Chang, Benjamin B.

Darling, R. Clement

Kreienberg, Paul B.

Mehta, Manish

Ozsvath, Kathleen J.

Paty, Philip S.K.

Roddy, Sean P.

Saltzberg, Stephanie S.

Shah, Dhiraj M.

Sternbach, Yaron

Taggert, John B.

Elsevier - Publisher Connector 

PP85. Venous Ablation Can be Performed Safely on High Risk Patients 

JOURNAL OF VASCULAR SURGERY
Volume 49, Number 5S Poster Presentations 39SResults: VV surgeries were done in 162 limbs of 94 patients (both in
68, right in 18, and left in 8). There were 56 females and 38 males with the
mean age of 57 years (2879). The CEAP classification was C2-3EpAsPr in all
patients. Perforators larger than 2mm near the varicose veins were detected
and marked on the CT volume-rendering images. The average numbers of
perforators marked by CTV were 13.44.22 in each limb. The perforators
were evaluated by duplex for the presence of reflux (0.5 sec). Mean
number of perforators with reflux in one limb was 1.3 1.35, which were
ligated during the surgery. Incidental detections of other disease were done
in 3 patients, including uterine myomas and ovarian cyst. Operation was
performed with the CTV images on screen. CTV was helpful in designing
the operation inmost patients. 3DCTV images of saphenopopliteal junction
especially provided thorough understanding of the complex variable anat-
omy of the lesion. There were no CT-related complications, such as renal
dysfunction or allergic reaction.
Conclusions: CT venography can provide excellent road map for VV
surgery without significant complications. It cannot replace duplex USG,
but can provide powerful 3D views for designing operation as well as
education and research.
Author Disclosures: S. Min,None; S.I. Min,None; S.Y. Kim,None;Y.J.
Park, None; I.M. Jung, None; T. Lee, None; J. Ha, None; J.K. Chung,
None; S.J. Kim, None.
PP83.
Factors Affecting Post Operative Pain Following Endovenous Ablation
of Varicose Veins
Amanda C Shepherd, Manj S Gohel, Chung S Lim, Maher Hamish, Alun H
Davies. Imperial College, London, United Kingdom
Objectives: A variety of endothermal treatments are currently available
for the treatment of varicose veins, offering the prospect of less discomfort
and quicker return to normal activities compared to traditional surgery. The
aim of this study was to evaluate which factors may contribute to post-
operative pain following endothermal ablation procedures.
Methods: Patients treated with endovenous laser ablation (EVLA) or
radiofrequency ablation (RFA) completed the Aberdeen Varicose Vein
Questionnaire (AVVQ) before surgery and a 100mm visual analogue diary
card to record post-operative pain scores. Initial VCSS and CEAP scores
were assessed by a clinician and recorded along with demographic and
operative details. Independent risk factors for post-operative pain were
identified using a multivariate linear regression model.
Results: Over a 6 month period, 75 patients completed diary cards.
RFA was performed in 43/75 and EVLA in 32/75. The median (range) age
was 48 years (27-78) and 57/75 were female. Median (range) AVVQ and
VCSS scores were 17.59 (2.47-74.3) and 4 (0-13) respectively. Age, sex,
AVVQ, VCSS and CEAP scores were comparable between the treatment
groups (p0.528, 0.862, 0.186, 0.930 & 0.240 respectively, Mann Whit-
ney U test). Overall median (range) pain scores after 3 and 10 days were
20mm (1-81mm) and 17mm (1-85mm). Pain scores were significantly
higher after EVLA compared to RFA after 3 days (31mm (2-80mm) versus
16mm (1-81mm) p0.016 Mann Whitney U) and after 10 days (24 mm
(1-85mm) versus 13mm (1-68mm), p0.003 Mann Whitney U). Using a
multivariate analysis, we found that none of the other factors assessed
predicted post operative pain score at 3 days or at 10 days. Table 1. Results
of multivariate linear regression analysis (outcome - average post-operative
pain score over 3 days and 10 days).
Multivariate linear
regression analysis over 3 days
Multivariate linear
regression analysis over 10
days
Risk factor assessed HR 95% CI P value HR 95% CI P value
Male sex 0.064 (16.702-10.620) 0.657 0.065 (13.143-8.196) 0.644
Patient age 0.063 (0.532-0.346) 0.672 0.225 (0.610-0.075) 0.123
Pre-op AVVQ 0.040 (0.707-0.558) 0.814 0.071 (0.601-0.387) 0.666
Pre-op VCSS 0.256 (1.059-6.529) 0.154 0.310 (0.295-5.632) 0.077
Pre-op CEAP grade 0.066 (6.311-8.978) 0.728 0.064 (4.927-7.015) 0.727
Bilateral surgery 0.008 (12.564-13.217) 0.960 0.070 (12.350-7.786) 0.651
Total length of vein
ablated
0.072 (0.284-0.180) 0.657 0.130 (0.256-0.106) 0.410
Conclusions Pain scores were lower after RFA compared to EVLA,
however, sex, age, AVVQ, VCSS, CEAP score, bilateral intervention or the
length of vein ablated were not predictive of post operative pain.Author Disclosures: A.C. Shepherd, None; M.S. Gohel, None; C.S.
Lim, None; M. Hamish, None; A.H. Davies, None.PP84.
Iliofemoral Stenting in Venous Occlusive Disease
Jessica Titus, Mireille A Moise, Sean Lyden, Daniel Clair. Cleveland Clinic,
Cleveland, OH
Objective: Venous hypertension is a significant cause of patient mor-
bidity and decreased quality of life. Common etiologies of venous hyperten-
sion include deep venous thrombosis (DVT) or congenital abnormalities
resulting in chronic outflow obstruction. We have implemented an aggres-
sive endovascular approach to the treatment of iliac venous occlusion with
angioplasty and stenting. The aim of this study is to determine the patency
rates with this approach at a large tertiary care center.
Materials/Methods: All patients undergoing ilio-femoral venous an-
gioplasty and stenting over a 2 1/2 year period were identified from a
vascular surgical registry. Charts were reviewed retrospectively for patient
demographics, the extent of venous system involvement and the time course
of the venous pathology. Technical aspects of the procedure including
previous angioplasty or stenting attempts, presence of collaterals on com-
pletion venogram and stent patency were then recorded.
Results: A total of 34 patients ( 37 limbs) were stented from Jan 2005
through August 2008. Of these patients 25 were women ( 73%). Both lower
extremities were involved in 4 patients. Thrombosis was considered acute (30
days) in 13 patients (38%). The majority of patients who had a recognized
underlying etiology were diagnosed withMay-Thurner syndrome (12 patients,
48%). Mean follow-up time period in the study population was 10.5 months.
One stent in the study occluded acutely and required re-stenting. Primary
patency rates at 6, 12, and 24months were 83% (67.4, 98.6), 70% (49.3, 91.2),
and 58.5% (31.3, 85.8) respectively. Secondary patency rates for the same time
intervals were 100.0% (100.0, 100.0), 93.8% (81.9, 100.0), and 82% (58.2,
100) respectively. Although not statistically significant, external compression
and thrombophilia appear to portend less favorable outcomes.
Conclusion: Ilio-femoral venous stenting provides a safe and effective
alternative to either anti-coagulation, or open surgical bypass for the treat-
ment of iliac venous occlusive disease. Acceptable patency rates can be
expected through short-term follow-up. Further experience with this ap-
proach and longer-term follow-up is necessary.
Author Disclosures: J. Titus, None; M.A. Moise, None; S. Lyden,
Boston Scientific, Medtronic, Cook, EV3; D. Clair, Cordis, WL Gore,
Cook; Boston Scientific, Medtronic.
PP85.
Venous Ablation Can be Performed Safely on High Risk Patients
Kathleen J Ozsvath, Stephanie S Saltzberg, John B Taggert, Benjamin B
Chang, Paul B Kreienberg, Manish Mehta, Philip S K Paty, Sean P Roddy,
Yaron Sternbach, Dhiraj M Shah, R Clement Darling, III. Albany Medical
College, Albany, NY
Introduction: Patients with a previous history of DVT or family
history of DVT are considered at high risk for thrombotic complications
(DVT) after endovenous ablation. In this study, we examine our outcomes
on patients presenting for “high risk” endovenous ablation.
Methods:We reviewed our vascular registry for all patients undergoing
EVA from 2006-2008. All patients were evaluated with venous ultrasonog-
raphy and initially treated with a minimum of 3 months of compression
stockings. Candidates for EVA were treated with laser ablation or radiofre-
quency ablation using a standardized technique. All patients that were
identified as potential high risk for DVT had hematology consultation and
were placed on peri-procedure anticoagulation prophylactically. Post proce-
dure ultrasound was performed at 1week, 1 month, 3 months and every 6
months thereafter for two years.
Results: A total of 685 endovenous ablations were performed (480 laser,
205 radiofrequency); the majority being greater saphenous veins. A sub-group
of patients n15(2.1%) were identified to be high risk for DVT.Mean age was
44 years. CEAP classifications ranged from 2-6, with ankle edema being the
most common diagnosis. The immediate technical success rate was 99.6%.
Access failure occurred in 3 patients (0.4%). Themost common post procedural
complications included bruising 29% (n203), phlebitis in branch varicosities
in 4% (n28) and heat induced thrombus formation in 1.9% (n13). There
was no significant difference between laser and radiofrequency groups. None of
the presumed hyper congealable patients developed thrombotic complications.
There were no mortalities in this series. Mean follow up was 6 months (range
1-27 months). Ancillary procedures were performed in 19% including stab
phlebectomy, schlerotherapy, and perforator injection or ablations. All patients
remain successfully ablated to date.
Conclusions: In our experience, EVA can be safely performed in
appropriate candidates with excellent clinical outcomes and minimal mor-
bidity and mortality. Preliminary data suggests that patients with hyperco-
agulable conditions or strong family history of thrombosis can be considered
for EVA with peri-procedural anticoagulation.
JOURNAL OF VASCULAR SURGERY
May Supplement 200940S Poster PresentationsAuthor Disclosures: K.J. Ozsvath, None; S.S. Saltzberg, None; J.B.
Taggert, None; B.B. Chang, None; P.B. Kreienberg, None; M. Mehta,
None; P.S.K. Paty, None; S.P. Roddy, None; Y. Sternbach, None; D.M.
Shah, None; R. Darling, None.
PP86.
Intravenous Leiomyomatosis with Inferior Vena Cava and Heart Ex-
tention: A Report of 6 Cases
Bao Liu, Sr., Changwei Liu, Sr.. Peking Union Medical College Hospital,
Beijing, China
Background: Intravenous Leiomyomatosis(IVL)is a rare, histological
benign but biological behavior malignant tumor. Literature reports on IVL
are less than 200 cases, and most majority of them are individual reports.
Methods: Six patients with intravenous leiomyomatosis involved in the
cava inferior vena were analyzed.
Results: Three patients received one-stage operation and two received
two-stage operation. All the operations were successful. No perioperative
death or other complications were observed. Among the six patients, pri-
mary tumor and intravenous tumor embolus were completely resected from
four patients. Residual tumor was remained in one patient who had serious
adherence due to multiple operations. However, with the anti-estrogen
therapy, the residual tumor had significantly regressed. All the patients had
tumor relapse after the operation.
Conclusion: We believe that IVL is group of disease and not a single
disease entity. Although IVL is extremely rare, vascular surgeon must pay
more attention to this disease. There are many therapeutic methods to
choose from when uterine leiomyomatosis involves the cava inferior vena,
amongwhich operation is the best choice. Anti-estrogen therapy seems to be
justified in patients with ER() and PR().
Author Disclosures: B. Liu, None; C. Liu, None.
PP87.
Iliac Venous Stenting for Lower Extremity Venous Stasis Disease
Saadi Alhabouni, Anil Hingorani, Enrico Ascher, Natalie Marks, Alexander
Shiferson, Nirav Patel, Kapil ’Gopal, Theresa Jacob. Maimonides Medical
Center, Brooklyn, NY
Introduction: In a small subset of patient presenting with severe
venous stasis disease, we have been unable to identify the sources of reflux
with standard duplex imaging of the superficial, deep and perforating veins.
Recently we have been examining the iliac veins with IVUS and venography
to identify stenotic lesions.We herein review our finding with this technique.
Study Population: Patients with chronic venous stasis symptoms not
responding to conventional methods of treatment (leg elevation, compres-
sion stockings, Unna boots, radiofrequency ablation/stripping of varicose
veins/perforators/great saphenous vein). 54 patients were included, all of
which underwent iliac-femoral venography with assessment for stenosis. 24
(44.4%) patients had no detectable stenotic lesions are had no further
intervention. 30 (55.6%) patients had stenotic lesions and underwent vein
stenting. The stents spanned across the inguinal ligament in all but 3 patients
(90%).
Results: The venography-only group included 24 patients with an
average follow-up period of 4.5 months (range 1 week to 8 months). 11
(45.8%) had a CEAP of 6, only one of which (9.1%) healed their ulcers after
3 months.The vein stenting group included 30 patients with an average
follow-up period of 3.4 months (range 1 week-10 months). 22 (73.3%) had
a open ulcers, 11 (50%) of which healed their ulcers over a period of 1 week
to 8 months (average 3.25 months). (p0.02) (5.5%) patients developed
complications. Two developed stent thrombosis (one with a documented
hypercoagulable state, the other with a suspected hypercoagulable state).
Both were re-opened and re-stented. One patient developed a superficial
femoral artery pseudoaneurysm which was repaired with a stent graft. All
patient not needing postoperative anticoagulation were able to be stented on
an outpatient basis.
Conclusion: Many patients with lower extremity venous stasis symp-
toms have a component of iliac vein stenosis, and iliac vein stenting may
especially help patients with open ulcers. In contrast to pre-existing series,
only one-half of the patients were able to have lesions identified to be
stented. The procedure is relatively simple and safe, and can be performed on
an ambulatory basis.
Author Disclosures: S. Alhabouni, None; A. Hingorani, None; E.
Ascher,None;N. Marks,None;A. Shiferson,None;N. Patel,None;K.‘.
Gopal, None; T. Jacob, None.PP88.
Lower Extremity Occlusive vs Non-occlusive DVT and the Risk of
Pulmonary Embolism
Saadi Alhabouni, Anil Hingorani, Enrico Ascher, Natalie Marks, Alexander
Shiferson, Nirav Patel, Kapil Gopal, Theresa Jacob. Maimonides Medical
Center, Brooklyn, NY
Introduction: Acute DVT has been appreciated as a risk factor for
pulmonary embolism (PE). However, it is not known whether having an
incomplete occlusion of the vein (AcuteNon-Occlusive-ANODVT) confers
a higher risk of PE when compared to completely occlusive thrombi (Acute
Occlusive-AO DVT). An incomplete occlusion indicates that there is some
flow of blood around the clot, and whether that flow could dislodge the clot.
Conversely, a completely occlusive clot may indicate a higher thrombus load
and thus confer a higher risk of PE.
Methods: We reviewed 2894 consecutive lower extremity venous
duplex studies performed for 2248 inpatients betweenNovember 2007-July
2008.All studies to evaluate for PE were noted.We divided the patients into
3 groups based on the location of their DVT: IVC/Iliac, Femoral-popliteal,
and Infra-popliteal DVTs. Analysis was done on two sets of data.The first set
included comparison of DVTs isolated to only one of the three anatomical
groups. The second set compared DVTs based on the location of the most
proximal clot.
Results: DVTs isolated to one anatomical group:In the IVC/Iliac
vein group, only one isolated AO DVT was found with no evidence of PE
(0%). Two ANO DVTs were identified with evidence of PE in one (50%).
(p0.667).In the Femoral-popliteal group, 31 isolated AO DVT were
found with evidence of PE in 6 patients (19.3%). 64 isolated ANO DVT
were found with evidence of PE in 8 patients (incidence of 12.5%).
(p0.374).In the Infra-popliteal group, 140 patients with isolated AO
DVT were identified with evidence of PE in 12 of them (incidence of
8.6%). 21 patients with isolated ANO DVT were identified with evidence
of PE in one (incidence of 4.8%). (p0.471)Analysis based on the most
proximal DVT:In the IVC/Iliac vein group, 41 AO DVT was found with
evidence of PE in four (9.75%). 30 ANO DVTs were identified with
evidence of PE in two of them (6.67%). (p0.496).In the Femoral-
popliteal group, 83 AO DVT were found with evidence of PE in 17
patients (20.5%). 125 ANO DVT were found with evidence of PE in 14
patients (11.2%) (p0.075).
Conclusion: There is no difference in the risk of pulmonary embolism
between acute occlusive and acute non-occlusive DVTs, and hence both
should be treated similarly.
Author Disclosures: S. Alhabouni, None; A. Hingorani, None; E.
Ascher, None; N. Marks, None; A. Shiferson, None; N. Patel, None; K.
Gopal, None; T. Jacob, None.
Endovascular AAA
PP89.
Treatment of Acute Iliofemoral Deep Vein Thrombosis: A Systematic
Review and Meta-analysis
Edward T. Casey1, M. Hassan Murad1, Mark Meissner2, Magaly Zumaeta
Garcia1, Mohamed B Elamin,1, Qian Shi1, Patricia J Erwin1, Victor M
Montori1, Peter Gloviczki1. 1Mayo Clinic, rochester, MN; 2University of
Washington, Seattle, WA
Objectives: To conduct a systematic review of the literature to identify
and summarize the best available evidence about the efficacy of the different
treatments for acute iliofemoral deep vein thrombosis (catheter-directed
thrombolysis, surgical thrombectomy and systemic anticoagulation).
Methods: Electronic databases (MEDLINE, EMBASE, Cochrane
CENTRAL, Web of Science, and SCOPUS) were searched with appropriate
terms through February 2008. Eligible studies were controlled trials (ran-
domized or non randomized) that enrolled participants with acute iliotibial
thrombosis. Relative risks (RR) were pooled from each study using random
effects model and I2 statistic was used to assess heterogeneity.
Results: Compared with systemic anti-coagulation, thrombectomy
was associated with a statistically significant reduction in the risk of devel-
oping postthrombotic syndrome (RR 0.67 (95% confidence interval [CI],
0.52-0.87; I20%) and venous reflux (RR 0.68; 95% CI, 0.46-0.99;
I243%), and a trend for reduction in the risk of venous obstruction (RR
0.84; 95% CI, 0.60-1.19; I266%). Compared with systemic anti-coagula-
tion, catheter-directed thrombolysis was associated with statistically signifi-
cant reduction in the risk of postthromotic syndrome (RR 0.19; 95% CI,
0.07-0.48; I264%), venous reflux (RR 0.21; 95% CI, 0.09-0.53; I20%)
and venous obstruction (RR 0.35; 95% CI, 0.17-0.34; I268%). Subgroup
analyses showed no significant interactions between effect size and the time
lapsed since symptoms onset or the proportion of patients lost to follow up.
The superiority of thrombectomy over anticoagulation was significant in


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PP85. Venous Ablation Can be Performed Safely on High Risk Patients

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