Misaki M. Kiguchi

Factors that influence perforator thrombosis and predict healing with perforator sclerotherapy for venous ulceration without axial reflux

OBJECTIVE Refluxing perforators contribute to venous ulceration. We sought to describe patient characteristics and procedural factors that (1) impact rates of incompetent perforator vein (IPV) thrombosis with ultrasound-guided sclerotherapy (UGS) and (2) impact the healing of venous ulcers (CEAP 6) without axial reflux. METHODS A retrospective review of UGS of IPV injections from January 2010 to November 2012 identified 73 treated venous ulcers in 62 patients. Patients had no other superficial or axial reflux and were treated with standard wound care and compression. Ultrasound imaging was used to screen for refluxing perforators near ulcer(s). These were injected with sodium tetradecyl sulfate or polidocanol foam and assessed for thrombosis at 2 weeks. Demographic data, comorbidities, treatment details, and outcomes were analyzed. Univariate and multivariable modeling was performed to determine covariates predicting IPV thrombosis and ulcer healing. RESULTS There were 62 patients (55% male; average age, 57.1 years) with active ulcers for an average of 28 months with compression therapy before perforator treatment, and 36% had a history of deep venous thrombosis and 30% had deep venous reflux. At a mean follow-up of 30.2 months, ulcers healed in 32 patients (52%) and did not heal in 30 patients (48%). Ulcers were treated with 189 injections, with an average thrombosis rate of 54%. Of 73 ulcers, 43 ulcers (59%) healed, and 30 (41%) did not heal. The IPV thrombosis rate was 69% in patients whose ulcers healed vs 38% in patients whose ulcers did not heal (P < .001). Multivariate models demonstrated male gender (P = .03) and warfarin use (P = .01) negatively predicted thrombosis of IPVs. A multivariate model for ulcer healing found complete IPV thrombosis was a positive predictor (P = .02), whereas a large initial ulcer area was a negative predictor (P = .08). Increased age was associated with fewer ulcer recurrences (P = .05). Predictors of increased ulcer recurrences were hypertension (P = .04) and increased follow-up time (P = .02). Calf vein thrombosis occurred after 3% (six of 189) of injections. CONCLUSIONS Thrombosis of IPVs with UGS increases venous ulcer healing in a difficult patient population. Complete closure of all IPVs in an ulcerated limb was the only predictor of ulcer healing. Men and patients taking warfarin have decreased rates of IPV thrombosis with UGS.

Endovascular Repair of 2 Iliac Pseudoaneurysms and Arteriovenous Fistula Following Spine Surgery

Purpose: To describe endovascular repair of traumatic iliac pseudoaneurysm and arteriovenous fistula (AVF) following spinal surgery. Case Report: A 48-year-old male underwent minimally invasive L5-S1 hemilaminectomy, foraminotomy, and microdiscectomy spinal surgery for trauma related to a motor-vehicle accident. Postoperative angiogram demonstrated pseudoaneurysm of the right internal iliac artery and AVF at the common iliac bifurcation with the right iliac vein with prompt filling of the iliac vein and vena cava. The second patient, a 25-year-old female, underwent minimally invasive L4-S1 hemilaminectomy, foraminotomy, and microdiscectomy spinal surgery for intractable pain and was complicated with postoperative symptoms of congestive heart failure. Postoperative angiogram demonstrated AVF between the right common iliac artery and vein with associated pseudoaneurysm formation. Endovascular repair was performed in both cases. Follow-up imaging revealed no endoleak and complete pseudoaneurysm and AVF exclusion. Conclusions: Endovascular repair of iliac injuries following spine surgery can be successfully performed with minimal morbidity.

Clinical application and early outcomes of the aortouni-iliac configuration for endovascular aneurysm repair

OBJECTIVE The objective of this study was to review the current anatomic indications for and early results of aortouni-iliac (AUI) devices for endovascular aneurysm repair. METHODS A total of 128 patients receiving an Endurant (Medtronic Inc, Minneapolis, Minn) AUI device in the U.S. Investigational Device Exemption trial (44 patients) or the Endurant Stent Graft Natural Selection Global Postmarket Registry (84 patients) were reviewed. Preoperative computed tomography imaging of patients in the Investigational Device Exemption trial and case report forms of Registry patients were used to determine anatomic indications. Baseline characteristics and early results were compared with those of 1305 patients receiving a bifurcated (BIF) device in sister studies. RESULTS The indication for the AUI device was unclear from case report forms in two Registry cases. The remaining 126 patients had a unilateral iliac occlusion in 30 (23%), a severely narrowed aortic segment in 58 (45%), severe iliac occlusive disease in 28 (22%), severe iliac tortuosity in 29 (23%), or complex iliac aneurysms in 19 (15%). Two patients had a previous aortobifemoral graft; 38 patients (30%) had multiple indications. The AUI cohort included more women than the BIF group did (19% vs 10%; P < .01) and had more severe comorbidities. Successful deployment was achieved in all AUI cases. The 30-day mortality was 2% (BIF cohort, 1%; P = .21). More AUI patients underwent repair under general anesthesia (81% vs 64%; P < .01), and procedures were longer (110.9 ± 54.9 minutes vs 99.2 ± 44.3 minutes; P = .02). Except for longer intensive care unit stays (19.6 ± 80.0 hours vs 9.0 ± 34.8 hours; P = .01) and higher myocardial infarction rates (4% vs 1%; P < .01), outcomes of the AUI cohort were similar to those of the BIF cohort. There were no migrations, ruptures, fractures, or open conversions at up to 1-year follow-up. CONCLUSIONS The AUI configuration extends endovascular aneurysm repair feasibility to several hostile anatomic conditions. Despite increased comorbidities in the recipient patient population and associated higher rates of postoperative myocardial infarction and respiratory complications, early outcomes with the new generation of AUI devices are acceptable and comparable to those after treatment with BIF configurations.

Pharmacomechanical thrombolysis for renal salvage after filter migration and renal vein thrombosis

A 64-year-old woman underwent prophylactic inferior vena cava filter placement immediately after spinal surgery for pulmonary embolus prophylaxis. One week after surgery, acute renal failure developed, and she required hemodialysis secondary to filter migration with iliocaval and renal vein thrombosis. Pharmacomechanical thrombolysis was performed, with complete recovery of renal function and no evidence of recurrence on follow-up imaging. This report highlights an important and rare complication of filter placement and the importance of prompt thrombus debulking to preserve end organ function while reducing the risks of hemorrhagic complications. Pharmacomechanical thrombolysis allows prompt clearance of venous outflow channels and is attractive in patients with end-organ compromise and high risk for bleeding.

Endovascular repair of thoracic aortic pathology

Endovascular repair of thoracic aortic pathology is an evolving and increasingly attractive alternative to open repair. Endograft technology and delivery systems have improved rapidly since their introduction in the 1990s, and early and mid-term results for currently available devices are promising. No individual device has proven to be superior as no comparative trials have been performed. However, each available device is unique in its characteristics to treat aortic disease: GORE® TAG® (WL Gore and Associates, AZ, USA), Zenith® (TX1® and TX2®, Cook, IN, USA), and Talent™ (Medtronic Vascular, CA, USA). In addition to a prerequisite set of endovascular skills, a detailed knowledge of different graft designs and an understanding of aortic pathology significantly affect the efficacy of endovascular repair of thoracic aortic disease. This article focuses on the currently available devices, their characteristics and pivotal clinical trial results.

Open Surgical Management of Deep Venous Occlusive Disease

Endovascular techniques have revolutionized the management of deep venous occlusive disease. Open surgery, however, is still required for cases that prove refractory to endovascular interventions. The surgical management of deep venous occlusive disease typically involves venous bypass. Preoperative planning before open venous surgery relies upon dynamic imaging to clarify the location and severity of venous obstruction, the assessment of infrainguinal reflux, and the delineation of bypass origination and target vessels. Adjunct arteriovenous fistulas and anticoagulation may improve patency rates of open surgical venous bypass. The timely recognition and management of complications improves secondary patency rates.

Thermal and Nonthermal Endovenous Ablation Options for Treatment of Superficial Venous Insufficiency

Open saphenous removal, phlebectomy, and venous ligation were historic mainstays of surgical treatment of venous disease. Duplex ultrasound has become standard to diagnose venous insufficiency. Percutaneous modalities have allowed treatments to include thermal and nonthermal endovenous ablation. These treatments vary in preoperative planning, procedural steps, and postprocedural care, but all are safe and effective. An individualized approach should be taken in determining which modality is offered to each patient. Endovenous options, which often are minimally invasive and safely performed in an outpatient setting, allow access to effective treatments with low risk and discomfort.

VESS06. An Intravascular Ultrasound-Based Scoring System May Predict Future Stent Failure in the Treatment of May-Thurner Syndrome

comparison to CEA. Patients enrolled in this project were compared with those undergoing CEA during the same period (2016-2017). The primary outcome was a composite of in-hospital stroke and death. Average treatment effects were estimated by augmented inverse-probability weighting. Additional analysis was performed using multivariable logistic regression as well as various matching techniques, such as propensity score matching and coarsened exact matching. Adjusted analysis accounted for age, sex, race, insurance status, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, symptomatic status, restenosis, prior vascular procedures, degree of ipsilateral stenosis, and preoperative medication use. Results: A total of 637 patients underwent TCAR compared with 12,049 patients who underwent CEA. Patients undergoing TCAR were older, more likely to be symptomatic, and had more medical comorbidities, such as coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and prior vascular procedures, compared with CEA patients (Table). The majority of TCAR procedures were done under local/regional anesthesia (95.3% vs 9.7% in CEA; P < .001). On average, TCAR was 36.7 minutes shorter than CEA (78.0 6 33.9 vs 114.7 6 42.5 minutes; P < .001). On univariate analysis, there were no differences in the rates of in-hospital stroke/death (1.3% vs 1.7%; P 1⁄4 .42), overall neurologic events (2.0% vs 1.9%; P 1⁄4 .83), in-hospital myocardial infarction (0.7% vs 1.1%; P 1⁄4 .31), and 30-day mortality (0.5% vs 0.9%; P 1⁄4 .08) between CEA and TCAR, respectively. Patients undergoing CEA had higher rates of cranial nerve injury (2.8% vs 0.8%; P < .01) and postoperative hypertension (18.3% vs 11.6%; P < .001) compared with TCAR patients. On multivariable analysis and using different matching methods, there were no differences in overall stroke, stroke/death, or overall neurologic events (Fig). The absolute difference in adjusted stroke/death rates between the two groups was 0.3% (95% confidence interval, 1.7% to 1.0%; P 1⁄4 .64). Conclusions: Despite a substantially higher medical risk in patients undergoing TCAR, analysis of the preliminary results from the SVS Vascular Quality Initiative TCAR Surveillance Project showed similar in-hospital stroke/death rates between TCAR and CEA after multivariable adjustment and rigorous matching. Further studies with larger sample sizes and longer follow-up will be needed to establish the equivalence of TCAR compared with CEA.

PC182 The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing

Fig 1. Peter Lawrence, Eric Hager, Michael P. Harlander-Locke, Lowell Kabnick, Naveed Saqib, Kristofer M. Charlton-Ouw, Misaki Kiguchi, The Vascular Low-Frequency Disease Consortium. University of California Los Angeles School of Medicine, Los Angeles, Calif; University of Pittsburgh Medical Center, Pittsburgh, Pa; Lake Erie College of Osteopathic Medicine, Erie, Pa; New York University Langone Medical Center, New York, NY; University of Texas Health Science Center, Austin, Tex; MedStar Heart and Vascular Institute, Washington, D.C.

Inferior Vena Cava Filters

Since the Greenfield filter was introduced in 1973, inferior vena cava (IVC) filters have evolved and adapted, and their use has exploded. This chapter will review standard and expanded uses of temporary and permanent IVC filters and discuss efficacy and use in specific patient populations. The technical considerations of filter placement and retrieval will be reviewed, and complications of IVC filters will be discussed.