Neil M. Khilnani

Endovenous laser treatment of saphenous vein reflux: long-term results.

PURPOSE To report long-term follow-up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. MATERIALS AND METHODS Four hundred ninety-nine GSVs in 423 subjects with varicose veins were treated over a 3-year period with 810-nm diode laser energy delivered percutaneously into the GSV via a 600- micro m fiber. Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafter to assess treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow-up for treatment of associated tributary varicose veins and secondary telangiectasia. RESULTS Successful occlusion of the GSV, defined as absence of flow on color Doppler imaging, was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed, with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months, with the majority noted before 3 months. Bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias, or cases of deep vein thrombosis. CONCLUSIONS Long-term results available in 499 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7% at 2-year follow-up. These results are comparable or superior to those reported for the other options available for treatment of GSV reflux, including surgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.

Contrast-enhanced peripheral MR angiography from the abdominal aorta to the pedal arteries: combined dynamic two-dimensional and bolus-chase three-dimensional acquisitions.

Wang Y, Winchester PA, Khilnani NM, et al. Contrast-enhanced peripheral MR angiography from the abdominal aorta to the pedal arteries: Combined dynamic two-dimensional and bolus-chase three-dimensional acquisitions. Invest Radiol 2001;36:170–177. rationale and objectives. To obtain reliable contrast-enhanced peripheral MR angiography for imaging peripheral vascular disease from the abdominal aorta to the pedal arteries. methods.A protocol consisting of contrast-enhanced, dynamic two-dimensional (2D) acquisition at the feet and calf and bolus-chase three-dimensional (3D) acquisition from the abdominal aorta to the calf was developed and applied in patients with peripheral vascular disease. The performance of this integrated protocol was assessed in 89 consecutive patients. results.The bolus-chase 3D acquisition was of diagnostic quality in 100% of the acquisitions in the abdomen, 96% in the thigh, and 43% in the calf. The poor quality of the calf acquisitions was due to insufficient spatial resolution, poor arterial signal, and venous contamination. Diagnostic-quality images were obtained in 100% of the dynamic 2D acquisitions of the calf and 98% of the feet. conclusions.The combined dynamic 2D and bolus-chase 3D contrast-enhanced MR angiography technique provides diagnostic images of the entire lower extremity.

Multi-society consensus quality improvement guidelines for the treatment of lower-extremity superficial venous insufficiency with endovenous thermal ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology and Canadian Interventional Radiology Association.

Neil M. Khilnani, MD, Clement J. Grassi, MD, Sanjoy Kundu, MD, FRCPC, Horacio R. D’Agostino, MD, Arshad Ahmed Khan, MD, J. Kevin McGraw, MD, Donald L. Miller, MD, Steven F. Millward, MD, Robert B. Osnis, MD, Darren Postoak, MD, Cindy Kaiser Saiter, NP, Marc S. Schwartzberg, MD, Timothy L. Swan, MD, Suresh Vedantham, MD, Bret N. Wiechmann, MD, Laura Crocetti, MD, John F. Cardella, MD, and Robert J. Min, MD, for the Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Society of Interventional Radiology Standards of Practice Committees

Bolus arterial-venous transit in the lower extremity and venous contamination in bolus chase three-dimensional magnetic resonance angiography

Wang Y, Chen CZ, Chabra SG, et al. Bolus arterial-venous transit in the lower extremity and venous contamination in bolus chase three-dimensional magnetic resonance angiography. Invest Radiol 2002;37:458–463. rationale and objectives. To investigate the phenomena and causes for undesired venous signal in the distal station of bolus chase 3D MRA. methods. Consecutive patients (in 8 months) undergoing peripheral MRA consisting of 2D projection MRA of the tibial trifurcation and 3D bolus chase MRA were retrospectively evaluated. Venous contamination in mid-calf in bolus chase 3D MRA was correlated to the arterial phase duration, the time between the contrast bolus arrival and venous return measured on time resolved 2D images. Statistical analyses were performed to identify the clinical parameters indicative of venous contamination. results. The arterial phase durations at the mid-calf were 49 ± 8 seconds on 101 legs without venous signal in the bolus chase 3D MRA, 35 ± 9 seconds on 13 legs with moderate venous signal, and 20 ± 4 seconds on 40 legs with substantial venous signal; the differences were significant among different venous signal levels (P < 0.001 for all pairs). Legs with cellulitis had shorter arterial phase and more venous contamination than legs without cellulitis (P < 0.05). Patients with myocardial infarction had longer arterial phase and less venous contamination than patients without myocardial infarction (P < 0.01). conclusion. Venous signal in the distal calf station of bolus chase 3D peripheral MRA is caused by fast arterial-venous transit. It is worse in legs with cellulitis and less in patients with a history of myocardial infarction.

Duplex Ultrasound Evaluation of Lower Extremity Venous Insufficiency

Physicians unfamiliar with venous insufficiency, particularly disorders of the superficial venous system, often underestimate the complexity of the problem and the importance of proper evaluation before initiating treatment. In addition to a directed history evaluation and physical examination, additional evaluation with use of a variety of noninvasive diagnostic instruments, including duplex ultrasound, may be necessary when determining the cause, severity, and best treatment options available for a particular patient. After such evaluation, the treating physician should have a precise map of the patients pathways of venous insufficiency, including sources of reflux (eg, saphenofemoral junction, saphenopopliteal junction, perforators), tributaries, vein size, and vein morphology.

Endovenous laser treatment of saphenous vein reflux.

Readily available noninvasive diagnostic tests now allow physicians to accurately map out abnormal venous pathways and identify sources of reflux. In recent years, minimally invasive alternatives to surgical treatment of saphenous vein reflux, the main contributor to most cases of symptomatic varicose veins, have been developed with promising results.(1-8) The latest percutaneous technique developed to treat incompetent saphenous veins is endovenous laser, which allows delivery of laser energy directly into the vein lumen to cause collagen contraction and denudation of endothelium. This stimulates vein-wall thickening with eventual fibrosis of the vein. These modern percutaneous techniques now provide patients with alternatives to ligation and stripping for treatment of significant sources of venous reflux without many of the potential complications associated with surgery.

Recommended Reporting Standards for Endovenous Ablation for the Treatment of Venous Insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Sanjoy Kundu, MD, FRCPC, FCIRSE, FASA, Fedor Lurie, MD, Steven F. Millward, MD, FRCPC, FSIR, Frank Padberg Jr, MD, Suresh Vedantham, MD, Steven Elias, MD, Neil M. Khilnani, MD, William Marston, MD, John F. Cardella, MD, FSIR, FACR, Mark H. Meissner, MD, Michael C. Dalsing, MD, Timothy W.I. Clark, MD, FSIR, and Robert J. Min, MD, MBA, FSIR, Toronto and Peterborough, Ontario, Canada; Honolulu, Hawaii; Newark and Englewood, NJ; Saint Louis, Mo; New York, NY; Chapel Hill, NC; Springfield, Mass; Seattle, Wash; and Indianapolis, Ind

Comparison of Two-dimensional MR Digital Subtraction Angiography of the Lower Extremity with X-Ray Angiography☆

PURPOSE To perform a preliminary evaluation of the diagnostic accuracy of contrast-enhanced, two-dimensional (2D) magnetic resonance (MR) digital subtraction angiography (DSA) of the lower extremity by comparison with x-ray angiography (XRA). MATERIALS AND METHODS Forty lower extremities in 22 patients were imaged at multiple levels with both XRA and 2D MR DSA. Images were retrospectively analyzed by three radiologists in a randomized blinded manner. Seventeen vascular segments were graded as an insignificant lesion, a significant lesion, or as an occlusion. With the use of segments well depicted with XRA as the gold standard, the sensitivity, specificity, and accuracy of 2D MR DSA, as compared with XRA, were evaluated. The McNemar-Stuart-Maxwell test was performed to determine the significance of any differences found. RESULTS Three hundred eighty-three arterial segments were evaluated with both techniques. Three hundred one segments were well depicted with XRA. There was no significant difference between 2D MR DSA and XRA for assessing the degree of occlusive disease in these 301 segments (.25 < P < .5). The sensitivity, specificity, and diagnostic accuracy of 2D MR DSA were found to be 90%, 98%, and 93%, respectively. CONCLUSION Two-dimensional MR DSA is an accurate method for assessing arterial lesions in the lower extremity.

FLUOROSCOPIC LANDMARKS FOR OPTIMAL VISUALIZATION OF THE PROXIMAL RENAL ARTERIES

PURPOSE To accurately determine the in vivo orientation of the origin of the renal arteries from the aorta relative to a fluoroscopic bony landmark for optimal diagnostic arteriography and renal artery stent placement. MATERIALS AND METHODS One hundred sixty abdominal computed tomography (CT) scans of patients in eight age groups (20-90 years) were reviewed to determine the angle of the origins of the renal arteries from the aorta relative to the long axis of the L-1 spinous process (L1SP). RESULTS The right renal artery arises ventrally at an angle of 30 degrees (standard deviation [SD] = 15 degrees) from a plane orthogonal to the long axis of the L1SP. The left renal artery arises dorsally at an angle of 7 degrees (SD = 13 degrees) relative to the same plane. CONCLUSIONS The optimal initial angle for angiographic evaluation of the origin of the renal artery and for renal artery stent placement is 30 degrees left anterior oblique (LAO) relative to the L1SP for the right renal artery and 7 degrees LAO for the left renal artery. Unfortunately, there is variability in the angle of the renal artery origins from the aorta which cannot be controlled for using this technique. In some patients, additional views will be necessary to optimally depict the origins of the renal arteries.

Placement of subcutaneous chest wall ports ipsilateral to axillary lymph node dissection.

Without scientific evidence, practice has been to avoid placing chest wall ports ipsilateral to axillary lymph node dissection. Because the lymphatic system in the chest wall drains via both the internal mammary and axillary nodes, it seems that this practice might unduly restrict venous access options. Our study was designed to evaluate outcome after placement of chest wall ports ipsilateral to axillary lymph node dissection in patients with breast cancer. Twenty-eight patients were studied in this retrospective two-institution review. The incidence of lymphedema after port placement (3.6%) was no higher than that reported after axillary lymph node dissection alone.