Showing papers in "Journal of vascular surgery. Venous and lymphatic disorders in 2023"

Standing position for real-time evaluation of retrograde lymph flows in indocyanine green lymphography.

Abstract: We read with great interest the article titled “Retrograde lymph flow in the lymphatic vessels in limb lymphedema” by Mackie et al.1Mackie H. Suami H. Thompson B.M. Ngo Q. Heydon-White A. Blackwell R. et al.Retrograde lymph flow in the lymphatic vessels in limb lymphedema.J Vasc Surg Venous Lymphat Disord. 2022; 10: 1101-1106Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Their study used Harvey's technique as a criterion for determining the presence of retrograde lymphatic flow. As previously reported, indocyanine green (ICG) lymphography is useful for the real-time evaluation of superficial lymph flow, including lymphedema diagnosis, severity evaluation, and preoperative mapping.2Yamamoto T. Narushima M. Doi K. Oshima A. Ogata F. Mihara M. et al.Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns.Plast Reconstr Surg. 2011; 127: 1979-1986Crossref PubMed Scopus (296) Google Scholar, 3Yamamoto T. Matsuda N. Doi K. Oshima A. Yoshimatsu H. Todokoro T. et al.The earliest finding of indocyanine green (ICG) lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow (DB) stage and concept of subclinical lymphedema.Plast Reconstr Surg. 2011; 128: 314e-321eCrossref PubMed Scopus (217) Google Scholar, 4Yamamoto T. Yamamoto N. Indocyanine green lymphography for evaluation of breast lymphedema secondary to breast cancer treatments.J Reconstr Microsurg. 2022; 38: 630-636Crossref PubMed Scopus (6) Google Scholar, 5Yamamoto T. Yamamoto N. Yoshimatsu H. Hayami S. Narushima M. Koshima I. Indocyanine green lymphography for evaluation of genital lymphedema in secondary lower extremity lymphedema patients.J Vasc Surg Venous Lymphat Disord. 2013; 1: 400-405Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar In addition to the methods described by the authors, another method can be used to effectively evaluate retrograde lymph flow using ICG lymphography. Harvey's technique is a method to manually increase the internal pressure of the lymph vessels to promote retrograde lymph flow. In their report, the examination was performed with the patient in the supine position, as in most previous reports. When the lymphatic valve function is insufficient owing to the progression of lymphosclerosis or lymphatic malformation, the technique will be sufficient to clarify the existence of retrograde lymph flow. However, the maneuver is performed to cause retrograde lymph flow, which should be different from the natural conditions. To evaluate the existence of retrograde lymph flow in natural conditions, it would seem ideal to perform ICG lymphography with the patient in the standing position without using specific maneuvers. Because lymphedema patients use the standing position daily, lower extremity lymphedema will progress because of gravity or increased hydrostatic pressure in the lymph vessels. Therefore, having patients stand during the ICG lymphography examination would be optimal to properly evaluate retrograde lymph flow. Although several studies have reported on venous evaluations with patients in the standing position, little is known regarding the ICG lymphography findings of real-time lymph flow evaluations with the patient standing. Further studies are warranted to elucidate the pathologic lymph flow changes in natural settings. Retrograde lymph flow in the lymphatic vessels in limb lymphedemaJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 10Issue 5PreviewRetrograde movement of lymph owing to damaged and/or incompetent valves in the lymphatic vessels has been considered a pathological feature of lymphedema. This study aimed to determine the prevalence of retrograde lymph flow and the characteristics of patients with this condition using indocyanine green (ICG) lymphography. Full-Text PDF ReplyJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 11Issue 3PreviewThank you for the opportunity to reply to the letter by Ishizuka and Tsukuura,1 titled “Standing position for real-time evaluation of retrograde lymph flows in indocyanine green lymphography,” They recommended the standing position for patients during the indocyanine green (ICG) lymphography examination as “optimal to properly evaluate retrograde lymph flow.” Full-Text PDF

12-month Endpoint Results from the Evaluation of the Zilver Vena Venous Stent in the Treatment of Symptomatic Iliofemoral Venous Outflow Obstruction (VIVO Clinical Study).

Abstract: BackgroundIn the present study, we evaluated the safety and effectiveness of the Zilver Vena venous stent in the treatment of patients with symptomatic iliofemoral outflow obstruction.MethodsThe VIVO clinical study was a prospective, nonrandomized, multicenter study that enrolled patients with symptomatic obstruction of one iliofemoral venous segment. Included were patients with Clinical, Etiological, Anatomical, Pathophysiological (CEAP) clinical classification of ≥3 or a Venous Clinical Severity Score (VCSS) pain score of ≥2. All patients received a self-expanding venous stent (Zilver Vena venous stent; Cook Ireland Ltd, Limerick, Ireland). The primary safety end point was 30-day freedom from major adverse events. The primary effectiveness end point was the 12-month rate of primary quantitative patency by venography as determined by the core laboratory. The secondary end point was the change in the VCSS from baseline to 1 and 12 months. Additional measures included freedom from clinically driven reintervention; change in the CEAP C classification, Venous Disability Score (VDS), and Chronic Venous Disease Quality of Life Questionnaire (CIVIQ) scores from baseline to 12 months; and stent durability measures.ResultsBetween December 2013 and October 2016, 243 patients (70% female; mean age, 53 ± 15 years; 67.5% with current or previous deep vein thrombosis) were enrolled at 30 institutions. Iliac vein compression by the iliac artery (n = 191; 78.6%) was the primary indication for stent placement. The mean lesion length was 98.6 ± 69.8 mm. The 30-day freedom from major adverse events rate was 96.7%, greater than the literature-defined performance goal of 87% (95% confidence interval [CI], 93.5%-98.6%; P < .0001). The 12-month primary quantitative patency rate was 89.9%, greater than the literature-defined performance goal of 76% (95% CI, 85.1%-93.4%; P < .0001). The change in the VCSS from baseline was −3.0 (95% CI, −3.5 to −2.6; P < .0001) at 1 month and −4.2 (95% CI, −4.7 to −3.7; P < .0001) at 12 months, demonstrating clinical improvement. Similarly, significantly (P < .0001) fewer symptoms over time (from preprocedure through 12 months) were measured using the clinical measures of VDS, CEAP C classification, and CIVIQ. The 12-month rate of freedom from clinically driven reintervention was 95.8% ± 1.3%. Through 12 months, no stent fractures and one clinical migration (Clinical Events Committee adjudicated the latter as technique-related due to device undersizing at placement) had occurred.ConclusionsThe 12-month results of the VIVO study have demonstrated the safety and effectiveness of the Zilver Vena venous stent for the treatment of symptomatic iliofemoral venous outflow obstruction, including clinical symptom improvement compared with baseline.

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months.

Abstract: To determine the safety and effectiveness of vena cava filters (VCFs).A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed.VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement.Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months.

Abstract: To determine the safety and effectiveness of vena cava filters (VCFs).A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed.VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement.Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.

Prevalence and predictors of combined >50% iliocaval venous obstruction and superficial venous reflux in chronic venous insufficiency patients with healed or active venous leg ulcer.

Abstract: The aim of the present study was to investigate the prevalence and predictors of combined >50% iliocaval venous obstruction (ICVO) and superficial venous reflux (SVR) in patients with chronic venous insufficiency (CVI) with a healed (C5) or an active (C6) venous leg ulcer (VLU).We conducted a retrospective review of prospectively collected data from patients with CVI with CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class C5 (healed ulcer) or C6 (active ulcer) with SVR who had been treated at our institution from February 2017 to January 2018. The demographic, clinical, and surgical data and duplex ultrasound and computed tomography venography findings were collected. We used OsiriX MD, version 2.9, software (Pixmeo SARL, Bernex, Switzerland) to measure the vein diameter via multiplanar reconstruction. The prevalence of combined >50% ICVO and SVR was evaluated, and univariate and multivariate analyses were performed to identify the independent predictors of >50% ICVO in patients with CVI and SVR.A total of 79 limbs from 67 patients were enrolled. The mean age was 59.82 ± 12.86 years, the mean body mass index was 28.68 ± 6.41 kg/m2, and 41.8% were men. The prevalence of >50% ICVO in the patients with SVR was 31.6%. Univariate analysis showed a history of deep vein thrombosis (DVT) in the affected leg (P = .001), a VLU in the left leg (P = .033), a history of a recurrent VLU (P = .038), and reversed flow in the superficial epigastric vein (P = .004) were significantly associated with >50% ICVO in patients with CVI and SVR. Multivariate analysis revealed a history of DVT in the affected leg (adjusted odds ratio [aOR], 8.31; 95% confidence interval [CI], 2.29-30.19; P = .001), a VLU in the left leg (aOR, 3.95; 95% CI, 1.18-13.19; P = .026), and a history of a recurrent VLU (aOR, 3.08; 95% CI, 1.02-9.32; P = .047) to be independently associated with combined >50% ICVO and SVR in patients with CVI.The prevalence of combined >50% ICVO and SVR in patients with CVI and CEAP C5 or C6 was 31.6%. The independent predictors of combined >50% ICVO and SVR in those with CVI were a history of DVT in the affected leg, a VLU in the left leg, and recurrent VLUs.

Iliac vein stent failure in community practice and results of corrective reinterventions.

Abstract: The goal of endovenous stenting is to relieve venous obstruction and reduce peripheral venous hypertension by using large caliber venous stents in the presence of adequate venous inflow and outflow for the stented conduit. The aim of this report is to describe the technical reasons and outcomes for reinterventions in a subset of patients who had a history of iliac vein stenting and were now referred to us at a specialty venous clinic for further care.From January 2016 to December 2021, records of all patients who were referred to us with a history of iliac vein stenting performed at an outside facility and who had a reoperation performed at our center were retrospectively analyzed.A total of 149 limbs underwent a deep venous reintervention after a failure of a trial of conservative therapy. The mean age of the sample was 57 ± 16 years. The ratio of non-thrombotic iliac vein lesions to post-thrombotic lesions was 1:2.5. The majority of the patients (84%) were CEAP class C4 or higher. The most common reason for reintervention was stent occlusion (74%), followed by iatrogenic stenosis (53%) and in-stent restenosis/shelving (38%). There was a trend for improvement in all clinical parameters (venous clinical severity score, visual analog scale for pain, and edema grade) after the reintervention. Poor inflow was present in 70% of limbs with stent occlusion. The median diameters of stented common femoral vein, external iliac vein, and common iliac vein prior to reintervention were 12, 12, and 13 mm, respectively. The median diameters of stented common femoral vein, external iliac vein, and common iliac vein after reintervention were 14, 15, and 16 mm, respectively. Eighty-eight percent of limbs required at least one further reintervention after initial reoperation.Venous reoperations are generally infrequent and required in a small number of patients. Poor inflow appeared to be a common cause of stent occlusion. Iatrogenic stenosis is another common reason for venous reoperation and is difficult to fully rectify through current endovascular techniques and tools. Use of intravascular ultrasound planimetry routinely in every deep venous intervention and thorough knowledge of the principles of venous stenting outlined in this report may help forestall the need for reoperative deep venous surgery in some cases.

Technique of stent sizing in patients with symptomatic chronic iliofemoral venous obstruction - The case for IVUS determined inflow channel luminal area-based stenting and associated long term outcomes.

Abstract: Objective Femoroiliocaval stenting has become the standard of care for patients with quality-of-life impairing chronic iliofemoral venous obstruction not responding to conservative measures. Although improvement after stenting has been noted in multiple large studies, sizing of stents has been subjective in nature with a general tendency to use smaller stents that would be required to relieve venous hypertension. This study evaluates the authors’ technique of using the intravascular ultrasound (IVUS) inflow channel luminal area to guide stent sizing. Methods Patients who underwent femoroiliocaval stenting for quality-of-life impairing chronic iliofemoral venous obstruction and had failed conservative therapy from 2015 to 2021 were included in the study. Clinical outcomes including venous clinical severity score (VCSS), visual analog scale (VAS) pain score, and grade of swelling (GOS) were appraised before and after stenting. Also evaluated were quality of life (Chronic Venous Insufficiency Questionnaire-20 [CIVIQ-20] instrument) and stent outcomes including patencies and reinterventions. Comparisons were made between limbs that underwent placement of larger caliber stents (largest stent diameter >20 mm: >20 mm stent group) vs smaller caliber stents (largest stent diameter ≤20 mm: ≤20 mm stent group). t tests and analysis of variance were used to compare outcomes, whereas the Kaplan-Meier analysis was used to evaluate patencies with log rank used to compare the curves. Results A total of 300 patients (300 limbs) underwent stenting with a median age of 58 years. There was a preponderance of men (159 of 300), left laterality (176 of 300), and post-thrombotic syndrome (176 of 300). The median body mass index was 41. There were 120 limbs in the >20 mm stent group and 180 limbs in the ≤20 mm stent group. The median follow-up was 23 months. There was no significant difference in baseline VCSS, VAS pain score, or GOS between the two groups. However, there was a significant difference in IVUS-determined inflow channel luminal area between the two groups (228 mm2 >20 mm stent group vs 176 mm2 for ≤20 mm stent group [P < .0001]). After stenting there was a significant improvement in the VCSS, VAS pain score, and GOS at 6 weeks, 3, 6, 12, and 24 months (P < .0001) without any difference between the groups (P > .05). The CIVIQ-20 score also improved from 58 to 38 (P < .0001) for the entire cohort and for the two groups (P < .0001). Overall primary, primary-assisted, and secondary patencies at 60 months were 84%, 100%, and 100%, respectively. Reintervention rate was 10% without any difference between the groups. Conclusions Stent sizing using IVUS-determined inflow channel luminal area in patients undergoing stenting for quality-of-life impairing chronic iliofemoral venous obstruction resulted in a significant improvement in the VCSS, VAS pain score, GOS, and quality of life (CIVIQ-20) after stenting. Excellent stent patencies and low reintervention rates were also noted. IVUS-determined inflow channel luminal area represents an objective technique of stent sizing in comparison to the subjective techniques that currently exist.

Pulmonary Embolism Response Team for hospitalized patients with submassive and massive pulmonary embolism: A Single Center Experience.

Abstract: BackgroundPulmonary embolism (PE) is a major cause of mortality with presentation varying between few or no symptoms to sudden death. This makes timely and appropriate treatment extremely important. Multidisciplinary PE response teams (PERT) have emerged to improve the management of acute PE. This study aims to describe the experience of a large multihospital single-network institution with PERT.MethodsA retrospective cohort study of patients admitted for submassive and massive PE between 2012 and 2019 was conducted. The cohort was divided based on time of diagnosis and hospital into two groups: non-PERT included patients treated at hospitals that did not initiate PERT and patients diagnosed before the introduction of PERT (June 1, 2014); and the PERT group included those admitted after June 1, 2014, to a hospital with PERT. Patients with low-risk PE and those who had admissions in both time periods were excluded. Primary outcomes included all-cause mortality at 30, 60, and 90 days. Secondary outcomes included causes of death, intensive care unit (ICU) admission, ICU length of stay (LOS), total hospital LOS, type of treatment, and specialty consultations.ResultsWe analyzed 5190 patients, with 819 (15.8%) being in the PERT group. Patients in the PERT group were more likely to receive extensive workup that included troponin-I (66.3% vs 42.3%; P < .001) and brain natriuretic peptide (50.4% vs 20.3%; P < .001). They also more often received catheter-directed interventions (12% vs 6.2%; P < .001) rather than anticoagulation monotherapy. Mortality outcomes were similar between both groups at all measured timepoints. Rates of ICU admission (65.2% vs 29.7%; P < .001), ICU LOS (median, 64.7 hours; interquartile range [IQR], 41.9-89.1 hours vs median, 38 hours; IQR, 22-66.4 hours; P < .001), and total hospital LOS (median, 5 days; IQR, 3-8 days vs median, 4 days; IQR, 2-6 days; P < .001) were all higher among the PERT group. Patients in the PERT group were more likely to receive vascular surgery consultation (5.3% vs 0.8%; P < .001) and the consultation occurred earlier in the admission when compared with the non-PERT group (median, 0 days; IQR, 0-1 days vs median, 1 day; IQR, 0-1; P = .04).ConclusionsThe data presented here showed that there was no difference in mortality after PERT implementation. These results suggest that the presence of PERT increases the number of patients receiving a full PE workup with cardiac biomarkers. PERT also leads to more specialty consultations and more advanced therapies such as catheter-directed interventions. Further research is needed to assess the effect of PERT on long-term survival of patients with massive and submassive PE.

Improvement following restoration of inline flow argues against comprehensive thrombus removal strategies and for selective stenting in acute symptomatic iliofemoral venous thrombosis

Abstract: Randomized trials have demonstrated the benefit of thrombus removal strategies in iliofemoral deep venous thrombosis (IFDVT) in providing early symptom relief and decreasing the incidence of post-thrombotic syndrome (PTS), especially severe PTS. However, the impact of quantum of residual thrombus burden (RTB) on PTS as determined by intravascular ultrasound examination and the role of venous stenting in the acute setting have not been evaluated and represent the focus of this study.Sixty-nine limbs (65 patients) undergoing thrombus removal for acute symptomatic IFDVT between 2015 and 2021 formed the study cohort. The Venous Clinical Severity Score (VCSS) (range, 0-27) grade of swelling (GOS) (range, 0-4), and visual analog scale (VAS) pain scores (range, 0-10) were evaluated initially and at 6, 12, and 24 months after thrombus removal. Quality of life was appraised using the CIVIQ-20 instrument. The extent of initial and RTB after the intervention was estimated using intravascular ultrasound examination. Grading was done as less than 50% (1), 50% to 99% (2), or 100% (3) of luminal thrombus fill within each segment (common femoral vein, external iliac vein, and common iliac vein) by a blinded rater and then combined to generate a total score. The use of stenting, both concurrent (severe residual stenosis/persistent occlusion) and delayed (quality of life impairing residual or recurrent symptoms), was evaluated.Of the 69 limbs, 53 underwent pharmacomechanical/mechanical thrombectomy (PMT), whereas 16 patients underwent PMT and catheter-directed thrombolysis with restoration of inline flow in all limbs. Post-intervention VCSS improved from 6 to 2 at 24 months (P < .0001). GOS improved from 4 to 0 at 24 months (P < .0001). The VAS pain score went from 5 to 0 at 6 months (P < .0001) and remained at 0 at 12 months (P < .0001), but increased to 3 at 24 months (P = .02). The CIVIQ-20 score improved from 38 to 22 (P = .001) over a median follow-up of 19 months. The median RTB total score improved from 9 to 4 (P < .0001). There was no impact of RTB total score (<3 vs >3) on VCSS (P = NS), GOS (P = NS), VAS pain score (P = NS) or CIVIQ-20 score (P = NS) at the various time points. Concurrent stenting was used in 23 limbs (33%) and delayed stenting was carried out in 10 limbs (14%). The median time to delayed stenting was 4 months after the initial thrombus removal intervention.In patients undergoing PMT or PMT with catheter-directed thrombolysis for acute symptomatic IFDVT, the restoration of inline flow seems to be adequate to provide symptom relief and decrease the incidence of PTS. The extent of RTB does not seem to impact the VCSS, GOS, VAS pain score, or quality of life after such restoration. Stenting can be pursued selectively in the acute setting to help restore inline flow.

A network meta-analysis on the efficacy and safety of thermal and non-thermal endovenous ablation treatments.

Abstract: We assessed the mid-term efficacy and safety of thermal and nonthermal endovenous ablation for the treatment of lower limb superficial venous insufficiency.We performed a systematic review in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and a Bayesian network meta-analysis. The primary end points were great saphenous vein (GSV) closure and venous clinical severity score (VCSS) improvement. A meta-regression using GSV diameter as a covariate was undertaken for the two primary end points.We included 14 studies and 4177 patients, with a mean follow-up of 25.7 months. Radiofrequency ablation (RFA; odds ratio [OR], 3.99; 95% confidence interval [CI], 1.82-10.53), cyanoacrylate ablation (CAC; OR, 3.09; 95% CI, 1.35-8.37), and endovenous laser ablation (EVLA; OR, 2.72; 95% CI, 1.23-7.38) displayed increased odds for GSV closure compared with mechanochemical ablation (MOCA). MOCA inferiority compared with RFA (mean difference [MD], 0.96; 95% CI, 0.71-1.20), EVLA (MD, 0.94; 95% CI, 0.61-1.24), and CAC (MD, 0.89; 95% CI, 0.65-1.15) was also depicted regarding VCSS improvement. EVLA resulted in an increased risk of postoperative paresthesia compared with MOCA (risk ratio [RR], 9.61; 95% CI, 2.32-62.29), CAC (RR, 7.90; 95% CI, 2.44-38.16), and RFA (RR, 6.96; 95% CI, 2.31-28.04). Although the overall analysis identified nonstatistically significant differences for Aberdeen varicose vein questionnaire score improvement, thrombophlebitis, ecchymosis, and pain, further investigation revealed an increase pain profile for EVLA at 1470 nm compared with RFA (MD, 3.22; 95% CI, 0.93-5.47) and CAC (MD, 3.04; 95% CI, 1.05-4.97). A sensitivity analysis displayed a persistent underperformance of MOCA compared with RFA (OR, 4.33; 95% CI, 1.15-55.54) for GSV closure and both RFA (MD, 0.99; 95% CI, 0.22-1.77) and CAC (MD, 0.84; 95% CI, 0.08-1.65) regarding VCCS improvement. Although no regression model reached statistical significance, the GSV closure regression model revealed a trend for considerably decreased efficacy for both CAC and MOCA with larger GSV diameters compared with RFA and EVLA.Although our analysis has produced skepticism regarding the efficacy of MOCA in the mid-term period for VCSS improvement and GSV closure rates, CAC showed equivalent results compared with both RFA and EVLA. Additionally, CAC displayed a decreased risk of postprocedural paresthesia and pigmentation and induration compared with EVLA. Also, both RFA and CAC had an improved pain profile compared with EVLA 1470 nm. The potential underperformance of nonthermal, nontumescent ablation modalities in ablating large GSVs necessitates further research.

Natural History and Role of Anticoagulation in the Management of Endovenous Glue Induced Thrombus.

Abstract: •Key Findings: For EGIT 1 and 2s, 86% and 60% resolved by four weeks without anticoagulation. For EGIT 3s, 68% resolved or regressed regardless of anti-coagulation. For EGIT 4s, 82% were remote DVTs. CFV and POPV EGIT 4s are rare. Shorter treatment lengths were associated with EGIT 3 and 4 formation. •Take home message: The majority of EGIT 1, 2 and 3s resolve by 4 weeks regardless of AC use. Eighty six percent of EGIT 4s are calf vein DVTs. CFV and POPV EGIT 4s are rare. EGIT 3 and 4 development is associated with shorter treatment lengths. •Table of Contents Summary: From January 2020 to December 2021, 2,374 patients received 4,321 CAG procedures. EGITs were observed in 133 (3.1%) patients. EGIT 1 (86%) and EGIT 2 (60%) resolved by 4 weeks without anticoagulation. EGIT 3s (84%) were mostly observed in the CFV and 86% of EGIT 4s were calf vein DVTs. Larger vein diameters and longer treatment lengths were associated with EGIT 1 and 2 development. Introduction The natural history of endovenous glue induced thrombus (EGIT) resolution and the role of anticoagulation (AC) and/or anti-platelet (AP) agents in their management is currently ill-defined. The goal of this investigation is to determine the clinical behavior of EGITs and whether or not AC or AP affects treatment outcomes. Methods We performed a retrospective review of all endovenous ablations utilizing cyanoacrylate glue (CAG) from January 2020 to December 2021 at the Center for Vein Restoration. Patients were divided into two groups: Patients who developed an EGIT (EGIT/CAG) and patients treated with CAG and no EGIT development (CAG). Demographics, medical/surgical histories, rVCSS, CIVIQ 20, CEAP, EGIT category, type of anticoagulation, resolution time, location of any deep vein thrombosis (DVT) were analyzed, catheter tip distance, treatment length and proximal thigh diameters were all analyzed. EGITs were categorized as follows: EGIT 1- Thrombus extension into the deep vein covering less than 25% of the luminal area, EGIT 2- Thrombus between 25% and 49%, EGIT 3- Thrombus between 50% and 74%, EGIT 4- Total occlusion. Our protocol is to perform post-procedure duplex scans within 3-7 days after endovenous ablations to assess for post intervention DVTs. Results During the study period, 2,374 patients received 4,321 CAG procedures. EGITs were observed in 133 patients (3.1%): EGIT 1 (n=57), EGIT 2 (n=35), EGIT 3 (n=19), EGIT 4 (n=22). All EGITs were identified by surveillance scanning. No patient presented with limb or pulmonary symptoms suggestive of VTE. The average age, rVCSS and CIVIQ 20 of the entire cohort was 65.3±14.2, 8.2±2.8, 48±18.3 respectively with 89 females and 44 males. For EGIT 1s, 56/57 (98%) resolved at 4.2±5.1 weeks, with one patient lost to follow up. AC/AP regimen included two Aspirin (ASA), one Eliquis, 5 Xarelto and nothing in 49 (86%). For EGIT 2s, 27/35 (77%) resolved at 4.4±3.4 weeks, one was unresolved, six regressed to EGIT 1s and one remained an EGIT 2 at the last follow-up examination. AC/AP regimens included 7 ASA, three Eliquis, three Xarelto, one Coumadin and nothing in 21 (60%). For EGIT 3s, 12 were in the common femoral vein (CFV), three in the Popliteal Vein (POPV), one in the External Iliac Vein and three in the Gastrocnemius Veins. Nine of nineteen (47%) resolved at 6±5.9 weeks, 4 regressed, 1 migrated to the proximal common femoral vein, 3 became chronic, and 2 were lost to follow-up. AC/AP regimens included 3 ASA, three Eliquis, seven Xarelto, and nothing in six (32%). AC/AP compared to no AC/AP had no effect on clot resolution (p=0.3). Of the 22 EGIT 4s, one was in the CFV, two were in the POPV and 18 (82%) were remote calf vein DVTs (15 Gastrocnemius, one peroneal (PV) and three posterior tibial veins (PTV)). The CFV EGIT became chronic, one POPV resolved and one was lost to follow-up. For the Gastrocnemius clots, five became chronic, 8 resolved and two were lost to follow-up. For the PTV clots, one resolved, one became chronic and one was lost to follow-up. The PV clot became chronic. AC/AP regimen included four ASA, five Eliquis, six Xarelto, and nothing in seven. AC/AP compared to no AC/AP had no effect on clot resolution (p=0.9). The average proximal thigh diameter, vein length treated and catheter distance from the junction were the following: EGIT 1 (5.9±2.4/37.5±17.6/5.2±1), EGIT 2 (5.9±1.7/38±16.9/4.79±0.71), EGIT 3 (5.1±2.6/27.9±16.6/5.26±1.4) and EGIT 4 (5±1.7/29.9±15.8/5.39±2.18) respectively. Treatment length alone was significantly shorter in EGIT 3 and 4s, compared to EGIT 1 and 2s (p≤0.05). Catheter distance from the junction was longer in EGIT 1,3 and 4 patients compared to CAG patients (p≤0.02). Conclusion Regardless of EGIT class or severity, the majority of EGITs are not associated with clot extension or migration and tend to resolve or regress. For EGIT class 1 and 2 patients, anticoagulation or anti-platelet therapy is not necessary as 86% and 60% respectively, resolved with observation alone by four weeks. For EGIT 3s, 68% resolved or regressed regardless of anticoagulant or anti-platelet use. The majority of EGIT 4s were remote calf vein DVTs. EGIT 3 and 4s associated with the saphenofemoral/popliteal junction are rare. When compared to CAG patients, proximal thigh diameters and treatment lengths were larger and longer in EGIT 1 and 2 patients. Catheter proximity to the junction was not associated with a higher incidence of EGIT formation. The natural history of endovenous glue induced thrombus (EGIT) resolution and the role of anticoagulation (AC) and/or anti-platelet (AP) agents in their management is currently ill-defined. The goal of this investigation is to determine the clinical behavior of EGITs and whether or not AC or AP affects treatment outcomes. We performed a retrospective review of all endovenous ablations utilizing cyanoacrylate glue (CAG) from January 2020 to December 2021 at the Center for Vein Restoration. Patients were divided into two groups: Patients who developed an EGIT (EGIT/CAG) and patients treated with CAG and no EGIT development (CAG). Demographics, medical/surgical histories, rVCSS, CIVIQ 20, CEAP, EGIT category, type of anticoagulation, resolution time, location of any deep vein thrombosis (DVT) were analyzed, catheter tip distance, treatment length and proximal thigh diameters were all analyzed. EGITs were categorized as follows: EGIT 1- Thrombus extension into the deep vein covering less than 25% of the luminal area, EGIT 2- Thrombus between 25% and 49%, EGIT 3- Thrombus between 50% and 74%, EGIT 4- Total occlusion. Our protocol is to perform post-procedure duplex scans within 3-7 days after endovenous ablations to assess for post intervention DVTs. During the study period, 2,374 patients received 4,321 CAG procedures. EGITs were observed in 133 patients (3.1%): EGIT 1 (n=57), EGIT 2 (n=35), EGIT 3 (n=19), EGIT 4 (n=22). All EGITs were identified by surveillance scanning. No patient presented with limb or pulmonary symptoms suggestive of VTE. The average age, rVCSS and CIVIQ 20 of the entire cohort was 65.3±14.2, 8.2±2.8, 48±18.3 respectively with 89 females and 44 males. For EGIT 1s, 56/57 (98%) resolved at 4.2±5.1 weeks, with one patient lost to follow up. AC/AP regimen included two Aspirin (ASA), one Eliquis, 5 Xarelto and nothing in 49 (86%). For EGIT 2s, 27/35 (77%) resolved at 4.4±3.4 weeks, one was unresolved, six regressed to EGIT 1s and one remained an EGIT 2 at the last follow-up examination. AC/AP regimens included 7 ASA, three Eliquis, three Xarelto, one Coumadin and nothing in 21 (60%). For EGIT 3s, 12 were in the common femoral vein (CFV), three in the Popliteal Vein (POPV), one in the External Iliac Vein and three in the Gastrocnemius Veins. Nine of nineteen (47%) resolved at 6±5.9 weeks, 4 regressed, 1 migrated to the proximal common femoral vein, 3 became chronic, and 2 were lost to follow-up. AC/AP regimens included 3 ASA, three Eliquis, seven Xarelto, and nothing in six (32%). AC/AP compared to no AC/AP had no effect on clot resolution (p=0.3). Of the 22 EGIT 4s, one was in the CFV, two were in the POPV and 18 (82%) were remote calf vein DVTs (15 Gastrocnemius, one peroneal (PV) and three posterior tibial veins (PTV)). The CFV EGIT became chronic, one POPV resolved and one was lost to follow-up. For the Gastrocnemius clots, five became chronic, 8 resolved and two were lost to follow-up. For the PTV clots, one resolved, one became chronic and one was lost to follow-up. The PV clot became chronic. AC/AP regimen included four ASA, five Eliquis, six Xarelto, and nothing in seven. AC/AP compared to no AC/AP had no effect on clot resolution (p=0.9). The average proximal thigh diameter, vein length treated and catheter distance from the junction were the following: EGIT 1 (5.9±2.4/37.5±17.6/5.2±1), EGIT 2 (5.9±1.7/38±16.9/4.79±0.71), EGIT 3 (5.1±2.6/27.9±16.6/5.26±1.4) and EGIT 4 (5±1.7/29.9±15.8/5.39±2.18) respectively. Treatment length alone was significantly shorter in EGIT 3 and 4s, compared to EGIT 1 and 2s (p≤0.05). Catheter distance from the junction was longer in EGIT 1,3 and 4 patients compared to CAG patients (p≤0.02). Regardless of EGIT class or severity, the majority of EGITs are not associated with clot extension or migration and tend to resolve or regress. For EGIT class 1 and 2 patients, anticoagulation or anti-platelet therapy is not necessary as 86% and 60% respectively, resolved with observation alone by four weeks. For EGIT 3s, 68% resolved or regressed regardless of anticoagulant or anti-platelet use. The majority of EGIT 4s were remote calf vein DVTs. EGIT 3 and 4s associated with the saphenofemoral/popliteal junction are rare. When compared to CAG patients, proximal thigh diameters and treatment lengths were larger and longer in EGIT 1 and 2 patients. Catheter proximity to the junction was not associated with a higher incidence of EGIT formation.

Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of ECMO in patient rescue.

Abstract: Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients.This single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated.A total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO.Large-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.

Hypercoagulability status, operative mortality and long-term survival in patients operated on for mesenteric venous thrombosis.

Abstract: Objective Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis. Methods All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease). Results Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival. Conclusions Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

Primary leiomyoma of the great saphenous vein using multimodal imaging.

Abstract: A 28-year-old man had presented with a complaint of a mass in the left lower limb that had been present for 10 years. The mass had increased slowly, with aggravated pain during the most recent week. On physical examination, a soft mass was present in the front of left lower limb with poor activity, and preserved sensation and palpable arterial pulses within the distal extremity. Ultrasound revealed a hypoechoic lesion without a shape change after compression around the distal great saphenous vein. The lesion measured 1.9 × 1.3 × 2.1 cm, with a well-circumscribed boundary that seemed to be a continuation of the venous wall (A). Some dot-like blood flow signals were detected inside the lesion with a pulsatile arterial spectrum. The great saphenous vein was patent with intact intima (B/Cover). Magnetic resonance imaging was further performed, which revealed an equal T1-weighted signal and an equal or a long T2-weighted signal, similar to that for muscle tissue, for the mass. Continuous and intact adventitia was observed, which confirmed that the mass was localized to the vascular wall (C). A tentative preoperative diagnosis was a muscle-derived benign tumor of the great saphenous vein wall. The possibility of malignancy was excluded by the slow progression, clear boundary, and no invasiveness. The patient subsequently underwent resection of the mass without vascular reconstruction, and the excised mass displayed a fish-flesh cut surface. Postoperative pathologic examination revealed the mass was composed of benign spindle cells with a reticular or parallel arrangement and was positive for smooth muscle actin and desmin (D). Ultimately, the definite diagnosis was a primary leiomyoma of the great saphenous vein. The patient recovered uneventfully without complications. The patient provided written informed consent for the report of his case details and imaging studies.

Deep vein thrombosis, pulmonary embolism, and portal vein thrombosis occurred in the same patient with the JAK2-V617F mutation treated with AngioJet-assisted thrombectomy via transjugular intrahepatic route.

Abstract: A 57-year-old male patient was admitted to our department with a 7-day history of severe abdominal pain. He had a history of venous thromboembolism (VTE). Six years before his current presentation, deep vein thrombosis (DVT) had developed in the right lower extremity. One year later, owing to warfarin discontinuation, DVT recurrence and pulmonary embolism (PE) had developed. He took warfarin for 1 year and stopped it again. Other clinical manifestations included signs of peritonitis, systemic inflammation, and imaging findings of ascites. Acute portal vein (PV) thrombosis (PVT) was definitively diagnosed using contrast-enhanced computed tomography (A/Cover, B, and C). Through whole-exome sequencing analysis, a JAK2V617F mutation was identified. Other thrombophilic defects, such as SERPINC1 and others, were not found. Antinuclear antibody, anticardiolipin antibody, lupus anticoagulant antibody, and antineutrophil cytoplasmic antibody test results were negative. During 2 days of treatment with low-molecular-weight heparin, his abdominal pain had continued. He underwent AngioJet-assisted (Boston Scientific, Marlborough, MA) pharmacomechanical thrombectomy (PMT) with a transjugular intrahepatic portosystemic stent shunt (TIPS). After surgery, symptom relief and complete recanalization of the PV system (D, E, and F) were achieved, with no complications. After discharge, 20 mg of rivaroxaban was administered for long-term anticoagulation. During 3 years of follow-up, no VTE had recurred, and the TIPS was patent. The patient provided written informed consent for the report of his case details and imaging studies.

Meta-analysis of lytic catheter-based intervention for acute proximal deep vein thrombosis in the reduction of post-thrombotic syndrome.

Abstract: Post-thrombotic syndrome (PTS) is a common complication of deep vein thrombosis (DVT) that can result in significant morbidity for the patient with detrimental impact on their quality of life. Evidence supporting lytic catheter-based interventions (LCBI) undertaken for early thrombus reduction in acute proximal DVT for the prevention of PTS is conflicting. Despite this, rates of LCBIs are increasing. To summaries the existing evidence and pool treatment effects, a meta-analysis of randomized controlled trials assessing the efficacy of LCBIs in proximal acute DVT for the prevention of PTS was undertaken.This meta-analysis was undertaken aligning with PRISMA guidelines following a protocol pre-registered on PROSPERO. Online searches of Medline and Embase databases, as well as the gray literature, were performed up to December 2022. Included articles were randomized controlled trials that studied the use of LCBIs with additional anticoagulation vs anticoagulation alone and had determined follow-up periods. Outcomes of interest were PTS development, moderate to severe PTS, major bleeding episodes, and quality-of-life measures. Subgroup analyses were performed for DVTs involving the iliac vein and/r common femoral vein. Meta-analysis was performed using a fixed effects model. Quality assessment was performed using the Cochrane Risk of Bias and GRADE assessment tools.Three trials were included in the final meta-analysis, the Post-thrombotic Syndrome after Catheter-directed Thrombolysis for Deep Vein Thrombosis (CaVenT), Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT), and Ultrasound-accelerated Catheter-directed Thrombolysis Versus Anticoagulation for the Prevention of Post-thrombotic Syndrome (CAVA) trials, comprising 987 patients. Patients undergoing LCBIs had a reduced risk of PTS (relative risk [RR], 0.84; 95% confidence interval [CI], 0.74-0.95; P = .006) and a lower risk of developing moderate to severe PTS (RR, 0.75; 95% CI, 0.58-0.97; P = .03). LBCIs increased the risk of having a major bleed (RR, 2.03; 95% CI, 1.08-3.82; P = .03). In the iliofemoral DVT subgroup analysis, there was a trend toward decreasing the risk of developing PTS and moderate to severe PTS (P = .12 and P = .05, respectively). There was no significant difference in quality-of-life score (as measured by the Venous Insufficiency Epidemiological and Economic Study - Quality of Life/Symptoms) between the two groups (P = .51).Pooling of current best evidence suggests that LCBIs in acute proximal DVT decreases the rate of PTS and moderate to severe PTS with a number needed to treat of 12 and 18, respectively. However, this is complicated by a significantly higher rate of major bleeding with a number needed to treat of 37. This evidence supports the use of LCBIs in selected patients, including those who are at low risk of major bleeding.

Outcome after Surgical Treatment of Venous Malformations of the Hand in Childhood.

Abstract: Objective Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand’s small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects. Methods We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences. Results Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse. Conclusions VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

Exploring the Perception of Venous Disease Within Vascular Surgery

Abstract: Background Biases and gender disparities influence career pathways within medicine and vascular surgery is no exception. Venous disease comprises an estimated 1-3% of total health care expenditures, yet its value amongst vascular surgeons is poorly understood. This study aims to investigate factors that influence vascular surgeons’ current perceptions of superficial and deep venous disease treatments. Study Design An anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. Responders were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥ 25% of total volume. Changes in practice patterns over the respondent’s career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA. Results 315 practicing vascular surgeons responded, with 81.5% from the United States. Mean age was 46.6 ± 9.6 years and the majority identified as men (63.3%). Race and ethnicity breakdown was as follows: White (non-Hispanic) (63.0%), Asian or Asian Indian (17.1%), Hispanic, Latinx or Spanish (8.4%), Black (1.6%), and unknown (9.9%). Practice settings were academic (47.0%), private practice (26.5%), hospital employed (23.3%) or other (3.2%). Women respondents were significantly younger (p<0.0001), with fewer years in practice (p<0.0001) and were more likely to perceive gender bias within a career encompassing venous disease compared to men (p=0.02). 143 (45.4%) participants had a venous-heavy practice. There were no differences in age or gender between the venous-heavy or light practices. Those with a venous-heavy practice had statistically significant more years in practice (p=0.02), sought more venous training post-graduation (p<0.0001), were more likely to be in private practice (p<0.0001), and desired a practice change (p=0.001) compared to those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work may be less “valued” than arterial work in the field of vascular surgery. On multivariable regression, predictors for perception of venous work being less valued were women (OR 2.01, 95%CI 1.14-4.03) and completion of a vascular surgery fellowship (OR 2.0, 95%CI 1.15-3.57). Conclusions Vascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly among women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the US healthcare budget, cannot be overlooked. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.

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Abstract: Dear Editor, We thank Dr Ketenci for showing interest in our article. In the past three years, COVID-19 has caused substantial morbidity and mortality.1Topcu A.C. Ozturk-Altunyurt G. Akman D. Batirel A. Demirhan R. Acute limb ischemia in hospitalized COVID-19 patients.Ann Vasc Surg. 2021; 74: 88-94Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The rapid transmission of COVID-19 disease has adversely impacted healthcare providers with the burden of massive numbers of inpatients and the risk of transmission from patients to themselves. As a result, healthcare providers are sometimes hesitant or unable to perform diagnostic or therapeutic procedures which require close contact with patients, fearing transmission of COVID-19 infection and without guidance in prioritizing the waitlist. In addition to diagnosing deep venous thrombosis (DVT) in the fastest and most accurate way, it is also important to protect healthcare providers to ensure the sustainability of healthcare services during a pandemic. Our study aimed to identify which COVID-19 patients with a preliminary diagnosis of DVT should be prioritized for a timely venous duplex ultrasonography (US).2Özhan A. Bastopcu M. Factors associated with positive thrombus findings at ultrasonography in COVID-19 ward patients who underwent imaging for suspected deep vein thrombosis under prophylactic anticoagulation.J Vasc Surg Venous Lymphat Disord. 2022; 10: 811-817Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar As Dr Ketenci mentioned, patients with persistent symptoms and suspicion of DVT underwent repeat duplex US according to the current guidelines.3Kakkos S.K. Gohel M. Baekgaard N. Bauersachs R. Bellmunt-Montoya S. Black S.A. et al.Editor's choice - European Society for Vascular Surgery (ESVS) 2021 clinical practice guidelines on the management of venous thrombosis.Eur J Vasc Endovasc Surg. 2021; 61: 9-82Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar However, we do not have data on how many of the patients requiring repeat US had positive findings and whose DVT was evident on repeat US. The rate of DVT reported in our study concerns patients treated in the ward setting and not patients with more severe disease treated in the intensive care unit, which should be considered when comparing with other studies that report DVT rates in COVID-19 patients. It is also worth noting that our results should be interpreted as a guidance for prioritization and efforts should be made for all patients with likely DVT to undergo diagnostic US as healthcare resources permit. Iliofemoral and crural vein thrombosis involve different levels of risk, especially for pulmonary thromboembolism.4Kuplay H. Erdoğan S.B. Bastopcu M. Arslanhan G. Baykan D.B. Orhan G. The neutrophil-lymphocyte ratio and the platelet-lymphocyte ratio correlate with thrombus burden in deep venous thrombosis.J Vasc Surg Venous Lymphat Disord. 2020; 8: 360-364Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Regardless of the level of DVT, timely initiation of proper treatment is paramount to prevent venous thromboembolism or other complications. Therefore, patients with DVT of any extent benefit from a timely US. The investigation of risk factors for severe DVT in COVID-19 patients may be the subject of future research, providing valuable information. We hope that our research will assist healthcare service providers in battling the global pandemic. A critical issue in COVID-19 patients: Deep venous thrombosisJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 11Issue 3PreviewDear Editor, Full-Text PDF