superficial Venous Thrombophlebitis Among Phlebologists and Vascular Surgeons

INTRODUCTION This study aimed to compare management patterns of patients with superficial venous thrombophlebitis (SVT) among phlebologists and vascular surgeons. METHODS A survey was provided to practitioners who attended the American Venous Forum meeting in 2011. Statistical analysis included descriptive statistics, unpaired t tests, and Friedmans test for correlation. RESULTS There were 354 US or Canadian health care providers of whom 169 were phlebologists and 185 were vascular surgeons. There was a significant different in anticoagulation administration and duration (P = .034, P = .032, respectively). Friedmans test for correlation between multiple surgical treatments showed no correlation between surgical treatments tested with all treatments having an equal distribution in our data. Follow-up differed between groups with vascular surgeons following up with imaging more than phlebologists (P = .03). CONCLUSION Our data indicate that there is no consensus between or among phlebologists or vascular surgeons as to the surgical management of superficial venous thrombophlebitis, duration of follow-up, and anticoagulation parameters.

Epidemiology and treatment strategies of iliac vein thrombophlebitis.

Introduction This study aimed to determine the epidemiology of iliac vein thrombophlebitis and describe gender differences associated with the management of this pathology. Methods The 2010 National Inpatient Sample was retrospectively reviewed to include all inpatients with ICD-9 codes identifying iliac vein thrombophlebitis (451.81). Demographics, disposition, anticoagulation, thrombolytics, stent placement, open operative intervention, complications (deep vein thrombosis/pulmonary embolism), and mortality rates were reported. Statistical analysis included descriptive statistics and Student’s t-testing with P < 0.05 deemed significant. Results The incidence of iliac vein thrombophlebitis was 1/1,000,000 people. Men had an average age of 48 ± 20 years and women were significantly older at 59 ± 18 years (P = 0.02). There were no differences in treatment strategies or rates of complications between men and women including pulmonary embolism (23% for males, 16% of females) and deep vein thrombosis (29% for males and 19% for females). Length of stay between groups was not significant (11 ± 20 days for males and 7.7 ± 6 days for females). Overall mortality was 1.5%. Conclusion Iliac vein thrombophlebitis is a rare disease. Females who develop iliac vein thrombophlebitis are significantly older than their male counterparts. The rates of deep vein thrombosis, pulmonary embolism, and interventional strategies are not different between the sexes.

Diagnosis and management of a ruptured popliteal mycotic pseudoaneurysm

Infected popliteal aneurysms are a rare but high-risk pathology that may present as a surgical emergency with acute rupture and sepsis. Management of acute ischemia in the presence of systemic sepsis is challenging and requires timely diagnosis, rapid intervention, and multidisciplinary communication to ensure an optimum outcome for both life and limb in these patients. We report on a case of a ruptured mycotic popliteal artery aneurysm as a consequence of septic embolization from infective endocarditis managed by reverse saphenous vein bypass. The clinical presentation, diagnostic process, and approach to management along with a literature review on mycotic popliteal aneurysm are presented in this case report.

Management of Post-Traumatic Phlegmasia Cerulea Dolens via Right-to-Left Femoral Vein to Femoral Vein Bypass (Palma Procedure)

Phlegmasia cerulea dolens (PCD) is a rare condition resulting from venous occlusion that impairs arterial flow. We report a rare case of post-traumatic PCD after ligation of the iliac vein with successful treatment by right-to-left femoral vein to femoral vein bypass using left great saphenous vein (Palma procedure). The clinical presentation, diagnostic process, and approach to management along with a literature review on the operative management of PCD are presented in this case report.

Advanced Chronic Venous Insufficiency: Does Race Matter?

Introduction: Intervention for advanced chronic venous insufficiency is considered an appropriate standard of care. However, outcomes vary among patients who present in advanced clinical stages of disease. The main objectives of this study were to determine whether racial disparity exists at initial presentation and response to intervention. Methods: A retrospective database was created to include all radiofrequency ablation procedures performed by a single surgeon from January 14, 2009, through May 25, 2011. Demographics, clinical traits, race, procedure, and outcomes were analyzed. Stepwise model selection reduced candidate baseline factors to a final parsimonious model, which was analyzed using analysis of variance. Results: The database consisted of 300 patients with a predominant female (n = 215, 85%) base and 85 (15%) males, with a mean age distribution of 53 years. The mean body mass index was 30.2. Racial distribution revealed Asian (n = 9, 3.3%), Pacific Islander (n = 1, 0.4%), African American (n = 37, 13.6%), and Caucasian (CAU, n = 225, 82.7%). African Americans presented with more advanced clinical stages than the CAU group—C2: African American 21.6%, CAU 36.7%; C4: African American 35%, CAU 24.3%; and C6: African American 35.1%, CAU 7.5%. African Americans demonstrated a higher preoperative venous clinical severity score (VCSS) than their CAU counterparts. Postprocedural decrease in VCSS score was lower in African Americans than their CAU counterparts. Conclusion: African American patients present with more advanced venous insufficiency than CAUs. Postprocedural analysis reveals not only slower ulcer healing times but also higher ulcer recurrence rates.

Herpes simplex virus following stab phlebectomy.

Herpes simplex virus infection following surgery is an unusual postoperative phenomenon. Many mechanisms have been suggested, with the most likely explanation related to latent virus reactivation due to a proinflammatory response in the setting of local trauma. Here, we present a case of herpes simplex virus reactivation in an immunocompetent female following a conventional right lower extremity stab phlebectomy. Salient clinical and physical examination findings are described, and management strategies for herpes simplex virus reactivation are outlined. This is the first known case report of herpes simplex virus reactivation following lower extremity phlebectomy.

The Impact of Race on Advanced Chronic Venous Insufficiency

Background: The study aimed to determine the association between race and patient variables, hospital covariates, and outcomes in patients presenting with advanced chronic venous insufficiency. Methods: The National Inpatient Sample was queried to identify all Caucasian and AfricanAmerican patients with a primary International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for venous stasis with ulceration (454.0), inflammation (454.1), or complications (454.2) from 1998 to 2011. CEAP scores were correlated with ICD-9 diagnosis. Demographics, CEAP classification, management, cost of care, length of stay (LOS), and inpatient mortality were compared between races. Statistical analysis was via descriptive statistics, Student’s t-test, and the Fisher’s exact test. Trend analysis was completed using the ManneKendall test. Results: A total of 20,648 patients were identified of which 85% were Caucasian and 15% were African-American. Debridement procedures had the highest costs at