Chronic venous insufficiency with active or healed ulceration is commonly seen in our academic vein center. In this series, endovenous ablation allowed for excellent healing rates and acceptable recurrent ulcer rates. It is unclear from this small cohort whether the addition of perforator ablation was of benefit in improving venous hemodynamics.
Designed to treat degenerative aneurysms of the thoracic and abdominal aorta, endovascular stent-grafts have been increasingly employed as an off-label emergency treatment for blunt traumatic aortic injury (BTAI). In this review we explore the controversies associated with thoracic endovascular aortic repair (TEVAR) for BTAI. Early versus delayed treatment of aortic injuries is controversial, and stent-graft repair has further confused the issue of timing the repair. The diagnosis and management of minimal aortic injuries remains elusive. We analyze the available literature pertaining to BTAI, including the recent multicenter prospective trial from the American Association for the Surgery of Trauma. The strengths and weaknesses of the stent-grafts currently available for use in the US are examined to provide insight into which graft may be best suited for BTAI at the present time. Also of importance, we offer recommendations regarding clinical situations in which TEVAR should not be the first line therapy for BTAI. We conclude with a discussion of upcoming trials and new devices that will shape the future of endovascular treatment of BTAI.
Intravascular ultrasound (IVUS) has an interesting history that parallels that of many of the advancements that have led to the endovascular era. The use of IVUS in conjunction with standard cross-sectional imaging and three-dimensional reconstructions offers a powerful tool in both the diagnosis and treatment of complex vascular pathology. The use of IVUS has increased over the years and is currently in the process of being incorporated into several modalities that will offer more in the way of real-time information in both the aortic arena and the treatment of increasingly complex peripheral vascular disease. Currently, we use IVUS as a powerful adjunct in combination with other modalities to increase our understanding of vessel architecture and assist in the management of complex vascular pathology.
pattern of venous reflux on duplex ultrasound imaging in patients with primary CVD.Methods: A retrospective analysis was performed of duplex ultrasound reports of patients with CVD in one institution between January 1, 2000, and August 31, 2009. Excluded were patients with secondary CVD and limbs previously treated with open surgery, endovenous ablation, and injection sclerotherapy, as were patients whose scan reports contained inadequate information. Subgroup analysis was performed to compare the pattern of venous reflux in men and women, and three age groups (Ͻ30, 30-60, Ͼ60 years). The 2 test was used. P Ͻ .05 was considered significant.Results: The Fig summarizes the limbs that were included and excluded. After exclusion, 2888 patients (1084 men and 1804 women; mean age, 53.8 years; range, 11.9-101.2 years) were included for analysis. Saphenofemoral junction (SFJ) reflux was demonstrated in 53% of limbs (2137 of 4020; men, 58%; women, 50%; P Ͻ .0001). No significant difference was noticed in the proportion of SFJ incompetence between age groups (P ϭ .9866). Great saphenous vein (GSV) reflux was found in 82% of limbs (3303 of 4020; men, 84%; women, 81%; P ϭ .0044). No significant difference was observed in the proportion of GSV incompetence between age groups (P ϭ .2035). Saphenous-popliteal junction (SPJ) reflux was found in 22% of limbs (871 of 4020; men, 21%; women, 22%; P ϭ .2829). The percentage of SPJ incompetence was not significantly different between age groups (P ϭ .0687). Small saphenous vein (SSV) incompetence was shown in 30% of limbs (1224 of 4020; men, 33%; women, 29%; P ϭ .0117). A significant difference was also noted in the proportion of SSV reflux in between age groups (P ϭ .0167). Of 1883 limbs with a competent SFJ, 1280 (68%) had refluxing GSV, and 51% of limbs (762 of 1479) with competent GSV above the knee showed GSV reflux below the knee. Five percent of limbs with an incompetent SFJ and distal GSV had a competent proximal GSV (81 of 1621). Furthermore, 20% of limbs (630 of 3149) with competent SPJ demonstrated refluxing SSV.Conclusions: Reflux does not invariably originate at junctions of patients with primary CVD. There appears to be multifocal initiation of disease rather than following the ascending or descending theory. Some variations were observed between men and women and in different age groups. This pattern of venous reflux is likely to be due to primary venous wall changes rather than primary valvular dysfunction.
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