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The Short-term Outcomes of Neovalve Deep Venous Reconstructive Surgery
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 3, Number 1
were considered a positive IVUS (PIVUS) examination finding and an indication for stenting. Results: In the present series, no 1-month mortality or 1-month morbidity was observed in these patients. There was no venographic or IVUS evidence of inferior vena cava stenosis or dilation in this series. Of the 92 venograms studied, 88 had PIVUS findings and are distributed in the Table. Table. Distribution of positive intravascular ultrasound (PIVUS) among vein segments with type I-V venogram findings
Venogram
Left common iliac vein
Left external iliac vein
Right common iliac vein
Right external iliac vein
Right common fem. vein
Type I Type II Type IV Type V Total, No. (%)
4 6 7 11 28 (32)
4 2 2 7 15 (17)
2 5 5 0 12 (14)
11 9 10 1 31 (35)
1 0 1 0 2 (2)
The correlation of venographic findings and PIVUS was as follows: type I cases (26) had 85% PIVUS; type II (22) had 100% PIVUS; type III (25) had 100% PIVUS; and type IV (19) had 100% PIVUS. Conclusions: Contrary to previous belief, there was an almost equal distribution of PIVUS between the left side (43 cases) and the right side (45 cases) in this population of patients. If this new proposed classification of venographic findings is confirmed in a prospective evaluation, IVUS may be required in only <30% of the cases (28% in this series).
Abstracts 129
Objectives: Deep venous reflux arises from three causes: post-thrombotic syndrome (PTS), primary deep valve incompetence (PDVI), and congenital valve aplasia. According to the causes, several surgical techniques have been used to correct deep venous reflux, reconstructing the valves. The main procedures described are internal or external valvuloplasty, femoral transposition, axillary vein transfer, and artificial venous valve. Overall, the results vary on the basis of the technique used, the surgeon’s expertise, and postprocedure care. The neovalve is obtained by dissecting the vein wall to create a flap, which is positioned as a monocuspid or bicuspid valve. Because the principle of this surgery is creation of a new valve in the deep venous system, this technique can be employed not only in PTS but also in PDVI and valve aplasia. This study reports our first case series and the short-term outcomes of the neovalve surgery in patients with deep venous insufficiency affected by PTS and PDVI. Methods: The indications for this surgery were patients who had deep venous insufficiency and persistent active ulcers (CEAP classification class C6) even after superficial vein surgery, perforator surgery, and compression treatment. From July 2013 to April 2014, the neovalve surgery was performed in four limbs on four patients (two PTS and two PDVI). The monocuspid valves were created by dissecting the venous wall on the femoral veins in all four limbs. In the post-thrombotic lesion, the neovalve was created by using the intraluminal septum after endophlebectomy. Results: Ulcer healing was observed in four limbs within 2 and 12 weeks after surgery (median, 6.5 weeks), with no recurrent symptoms with a mean follow-up of 8 months (range, 6-14 months). Postoperative evaluations (descending venography and duplex scanning) were performed at 1 month after the operation and showed the venous patency and the neovalve competence in four limbs. Conclusions: Neovalve technique seems to be feasible and effective in the patients with deep venous insufficiency affected by PTS or PDVI. Although these results are encouraging, a larger volume of patients and long-term outcomes are warranted to validate the technique.
Author Disclosures: E. Ascher: Nothing to disclose; N. J. Bauer: Nothing to disclose; J. Eisenberg: Nothing to disclose; A. Hingorani: Nothing to disclose; N. Marks: Nothing to disclose.
Author Disclosures: Y. Hoshino: Nothing to disclose; S. Hoshino: Nothing to disclose.
Effects of Venous Stent Placement on Cutaneous Microvascular Function in Iliocaval Venous Obstruction C. Koksoy, Y. Sevim, Z. Unal, E. Y. Demirel. Ankara University, Ankara, Turkey
Reintervention in Patients Undergoing Iliofemoral Venous Stenting D. I. Fremed, R. O. Tadros, M. Lee, R. A. Ravin, M. L. Marin, P. L. Faries, W. Ting. Icahn School of Medicine at Mount Sinai, New York, NY
Objectives: Cutaneous microvascular dysfunction has an important role in the development of venous disease. However, the effects of venous obstruction on microcirculation have not been well investigated. The aim of the present study was to assess cutaneous microvascular function in patients with iliocaval venous obstruction before and after venous stent placement. Methods: Endothelial-dependent and endothelial-independent vasodilator responses to iontophoretic administration of incremental doses of acetylcholine (Ach) and sodium nitroprusside (SNP) were evaluated with a laser Doppler scanner in the perimalleolar region in the supine and sitting positions in patients with iliocaval venous obstruction (n ¼ 11) and healthy controls (n ¼15). After evaluation of cutaneous microvascular function, patients with iliocaval obstruction underwent iliocaval venous stent placement. Treatment effects were assessed by Venous Clinical Severity Score and CEAP (clinical, etiologic, anatomic, and pathologic elements) class before and after intervention. Cutaneous microvascular function was re-evaluated at the third month after stent placement in patients with patent stents. Results: The responses to Ach and SNP in the cutaneous microcirculation were lower in patients with iliocaval obstruction compared with those in healthy subjects in the sitting position (P < .05). Recanalization and stent placement were successful in all patients. CEAP class and Venous Clinical Severity Score showed a significant decrease in the severity of venous disease signs and symptoms (P < .01). Stent placement in patients with iliocaval venous obstruction resulted in a significant increase in vasodilation response to both Ach and SNP in the supine position (P < .05). Conclusions: Iliocaval venous obstruction impairs the endothelialdependent and endothelial-independent vasodilation in the perimalleolar region. Iliocaval venous stent placement may recover microvascular function. Author Disclosures: C. Koksoy: Nothing to disclose; Y. Sevim: Nothing to disclose; Z. Unal: Nothing to disclose; E. Y. Demirel: Nothing to disclose. The Short-term Outcomes of Neovalve Deep Venous Reconstructive Surgery Y. Hoshino,1 S. Hoshino2. 1Saiseikai Fukuoka General Hospital, Fukuoka, Japan; 2Fukushima Diichi Hospital, Fukushima, Japan
Objectives: Venous stenting is increasingly being used as a treatment of chronic proximal venous outflow obstruction (PVOO) in the abdomen and pelvis. We observed that some patients underwent a secondary intervention after the initial vein stent procedure. This retrospective study was undertaken to identify the clinical and technical factors associated with the need for secondary interventions among patients who had previously undergone vein stent placement for chronic PVOO. Methods: A retrospective, single-institution review of 107 patients who previously underwent venous stenting for chronic PVOO between December 2012 and June 2014 was conducted. The indications for the primary and secondary procedures were reviewed. Secondary procedures that were part of a staged contralateral procedure or endovenous thermal ablations were excluded from this study. Results: Of the 107 patients, 64% of patients were male, and the mean age was 62 years (range, 31-90 years). The indications for the primary vein stent procedure included varicose veins (with or without ulcer) in 41 patients (38.3%), post-thrombotic syndrome (with or without ulcer) in 19 patients (17.6%), and isolated lower extremity edema in 47 patients (43.9%). A total of 11 patients (10.2%) required a secondary reintervention. The need for reintervention was prompted by a recurrence of preprocedure symptoms in all 11 patients. Average length of time from the initial procedure to secondary intervention was 5.5 months. Of these 11 patients, seven patients (63%) had a remote history (>6 months) of deep venous thrombosis and presented with post-thrombotic syndrome during their initial procedures. Seven (63%) presented with CEAP class 4 or higher. Two (18%) presented with acute deep venous thrombosis after discontinuation of anticoagulation. Four patients (36%) tested positive for hypercoagulable disorders. Findings during secondary procedures included iliofemoral stenosis distal to the prior stents (six of 11), in-stent restenosis or occlusion (five of 11), and malposition of stent (three of 11). Secondary interventions included new stent placement (nine of 11), balloon angioplasty alone (two of 11), and need for catheter-directed thrombolysis (one of 11) Follow-up at 30 days showed resolution of symptoms in five patients, improvement of symptoms in four, and unchanged symptoms in two. Conclusions: Reintervention should be considered in any patient with recurrence of symptoms after vein stent placement for chronic PVOO. These patients may have findings that are amenable to secondary interventions with a reasonable chance of symptom resolution or improvement. Longer
were considered a positive IVUS (PIVUS) examination finding and an indication for stenting. Results: In the present series, no 1-month mortality or 1-month morbidity was observed in these patients. There was no venographic or IVUS evidence of inferior vena cava stenosis or dilation in this series. Of the 92 venograms studied, 88 had PIVUS findings and are distributed in the Table. Table. Distribution of positive intravascular ultrasound (PIVUS) among vein segments with type I-V venogram findings
Venogram
Left common iliac vein
Left external iliac vein
Right common iliac vein
Right external iliac vein
Right common fem. vein
Type I Type II Type IV Type V Total, No. (%)
4 6 7 11 28 (32)
4 2 2 7 15 (17)
2 5 5 0 12 (14)
11 9 10 1 31 (35)
1 0 1 0 2 (2)
The correlation of venographic findings and PIVUS was as follows: type I cases (26) had 85% PIVUS; type II (22) had 100% PIVUS; type III (25) had 100% PIVUS; and type IV (19) had 100% PIVUS. Conclusions: Contrary to previous belief, there was an almost equal distribution of PIVUS between the left side (43 cases) and the right side (45 cases) in this population of patients. If this new proposed classification of venographic findings is confirmed in a prospective evaluation, IVUS may be required in only <30% of the cases (28% in this series).
Abstracts 129
Objectives: Deep venous reflux arises from three causes: post-thrombotic syndrome (PTS), primary deep valve incompetence (PDVI), and congenital valve aplasia. According to the causes, several surgical techniques have been used to correct deep venous reflux, reconstructing the valves. The main procedures described are internal or external valvuloplasty, femoral transposition, axillary vein transfer, and artificial venous valve. Overall, the results vary on the basis of the technique used, the surgeon’s expertise, and postprocedure care. The neovalve is obtained by dissecting the vein wall to create a flap, which is positioned as a monocuspid or bicuspid valve. Because the principle of this surgery is creation of a new valve in the deep venous system, this technique can be employed not only in PTS but also in PDVI and valve aplasia. This study reports our first case series and the short-term outcomes of the neovalve surgery in patients with deep venous insufficiency affected by PTS and PDVI. Methods: The indications for this surgery were patients who had deep venous insufficiency and persistent active ulcers (CEAP classification class C6) even after superficial vein surgery, perforator surgery, and compression treatment. From July 2013 to April 2014, the neovalve surgery was performed in four limbs on four patients (two PTS and two PDVI). The monocuspid valves were created by dissecting the venous wall on the femoral veins in all four limbs. In the post-thrombotic lesion, the neovalve was created by using the intraluminal septum after endophlebectomy. Results: Ulcer healing was observed in four limbs within 2 and 12 weeks after surgery (median, 6.5 weeks), with no recurrent symptoms with a mean follow-up of 8 months (range, 6-14 months). Postoperative evaluations (descending venography and duplex scanning) were performed at 1 month after the operation and showed the venous patency and the neovalve competence in four limbs. Conclusions: Neovalve technique seems to be feasible and effective in the patients with deep venous insufficiency affected by PTS or PDVI. Although these results are encouraging, a larger volume of patients and long-term outcomes are warranted to validate the technique.
Author Disclosures: E. Ascher: Nothing to disclose; N. J. Bauer: Nothing to disclose; J. Eisenberg: Nothing to disclose; A. Hingorani: Nothing to disclose; N. Marks: Nothing to disclose.
Author Disclosures: Y. Hoshino: Nothing to disclose; S. Hoshino: Nothing to disclose.
Effects of Venous Stent Placement on Cutaneous Microvascular Function in Iliocaval Venous Obstruction C. Koksoy, Y. Sevim, Z. Unal, E. Y. Demirel. Ankara University, Ankara, Turkey
Reintervention in Patients Undergoing Iliofemoral Venous Stenting D. I. Fremed, R. O. Tadros, M. Lee, R. A. Ravin, M. L. Marin, P. L. Faries, W. Ting. Icahn School of Medicine at Mount Sinai, New York, NY
Objectives: Cutaneous microvascular dysfunction has an important role in the development of venous disease. However, the effects of venous obstruction on microcirculation have not been well investigated. The aim of the present study was to assess cutaneous microvascular function in patients with iliocaval venous obstruction before and after venous stent placement. Methods: Endothelial-dependent and endothelial-independent vasodilator responses to iontophoretic administration of incremental doses of acetylcholine (Ach) and sodium nitroprusside (SNP) were evaluated with a laser Doppler scanner in the perimalleolar region in the supine and sitting positions in patients with iliocaval venous obstruction (n ¼ 11) and healthy controls (n ¼15). After evaluation of cutaneous microvascular function, patients with iliocaval obstruction underwent iliocaval venous stent placement. Treatment effects were assessed by Venous Clinical Severity Score and CEAP (clinical, etiologic, anatomic, and pathologic elements) class before and after intervention. Cutaneous microvascular function was re-evaluated at the third month after stent placement in patients with patent stents. Results: The responses to Ach and SNP in the cutaneous microcirculation were lower in patients with iliocaval obstruction compared with those in healthy subjects in the sitting position (P < .05). Recanalization and stent placement were successful in all patients. CEAP class and Venous Clinical Severity Score showed a significant decrease in the severity of venous disease signs and symptoms (P < .01). Stent placement in patients with iliocaval venous obstruction resulted in a significant increase in vasodilation response to both Ach and SNP in the supine position (P < .05). Conclusions: Iliocaval venous obstruction impairs the endothelialdependent and endothelial-independent vasodilation in the perimalleolar region. Iliocaval venous stent placement may recover microvascular function. Author Disclosures: C. Koksoy: Nothing to disclose; Y. Sevim: Nothing to disclose; Z. Unal: Nothing to disclose; E. Y. Demirel: Nothing to disclose. The Short-term Outcomes of Neovalve Deep Venous Reconstructive Surgery Y. Hoshino,1 S. Hoshino2. 1Saiseikai Fukuoka General Hospital, Fukuoka, Japan; 2Fukushima Diichi Hospital, Fukushima, Japan
Objectives: Venous stenting is increasingly being used as a treatment of chronic proximal venous outflow obstruction (PVOO) in the abdomen and pelvis. We observed that some patients underwent a secondary intervention after the initial vein stent procedure. This retrospective study was undertaken to identify the clinical and technical factors associated with the need for secondary interventions among patients who had previously undergone vein stent placement for chronic PVOO. Methods: A retrospective, single-institution review of 107 patients who previously underwent venous stenting for chronic PVOO between December 2012 and June 2014 was conducted. The indications for the primary and secondary procedures were reviewed. Secondary procedures that were part of a staged contralateral procedure or endovenous thermal ablations were excluded from this study. Results: Of the 107 patients, 64% of patients were male, and the mean age was 62 years (range, 31-90 years). The indications for the primary vein stent procedure included varicose veins (with or without ulcer) in 41 patients (38.3%), post-thrombotic syndrome (with or without ulcer) in 19 patients (17.6%), and isolated lower extremity edema in 47 patients (43.9%). A total of 11 patients (10.2%) required a secondary reintervention. The need for reintervention was prompted by a recurrence of preprocedure symptoms in all 11 patients. Average length of time from the initial procedure to secondary intervention was 5.5 months. Of these 11 patients, seven patients (63%) had a remote history (>6 months) of deep venous thrombosis and presented with post-thrombotic syndrome during their initial procedures. Seven (63%) presented with CEAP class 4 or higher. Two (18%) presented with acute deep venous thrombosis after discontinuation of anticoagulation. Four patients (36%) tested positive for hypercoagulable disorders. Findings during secondary procedures included iliofemoral stenosis distal to the prior stents (six of 11), in-stent restenosis or occlusion (five of 11), and malposition of stent (three of 11). Secondary interventions included new stent placement (nine of 11), balloon angioplasty alone (two of 11), and need for catheter-directed thrombolysis (one of 11) Follow-up at 30 days showed resolution of symptoms in five patients, improvement of symptoms in four, and unchanged symptoms in two. Conclusions: Reintervention should be considered in any patient with recurrence of symptoms after vein stent placement for chronic PVOO. These patients may have findings that are amenable to secondary interventions with a reasonable chance of symptom resolution or improvement. Longer