Endovascular Laser Ablation (EVLA) for the Treatment of Chronic Venous Insufficiency

Endovascular laser ablation (EVLA) for the treatment of chronic venous insufficiency of the lower extremities can be applied to the perforating veins which connect the superficial and deep venous systems. This retrospective study evaluated outcomes of EVLA using a bare-tip fiber with a 1470 nm laser (with or without additional sclerotherapy or microphlebectomy) of 171 perforating veins in 87 patients with 3 month follow up. Of the 171 perforating veins, 49 had previous GSV disruption on the same extremity, 25 had previous SSV disruption on the same extremity, 88 had previous GSV and SSV disruption on the same extremity, and 9 had patent saphenous veins. On follow up, 94% of perforating veins were occluded at 1 month and 98% were occluded at 3 months. Complete chronic venous insufficiency symptom resolution was found to be 82% and 96% at 1 month and 3 month follow up, respectively. Perforator patency after ablation correlated with higher CEAP scores and the presence of prior GSV/SSV interruption.

Comment:

This study demonstrates impressive success rates following bare tip EVLA of perforating veins, both in terms of perforating vein occlusion and improvement in clinical symptoms. The study results are likely more pertinent to patients with pre-existing saphenous interruption given the small subset of patients within the study without pre-existing saphenous interruption. While the clinical utility of treating perforating veins is uncertain and current recommendations from the American Venous Forum and the Society of Vascular Surgery argue for ablation only in close proximity to venous stasis ulcers or advanced disease, this study makes a case for revisiting these recommendations. Future studies with follow up extended past 3 months would be notable to determine long term efficacy of perforator ablation.


Click here to see the full abstract

Color US images demonstrate a dilated perforating vein in the region of the right medial calf with spontaneous bidirectional flow.


Citation: Chehab, M. et al. Endovenous Laser Ablation of Perforating Veins: Feasibility, Safety, and Occlusion Rate Using a 1,470-nm Laser and Bare-Tip Fiber. Journal of Vascular and Interventional Radiology 26, 871–877 (2015).


Post author: Brian Gardner, MD, Resident in the VIR Pathway, University of Virginia

Proximal splenic artery embolization appears to be a safe alternative to distal splenic embolization in the setting of chemotherapy induced thrombocytopenia

Chemotherapy induced thrombocytopenia results in suboptimal cancer treatment due to interruption of chemotherapy and reduced dosing, as well as complications secondary to bleeding and transfusion. Distal splenic artery embolization is an alternative to medical therapy for CIT; however, there is a high rate of post-embolization syndrome associated with the procedure. In this retrospective study, 13 patients underwent proximal splenic artery embolization for CIT. Embolization of the splenic artery was performed distal to the origin of the dorsal pancreatic and pancreatica manga arteries with platinum coils oversized by 2-3 mm. The mean post procedure peak platelet count was 209x109 /L, increased from an average of 45x109 /L (p<0.01.) All patients were deemed eligible to resume chemotherapy by their oncologists. The splenic infarction rate at follow up was 29.5%. One patient developed symptoms consistent with post-embolization syndrome, and was treated with tramadol and Medrol dose pack. As an alternative to distal splenic embolization, the authors show that PSAE is safe, and allowed the patients studied to resume chemotherapy on average by 22 days post-procedure. Additionally, the splenic infarction rate appears lower than has been reported for DSE, resulting in a lower rate of post-embolization syndrome.

Comment:

Within the limitations of a small sample size, the current study demonstrates that PSAE is a safe alternative to DSE. The mean platelet count increased significantly after treatment, and all of the patients were deemed eligible to resume chemotherapy by their treating oncologists. Further investigation is warranted to compare PSAE and DSE in terms of efficacy and complication rate.


Click here to see the full abstract

Images from a 69-year-old man with a history of cholangiocarcinoma who developed CIT while he was being treated with gemcitabine and cisplatin. The platelet count decreased to 32 109/L; chemotherapy was discontinued and the patient was referred for PSAE. Pre-PSAE MR imaging (a) and splenic artery angiography (b) show an enlarged spleen consistent with hypersplenism. (c) DSA demonstrates coil embolization of the main splenic artery. (d) MR imaging at 1-year follow-up shows significant reduction in size of the spleen and a large area of infarct replacing approximately 50% of splenic parenchyma.


Citation: Bhatia, S. S. et al. Proximal Splenic Artery Embolization in Chemotherapy-Induced Thrombocytopenia: A Retrospective Analysis of 13 Patients. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.04.003


Post author: Timothy Huber MD, VIR Pathway Resident, University of Virginia

“Eyeballing” It May Not Be As Reliable As We Tell Ourselves

Thousands of peripheral vascular interventional procedures are performed annually to characterize, prevent, and treat consequences of atherosclerosis leading to arterial stenosis. A simple visual estimation (SVE) of the degree of stenosis is often used to determine if treatment is necessary. This study was performed to evaluate the reliability, accuracy and agreement of SVE compared to manual caliper measurements with regard to stenosis severity. This is a retrospective review of images of iliofemoral and carotid arterial lesions, with caliper measurements of stenotic images obtained prior to SVE evaluation. SVE was performed by 23 interventionists of different subspecialties and varying years of experience and compared to the caliper measurement. Correlation among estimates (reliability) was high for both intrareader and interreader image evaluation. Accuracy of visual estimate within 5% of the caliper measurement was 28.3 % overall, however highest for severe stenosis at 52.8%. Agreement as determined by whether SVE and caliper measurement of an image placed it in the same category of stenosis was 64% overall, and highest for severe stenosis at 92.6%. The findings of this study demonstrate SVE is a reliable but inaccurate method for determining degree of stenosis.

Comment:

The study points out the inaccuracy of SVE, which could lead to misclassification of a lesion resulting in inappropriate course of treatment. However, SVE allows for a reliable assessment of significant stenosis (>50%), highlighting its use as a potential screening tool.


Click here to see the full abstract

Note–Entries are counts (n) and percentages (%) of visual estimates within 5% of caliper measurement.


Citation: Rajebi, M. R. et al. Reliability and Accuracy of Simple Visual Estimation in Assessment of Peripheral Arterial Stenosis. Journal of Vascular and Interventional Radiology 26, 890–896 (2015).


Post author: Jamie Doster MD, Radiology Resident, University of Virginia

Covered Stents in Use of Kissing Iliac Lesions

Atherosclerotic occlusive disease involving the aortic bifurcation has historically been treated with surgical bypass; however endovascular treatment with the “kissing” stent technique is now considered a durable alternative treatment option. The aim of this retrospective review was to describe the performance of kissing covered balloon expandable stents (CBES) for aortoiliac occlusive disease at the level of the aortic bifurcation after a follow-up of up to 4 years. During the study time period, 73 kissing CBES procedures were performed, 42 primary procedures and 31 secondary procedures after prior endovascular interventions (excluding 4 patients previously treated with CBES). Primary outcomes were primary patency and freedom from target lesion reintervention (TLR), with loss of primary patency defined as a CBES that occluded, a CBES with restenosis or that required reintervention. Secondary outcomes were secondary patency, clinical improvement, and mortality. 22 TASC A, 21 TASC B, three TASC C and 23 TASC D lesions were treated with the kissing stent technique. Duplex ultrasound follow up examination was available for 51 patients at 1 year, 41 patients at 2 years, and 25 patients at 4 years. Primary patency was 88.1% at 1 year, 78.8% at 2 years and 71.5 % at 4 years, with loss of primary patency primarily occurring due to occlusion in 78% of the cases. Secondary patency rates were 88.1% at 1 year, 82.8% at 2 years and estimated secondary patency was 75.3% at 4 years. Freedom from TLR was 92.4% at 1 year and 76.5% at 4 years. While both primary and secondary patency rates were improved in the primary stent placement group compared to the reintervention group, this was not found to be significant at univariate analysis.

Comment: 

Although retrospective in design and with a limited number of patients available for follow up out to the 4 year time period, the results are comparable to other similar cohort studies and show satisfactory patency rates within 4 years of intervention. Also noteworthy is the improved primary and secondary patency rates demonstrated for primary stent placement compared to secondary stent placement.


Click here to see the full abstract

Kaplan-Meier survival curves showing patency rates and target lesion revascularization.


Citation: Grimme, F. A. B., Spithoven, J. H., Zeebregts, C. J., Scharn, D. M. & Reijnen, M. M. P. J. Endovascular Treatment of Occlusive Lesions in the Aortic Bifurcation with Kissing Polytetrafluoroethylene Covered Stents. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.04.007


Post author: Jamie Doster MD, Radiology Resident, University of Virginia