Jon C. Henry

Cephalic vein transposition is a durable approach to managing cephalic arch stenosis

INTRODUCTION The proximal cephalic vein that enters the axillary vein (cephalic arch) is a common site of stenosis in patients with upper extremity arteriovenous fistulas for hemodialysis (HD). In this study, we present the outcomes of a series of cephalic vein transposition, to determine its utility in the setting of refractory arch stenosis. METHODS We conducted a retrospective review of patients undergoing cephalic vein transposition to manage refractory cephalic arch stenosis from January 1, 2008 to August 31, 2015. Demographics, past medical history, access history of the patients as well as procedural details of the surgery to the stenotic segment, patency of the access, and the need for subsequent interventions were recorded. RESULTS Twenty-three patients underwent a cephalic vein transposition during the study period. The patients undergoing cephalic transposition had their current access for an average of 3.0 ± 2.6 years and had an average of 2.3 ± 0.9 interventions on the access prior to the surgery. Complications from the surgery were uncommon (8.7%) and no patient required a temporary tunneled dialysis catheter. The re-intervention rate was 0.2 ± 0.2 interventions per patient per year. At two years, primary patency was 70.9% and cumulative patency was 94.7% for the patients with cephalic transposition. CONCLUSIONS Cephalic vein transposition is safe and effective treatment for cephalic arch stenosis without interrupting utilization of the access. The surgical approach to stenosis of the proximal cephalic vein is effective, requires minimal re-interventions, and should be considered for isolated, refractory cephalic arch stenosis in mature arteriovenous fistulas.

Peroneal bypass versus endovascular peroneal intervention for critical limb ischemia

Objective: The peroneal artery is a well‐established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI. Methods: Patients presenting between 2006 and 2013 with CLI (Rutherford 4‐6) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow‐up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency. Results: There were 200 limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention included, with mean follow‐up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities, with the exception of the endovascular groups having more patients with cardiac and renal disease and diabetes mellitus but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Perioperatively, bypass patients had higher rates of myocardial infarction (4.5% vs 0%; P = .012) and incisional complications (13.0% vs 4.4%; P = .008). At 12 months, the bypass group compared with the endovascular group had better primary patency (47.9% vs 23.4%; P = .002) and primary assisted patency (63.6% vs 42.2%; P = .003) and a trend toward better secondary patency (74.2% vs 63.5%; P = .11). There were no differences in the rate of wound healing (52.6% vs 37.7% at 1 year; P = .09) or freedom from major amputation (81.5% vs 74.7% at 1 year; P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, whereas WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15). Conclusions: Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low‐risk intervention that may be sufficient to heal ischemic foot wounds.

Bypass versus endovascular intervention for healing ischemic foot wounds secondary to tibial arterial disease

Objective: Pedal (inframalleolar) bypass is a long‐standing therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb‐related clinical outcomes. Methods: We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data were collected on baseline demographics and comorbidities, procedural details, and postprocedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes. Results: We identified 417 patients who met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow‐up of 25.0 and 20.2 months, respectively (P = .08). The endovascular patients were older at baseline (P = .009), with higher rates of hyperlipidemia (P = .02), prior cerebrovascular accidents (P = .04), and smoking history (P = .04). Within 30 days postoperatively, there was no difference in mortality (P = .31), but bypass patients had longer hospital length of stay (P < .0001), higher rate of discharge to nursing facility (P < .001), and higher rates of myocardial infarctions (P = .03) and wound complications (P < .001). At 6 months, the rate of wound healing was 22.4% in the bypass group compared with 29.0% in the endovascular group (P = .02). At 1 year, survival was higher after bypass (86.2% vs 70.4%; P < .0001), but freedom from major amputation was similar (84.9% vs 82.8%; P = .42). Primary patency (53.1% vs 38.2%; P = .002) and primary assisted patency (76.6% vs 51.7%; P < .0001) were higher in the bypass group, but there was no difference in secondary patency (77.3% vs 73.8%; P = .13). Conclusions: Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the “gold standard” of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.

Clinical and Ultrasound Sequelae of Nonvisualized Calf Veins on Duplex Ultrasound for Suspected Deep Vein Thrombosis

Objectives Calf veins are not visualized in up to 40% of lower extremity venous duplex ultrasounds (DUS). Little is known about the clinical implications of nonvisualized calf veins. We sought to investigate the incidence of nonvisualized calf veins, rate of subsequent venous thromboembolism (VTE), and factors influencing successful visualization on subsequent DUS. Methods We reviewed all patients who had DUS in 2012 at our institution who had nonvisualized calf veins, no deep vein thrombosis (DVT), and available follow-up. Demographics, Wells score, body mass index (BMI), indication for DUS, activity level, reason for nonvisualization, initial and subsequent DUS results, and subsequent occurrence of VTE were collected. Results A total of 8,237 DUS were performed in 2012. Of these, 891 (10.8%) DUS in 717 patients had at least one nonvisualized calf vein. Seven hundred twenty-eight limbs (484 patients) had no DVT and had available follow-up and comprised the study population. The most common reasons for nonvisualization were edema (35.5%) and body habitus (31.8%). Twenty-two (4.5%) patients were subsequently identified to have VTE; 9 limbs had only pulmonary emboli, 12 had only DVT, and 1 had both. Only length of stay in the hospital correlated with the development of VTE. One hundred forty-eight of the 484 patients had subsequent DUS at a median of 2.43 months; 45.3% of subsequent DUS successfully imaged the previously nonvisualized veins. Whole lower extremity swelling, single vein nonvisualization, and single limb nonvisualization at initial DUS were associated with successful visualization on subsequent DUS. Thirteen (8.8%) new DVT were seen on subsequent DUS, six were seen in calf veins that previously were not visualized, and seven were seen in either femoropopliteal veins or calf veins that previously were visualized and did not have thrombus. Conclusions Non-visualized calf veins are common in DUS. Almost half of patients with nonvisualized veins on initial DUS had successful visualization on subsequent DUS. Whole lower extremity swelling, single vein nonvisualization, and single limb nonvisualization at initial DUS were associated with successful visualization on subsequent DUS. In all, 4.1% of patients with nonvisualized veins on initial DUS go on to develop VTE and 8.8% of patients who have subsequent DUS are found to have DVT. When initial DUS is unable to visualize calf veins, selective repeat DUS may be useful to identify either new or initially unseen DVT.