Pavel Kibrik

Endoureteral coil embolization of an ureteral arterial fistula

Background Ureteral arterial fistulas are rare but potentially life threatening. We present a female who developed a ureteral arterial fistula following a right robotic nephrectomy. After several endovascular interventions to control the bleeding had failed, we approached the fistula through the right ureteral stump with coil embolization. Methods Coil embolization of the right ureteral stump was performed. We utilized a 6Fr × 45 cm sheath inserted through one of the cystoscope channels to cannulate the right ureteral orifice. We then performed a retrograde ureterogram. After, we were able to visualize full length of the ureter, ahd we began placing several 10–12 mm Nester coils to pack the ureter and tamponade the fistula for hemostasis. After the ureter was packed, we injected 1 g of Vancomycin into the ureter. The sheath and cytoscope were removed and the patient did well and was sent to the recovery room. Results Postoperatively, the patient had no complaints of hematuria and her hemoglobin level remained unchanged. She was observed for a few days prior to being discharged to home. The patient’s follow-up at six months revealed resolution of her hematuria. Conclusion Ureteral arterial fistula is a potentially life-threatening condition. Endovascular stenting has provided a safe, reliable alternative to open surgery. However, when endovascular options are not satisfactory, coil embolization of the ureteral stump may serve as a safe and effective alternative treatment for these cases.

Is there an effect of race/ethnicity on early complications of iliac vein stenting?:

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases. Little literature has examined the effect of race/ethnicity on venous disease. Iliac vein stenting is an emerging technology in treating chronic venous insufficiency. To further characterize this disease and its treatment, we chose to study the effect of selected clinical factors including race/ethnicity on the early complications of non-thrombotic iliac vein stenting. Methods In this observational study, data analysis was performed for 623 patients with chronic venous insufficiency who underwent iliac vein stenting during the time period from August 2012 to September 2014. Patients were categorized by Caucasians (n = 396), African Americans (n = 89), Hispanics (n = 138), and others (n = 23). These were correlated with the age, gender, presenting sign according to CEAP classification, percentage of iliac vein stenosis, post-operative thrombosis and pain score. Pain score was obtained post-operatively on a Likert scale of 0–10. Follow-up was performed after completion of the procedure, through post-operative visits and duplex exams every three months for the first year. Statistical analysis was performed using Chi-square and Student’s t-test, Pearson’s test and multivariate regression. Results The average age of the study patients was 67.8 years (age range 23–96 years, ± 14.2 SD). Sixty-seven patients were women. The presenting sign according to CEAP classification was (C3 = 331, C4 = 175, C5 = 51, C6 = 66). The average pain score was 2.6 (±2.9 SD). The average degree of stenosis was 64.9% (±3.8 SD). There were insufficient numbers in the “other” race/ethnicity group for further analysis. The number of patients with iliac vein stent thrombosis was 14 (2.2%). When analyzing each race/ethnicity in our dataset with univariate analysis, we found that Caucasians were significantly older than the African Americans and Hispanics (P < 0.0001). There tended to be more women in the Caucasian group as compared to the Hispanics (P = 0.04). There were no differences in presenting sign according to CEAP classification or degree of stenosis between the three groups. Hispanics tended to have higher pain scores post-operatively than Caucasians (P = 0.01). It was found that 1.8% of Caucasians, 3.4% of African Americans and 2.9% of Hispanics had post-operative iliac vein stent thrombosis (P = 0.55). Men have higher CEAP score than women regardless of race/ethnicity (P = 0.0001). On the other hand, women tended to have higher pain score than men (P = 0.04). There were no differences between men and women regarding age, degree of stenosis, and stent thrombosis. Linear multivariate regression test and Pearson’s test revealed that age is inversely related to pain score (P < 0.0001). ANOVA multivariate regression statistical analysis showed no relation between race/ethnicity and pain score (P = 0.98), and one-way ANOVA showed that the Caucasians were the eldest ethnic group in the study (P < 0.0001). Linear multivariate regression test and Pearson’s correlation test revealed that race/ethnicity is not correlated with thrombosis of iliac vein after stenting (P = 0.8). Conclusion Race/ethnicity is not significantly associated with CEAP score, degree of iliac vein stenosis, or post-operative thrombosis or pain scores. Age was inversely associated with pain score after iliac vein stenting.

Safety and efficacy of stenting nonthrombotic iliac vein lesions in octogenarians and nonagenarians in an office setting

Objectives Treatment options for venous insufficiency are rapidly evolving in the office setting and include venography, intravascular ultrasound, and venous stenting. Non-thrombotic iliac vein lesions assessment and treatment in an office setting is currently an area of interest. The purpose of this study is to demonstrate the safety and efficacy of evaluating non-thrombotic iliac vein lesion with this office-based procedure in octogenarians and nonagenarians. Methods From January 2012 through December 2013, 300 non-thrombotic iliac vein lesion limbs in 192 patients with venous insufficiency ≥80 years old were evaluated for non-thrombotic iliac vein lesion. Patients were evaluated and treated with venography, intravascular ultrasound, and stent placement for significant lesions demonstrated by greater than 50% diameter or cross-sectional area reduction. Group 1: 168 of these patients were octogenarians; female/male ratio was 1.75:1, bilateral in 89/168 patients (53%), left sided in 131/259 limbs (51%), right sided in 128 limbs (49%), average age 83.5 ± 2.6 years (range 80–89) compared to Group 2: 24 nonagenarians; female/male was 3:1, bilateral in 17/24 patients (70%), left sided in 20/41 limbs (49%), right sided in 21/41 limbs (51%), average age 92.9 ± 2.2 years (range 90–99). Stent related outcomes were evaluated with communication to the patient within 24 h to assess post-procedure pain followed by serial iliocaval ultrasonography. Results Out of the 300 limbs evaluated, in Group 1, 86% of limbs had stents placed compared to 90% in Group 2 and 11% of both groups had two stents placed. Overall improvement in pain, edema, and ulcers was reported in 147 (59%) of octogenarians and 24 (65%) of nonagenarians. There were no surgical site infections, pseudo-aneurysms, arteriovenous fistulas, or femoral artery injuries. No patients required transfusion within three days post-operatively and there were no 30-day mortalities in both sets of patients. Conclusions Our results demonstrate that there is no statistical difference in the outcome of performing venography, intravascular ultrasound, and stent placement in an office-based setting in octogenarians and nonagenarians. Both groups maintained a similar safety profile with low morbidity and mortality. In conclusion, we believe that the treatment of non-thrombotic iliac vein lesion in an office-based setting is safe and efficacious in both groups.

Clinical outcomes of direct oral anticoagulants after lower extremity arterial procedures

Objectives The use of postoperative anticoagulation is not uncommon for patients undergoing lower extremity arterial procedures as adjunctive therapy. Longer postoperative length of stay is necessary to achieve adequate therapeutic international normalized ratio with traditional protocols that call for the use of unfractionated heparin and warfarin therapy. We hypothesized the direct oral anticoagulants are an attractive alternative to provide adequate anticoagulation in patients who undergo lower extremity arterial procedures. Methods We retrospectively studied patients who had lower extremity arterial procedures between 2012 and 2015 to examine the safety and efficacy of the direct oral anticoagulants in a single institution. Patency, freedom from re-intervention, and major adverse limb event were evaluated. The direct oral anticoagulant agents used included dabigatran, rivaroxaban, and apixaban. The primary patency, adverse effects and freedom from re-intervention were then compared to a control group of patients who were treated with traditional heparin–warfarin therapy after lower extremity bypass procedures. Results Direct oral anticoagulants were utilized in a total of 23 patients (48% men; mean age 69 ± 11 years) during the study period. Indication for use of direct oral anticoagulant after procedure included use of polytetrafluoroethylene (PTFE) bypass graft below the knee joint or after lower extremity angioplasty with disadvantaged runoff. Mean follow-up of the drugs was 23 months (SD ± 16 months). At the end of follow-up, the direct oral anticoagulants have been discontinued in four patients, who are currently only on plavix. Among 82.6% of patients who were given direct oral anticoagulants for PTFE bypasses, graft patency, freedom from re-intervention, and major adverse limb event were 100%, 100%, and 0%, respectively. Patients (17.4%) treated with direct oral anticoagulants for disadvantaged runoff after balloon angioplasty of the lower extremity, patency, freedom from re-intervention, and major adverse limb event were 100%, 100%, and 0%, respectively. For the patients who underwent direct oral anticoagulant administration for disadvantaged runoff primary patency was 100%. One patient developed wound dehiscence which was unrelated to direct oral anticoagulant administration. Our control group consisted of 100 patients who were treated with heparin–warfarin therapy for 30 days after lower extremity bypass procedures. The graft patency, freedom from intervention, and major adverse limb event were 93%, 12%, and 0%, respectively. There was however no statistically significant difference in graft patency rate (P = .34) or freedom from intervention (P = .07) between the two groups. Conclusions The preliminary data suggest that there may be a role for using the direct oral anticoagulants with patients who undergo lower extremity arterial procedures for prevention of thrombosis and warrants further investigation.

Demographic and clinical features do not affect the outcome of combined endovenous therapy to treat leg swelling

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases, yet there are limited data on risk factors and outcome of lower limb swelling. While many patients improve with endovenous therapy (thermal ablation or iliac vein stenting), some patients’ symptoms persist. The goal of this study was to identify clinical factors including race/ethnicity related to persistent leg swelling after treatment with both iliac vein stenting and thermal ablation. Methods From February 2012 to February 2014, this observational study analyzed data for 173 patients with chronic venous insufficiency who underwent both iliac vein stent placement as well as thermal ablation (radiofrequency ablation or endovenous laser ablation). All procedures of the thermal ablations and the iliac vein stenting were staged. Iliac vein stenosis was identified using intravascular ultrasound of the iliofemoral venous segment showing >50% cross-sectional area or diameter reduction. The patients were queried to the resolution of their leg swelling after both procedures were performed. The resolution of swelling was correlated with age, gender, presenting sign according to CEAP classification, race/ethnicity and degree of iliac vein stenosis. Patients were categorized by Caucasians (n = 97), African Americans (n = 27), or Hispanics (n = 49). Statistical analysis performed using Chi-square and Student’s t test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 117 (67.6%) patients were women. The average age was 67 (±13 SD) years. The average pain score was 2.9(±3.1 SD). The average degree of iliac vein stenosis was 66.5(±13.3 SD). About 56.1% were Caucasians, 15.6% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 2. One hundred fifty-two (87.9%) patients stated that they had improvement in swelling after combined procedures, 100 (65.8%) patients were women. The average age was 67.3 (±13 SD) years. The average pain score was 2.9 (±3.1 SD). The average degree of iliac vein stenosis was 67.3% (±12.8 SD). About 56.6% were Caucasians, 15.1% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 1. Twenty-one (12.1%) patients stated they had no improvement after both procedures. Correlating these group factors with the group of patients who improved their swelling after the combined procedures we found the following: 17 (81%) of these patients were females (P=0.16). The average age was 68.4 (±17 SD) years (P=0.72 SD). The average pain score was 3.2 (±3.7 SD) (P=0.68). The average degree of iliac vein stenosis was 60.2% (±15.9 SD) (P=0.02). Around 52.4% were Caucasians, 19% were African Americans, and 28.6% were Hispanics (P=0.88). The number of patients with iliac vein stent thrombosis was 1 (P = 0.1). Conclusion These data suggest that the clinical factors including race are not clinically significant factors in the response to swelling after combined iliac stent and endovenous ablation procedures. Interestingly, a higher degree of iliac vein stenosis was associated with improved resolution of swelling

VESS16. Iliac Vein Stent Placement and the Iliocaval Confluence

CAD, Coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; ESRD, end-stage renal disease; HTN, hypertension; IQR, interquartile range; MI, myocardial infarction. to identify the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) in patients with intermittent claudication (IC). Methods: We queried the Premier Healthcare Database for all adult patients undergoing first-recorded inpatient elective LEB from 2009 to 2015. ICU utilization on postoperative day 0 (POD0) was identified for each patient using Premier-provided room and board chargemaster codes. Baseline patient and hospital characteristics as well as crude postoperative outcomes are reported. A bivariate logistic regression with postestimation C statistics calculation was performed to identify predictors of ICU admission on POD0 (vs ward). Results: Of the 7493 patients who met the selection criteria, 3237 (45.3%) were admitted to the ward, 1138 (15.9%) to a stepdown unit, and 2772 (38.8%) to an ICU on POD0. Patient-level factors (demographics and comorbidities) contributed to minor differences of those who were admitted to ICU vs ward, whereas major differences were found in hospital characteristics. Specifically, ICU patients were more likely to be admitted in rural, nonteaching, small hospitals and hospitals in the South Atlantic division (all P < .001; Table). We found that patients who were admitted to the ICU on POD0 were more likely to be admitted to hospitals with median (interquartile range) total ward admissions after infrainguinal LEB for IC of 10.7% (3.4%-29.7%) vs 90.6% (64.0%-98.3%) for patients admitted to wards on POD0. Patient-level factors poorly predicted admission to ICU on POD0, with C statistics ranging from 0.50 to 0.53; hospital-level factors had higher C statistics ranging from 0.51 to 0.66. There was no difference in the risk of wound complications, major adverse limb events, or major adverse cardiac events of patients admitted to ICU vs wards on POD0 (all P > .05). However, the median total hospital cost was

Placement issues of hemodialysis catheters with pre-existing central lines and catheters:

2340 higher for ICU vs ward (

A Real-World Experience of Drug-Eluting and Nondrug-Eluting Stents in Lower Extremity Peripheral Arterial Disease

13,273 [

Recanilization After Endovenous Thermal Ablation

10,136

Recanalization After Endovenous Thermal Ablation

17,883] vs