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Correlation of Transabdominal Ultrasound With Intravascular Ultrasound in Diagnosis and Treatment of Iliac Vein Compression
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Abstracts
155
Volume 5, Number 1 thromboembolism occurred in five patients (16.7%) and was related to inadequate anticoagulation in all cases. Conclusions: We present a large, single-center experience with the AngioVac device. Our experience suggests a promising role for this device in the treatment of venous thromboembolism. This therapy can be safely performed with low complication rates and excellent technical results. Long-term follow-up and larger multicenter experience will further improve the understanding of this technology.
A 21-Year Report of the American Venous Forum-Mentored Career Development Faisal Aziz, Joesph Raffetto, Jose Diaz, Daniel Myers, Kathleen Ozsvath, Harry Ma, Michael Sadek, Prakash Saha, Rabih Chaer, Brajesh Lal. Background: The American Venous Forum (AVF) partnered with BSN-Jobst in 1995 to establish the BSN-Jobst Research Award for trainees and young faculty members. Awardees are selected through a competitive peer-review process. The purpose of this report was to analyze the impact of this award on the academic and clinical careers of recipients and on the promotion of scholarly activity in venous and lymphatic disease. Methods: AVF records were searched for recipients of the award. We recorded the number of applicants per year; the demographics, level of training, institution, and mentor of the recipients; and the amount of award. The subsequent clinical and academic performance of recipients and their impact on the field were then quantified by assessing their current scope of practice, years after graduation, and academic and administrative rank (if applicable). A PubMed and Google Scholar search was performed to identify the total number of publications authored. A National Institutes of Health Research Portfolio Online Reporting Tools (RePORT) search and personal interviews were used to identify VA Merit funding; financial return on investment was calculated as total research dollars received subsequent to the Jobst Award divided by total financial commitment by the award over 21 years. Results: Between 1995 and 2015, a total of 21 researchers have received the Jobst award. The mean number of applicants per year was nine (mean success rate of 11.1%). All recipients were MDs, with three having an additional PhD (14.3%). Gender distribution was 14 (66.7%) male and 7 (33.3%) female. Academic affiliations at the time of award were as follows: University of Rochester, four (19%); University of Michigan, four (19%); Mayo Clinic, four (19%); Rutgers New Jersey Medical School, two (9.5%); Boston University, two (9.5%); and one (4.8%) each to the University of Vermont, Stanford University, Duke University, University of North Carolina, University of Pittsburgh, and University of Oklahoma. A total of 15 (71.4%) recipients were vascular surgeons or trainees; 4 (19%) were training in allied fields treating venous disease, and 1 (4.8%) was a plastic surgeon and trauma surgeon. The mean number of publications per recipient has been 37. All recipients continue to treat patients with venous disease as all or part of their clinical practice. Four recipients have been promoted to the rank of Professor and two to Associate Professor; two are Program Directors of a vascular fellowship; one is a Vice-Chair and one a Chair of a surgery department. Recipients have subsequently received the following research funding: NIH-R01 grants (three), VA Merit Grants (three), R03 grants (two), and K08 grant (one). The total financial investment through AVF was $1,200,000; subsequent grant funding has totaled several millions, resulting in a more than fivefold research funding return on investment. Conclusions: The AVF-BSN-Jobst research award has been an effective investment in promoting the investigation and treatment of venous and lymphatic disease. It has nurtured the careers of clinical and academic physicians committed to the field. Several recipients have continued to contribute to research in venous disease. In financial terms, it has resulted in a more than fivefold return on investment.
Characterization of Profunda Femoris Vein Deep Venous Thrombosis Tana Repella, MD, PhD, Enjae Jung, MD, Olga Britantchouk, BS, Sadeeka Afrose, MBBS, Timothy Liem, MD, Erica Mitchell, MD, Gregory Landry, MD, Gregory Moneta, MD. Background: The profunda femoris vein (PFV) drains the inner thigh, traveling superiorly and medially to join the femoral vein. One prior study of >15,000 duplex ultrasound examinations with 2568 positive for deep
venous thrombosis (DVT) found only 8 instances of PFV DVT, many fewer than we were anecdotally observing in our vascular laboratory. We therefore prospectively identified patients with PFV DVT during a 1-year period in our vascular laboratory to characterize the anatomic distribution of venous thrombus in patients with PFV DVT as well as their demographic characteristics. Methods: This was a prospective study of patients at our tertiary care university hospital with DVT determined by venous duplex scanning between June 2014 and June 2015. DVT patients were categorized as to PFV involvement (yes or no), and the anatomic distribution of venous thrombi was further stratified to determine whether there was external iliac vein, common femoral vein, femoral vein, or popliteal vein involvement. Patient demographics were also compared between groups, PFV DVT+ vs PFV DVT (controls). Results: A total of 4584 lower extremity venous duplex ultrasound studies for DVT were performed; 398 (8.7%) were positive for DVT, with 22.1% of the 398 positive studies (88 studies in 60 individual patients, 2% of the overall studies) demonstrating DVT involving the PFV. There were 111 patients with common femoral vein DVT, and of those patients, 53 (47.7%) also had involvement of the PFV. Of the 60 patients with PFV DVT, 54 (90%) were found to also have involvement of the CFV. There was no difference in laterality of DVT between the PFV DVT and control DVT groups (35% vs 41.5%, respectively, for the left and 35% vs 33.5%, respectively, for the right; P ¼ .619). In the PFV DVT group, 30% had bilateral DVT compared with 25% of the control DVT group. There was a higher proportion of PFV DVT with external iliac vein DVT (21.7%) compared with control (2.5%; P < .00001). There was also a higher proportion of patients in the PFV DVT group with more distal DVT (femoral vein or popliteal vein) compared with control (68.3% vs 19%, respectively; P < .00001). Patients in the PFV DVT group were more likely to have a history of a hypercoagulable disorder compared with the control DVT group (26.7% vs 14.5%; P ¼ .029). There was also a higher proportion of patients in the PFV DVT group with a history of immobility compared with the control DVT group (58.3% vs 42%; P ¼ .026). There were no differences with regard to smoking, recent surgery, personal or family history of DVT, or other medical comorbidities. Conclusions: PFV DVT is more common in patients with DVT than previously reported, and patients with PFV thrombosis tend to have more thrombus burden with more frequent concurrent DVT in iliac veins as well as in distal deep veins. Patients with PFV DVT are also more likely to have a history of hypercoagulable disorder and immobility. Ultrasound protocols for assessment of DVT should include routine examination of the PFV as a potential marker of a more virulent prothrombotic state.
Correlation of Transabdominal Ultrasound With Intravascular Ultrasound in Diagnosis and Treatment of Iliac Vein Compression Polly Kokinos, MD, RPVI,1 Debbie Hoover, RVT2. 1South Bay Vascular Center; 2Institute for Vascular Testing. Background: Iliac vein compression is challenging to diagnose in patients who are symptomatic but who have not yet developed iliofemoral deep venous thrombosis (DVT). Compression can cause leg swelling and aching, nonhealing of ulcers, and development of leg DVT. Intravascular ultrasound (IVUS) has emerged as the most accurate tool for determining when there is clinically significant iliac vein compression and is used to guide intervention. We set out to determine whether transabdominal duplex ultrasound could accurately guide the need for IVUS and iliac vein stenting. Methods: Symptomatic patients underwent duplex ultrasound and Doppler waveform analysis of their deep pelvic venous system. Abdominal duplex ultrasound examinations were performed early in the morning, in a fasting patient, with a 2.5-5 MHz probe. Patients with narrowing of the iliac vein system were encouraged to pursue IVUS and possible iliac vein stenting. IVUS (Volcano Corp, San Diego, Calif) was performed by placing a 9F or 10F sheath in an ipsilateral great saphenous vein or common femoral vein in the angiography suite. Multiple measurements were made of both diameter and area of the examined venous structure. A self-expanding stent (Wallstent; Boston Scientific, Marlborough, Mass) was placed if there was an area decrease of at least 50% in the narrowed vein compared with the vein at a more distal “normal” site as measured by IVUS. Duplex ultrasound follow-up of all stented patients was done to look at the patency and iliac vein diameter.
156
Abstracts
Journal of Vascular Surgery: Venous and Lymphatic Disorders January 2017
Results: Between March 2015 and August 2016, there were 327 abdominal venous ultrasound examinations performed in a total of 136 patients. Parts of the iliac venous system were not visualized in one-third of these; however, 112 were adequate for diagnosis. Of the 112 patients with adequate visualization, 86 patients had evidence of compression of either an iliac vein or the distal inferior vena cava. Abnormal findings included decrease in diameter to <8 mm, pulsatility of the waveform, and evidence of scarring. Of these, 75 underwent IVUS and 68 underwent iliac vein stent placement or angioplasty of previously placed stents. One patient had a left-sided inferior vena cava with an abnormal left iliac system, and a second had a venous aneurysm that was seen on ultrasound but no stenosis. Six patients had normal findings on venography and IVUS. Therefore, transabdominal ultrasound was accurate in predicting findings in 69 of 75 patients for a 92% true positive rate. We do not have significant statistics on how accurate our negative/normal transabdominal ultrasound scans were. Postprocedure ultrasound done in all
stented patients confirmed patency in all but one patient (who had acute occlusion of his stent) and confirmed increase in iliac vein diameter in all of these patients as seen on the final IVUS pullback. Conclusions: Transabdominal duplex ultrasound of the iliac veins and inferior vena cava can accurately predict significant area decreases on IVUS and thus guide the need for iliac vein stenting. This is a cost-effective and noninvasive way to help diagnose and observe this large group of patients who are at risk for development of DVT, who suffer from chronic venous insufficiency symptoms such as swelling and aching, or who are some of the difficult-to-treat venous ulcer patients.
Fig 3.
Fig 1.
Fig 2.
Fig 4.
Abstracts
155
Volume 5, Number 1 thromboembolism occurred in five patients (16.7%) and was related to inadequate anticoagulation in all cases. Conclusions: We present a large, single-center experience with the AngioVac device. Our experience suggests a promising role for this device in the treatment of venous thromboembolism. This therapy can be safely performed with low complication rates and excellent technical results. Long-term follow-up and larger multicenter experience will further improve the understanding of this technology.
A 21-Year Report of the American Venous Forum-Mentored Career Development Faisal Aziz, Joesph Raffetto, Jose Diaz, Daniel Myers, Kathleen Ozsvath, Harry Ma, Michael Sadek, Prakash Saha, Rabih Chaer, Brajesh Lal. Background: The American Venous Forum (AVF) partnered with BSN-Jobst in 1995 to establish the BSN-Jobst Research Award for trainees and young faculty members. Awardees are selected through a competitive peer-review process. The purpose of this report was to analyze the impact of this award on the academic and clinical careers of recipients and on the promotion of scholarly activity in venous and lymphatic disease. Methods: AVF records were searched for recipients of the award. We recorded the number of applicants per year; the demographics, level of training, institution, and mentor of the recipients; and the amount of award. The subsequent clinical and academic performance of recipients and their impact on the field were then quantified by assessing their current scope of practice, years after graduation, and academic and administrative rank (if applicable). A PubMed and Google Scholar search was performed to identify the total number of publications authored. A National Institutes of Health Research Portfolio Online Reporting Tools (RePORT) search and personal interviews were used to identify VA Merit funding; financial return on investment was calculated as total research dollars received subsequent to the Jobst Award divided by total financial commitment by the award over 21 years. Results: Between 1995 and 2015, a total of 21 researchers have received the Jobst award. The mean number of applicants per year was nine (mean success rate of 11.1%). All recipients were MDs, with three having an additional PhD (14.3%). Gender distribution was 14 (66.7%) male and 7 (33.3%) female. Academic affiliations at the time of award were as follows: University of Rochester, four (19%); University of Michigan, four (19%); Mayo Clinic, four (19%); Rutgers New Jersey Medical School, two (9.5%); Boston University, two (9.5%); and one (4.8%) each to the University of Vermont, Stanford University, Duke University, University of North Carolina, University of Pittsburgh, and University of Oklahoma. A total of 15 (71.4%) recipients were vascular surgeons or trainees; 4 (19%) were training in allied fields treating venous disease, and 1 (4.8%) was a plastic surgeon and trauma surgeon. The mean number of publications per recipient has been 37. All recipients continue to treat patients with venous disease as all or part of their clinical practice. Four recipients have been promoted to the rank of Professor and two to Associate Professor; two are Program Directors of a vascular fellowship; one is a Vice-Chair and one a Chair of a surgery department. Recipients have subsequently received the following research funding: NIH-R01 grants (three), VA Merit Grants (three), R03 grants (two), and K08 grant (one). The total financial investment through AVF was $1,200,000; subsequent grant funding has totaled several millions, resulting in a more than fivefold research funding return on investment. Conclusions: The AVF-BSN-Jobst research award has been an effective investment in promoting the investigation and treatment of venous and lymphatic disease. It has nurtured the careers of clinical and academic physicians committed to the field. Several recipients have continued to contribute to research in venous disease. In financial terms, it has resulted in a more than fivefold return on investment.
Characterization of Profunda Femoris Vein Deep Venous Thrombosis Tana Repella, MD, PhD, Enjae Jung, MD, Olga Britantchouk, BS, Sadeeka Afrose, MBBS, Timothy Liem, MD, Erica Mitchell, MD, Gregory Landry, MD, Gregory Moneta, MD. Background: The profunda femoris vein (PFV) drains the inner thigh, traveling superiorly and medially to join the femoral vein. One prior study of >15,000 duplex ultrasound examinations with 2568 positive for deep
venous thrombosis (DVT) found only 8 instances of PFV DVT, many fewer than we were anecdotally observing in our vascular laboratory. We therefore prospectively identified patients with PFV DVT during a 1-year period in our vascular laboratory to characterize the anatomic distribution of venous thrombus in patients with PFV DVT as well as their demographic characteristics. Methods: This was a prospective study of patients at our tertiary care university hospital with DVT determined by venous duplex scanning between June 2014 and June 2015. DVT patients were categorized as to PFV involvement (yes or no), and the anatomic distribution of venous thrombi was further stratified to determine whether there was external iliac vein, common femoral vein, femoral vein, or popliteal vein involvement. Patient demographics were also compared between groups, PFV DVT+ vs PFV DVT (controls). Results: A total of 4584 lower extremity venous duplex ultrasound studies for DVT were performed; 398 (8.7%) were positive for DVT, with 22.1% of the 398 positive studies (88 studies in 60 individual patients, 2% of the overall studies) demonstrating DVT involving the PFV. There were 111 patients with common femoral vein DVT, and of those patients, 53 (47.7%) also had involvement of the PFV. Of the 60 patients with PFV DVT, 54 (90%) were found to also have involvement of the CFV. There was no difference in laterality of DVT between the PFV DVT and control DVT groups (35% vs 41.5%, respectively, for the left and 35% vs 33.5%, respectively, for the right; P ¼ .619). In the PFV DVT group, 30% had bilateral DVT compared with 25% of the control DVT group. There was a higher proportion of PFV DVT with external iliac vein DVT (21.7%) compared with control (2.5%; P < .00001). There was also a higher proportion of patients in the PFV DVT group with more distal DVT (femoral vein or popliteal vein) compared with control (68.3% vs 19%, respectively; P < .00001). Patients in the PFV DVT group were more likely to have a history of a hypercoagulable disorder compared with the control DVT group (26.7% vs 14.5%; P ¼ .029). There was also a higher proportion of patients in the PFV DVT group with a history of immobility compared with the control DVT group (58.3% vs 42%; P ¼ .026). There were no differences with regard to smoking, recent surgery, personal or family history of DVT, or other medical comorbidities. Conclusions: PFV DVT is more common in patients with DVT than previously reported, and patients with PFV thrombosis tend to have more thrombus burden with more frequent concurrent DVT in iliac veins as well as in distal deep veins. Patients with PFV DVT are also more likely to have a history of hypercoagulable disorder and immobility. Ultrasound protocols for assessment of DVT should include routine examination of the PFV as a potential marker of a more virulent prothrombotic state.
Correlation of Transabdominal Ultrasound With Intravascular Ultrasound in Diagnosis and Treatment of Iliac Vein Compression Polly Kokinos, MD, RPVI,1 Debbie Hoover, RVT2. 1South Bay Vascular Center; 2Institute for Vascular Testing. Background: Iliac vein compression is challenging to diagnose in patients who are symptomatic but who have not yet developed iliofemoral deep venous thrombosis (DVT). Compression can cause leg swelling and aching, nonhealing of ulcers, and development of leg DVT. Intravascular ultrasound (IVUS) has emerged as the most accurate tool for determining when there is clinically significant iliac vein compression and is used to guide intervention. We set out to determine whether transabdominal duplex ultrasound could accurately guide the need for IVUS and iliac vein stenting. Methods: Symptomatic patients underwent duplex ultrasound and Doppler waveform analysis of their deep pelvic venous system. Abdominal duplex ultrasound examinations were performed early in the morning, in a fasting patient, with a 2.5-5 MHz probe. Patients with narrowing of the iliac vein system were encouraged to pursue IVUS and possible iliac vein stenting. IVUS (Volcano Corp, San Diego, Calif) was performed by placing a 9F or 10F sheath in an ipsilateral great saphenous vein or common femoral vein in the angiography suite. Multiple measurements were made of both diameter and area of the examined venous structure. A self-expanding stent (Wallstent; Boston Scientific, Marlborough, Mass) was placed if there was an area decrease of at least 50% in the narrowed vein compared with the vein at a more distal “normal” site as measured by IVUS. Duplex ultrasound follow-up of all stented patients was done to look at the patency and iliac vein diameter.
156
Abstracts
Journal of Vascular Surgery: Venous and Lymphatic Disorders January 2017
Results: Between March 2015 and August 2016, there were 327 abdominal venous ultrasound examinations performed in a total of 136 patients. Parts of the iliac venous system were not visualized in one-third of these; however, 112 were adequate for diagnosis. Of the 112 patients with adequate visualization, 86 patients had evidence of compression of either an iliac vein or the distal inferior vena cava. Abnormal findings included decrease in diameter to <8 mm, pulsatility of the waveform, and evidence of scarring. Of these, 75 underwent IVUS and 68 underwent iliac vein stent placement or angioplasty of previously placed stents. One patient had a left-sided inferior vena cava with an abnormal left iliac system, and a second had a venous aneurysm that was seen on ultrasound but no stenosis. Six patients had normal findings on venography and IVUS. Therefore, transabdominal ultrasound was accurate in predicting findings in 69 of 75 patients for a 92% true positive rate. We do not have significant statistics on how accurate our negative/normal transabdominal ultrasound scans were. Postprocedure ultrasound done in all
stented patients confirmed patency in all but one patient (who had acute occlusion of his stent) and confirmed increase in iliac vein diameter in all of these patients as seen on the final IVUS pullback. Conclusions: Transabdominal duplex ultrasound of the iliac veins and inferior vena cava can accurately predict significant area decreases on IVUS and thus guide the need for iliac vein stenting. This is a cost-effective and noninvasive way to help diagnose and observe this large group of patients who are at risk for development of DVT, who suffer from chronic venous insufficiency symptoms such as swelling and aching, or who are some of the difficult-to-treat venous ulcer patients.
Fig 3.
Fig 1.
Fig 2.
Fig 4.