Single Tract Aortic Revascularization Technique in the Treatment of Aortoiliac Occlusive Disease.

Endovascular treatment is an acceptable option for patients with aortoiliac occlusive disease. However, bilateral passage of guidewires through the aortoiliac occlusion can be a challenging step in achieving successful revascularization. The aim of this article is to present a novel strategy for successfully passing bilateral guidewires through long aortoiliac occlusive lesions. After one guidewire is passed through the aortic and iliac lesions via one side of the femoral artery, the other guidewire is passed using the up-and-over technique and pulled out from the ipsilateral side of the body. This contralateral guidewire is then inserted into the ipsilateral angiographic catheter along with the ipsilateral guidewire. Subsequently, the angiographic catheter is removed in a manner similar to a peel-away sheath. Eventually, bilateral guidewires can be passed through the lesion via a single aortic tract.

Clinical outcomes of nonthermal ablation, thermal ablation, and surgical stripping for varicose veins.

OBJECTIVE: The purpose of this study was to compare the clinical outcomes of radiofrequency ablation (RFA), cyanoacrylate closure (CAC), mechanochemical ablation (MOCA), and surgical stripping (SS) for incompetent saphenous veins and to determine a suitable treatment modality for a specific clinical situation. METHODS: We retrospectively reviewed the data of patients with varicose veins who underwent RFA, CAC, MOCA, or SS from January 2012 to June 2023. The clinical outcomes, including postoperative complications and the Aberdeen Varicose Vein Questionnaire score, were assessed. RESULTS: During the study period, 2866 patients with varicose veins were treated. Among them, 1670 patients (57.9%) were women. The mean age was 55.3 ± 12.9 years. RFA, CAC, MOCA, and SS were performed in 1984 (68.7%), 732 (25.4%), 78 (2.7%), and 88 (3.0%) patients, respectively. The complete target vein closure rate after RFA, CAC, and MOCA was 94.5%, 98%, and 98%, respectively. The absence of a target vein after SS was 98%. Deep vein thrombosis developed in four patients: one in the RFA group and three in CAC group. Surgical or endovenous procedure-induced thrombosis occurred in 2.3%, 4.8%, 6.4%, and 2.3% of the patients after RFA, CAC, MOCA, and SS, respectively. Phlebitis along the target vein occurred in 0.2% and 3.8% of patients after RFA and MOCA, respectively. A hypersensitivity reaction occurred in 3.7% of patients after CAC. Readmission was required for two patients who had undergone SS. Transient nerve symptoms developed in five (0.3%), zero, one (1.3%), and two (2.3%) patients after RFA, CAC, MOCA, and SS, respectively. After treatment, the Aberdeen Varicose Vein Questionnaire score improved significantly in all groups. CONCLUSIONS: The clinical outcomes with improvement in quality of life were comparable among the different treatment modalities. The proximity of the nerve or skin to the target vein is the most important factor in selecting a suitable treatment modality.

Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting.

Purpose: Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to severe claudication or chronic limb-threatening ischemia. Stent placement for AIOD demonstrated excellent outcomes in terms of long-term patency. However, iliac artery rupture is the most fearful complication during the aortoiliac stenting (AIS). This study aimed to evaluate the incidence and risk factors of iliac artery rupture during AIS. Materials and Methods: A retrospective review of consecutive patients with AIOD treated with AIS from 2009 to 2021 was completed. We excluded patients with instent restenosis. All types of stents, including self-expanding stent (SES), balloon-expandable stent (BES), or balloon-expandable covered stent (CS), were used. Angiographic characteristics and procedural outcomes were analyzed. Procedural success was defined as the residual stenosis <30%. Results: A total of 242 patients (86.8% male; mean age 68.8±10.0 years) with de novo AIOD were treated with AIS. The procedural success rate was 100%. Rupture occurred in six patients (2.5%) and all ruptures were occurred in the external iliac artery (EIA). Stenting of the EIA and less calcified lesion were risk factors for iliac rupture (P=0.028). All cases of iliac artery rupture were successfully treated with the CSs. Overall primary patency rates were 98.0% and 93.4% at 12 and 36 months, respectively. Primary patency rates of SES, BES, and CS were 87.7%, 88.4%, and 100% at 36 months, respectively. Conclusion: The incidence of iliac artery rupture during AIS was 2.5%. Stent placement in the less calcified lesion and EIA was a risk factor for rupture during AIS. Placement of the CS can be the straightforward solution in case of iliac artery rupture during AIS.

A nationwide study of compliance of venoactive drugs in chronic venous disease patients.

Purpose: Venoactive drugs are widely used to improve the symptoms and signs of chronic venous disease. This study aimed to analyze the rate of adverse events after venoactive drug prescription and subsequent compliance and switching rates. Methods: Using the National Health Insurance Service database, individuals with at least one chronic venous disease code between January 2009 and December 2019 were identified, and 30% (2,216,780 individuals) of these were sampled. Finally, 1,551,212 patients were included, and we analyzed adverse events, compliance, and switching rates with 8 venoactive drugs, including Vitis vinifera extract, naftazone, micronized purified flavonoid fraction, Vitis vinifera leaf extract, diosmin, diobsilate calcium, bilberry fruit dried extract, and sulodexide. Results: The most commonly prescribed venoactive drug was Vitis vinifera extract (72.2%), followed by sulodexide (9.3%), and Vitis vinifera leaf dry extract (8.2%). Adverse event rates were significantly lower in the naftazone and diosmin groups (P = 0.001 and P = 0.002, respectively) and significantly higher in the Vitis vinifera leaf dry extract group (P = 0.009). Drug adherence to sulodexide was the highest throughout the study period, followed by billberry extract and dobesilate (all P < 0.001). For most drugs, the drug switching rate was low (<5.0%). Conclusion: Vitis vinifera extract was the most commonly prescribed venoactive drug in Korea, and drug adherence to sulodexide was the highest among all venoactive drugs. The adverse event rates were significantly lower in the naftazone and diosmin groups.

Prevalence and Risk Factors of Abdominal Aortic Aneurysms Detected with Ultrasound in Korea and Belgium.

The objective was to investigate the prevalence of abdominal aortic aneurysms (AAAs) and the diameters of the aorta and common iliac arteries (CIAs) in a Korean cohort and secondly to analyze the differences in aortic diameter by comparison with a European cohort. The Korean cohort included participants ≥ 50 years who consented to AAA screening and data were analysed retrospectively. Aortic and common iliac diameters were measured using the outer-to-outer diameter method and prevalence rates were calculated. Common risk factors such as smoking, body mass index, pulmonary disease, hypertension, diabetes, hyperlipidaemia, ischaemic heart disease, and cerebrovascular disease were reported in association with AAA occurrence and AAA development. The aortic diameters were then compared with those in a Belgian cohort of 2487 participants identified in the Liège AAA Screening Program. An aortic size index (ASI) was also calculated to account for the potential size differences in the Belgian and Korean populations. A total of 3124 Korean participants were examined using ultrasound. The prevalence of AAAs in this cohort was 0.7%. The combined prevalence of subaneurysmal dilatation and AAA was 1.5%. The prevalence in male smokers older than 65 years was 2.7% (19/715). The mean infrarenal aortic diameter was 17.3 ± 3.1 mm in men and 15.7 ± 2.7 mm in women; the corresponding values in Belgian participants were 19.4 ± 3.0 mm in men and 17.9 ± 2.4 mm in women. The median aortic size index was 0.99 (interquartile range 0.88-1.12). The mean infrarenal aortic diameter was significantly smaller in the Korean cohort than in the Belgian cohort. Considering the observed prevalence of AAAs in different age groups, the age groups which would contribute to most cases was male persons above 66 years in both cohorts.

National trend of the treatment for chronic venous diseases in Korea between 2010 and 2020.

Purpose: Limited data are available on the nationwide trend of treatments for chronic venous disease (CVD). The aim of the present study was to identify the nationwide trends of CVD treatments in Korea. Methods: A serial, cross-sectional study was conducted with the use of time trends to analyze patients with CVD between 2010 and 2020. The trends in the number of patients and procedures were analyzed including sclerotherapy, open surgery, and endovenous thermal ablation (ETA). Health Insurance Review and Assessment Service data were used to analyze the trends. For the statistical analysis, MedCalc Statistical software was used. P < 0.05 was considered statistically significant. Results: A total of 1,867,307 patients with CVD were managed in Korea between 2010 and 2020. The annual number of patients with CVD increased from 143,108 in 2010 to 219,319 in 2020 (risk ratio [RR], 1.53; P < 0.001). The percentage of patients with CVD who had venous ulcer gradually decreased from 3.1% in 2010 to 1.7% in 2020 (RR, 0.86; P < 0.001). The number of conventional surgeries including stripping and local resection of varicose veins decreased from 32,384 in 2010 to 21,792 in 2020 (RR, 0.67; P < 0.001). The number of ETAs performed increased, from 290 in 2011 to 12,126 procedures in 2020 (RR, 41.81; P < 0.001). Conclusion: The total number of patients with CVD increased during the last 11 years. The number of conventional open surgery and sclerotherapy procedures decreased. On the contrary, the number of ETAs significantly increased in Korea.

Rapid hemostasis of the residual inguinal access sites during endovascular procedures: A case report.

BACKGROUND: In endovascular procedures including total percutaneous endovascular aneurysm repair (pEVAR), percutaneous access through the common femoral artery is most commonly performed. Access-site bleeding is a major concern in percutaneous techniques. Herein, we present a case of successful control of continuous oozing using a vascular closure device (VCD) and the application of Surgicel (Johnson & Johnson, United States) over the access tract. CASE SUMMARY: An 82-year-old man presented with an unruptured abdominal aortic aneurysm measuring 83 mm × 75 mm. The patient had a medical history of atrial fibrillation and was receiving rivaroxaban (15 mg/d). Routine pEVAR was performed using the preclose technique with ProGlide (Abbott, Santa Clara, CA, United States). Significant amount of bleeding was observed at the end of the procedure after the deployment of the closure device at the access site. A sheet of Surgicel was applied to the suture thread using a surgical needle. Surgicel was applied to the surface of the artery along the access tract using a pusher, and hemostasis was immediately attained. CONCLUSION: This simple technique is an excellent adjunct to control residual bleeding from the access site following VCD use.

Ultrasound Elastography to Differentiate the Thrombus and Plaque in Peripheral Arterial Diseases.

Purpose: Arterial stiffness and steno-occlusion of the lower-extremity can result from many vascular lesions, including acute thromboembolisms, soft plaques, calcified plaques, or inflammatory disease. Ultrasound (US) elastography measures the tissue deformation response to compression and displays tissue stiffness. This study aimed to evaluate the characteristics of arterial lesions in the lower extremities using US elastography. Materials and Methods: We retrospectively analyzed the data of 20 patients who visited our institute for arterial disease treatment between May 2016 and November 2017. An US examination with B-mode and strain elastography (SE) was performed of four different lesion types at 45 sites: acute and subacute thromboembolisms, soft plaques, calcified plaques, and thromboangiitis obliterans lesions (TAOs). During SE, stress was externally applied by the operator using the transducer. Strain ratio (SR) was calculated as the fraction of the average strain in the reference area divided by the average strain in the lesion. The SR was compared among different lesion types, with the accompanying vein as the reference region of interest. Results: The strain was highest in the soft plaques (0.63%±0.23%), followed by the TAOs (0.45%±0.11%), calcified plaques (0.44%±0.13%), and acute thromboembolisms (0.34%±0.23%), which were statistically significant (P=0.026). However, the mean SR was highest for the calcified plaques (2.33%±0.80%), followed by the TAOs (1.63%±0.40%), acute thromboembolisms (1.60%±0.48%), and soft plaques (1.51±0.39), and which were statistically significant (P=0.013). Conclusion: Despite several limitations, vascular elastography may be useful for differentiating between lesion types in peripheral arterial disease.

In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement.

OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.

Changes of stump length depending on starting position of glue injection related to venous diameter during cyanoacrylate closure for incompetent saphenous veins.

OBJECTIVE: A common pattern of recurrence after cyanoacrylate treatment of incompetent saphenous veins has been associated with reflux from the residual stump. The purpose of this study was to analyze the starting point of cyanoacrylate glue injection from the junction to decrease the stump length. METHODS: A retrospective review was performed using prospectively collected data of patients with cyanoacrylate closure (CAC). Preoperatively, the diameter of the saphenous vein was measured. CAC was performed according to the manufacturer's instructions. After the procedure, clinical outcomes including pain, Venous Clinical Severity Score, and quality of life using the Aberdeen Varicose Vein Questionnaire were evaluated. Postoperative duplex scanning was performed to evaluate the occlusion rate of the target vein, stump length, and presence of endovenous glue-induced thrombosis. The stump length was analyzed according to the preoperative venous diameter to determine the proper point of glue injection to decrease the stump length. RESULTS: During the study period, CAC was performed in 408 patients. The mean age was 56.2 ± 11.5 years (range, 19-84 years). A total of 279 patients (68.4%) were women. Occlusion of the target vein was achieved in all patients. After the procedure, pain, Venous Clinical Severity Score, and quality of life were improved (P < .001). Endovenous glue-induced thrombosis developed in 5.8% of patients. There was a 1.53-fold linear increase in the stump length for every 1-mm increment of the preoperative venous diameter. In 20 patients with a venous diameter ≥5 mm, glue injection was performed safely 4 cm distal to the junction to decrease the stump length. CONCLUSIONS: The stump length linearly increased with an increase in the saphenous vein diameter. If the diameter of the saphenous vein is more than 5 mm, cyanoacrylate glue may be injected 4 cm distal to the junction to decrease the stump length.

A multicenter randomized controlled trial of cyanoacrylate closure and surgical stripping for incompetent great saphenous veins.

OBJECTIVE: The treatment of varicose veins has shifted from conventional surgical stripping (SS) to minimally invasive endovenous modalities. Cyanoacrylate closure (CAC) with the VenaSeal system (Medtronic, Dublin, Ireland) has increased in popularity owing to its nonthermal and nontumescent technique. The purpose of the present study was to compare the clinical outcomes of CAC and SS for the treatment of incompetent great saphenous veins. METHODS: An open-label, multicenter, prospective, randomized controlled trial was conducted. The subjects were randomized to either the CAC or SS procedure. The primary endpoint of the present study was to evaluate complete closure of the target vein at 3 months. Target vein occlusion was assessed on the third day and 1, 3, 6, and 12 months postoperatively using duplex ultrasound. The pain and ecchymosis grades were also assessed. Additionally, the clinical outcomes, such as the venous clinical severity score and Aberdeen Varicose Vein Questionnaire score, were assessed. RESULTS: Three-month follow-up data were obtained for all 126 enrolled and randomized subjects (63 with CAC and 63 with SS). At 3 months, complete target vein closure was observed in both groups. The postoperative pain score was significantly better in the CAC group than in the SS group (0.3 ± 0.6 in the CAC group and 1.1 ± 1.5 in the SS group; P < .001). In addition, the mean ecchymosis grade was 0.3 ± 0.5 in the CAC group and 1.1 ± 1.1 in the SS group (P < .001). The venous clinical severity score and quality of life had improved equally in both groups. The adverse events after both procedures were mostly minor complications (9 events in CAC group and 20 events in SS group). Major complications occurred in one patient who had undergone the SS procedure. CONCLUSIONS: The CAC and SS procedures were both associated with complete occlusion of the target vein at 3 months. The postoperative pain and ecchymosis grades were significantly lower in the CAC group. Other differences between the two groups included the frequency and nature of the complications. The results showed that CAC has high success with few complications.

Cyanoacrylate Closure of Small Saphenous Vein Insufficiency.

BACKGROUND: As minimally invasive techniques were issued, endovenous thermal ablations have emerged. However, the thermal-associated complication has been reported in the treatment of small saphenous vein (SSV) insufficiency, such as sural nerve injury. Recently introduced cyanoacrylate closure (CAC) is a nonthermal modality, so this thermal-associated complication can be avoided. OBJECTIVE: This retrospective study analyzed the feasibility, safety, and 2-year results of CAC for treating SSV insufficiency, particularly the incidence of sural nerve injury. MATERIALS AND METHODS: One hundred sixty-three SSV insufficiencies in 128 patients were treated with CAC were reviewed. Pain, venous severity, and quality of life (QoL) scores were evaluated. Postoperative duplex scanning also evaluated anatomical and clinical success rates. RESULTS: The mean patient age was 56.8 years. The initial technical success rate was 100%. The occlusion rate after 2 years was 96.3%. Pain, venous severity, and QoL scores were improved significantly from 2.4 to 0.0, 4.39 to 0.47, and 11.95 to 2.69, respectively, before and 2 years after CAC. No major complications were observed, such as sural nerve injury. CONCLUSION: Cyanoacrylate closure for the ablation of SSV insufficiency could be a great alternative to endothermal ablation with an excellent success rate and shorter procedure time.

Directional Atherectomy for Treating In-Stent Restenosis of the Superficial Femoral Artery.

PURPOSE: The optimal treatment for in-stent restenosis (ISR) of the superficial femoral artery (SFA) is still in debate. This study aimed to evaluate the safety and effectiveness of directional atherectomy (DA) as a primary treatment modality for ISR in SFA. MATERIALS AND METHODS: A retrospective single-center analysis was conducted. In total, 617 stents were deployed in 242 limbs for SFA diseases during the study period. ISR was identified in 29 limbs (12.0%); 14 limbs were treated with DA and 15 limbs with balloon angioplasty (BAP) alone. Technical success rate, target lesion revascularization (TLR) and patency rates (PRs) at 12 months, and any complications were evaluated. RESULTS: DA group included complete occlusions in 50% of patients and BAP group included in 40%. Mean improvement in the ankle-brachial index was 0.29 and 0.32, respectively (P=0.638). Technical success was achieved in all patients. The procedural success rates were 85.7% and 73.3%, respectively (P=0.651). There was no significant difference regarding residual stenosis, distal embolization, or flow-limiting dissection. Primary PRs at 1 year were 85.7% and 73.3%, secondary PRs were 100.0% and 93.3%, and TLR rates were 14.3% and 20.0% (P=0.411, 0.326, and 0.684, respectively). CONCLUSION: Short-term outcomes after DA for ISR were not different from those after BAP but showed a tendency of better primary PR and TLR. Larger multicenter prospective studies are needed to define the role of DA in ISR treatment.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

CASS (CyanoAcrylate closure versus Surgical Stripping for incompetent saphenous veins) study: a randomized controlled trial comparing clinical outcomes after cyanoacrylate closure and surgical stripping for the treatment of incompetent saphenous veins.

BACKGROUND: Several modalities are used for the treatment of varicose veins. Open surgical treatment with ligation and stripping of the saphenous vein has been the standard of care for many years. Endovenous thermal ablation has been shown to be a safe and effective alternative with high, long-term, target-vein closure rates. Despite this, there is the possibility of thermal injury to surrounding structures. The recently introduced cyanoacrylate closure is also considered to be a good alternative and the risk of injury to surrounding structures is minimal. The purpose of this study is to demonstrate the non-inferiority of cyanoacrylate closure with the VenaSeal™ closure system compared to surgical stripping in terms of clinical outcomes for the treatment of incompetent great saphenous veins. METHODS/DESIGN: This is an open-label, multicenter, prospective, randomized controlled trial evaluating the non-inferior clinical outcomes of cyanoacrylate closure compared to surgical stripping for the treatment of incompetent saphenous veins. After baseline measurements, participants will be randomly allocated into either the cyanoacrylate closure group or the surgical-stripping group. The primary endpoint of the study is the complete closure rate of the target vein in the cyanoacrylate closure group, and the absence of venous reflux or residual venous tissue after surgical stripping in the surgical-stripping group. These endpoints will be measured by Doppler ultrasound performed by qualified vascular technologists or investigators at 3 months after treatment. Secondary outcomes include perioperative pain, postoperative ecchymosis, clinical assessment (including general and disease-specific quality of life evaluations), complete closure rate, and absence of venous reflux or residual venous tissue at the 12- and 24-month follow-ups, as well as all adverse event rates during the 24-month follow-up period. DISCUSSION: This multicenter randomized controlled trial is designed to show non-inferiority in terms of complete closure rate of cyanoacrylate compared to surgical stripping for the treatment of incompetent saphenous veins. TRIAL REGISTRATION: Clinical Research Information Service (CRIS), ID: KCT0003203. Registered on 20 September 2018.

Optimal Prediction of the Central Venous Catheter Insertion Depth Targeting the Cavoatrial Junction.

BACKGROUND: Central venous catheters should be positioned at the cavoatrial junction or the right atrium. If catheters are inserted to a depth derived by adding the length between the needle insertion point and the clavicular notch and the length between the clavicular notch and the carina, the catheter tip can be placed near the carina. Based on this, we aim to make a formula to place a catheter tip near the cavoatrial junction. METHODS: This prospective nonrandomized interventional study included patients who needed a central venous catheter from June 2017 to July 2018. The location of the cavoatrial junction was identified using a fluoroscopic technique. The following variables were measured: L1, the length between the needle insertion point and the clavicular notch; L2, the length between the clavicular notch and the carina; and α, the length between the carina and the cavoatrial junction. RESULTS: A total of 70 patients were enrolled. The mean age was 65.5 ± 11.6 years, and 62.9% were male. The mean L1 and L2 were 7.6 ± 1.4 and 7.0 ± 1.4 cm, respectively. The mean α was 4.4 ± 1.5 cm (95% CI 4.1-4.8), and it was not affected by demographic factors, such as sex, age, height or weight. CONCLUSIONS: Central venous catheters in adult patients can be placed near the cavoatrial junction using a simple formula: the distance between the insertion point and the clavicular notch + the distance between the clavicular notch to the carina + 4.4 cm.

Incidence, classification, and risk factors of endovenous glue-induced thrombosis after cyanoacrylate closure of the incompetent saphenous vein.

BACKGROUND: The cyanoacrylate closure (CAC) procedure is a safe and effective modality for the treatment of an incompetent saphenous vein. Thrombus extension into the deep vein, known as endovenous glue-induced thrombosis (EGIT), may be a worrisome complication of the procedure. However, the incidence, classification, and risk factors of EGIT have not been elucidated. We report, herein, the incidence, classification, and risk factors of EGIT following the CAC procedure for an incompetent saphenous vein. METHODS: A retrospective review was performed of prospectively collected data of CAC patients. Preoperatively, the diameter, reflux time, and peak reflux velocity of the saphenous vein were measured. The CAC procedure was performed as per the instructions for use. Postoperative follow-up was conducted at 1 week, 3 months, 6 months, and 1 year after the procedure. Postoperative duplex scanning was performed to evaluate the occlusion of the target vein and presence of EGIT. Demographic data, risk factors, procedure details, and follow-up data were also obtained. A four-tier classification system and recommended treatment plan were developed based on the EGIT grade. All statistical analyses were performed using SPSS version 22.0 (IBM, Armonk, NY). A P value of <.05 was considered statistically significant. RESULTS: During the study period, the CAC procedure was performed in 191 patients (126 females [66.0%]). The mean age was 56.1 ± 11.7 years (range, 19-84) years. After the procedure, pain, the Revised Venous Clinical Severity Score, and the Aberdeen Varicose Vein Questionnaire score were significantly improved (P < .001). EGIT developed in 11 patients (5.8%). EGIT of grades I and II developed in seven (63.6%) and four (36.4%) patients, respectively. Duplex follow-up was conducted for all patients with EGIT without anticoagulation. Regarding the analysis of risk factors for the development of EGIT, the preoperative saphenous vein diameter of <5 mm was the only risk factor (P = .040). CONCLUSIONS: EGIT is not an uncommon complication of CAC. A small diameter of the saphenous vein (<5 mm) is a risk factor for the development of EGIT. A classification system and treatment protocol for EGIT based on the area of thrombus extension into the deep vein is proposed for managing patients.

Complete Revascularization of Acute Limb Ischemia With Distal Pedal Access.

Acute limb ischemia (ALI) is an abrupt decrease of blood flow to a limb, resulting in a potential threat to that body part. In ALI, which is commonly caused by embolism or traumatic occlusion, symptoms appear quickly due to a lack of collateral blood flow and extension of the thrombus to arterial outflow. In cases with ALI presentation, urgent evaluation and management are necessary. Here, we report 3 cases with ALI due to thromboembolism. Conventional open thromboembolectomy was performed with a femoral artery cutdown and antegrade passage of the embolectomy catheter. Further, distal access was created in the dorsalis pedis artery and/or posterior tibial artery at the ankle level. After the retrograde passage of the guidewire and antegrade insertion of the embolectomy catheter, the embolus was completely removed.