Steven Farley

Management of endovenous heat-induced thrombus using a classification system and treatment algorithm following segmental thermal ablation of the small saphenous vein

OBJECTIVE We evaluated our experience with segmental radiofrequency ablation (RFA) of the small saphenous vein (SSV), a less common procedure than great saphenous vein ablation, and developed a classification system and algorithm for endovenous heat-induced thrombus (EHIT), based on modifications of our prior algorithm of EHIT following great saphenous ablation. METHODS Endovenous ablation was performed on symptomatic patients with incompetent SSVs following a minimum of 3 months of compression therapy. Demographic data, risk factors, CEAP classification, procedure details, and follow-up data were recorded. A four-tier classification system and treatment algorithm was developed, based on EHIT proximity to the popliteal vein. RESULTS Eighty limbs (in 76 patients) were treated with RFA of the SSV between January 2008 and August 2012. Duplex ultrasound was performed between 24 and 72 hours postprocedure in all patients. Ablation was successful in 98.7% (79/80) of procedures. Sixty-eight (85%) patients had level A closures (≥ 1 mm caudal to popliteal vein) and 10 patients (13%) had level B closures (flush with popliteal vein) and were observed. Two limbs (3%) had EHIT extending into the popliteal vein (level C) and were treated with outpatient low-molecular-weight heparin anticoagulation. Thrombus retracted to the level of the saphenopopliteal junction in both patients following a short course of anticoagulation. No patient developed an occlusive deep vein thrombosis (DVT) (level D). Mean follow-up period was 6.2 months; no patient had small saphenous recanalization, occlusive DVT, or pulmonary embolus. The presence or absence of the Giacomini vein was not predictive of level B and C closure. CONCLUSIONS RFA of the SSV in symptomatic patients has a high success rate with a low risk of DVT. A classification system and treatment protocol based on the level of EHIT in relation to the saphenopopliteal junction is useful in managing patients. The approach to patients with thrombus flush with the popliteal vein or bulging has not been previously defined; our outcomes were excellent, using our treatment algorithm.

Masson's tumor in the ulnar artery

A healthy 30-year-old woman presented to the emergency department with a pulsatile right forearm mass and numbness of her fourth and fifth fingers. Duplex scan imaging revealed an ulnar artery aneurysm with intramural thrombus. After resection, histopathology revealed intravascular papillary endothelial hyperplasia, also known as Massons tumor, a rare but benign vascular neoplasm. Local resection of the tumor with vascular reconstruction is curative and resulted in resolution of her neurologic symptoms. To our knowledge, this is the first reported case of a Massons tumor occurring in an ulnar artery.

Bovine carotid artery (Artegraft) as a hemodialysis access conduit in patients who are poor candidates for native arteriovenous fistulae.

Our experience with bovine carotid artery graft (BCAG) for hemodialysis access (Artegraft, North Brunswick, New Jersey) is presented. A review of all patients who underwent placement of BCAG for hemodialysis access at our institution was performed. Between January 2012 and June 2013, 17 BCAGs were placed in 17 patients. Indications included skin compromise, recurrent expanded polytetrafluoroethylene (ePTFE) and catheter infections, immunosuppression, groin placement, and surgeons choice. Actuarial primary, primary-assisted, and secondary patency rates at 18 months were 73.3%, 67%, and 89%, respectively. One immunosuppressed patient developed a vancomycin-resistant enterococcus graft infection and required removal 2 months following the initial procedure. We conclude that BCAG can be used as an alternative to ePTFE for angioaccess in patients with no available superficial vein in high-risk patients with low morbidity and good functional patency. Our 1-year patency rates were superior to ePTFE as reported in the contemporary peer-reviewed literature.

Techniques for inferior vena cava resection and reconstruction for retroperitoneal tumor excision

Management of the inferior vena cava (IVC) after resection for treatment of retroperitoneal sarcomas is controversial. Ligation is well tolerated if collateral circulation is preserved. These pathways, however, are often interrupted or resected during tumor excision, and up to 50% of these patients will experience lower extremity edema with IVC ligation. We have favored IVC reconstruction, particularly when circumferential resection is necessary for complete retroperitoneal tumor removal. Our results with this approach have been recently updated, documenting that en bloc resection and reconstruction of the IVC can be performed with very low morbidity and mortality and is associated with a low incidence of postoperative symptoms of venous hypertension. This article describes our preferred techniques for the management of the IVC after partial or circumferential resection.

Is Heparin Reversal Required for the Safe Performance of Percutaneous Endovascular Aortic Aneurysm Repair

BACKGROUND Percutaneous endovascular aneurysm repair (PEVAR) can be performed with high technical success rates and low morbidity rates. Several peer-reviewed papers regarding PEVAR have routinely combined heparin reversal with protamine before sheath removal. The risks of protamine reversal are well documented and include cardiovascular collapse and anaphylaxis. The aim of this study is to review outcomes of patients who underwent PEVAR without heparin reversal. METHODS All patients who underwent percutaneous femoral artery closure after PEVAR between 2009-2012 without heparin reversal were reviewed. Only patients who underwent placement of large-bore (12- to 24-French) sheaths were included. Patient demographics, comorbidities, operative details, and complications were reported. RESULTS One hundred thirty-one common femoral arteries were repaired using the Preclose technique in 76 patients. Fifty-five patients underwent bilateral repair and 21 underwent unilateral repair. The mean age was 73.9±9.1 years. The mean heparin dose administered was 79±25.4 U/kg. The mean patient body mass index was 27.5±4.8 kg/m2. Ultrasound-guided arterial puncture was performed in all patients. Average operative times were 196.5±103.3 min, and the mean estimated blood loss was 277.6 mL. Four femoral arteries (3%) required open surgical repair after failed hemostasis with ProGlide closure (Abbott Vascular, Abbott Park, IL). Two patients required deployment of a third ProGlide device with successful closure. Two patients had small (<3 cm) groin hematomas that had resolved at the time of the postoperative computed tomography scan. No pseudoaneurysms or arteriovenous fistulas developed in our patient cohort. No early or late thrombotic complications were noted. One patient (1.3%) with a ruptured aneurysm died 48 hours after endovascular repair unrelated to femoral closure. CONCLUSIONS PEVAR may be performed with low patient morbidity after therapeutic heparinization without heparin reversal. Femoral artery repair after the removal of large-diameter sheaths using the Preclose technique can be performed in this setting with minimal rates of early and late bleeding or thrombosis.

Contemporary outcomes after venography-guided treatment of patients with May-Thurner syndrome.

OBJECTIVE Patients with May-Thurner syndrome (MTS) present with a spectrum of findings ranging from mild left leg edema to extensive iliofemoral deep venous thrombosis (DVT). Whereas asymptomatic left common iliac vein (LCIV) compression can be seen in a high proportion of normal individuals on axial imaging, the percentage of these persons with symptomatic compression is small, and debate exists about the optimal clinical and diagnostic criteria to treat these lesions in patients with symptomatic venous disease. We evaluated our approach to venography-guided therapy for individuals with symptomatic LCIV compression and report the outcomes. METHODS All patients with suspected May-Thurner compression of the LCIV between 2008 and 2015 were analyzed retrospectively. Patients with chronic iliocaval lesions not associated with compression of the LCIV were excluded from analysis. Criteria for intervention included LCIV compression in the setting of (1) leg edema/venous claudication with associated venographic findings (collateralization, iliac contrast stagnation, and contralateral cross cross-filling), or (2) left leg deep venous thrombosis. Outcome measures included presenting Clinical, Etiology, Anatomy, Pathophysiology (CEAP) score, postintervention CEAP score, primary patency, and secondary patency. Technical success was defined as successful stent implantation without intraoperative device complications, establishment of in-line central venous flow, and less than 30% residual LCIV stenosis. RESULTS Of the 63 patients evaluated, 32 (51%) had nonthrombotic MTS and presented with leg edema (100%) or venous claudication (47%). Thirty-one patients (49%) had thrombotic MTS and presented with acute (26%) or chronic (71%) DVT, leg edema (100%), or venous claudication (74%). The mean presenting CEAP score was 3.06 and 3.23 for nonthrombotic and thrombotic MTS, respectively. Forty-four patients (70%) underwent successful intervention with primary stenting (70%) or thrombolysis and stenting (30%); 14 nonthrombotic MTS patients were treated conservatively with compression therapy alone, and 5 thrombotic MTS patients were treated with lysis or angioplasty alone. Clinical improvement and decrease in CEAP score occurred in 95% and 77% of stented patients compared with 58% and 32% of nonstented patients. Complete symptom resolution was achieved in 48% of patients overall, or 64% of stented patients and only 21% of nonstented patients. Complications included two early reocclusions. Primary and secondary 2-year patency rates were 93% and 97% (mean follow-up, 20.3 months) for stented patients. CONCLUSIONS Venography-guided treatment of MTS is associated with excellent 1-year patency rates and a significant reduction in symptoms and CEAP score. Treating symptomatic MTS patients on the basis of physiologically relevant venographic findings rather than by intravascular ultrasound imaging alone results in excellent long-term patency and clinical outcomes but may result in undertreatment of some patients who could benefit from stent implantation.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs

Objective: The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. Methods: We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. Results: Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow‐up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow‐up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). Conclusions: This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision. Graphical abstract: Figure. No caption available.

New approaches to wound healing for diabetes 促进糖尿病患者伤口愈合的新方法: Commentary

Diabetic foot wounds are a major cause of morbidity and mortality and, even in centers in which nearly half the patients with moderate or severe wounds undergo revascularization, these wounds have median healing times of 6 months or more, with one-third requiring amputation. Such resource-intensive care is simply not available in most of the world, where “water or even gauze dressings may be scarce or not available”. Therefore, topical formulations to assist in wound healing are of significant interest: they can be simply applied, are not invasive, do not require advanced training for application, and can be used in an outpatient setting at relatively low cost. Moreover, many wounded patients have gone through exhaustive treatment with offloading, daily wound care, and invasive procedures, all without successful healing. Topical agents for wound healing have been described and used since antiquity. The study reported in the current issue of the Journal of Diabetes is therefore of interest in exemplifying the importance of research to find novel approaches to effective topical agents. Opiate receptors are present in the skin and stimulate keratinocyte formation. Gupta et al. used a delayed excisional wound-healing model in Zucker diabetic fatty mice to compare topical fentanyl with a saline-containing cream, finding significantly greater wound closure at 18 and 28 days, with a reduction in wound edema and increased re-epithelialization, vascularization, and granulation tissue formation with greater levels of collagen deposition. There is emerging data for the use of a number of topical antimicrobial, debriding, angiogenic, and cellular therapies as agents for wound healing. Probiotics and nitroglycerin have been proposed as offering therapeutic potential. Oxygen has been studied using a variety of application methods. Natural substances that have been studied include preparations based on beehive protectant propolis, aloe vera, Momordica charantia fruit, and kiwifruit. A recent meta-analysis suggested benefit of platelet-derived growth factor, and both epidermal growth factor and macrophage-stimulating agent have been studied as additional biological approaches. Although there is much interest in these topical treatments, none appears yet sufficiently well validated to be ready for widespread use. Topical honey for promotion of wound healing was studied in a Cochrane Database Systematic Review, which reported no benefit of such an approach. Another Cochrane review found “no statistically significant difference in healing between an antimicrobial [silver] fibrous-hydrocolloid dressing and standard alginate dressing; an antimicrobial dressing [iodine-impregnated] and a standard fibrous hydrocolloid dressing or a standard fibrous hydrocolloid dressing and a topical cream containing plant extracts”. We encourage ongoing basic and clinical research in these topics to address potential benefits of a variety of topical treatments on wound care.

New approaches to wound healing for diabetes 促进糖尿病患者伤口愈合的新方法

Diabetic foot wounds are a major cause of morbidity and mortality and, even in centers in which nearly half the patients with moderate or severe wounds undergo revascularization, these wounds have median healing times of 6 months or more, with one-third requiring amputation. Such resource-intensive care is simply not available in most of the world, where “water or even gauze dressings may be scarce or not available”. Therefore, topical formulations to assist in wound healing are of significant interest: they can be simply applied, are not invasive, do not require advanced training for application, and can be used in an outpatient setting at relatively low cost. Moreover, many wounded patients have gone through exhaustive treatment with offloading, daily wound care, and invasive procedures, all without successful healing. Topical agents for wound healing have been described and used since antiquity. The study reported in the current issue of the Journal of Diabetes is therefore of interest in exemplifying the importance of research to find novel approaches to effective topical agents. Opiate receptors are present in the skin and stimulate keratinocyte formation. Gupta et al. used a delayed excisional wound-healing model in Zucker diabetic fatty mice to compare topical fentanyl with a saline-containing cream, finding significantly greater wound closure at 18 and 28 days, with a reduction in wound edema and increased re-epithelialization, vascularization, and granulation tissue formation with greater levels of collagen deposition. There is emerging data for the use of a number of topical antimicrobial, debriding, angiogenic, and cellular therapies as agents for wound healing. Probiotics and nitroglycerin have been proposed as offering therapeutic potential. Oxygen has been studied using a variety of application methods. Natural substances that have been studied include preparations based on beehive protectant propolis, aloe vera, Momordica charantia fruit, and kiwifruit. A recent meta-analysis suggested benefit of platelet-derived growth factor, and both epidermal growth factor and macrophage-stimulating agent have been studied as additional biological approaches. Although there is much interest in these topical treatments, none appears yet sufficiently well validated to be ready for widespread use. Topical honey for promotion of wound healing was studied in a Cochrane Database Systematic Review, which reported no benefit of such an approach. Another Cochrane review found “no statistically significant difference in healing between an antimicrobial [silver] fibrous-hydrocolloid dressing and standard alginate dressing; an antimicrobial dressing [iodine-impregnated] and a standard fibrous hydrocolloid dressing or a standard fibrous hydrocolloid dressing and a topical cream containing plant extracts”. We encourage ongoing basic and clinical research in these topics to address potential benefits of a variety of topical treatments on wound care.

New approaches to wound healing for diabetes.

Diabetic foot wounds are a major cause of morbidity and mortality and, even in centers in which nearly half the patients with moderate or severe wounds undergo revascularization, these wounds have median healing times of 6 months or more, with one-third requiring amputation. Such resource-intensive care is simply not available in most of the world, where “water or even gauze dressings may be scarce or not available”. Therefore, topical formulations to assist in wound healing are of significant interest: they can be simply applied, are not invasive, do not require advanced training for application, and can be used in an outpatient setting at relatively low cost. Moreover, many wounded patients have gone through exhaustive treatment with offloading, daily wound care, and invasive procedures, all without successful healing. Topical agents for wound healing have been described and used since antiquity. The study reported in the current issue of the Journal of Diabetes is therefore of interest in exemplifying the importance of research to find novel approaches to effective topical agents. Opiate receptors are present in the skin and stimulate keratinocyte formation. Gupta et al. used a delayed excisional wound-healing model in Zucker diabetic fatty mice to compare topical fentanyl with a saline-containing cream, finding significantly greater wound closure at 18 and 28 days, with a reduction in wound edema and increased re-epithelialization, vascularization, and granulation tissue formation with greater levels of collagen deposition. There is emerging data for the use of a number of topical antimicrobial, debriding, angiogenic, and cellular therapies as agents for wound healing. Probiotics and nitroglycerin have been proposed as offering therapeutic potential. Oxygen has been studied using a variety of application methods. Natural substances that have been studied include preparations based on beehive protectant propolis, aloe vera, Momordica charantia fruit, and kiwifruit. A recent meta-analysis suggested benefit of platelet-derived growth factor, and both epidermal growth factor and macrophage-stimulating agent have been studied as additional biological approaches. Although there is much interest in these topical treatments, none appears yet sufficiently well validated to be ready for widespread use. Topical honey for promotion of wound healing was studied in a Cochrane Database Systematic Review, which reported no benefit of such an approach. Another Cochrane review found “no statistically significant difference in healing between an antimicrobial [silver] fibrous-hydrocolloid dressing and standard alginate dressing; an antimicrobial dressing [iodine-impregnated] and a standard fibrous hydrocolloid dressing or a standard fibrous hydrocolloid dressing and a topical cream containing plant extracts”. We encourage ongoing basic and clinical research in these topics to address potential benefits of a variety of topical treatments on wound care.