Venous Duplex Ultrasound Examination Research Articles

Is catheter-based foam sclerotherapy more effective than direct foam sclerotherapy when combined with high ligation for the treatment of primary great saphenous vein incompetence?

To retrospectively analyze the short-term outcomes of catheter-based versus direct foam sclerotherapy when combined with high ligation (HL) for the treatment of great saphenous vein (GSV) incompetence. From July 2018 to October 2019, a total of 82 lower limbs of 70 patients with GSV incompetence received HL combined with catheter-based foam sclerotherapy (CFS group) or direct foam sclerotherapy (DFS group) for GSV proximal trunk. Among them, 40 limbs of 36 patients were treated with CFS, and 42 limbs of 34 patients were treated with DFS. The occlusion of GSV proximal trunk was evaluated with venous duplex ultrasound examinations; Venous Clinical Severity Scores (VCSS) was used to assess clinical improvement; Aberdeen Varicose Veins Questionnaire (AVVQ) was used to assess quality-of-life scores; and Complications was used for the safety evaluation. At day 7 post-operatively, complete occlusion of proximal trunk of the GSV was achieved in 92.5% legs of the CFS group and 71.4% of the DFS group (p = 0.014). Additionally, anterograde flow was found in 7.5% legs of the CFS group and 26.2% of the DFS group (p = 0.025). No significant differences in the occurrence of complications were observed between the two groups. The median follow-up was 285.5days in the DFS group and 318days in the CFS group (p = 0.140). VCSS and AVVQ reduction were significant in both CFS group and DFS group (5.3 ± 2.5, 5.5 ± 2.4, p < 0.001 for VCSS; 15.9 ± 8.0, 16.3 ± 8.6, p < 0.001 for AVVQ), but no significant difference were observed between two groups (p = 0.655 for VCSS, p = 0.934 for AVVQ). Although the occlusion of great saphenous vein proximal trunk were different, two modalities result in similar clinical and quality-of-life improvements. DFS is a feasible alternative to CFS when combined with HL.

A single-center experience of anterior accessory saphenous vein endothermal ablation demonstrates safety and efficacy

ObjectiveEndothermal ablation is well-established for the treatment of the great and small saphenous veins. Data are lacking for treatment of the anterior accessory saphenous vein (AASV). The purpose of this study was to evaluate the safety and efficacy of AASV treatment using endothermal ablation. MethodsThis retrospective review included 314 limbs at a single academic institution from 2016 to 2018 using the institutional Vascular Quality Initiative database. All limbs had documented AASV reflux. Baseline characteristics were evaluated including age; sex; ethnicity; clinical, etiology, anatomy, pathophysiology classification; Venous Clinical Severity Score (VCSS); and vein diameter. Outcomes relating to procedure safety and efficacy included treatment modality and length, successful ablation on postoperative imaging, postprocedural clinical outcomes, incidence of endothermal heat-induced thrombosis (EHIT), and any postprocedural complication. ResultsA total of 314 consecutive limbs were identified from 2016 to 2018. The preprocedure VCSS scores were available for 312 limbs and averaged 6.13 ± 3.33. A history of varicose veins were reported in all limbs with 49.4% (n = 155) having previously undergone a procedure. The most common presenting symptom was mild edema in 52.5% (n = 165). Vein diameter and assessment of reflux were obtained by venous duplex ultrasound (DUS) examination. The largest AASV diameter was available for 304 limbs, averaging 7.93 ± 2.69 mm. Treatment modalities included radiofrequency ablation (RFA) in 59.2% (n = 186), endovenous laser ablation (EVLA) in 37.9% (n = 119), and isolated microphlebectomy in 2.9% (n = 9). In all, 38.5% (n = 121) of limbs underwent concomitant microphlebectomy at the time of EVLA. The total treatment length was obtained in 297 limbs, averaging 23.0 cm ± 12.0. Postoperatively, 94.6% of limbs (n = 297) were prescribed compression stockings. Postoperative DUS examination was performed in 312 limbs, revealing successful ablation in 96.5% (n = 303) with 2 limbs (0.6%) developing an EHIT, both treated with therapeutic enoxaparin for 1 week. Repeat DUS examination revealed thrombus resolution in one limb; the other patient was lost to follow-up. VCSS scores after the procedure were available for 145 limbs and averaged 4.45 ± 2.31. This was a statistically significant decrease from preprocedure VCSS scores (P < .01). Average duration of follow-up was 2.2 years, with two limbs lost to follow-up. Of the nine limbs (3.5%) whose initial procedure failed, five (56%) were treated using RFA and four (44%) were treated using EVLA. There were no other postoperative complications. ConclusionsOur experience over a 3-year period for treating the AASV shows it to be safe and effective in a broad range of disease severity with an improvement in VCSS and a low incidence of EHIT. Additionally, RFA and EVLA exhibit similar treatment efficacy. Long-term follow-up data are needed.

Prevalence and clinical outcomes of hospitalized patients with upper extremity deep vein thrombosis

ObjectiveUpper extremity (UE) deep vein thrombosis (DVT) is a common and increasing complication in hospitalized patients. The objective of the present study was to determine the prevalence, treatment strategies, complications, and outcomes of UE-DVT. MethodsWe performed a retrospective single-institution study of patients with a diagnosis of UE-DVT from January 2016 through February 2018 (26 months). Patients aged ≥18 years who had been admitted to the hospital and who had had positive UE duplex ultrasound findings for acute UE-DVT were included in the present study. The outcomes were in-hospital mortality, major bleeding, pulmonary embolism (PE), and recurrent UE-DVT. ResultsAmong 63,045 patients admitted to the hospital, 1000 (1.6%) had been diagnosed with UE-DVT. Of 3695 UE venous duplex ultrasound examinations performed during the study period, almost one third (27.0%) were positive for acute UE-DVT. The mean age was 55.0 ± 17.2 years, and most patients were men (58.3%), white (49.2%), and overweight (mean body mass index, 29.4 ± 10.3 kg/m2). The most affected vein was the right internal jugular vein (54.8%). Most of the patients (96.9%) has been receiving venous thromboembolism prophylaxis or anticoagulation therapy at the diagnosis. Most patients (77.8%) had had an intravenous device (IVD) in place at the diagnosis. Most of the patients (84.4%) were treated with anticoagulation therapy in the hospital but only one half (54.5%) were discharged with anticoagulation therapy. In-hospital mortality was 12.1% unrelated to UE-DVT, major bleeding occurred in 47.6% of the patients during hospitalization (fatal bleeding, 1%), PE was diagnosed in 4.8% of the patients, and 0.7% were fatal. Recurrent UE-DVT occurred in 6.1% of the patients. On multivariable analysis, the risk of death was increased by older age, cancer, intensive care unit admission, concomitant lower extremity DVT, and bleeding before the UE-DVT diagnosis. The presence of an IVD increased the risk of PE and the risk of recurrent UE-DVT. The risk of major bleeding was increased by the presence of an IVD, female sex, and concomitant lower extremity DVT. ConclusionsUE-DVT is a common complication in hospitalized patients (1.6%). Consequent acute PE and recurrent DVT remain important complications, as does bleeding. It is unclear whether standard thromboprophylaxis effectively protects against UE-DVT. More studies dedicated to UE-DVT are required to provide appropriate guidance on prophylaxis and treatment.

Improving follow-up of incomplete lower extremity venous duplex ultrasound examinations performed for deep and superficial vein thromboses

ObjectiveA lower extremity venous duplex ultrasound (LEVDUS) examination is the standard diagnostic test to evaluate patients for lower extremity deep vein thrombosis (DVT). However, some studies will be incomplete for a variety of reasons, including patient-related factors such as pain, edema, a large leg circumference, or the presence of overlying bandages or orthopedic devices. We previously reported that the frequency of obtaining a follow-up examination after an incomplete and negative (I/N) LEVDUS examination was low but that the rates of DVT found on the follow-up studies of initially I/N LEVDUS studies were similar to the rates of DVT found with initially complete LEVDUS examinations. Therefore, we recommended process improvements to increase follow-up LEVDUS studies after an I/N LEVDUS examination. In the present study, we have described the results of appending a recommendation to obtain a follow-up LEVDUS study to preliminary and final reports of I/N LEVDUS. MethodsStarting in January 2019 through December 2019, a recommendation to obtain a repeat LEVDUS examination after an I/N study was appended to the preliminary and final reports of all I/N LEVDUS examination of patients who did not, otherwise, have an indication for anticoagulation (group 2). The patients were identified on an ongoing basis through the study period and entered into an Excel database (Microsoft Corp, Redmond, Wash). Group 2 was compared with a previously reported historic control cohort of patients identified from January 2017 to December 2017 (group 1). We compared groups 1 and 2 with respect to the frequency of the repeat studies performed within 4 weeks after an I/N LEVDUS examination and the DVT rates found from the follow-up LEVDUS examinations after an I/N LEVDUS study. ResultsOf the patients in groups 1 and 2, 187 and 229 had had I/N LEVDUS examinations, with 28% and 40.2% of group 1 and 2 studies having follow-up LEVDUS examinations (P < .01). Previously unidentified lower extremity thrombi were discovered in 21% of the group 2 follow-up examinations. Also, the rate of new thrombi detected was not different between groups 2 and 1 (historic controls; DVT, 14.3% vs 18.5% [P = .25]; SVT, 6.3% vs 3.3% [P = .15]). A definitive finding of either positive or negative for DVT and SVT with a complete examination in 50% of the group 2 patients with follow-up examinations. ConclusionsA recommendation to obtain a follow-up examination appended to the preliminary and final I/N LEVDUS reports was associated with an increased rate of follow-up examinations, which revealed many previously undetected DVTs and SVTs or had allowed for definitive exclusion of DVT.

High Incidence of Patients Lost to Follow-up After Venous Thromboembolism Diagnosis—Identifying an Unmet Need for Targeted Transition of Care

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), affects approximately 5% of the population, and approximately 30% of affected individuals will die within 30 days of diagnosis. Given the prevalence of VTE and its associated mortality, our study evaluated the success of longitudinal treatment in patients diagnosed with VTE with particular attention to those lost to appropriate follow-up. This is a single-center retrospective study of all consecutive admitted (inpatient [IP]) and emergency department (ED) patients diagnosed with acute VTE by venous duplex ultrasound examination or chest computed tomography from January 2018 to March 2019. Patients with chronic DVT and those diagnosed in the outpatient setting were excluded. Data collected included age, sex, clinical setting at time of diagnosis, discharge anticoagulation choice, discharge disposition, and clinical follow-up. Lost to VTE follow-up (LTFU) was defined as those patients who did not follow up with vascular, cardiovascular, hematology/oncology, pulmonology, or primary care clinic for VTE management at our institution within 3 months after discharge. Patients discharged to hospice were excluded from LTFU analysis. Statistical analysis was performed using Stata 16 software (StataCorp LLC, College Station, Tex) and a threshold P value of < .05 set for significance. During the study period, 291 DVTs (237 lower extremity DVTs, 58 upper extremity DVTs, 4 mixed), 25 isolated PEs, and 55 PEs with associated DVT (53 lower extremity DVTs, 2 upper extremity DVTs) were identified in 371 patients. Of these patients, 130 (35%) were diagnosed in the ED and 241 (65%) in the IP setting. At discharge, 291 (78.4%) were receiving anticoagulation, 64 (17.3%) were not, and 16 (4.3%) were deceased. Ultimately, 133 patients (35.9%) were LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU with respect to age (P = .373), sex (P = .194), diagnosis time of day (P = .272), VTE type (P = .367), or discharge unit location (IP vs ED, 33.7% vs 43.8% LTFU; P = .114); however, there was a statistically significant association between longer IP length of stay and those patients LTFU in controlling for age (11.8 days vs 16.6 days; P = .028). This study demonstrates that more than one-third of patients diagnosed with VTE at our institution are LTFU, suggesting that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a VTE-specific follow-up clinic.

Utility of d-dimer for diagnosis of deep vein thrombosis in coronavirus disease-19 infection

ObjectiveThe objective of this study was to investigate the clinical usefulness of d-dimer in excluding a diagnosis of deep vein thrombosis (DVT) in patients with coronavirus disease (COVID-19) infection, potentially limiting the need for venous duplex ultrasound examination. MethodsWe retrospectively reviewed consecutive patients admitted to our institution with confirmed COVID-19 status by polymerase chain reaction between March 1, 2020, and May 13, 2020, and selected those who underwent both d-dimer and venous duplex ultrasound examination. This cohort was divided into two groups, those with and without DVT based on duplex ultrasound examination. These groups were then compared to determine the value of d-dimer in establishing this diagnosis. ResultsA total of 1170 patients were admitted with COVID-19, of which 158 were selected for this study. Of the 158, there were 52 patients with DVT and 106 without DVT. There were no differences in sex, age, race, or ethnicity between groups. Diabetes and routine hemodialysis were less commonly seen in the group with DVT. More than 90% of patients in both groups received prophylactic anticoagulation, but the use of low-molecular-weight heparin or subcutaneous heparin prophylaxis was not predictive of DVT. All patients had elevated acute-phase d-dimer levels using conventional criteria, and 154 of the 158 (97.5%) had elevated levels with age-adjusted criteria (mean d-dimer 16,163 ± 5395 ng/mL). Those with DVT had higher acute-phase d-dimer levels than those without DVT (median, 13,602 [interquartile range, 6616-36,543 ng/mL] vs 2880 [interquartile range, 1030-9126 ng/mL], P < .001). An optimal d-dimer cutoff of 6494 ng/mL was determined to differentiate those with and without DVT (sensitivity 80.8%, specificity 68.9%, negative predictive value 88.0%). Wells DVT criteria was not found to be a significant predictor of DVT. Elevated d-dimer as defined by our optimal metric was a statistically significant predictor of DVT in both univariate and multivariable analyses when adjusting for other factors (odds ratio, 6.12; 95% confidence interval, 2.79-13.39; P < .001). Conclusionsd-dimer levels are uniformly elevated in patients with COVID-19. Although standard predictive criteria failed to predict DVT, our analysis showed a d-dimer of less than 6494 ng/mL may exclude DVT, potentially limiting the need for venous duplex ultrasound examination.

Common iliac vein obstruction in a symptomatic population is associated with previous deep venous thrombosis, and with chronic pelvic pain in females

ObjectiveThe objectives of this study were to determine the incidence of common iliac vein obstruction, gonadal vein incompetence, and renal vein compression/stenosis and to ascertain which referral reasons were associated with common iliac vein obstruction and gonadal vein incompetence in a population symptomatic for chronic venous insufficiency. MethodsData were obtained from patients, at least 18 years old, who were referred to a private vascular laboratory for venous duplex ultrasound examination between 2016 and 2017. Transabdominal ultrasound was used to assess the iliac, gonadal, and renal veins in a dedicated protocol. Demographic data, referral reasons (varicose veins, lower limb pain, lower limb edema, lower limb ulcers, chronic pelvic pain [CPP]) and history of previous deep venous thrombosis (DVT) were recorded. ResultsAmong 421 patients (78.6% female; 57.7 ± 16.7 years), 46.7% had iliac vein obstruction, 40.1% had gonadal vein incompetence, and 29.9% had renal vein compression/stenosis. Venous disorders were significantly more prevalent among female patients and on the left side. The most common referral reasons were varicose veins for both sexes, followed by lower limb pain for females and lower limb edema for males, none of which were associated with any venous obstruction or incompetence. Previous DVT was significantly associated with common iliac vein obstruction for all patients (β = .189; P = .001), despite its being a previous known diagnosis for only 11.4% of patients. Among females, CPP was also significantly associated with common iliac vein obstruction and gonadal vein incompetence (β = .246 [P < .001] and β = .201 [P = .012], respectively). Among those with CPP in this study, common iliac vein obstruction, with and without gonadal vein incompetence (33% and 35%, respectively), was more prevalent than gonadal vein incompetence alone (14%). ConclusionsHistory of DVT, as well as CPP among females warrants investigations of common iliac vein obstruction. Common iliac vein obstruction is likely to be a more significant contributor to CPP than gonadal vein incompetence.

Spine stabilization is a risk factor for the development of pelvic iliac vein lesions

BackgroundOpen lumbar spine stabilization surgery often requires mobilization of the left and right common iliac veins (CIVs) and the placement of plates and screws that can impinge on them. We reviewed our venography experience of the past 3 years to determine whether there is an association between spine stabilization surgery and the development of symptomatic iliac vein outflow lesions. MethodsA retrospective chart review of prospectively collected data from our electronic medical record system was performed to identify patients who underwent venography with or without venous stenting and had a history of previous lumbar spine stabilization. Patients' demographics, medical comorbidities, venograms, and intravascular ultrasound (IVUS) data were collected and analyzed. The senior author reviewed all venograms and IVUS images of patients with previous spine stabilization procedures. ResultsFrom January 2014 to April 2018, venography was performed in 1713 limbs in 1245 patients at the Center for Vascular Medicine. Of the 1245 patients, 18 patients had a history of lumbar spine stabilization procedures: five anterior-posterior and 13 posterior. Nine had single-level and eight had two- or three-level fusions. All 18 patients demonstrated pelvic lesions. These included 1 left CIV aneurysm, 5 left CIV stenoses, 3 bilateral CIV stenoses, 2 left CIV and inferior vena cava occlusions, and 2 external iliac vein stenoses. The aneurysm patient was treated with anticoagulation, 8 patients underwent stenting, 1 patient refused stenting because of relocation to another country, 1 inferior vena cava-CIV occlusion could not be crossed, fear of dislodging a thrombus and the proximity to a protruding posteriorly placed screw prevented stenting in 2 patients, and 4 patients had a venoplasty alone because of undersizing of a stenosis or missed lesions with IVUS after review by a blinded reviewer. Lesions in anterior lumbar interbody fusion patients were extremely stenotic, required predilation, and resulted in a residual stenosis requiring venoplasty at a second setting in one patient. ConclusionsLumbar spine stabilization surgery may be a risk factor for development of symptomatic venous outflow obstruction lesions. During venography and stenting in patients with anterior lumbar interbody fusion approaches, significant scarring may be encountered, resulting in a residual stenosis after stent placement. Predilation venoplasty, before stent deployment, is recommended to prevent stent migration. Furthermore, a history of spine stabilization surgery in patients presenting with pelvic symptoms, lower extremity pain or swelling, or post-thrombotic symptoms should prompt consideration of a pelvic venous duplex ultrasound examination to determine whether an iliac venous outflow lesion is present.

Multicenter Trial of Vena Cava Filters in Severely Injured Patients

A multicenter, randomized, controlled trial was performed between June 2015 and December 2017. There were 240 severely injured patients who had a contraindication to anticoagulation and were randomized to receive a retrievable filter (122) within the first 72 hours of the traumatic event (89% of patients underwent filter insertion with 24 hours) or not to have a filter placed (118). Prophylactic anticoagulation was started as soon as clinically feasible. All patients underwent lower extremity venous duplex ultrasound examination at 2 weeks. There was no significant difference in symptomatic pulmonary embolism (PE) or death for patients with (13.9%) or without (14.4%) filter placement. In the prespecified subgroup of patients who survived 7 days and did not receive prophylactic anticoagulation within 7 days after injury (33% of patients: 46 with filters, 34 controls), symptomatic PE developed in 0% of the filter patients vs 15% of the nonfilter group. Early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic PE or death at 90 days compared with no placement of a filter. Given the cost and risks associated with a vena cava filter, the results suggest that there is no urgency to insert a filter in patients who can be treated with prophylactic anticoagulation within 7 days after injury.

Repeated venous duplex ultrasound examination when the initial study is incomplete

What do you do when you order a venous duplex ultrasound study to determine whether your patient has a deep venous thrombosis and the examination is incomplete? Do you assume that because most of the examination findings were negative that the study probably was overall negative? Alternatively, do you insist that the study be repeated? If the latter, when do you order the new study, immediately or some days later? Is there anything else that you can request to achieve a final valid diagnosis? Prospective study comparing the rate of deep venous thrombosis of complete and incomplete lower extremity venous duplex ultrasound examinationsJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 7Issue 6PreviewA lower extremity venous duplex ultrasound (LEVDUS) examination positive for deep venous thrombosis (DVT) is an indication for anticoagulation. Incomplete examinations that fail to examine all lower extremity veins in patients not otherwise indicated for anticoagulation may be followed by repeated examination to exclude missed or progressing DVT. This study examined the frequency of incomplete LEVDUS studies, reasons for incomplete studies, veins incompletely examined, and follow-up LEVDUS after incomplete LEVDUS. Full-Text PDF

Prospective study comparing the rate of deep venous thrombosis of complete and incomplete lower extremity venous duplex ultrasound examinations

BackgroundA lower extremity venous duplex ultrasound (LEVDUS) examination positive for deep venous thrombosis (DVT) is an indication for anticoagulation. Incomplete examinations that fail to examine all lower extremity veins in patients not otherwise indicated for anticoagulation may be followed by repeated examination to exclude missed or progressing DVT. This study examined the frequency of incomplete LEVDUS studies, reasons for incomplete studies, veins incompletely examined, and follow-up LEVDUS after incomplete LEVDUS. The incidence of a positive finding of DVT was compared between initial complete LEVDUS and follow-up LEVDUS after an initial incomplete examination to determine whether improving rates of follow-up LEVDUS after an incomplete examination is a reasonable target for quality improvement. MethodsAt a single academic medical center from January 2017 to December 2017, incomplete LEVDUS studies were prospectively identified in patients who did not otherwise have an identified indication for anticoagulation. Rate of DVT in complete LEVDUS was also determined during the same time frame. Incomplete LEVDUS reports were reviewed for clinical setting, patient demographics, examination indication, ordering providers, reasons for incomplete examinations, anatomic locations of veins not visualized, rates of follow-up LEVDUS examinations within 30 days of the initially incomplete study, and rates of DVT identified in follow-up examinations of initially incomplete examinations. ResultsOf the 2843 LEVDUS examinations performed in 2017, 341 studies identified DVT and 197 incomplete examinations did not identify DVT. Veins not visualized on incomplete studies included tibial veins (n = 170 [86.3%]), femoral veins (n = 73 [37.1%]), and popliteal veins (n = 76 [38.6%]), with the most common reasons for incomplete studies being bandages or fixation devices (46.2%), intolerance of the patient for the study (14.7%), and body habitus or edema (17.4%). Only a minority of incomplete studies not identifying DVT (27.9%) had a follow-up examination performed. The majority of the repeated examinations were performed after incomplete LEVDUS examinations that were originally performed for high-risk screening (80%) as opposed to clinical suspicion for DVT (20%). There was no significant difference in demographic features of patients with initially incomplete studies who did or did not have a follow-up examination and no significant difference in the rates of DVT (13.1%) in complete LEVDUS examinations compared with the rate of DVT found in follow-up examinations of initially incomplete LEVDUS examinations (9.1%; P = .33). ConclusionsThe majority of patients with incomplete LEVDUS, even those with symptoms or signs suggestive of DVT, do not have a follow-up examination within 30 days of the incomplete study. The rate of DVT detected in initially complete studies was similar to that in patients with follow-up examinations whose initial study was incomplete and did not identify DVT. This suggests that to avoid missing DVT in patients with incomplete LEVDUS studies, quality assurance programs should be initiated to ensure that follow-up LEVDUS studies are performed after an incomplete LEVDUS examination.

Single-center retrospective review of early outcomes of radiofrequency ablation versus cyanoacrylate ablation of isolated great saphenous vein insufficiency

ObjectiveData comparing radiofrequency ablation (RFA) with cyanoacrylate closure (CAC) treatment of isolated great saphenous vein (GSV) insufficiency are limited. In this study, we present our early outcomes of RFA vs CAC for the treatment of GSV insufficiency. MethodsBetween March 2015 and February 2017, a total of 159 patients underwent CAC (n = 75) or RFA (n = 84) for treatment of GSV insufficiency by a single surgeon. Medical data of the patients were retrieved from the institutional database and retrospectively analyzed. All patients underwent lower extremity venous color duplex ultrasound examination. The Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire were used. Total closure rates of the GSV with RFA or CAC were recorded at 1 month, 6 months, and 12 months. Procedure-related adverse events and quality of life of the patients were also evaluated. ResultsThe mean age was 46.33 ± 14.40 years in the CAC group and 48.09 ± 13.25 years in the RFA group (P = .4). The mean treated saphenous vein diameter was 7 mm in the CAC group and 7.25 mm in the RFA group (P = .07). The length of treated venous segment was 30 cm in both the CAC and RFA groups (P = .66). The mean duration of operation was 25 minutes in the CAC group and 35 minutes in the RFA group (P < .001). The incidence of adverse events was higher in the RFA group (P < .05). At 1 month, 6 months, and 12 months of follow-up, there was no statistically significant difference in the total closure rates between the CAC and RFA groups. There was no significant difference in the Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire score between the groups (P > .05). ConclusionsOur study results suggest that both RFA and CAC are effective in closure of the target GSV. Although the incidence of tumescent anesthesia-related and procedure-related complications is higher with the RFA technique, both techniques can be used safely with similar success rate and patient satisfaction.

Four-extremity venous duplex ultrasound for suspected deep venous thrombosis is an anachronism

BackgroundDuplex ultrasound is the “gold standard” for diagnosis of acute deep venous thrombosis (DVT) because of its high specificity, sensitivity, safety, and portability. However, unnecessary testing epitomizes inefficient use of scarce health care resources. Here we hypothesize that the majority of simultaneous four-extremity duplex ultrasound (FED) examinations are unnecessary. By analyzing clinical factors of patients with acute DVT found on FED, we aimed to identify a subset of high-risk patients who may have a valid indication for four-extremity testing. MethodsWe retrospectively reviewed all venous duplex ultrasound examinations performed in our Intersocietal Accreditation Commission-accredited vascular laboratory from January 1, 2009, to December 31, 2016. Patients with duplex ultrasound scans of all four limbs were included. DVT risk factors and indication for duplex ultrasound examination were recorded. The primary outcome was finding of acute DVT. ResultsThere were 188 patients who met our search criteria, of whom 31 patients (16.5%) had acute DVT (11 upper extremity, 16 lower extremity, and 4 upper and lower extremity). Fever of unknown origin (FUO) was the main indication for requesting FED (53.7%). Patients who underwent FED for FUO had a significantly lower likelihood of DVT (odds ratio, 0.21; P = .01). DVT was rarely the proximate cause (<1% of all cases) as follow-up culture results and clinical course most often revealed other sources of fever. Only patients with an upper extremity central venous catheter (CVC; n = 103) with at least two associated risk factors had an upper extremity DVT, which was usually line associated (93%). Only patients with at least two associated risk factors had a lower extremity DVT. ConclusionsFED for FUO is inefficient, given that DVT was rarely the proximate cause of fever. Acute upper extremity DVT was found only in patients with an upper extremity CVC, demonstrating that patients without upper extremity CVC do not benefit from upper extremity duplex ultrasound examination. Upper extremity DVT is usually line associated and dependent on the number of cumulative risk factors present, suggesting that only the extremity associated with the CVC in the right clinical context should be imaged. Lower extremity DVT is also dependent on the number of cumulative risk factors present, and testing should be reserved for patients according to the clinical context. Our results indicate that a restrictive strategy can reduce testing inefficiency and health care cost without compromising patients' safety.

Overuse of Lower Extremity Venous Duplex by the Emergency Department for Detection of DVT: Pilot Study to Evaluate Use of D-Dimers as a Screening Tool in Low-Risk Patients

As the cost of health care remains a major concern for patients, providers, and payers, it has become increasingly important to evaluate resource utilization behaviors. The purpose of this study was to evaluate the utilization patterns of the emergency department in the ordering of lower extremity venous duplex ultrasound examinations for detection of acute deep venous thrombosis (DVT) and the use of D-dimer as a screening test in low-risk (by Wells criteria) patients. Estimated cost at our institution is $15 for the D-dimer test and $300 for the venous duplex ultrasound scan. All venous duplex ultrasound examinations that were ordered by the emergency department during the course of 10 days were evaluated. After-hours duplex ultrasound examinations were those ordered between the hours of 9 pm and 7 am on weekdays and between the hours of 4 pm and 7 am on weekends. Studies were evaluated for the patient’s presenting complaint, indication for duplex ultrasound as documented in the provider’s notes, results of the duplex ultrasound examination (positive vs negative for DVT), D-dimer studies, and Wells criteria scores. During this 10-day period, 68 lower extremity venous duplex ultrasound examinations were performed for emergency department patients, 28% of which were performed after hours (n = 19). Only 13% (n = 9) of these patients received concomitant D-dimer serum tests, of which 56% (5/9) of results were positive; 26 studies were bilateral, and only 5 studies were positive for acute DVT in one (n = 4) or both (n = 1) legs. Of 42 unilateral studies, only 9% (n = 4) were positive for acute DVT. Among patients with Wells criteria score <2, only 5 of 63 (8%) had a D-dimer sample sent. Among these, one had a positive duplex ultrasound scan. Five (8%) other positive duplex ultrasound scans occurring in the low-risk population did not have concomitant D-dimer samples sent. No patients with negative D-dimer results had acute DVT on duplex ultrasound examination. Based on the preliminary results of our pilot study, it appears there is significant overutilization of venous duplex ultrasound imaging by the emergency department for DVT screening with underutilization of D-dimer in low-risk patients. Use of D-dimer tests instead of duplex ultrasound scan in low-risk (Well criteria score <2) patients would have potentially saved $16,359 during a 10-day period, which would be approximately $597,104 per annum. Larger studies are recommended to examine the overuse of duplex ultrasound in the emergency department setting.

Spine Stabilization Is a Risk Factor for the Development of Pelvic Iliac Vein Lesions

Open lumbar spine stabilization surgery often requires mobilization of the left and right common iliac veins (CIVs) and the placement of plates and screws that can impinge on iliac veins. We reviewed our venography experience during the past 3 years to determine whether there is an association between spine stabilization surgery and the development of iliac vein lesions and symptomatic iliac vein outflow obstruction. A retrospective chart review was performed to identify patients who underwent venography with or without venous stenting and who had a history of previous lumbar spine stabilization. From January 2014 to April 2018, venography were performed in 1713 limbs in 1245 patients at the Center for Vascular Medicine. Of the 1245 patients, 17 patients had a history of lumbar spine stabilization procedures (4 anterior-posterior and 13 posterior). Nine had single-level and eight had two- or three-level fusions. All 17 patients demonstrated pelvic lesions, which included the following: one left CIV aneurysm, five left CIV stenoses, three bilateral CIV stenoses, two left CIV and inferior vena cava occlusions, and two external iliac vein stenoses. The aneurysm patient was treated with anticoagulation. Eight patients underwent stenting, and one patient refused stenting because of relocation to another country. One inferior vena cava-CIV occlusion could not be crossed. Fear of dislodging a thrombus and the proximity to a protruding posteriorly placed screw prevented stenting in two patients. Four patients had a venoplasty alone because of undersizing of a stenosis or missed lesions with intravascular ultrasound after review by a blinded reviewer. Lesions in anterior-posterior patients were extremely stenotic, required predilation, and resulted in a residual stenosis requiring venoplasty at a second setting in one patient. Lumbar spine stabilization surgery may be a risk factor for development of symptomatic venous outflow obstruction lesions. During venography and stenting in patients with anterior-posterior approaches, significant scarring may be encountered, resulting in a residual stenosis after stent placement. Predilation venoplasty, before stent deployment, is recommended to prevent stent migration. Furthermore, a history of spine stabilization surgery in patients presenting with pelvic or lower extremity pain or swelling should prompt consideration of a pelvic venous duplex ultrasound examination to assess for the presence of an iliac venous outflow lesion.

PC164. Evaluation of Incomplete Lower Extremity Duplex Venous Ultrasound Examinations

Deep venous thrombosis (DVT) positive lower extremity venous duplex ultrasound (LEVDUS) examination is an indication for anticoagulation. Incomplete examinations that fail to examine all LE veins in patients not otherwise indicated for anticoagulation may be followed by a repeat examination to exclude missed/progressing DVT. This study examined the frequency of follow-up LEVDUS following incomplete LEVDUS and compared the incidence of positive DVT between initial complete LEVDUS and follow-up LEVDUS after an initial incomplete examination to determine if improving rates of follow-up LEVDUS following an incomplete examination is a reasonable target for quality improvement. From December 2016 to December 2017, incomplete LEVDUS were prospectively identified in patients who did not have an identified indication for anticoagulation. We determined the frequency/demographics of repeat studies performed within 2 weeks after incomplete LEVDUS and DVT rates of initial and repeat LEVDUS. There were 4,828 LEVDUS studies (ankle to groin) performed; 223 (4.8%) were incomplete and did not otherwise identify DVT in the ipsilateral or contralateral leg. Of incomplete studies, 80.3% were ordered in-hospital, 12.1% from outpatient clinics, 7.6% from the ED, with 9.9% ordered by primary care providers, 33.6% by specialists, 29.1% by trauma surgeons and 27.4% by emergency department providers. Initial indications for incomplete studies were high-risk screening in 52.5%, and LE signs/symptoms in 47.5%. In addition, 63.2% of incomplete studies resulted from bandages, wounds, braces, casts or fixation devices, 13.5% from edema, 5.8 % from body habitus and 12.1% from patient study intolerance. Deep veins inadequately evaluated on initial LEVDUS included femoral (36.8%), popliteal (40%) and axial calf veins (85.7%). Sixty-one patients (27.3%) with incomplete LEVDUS had repeat examinations. 11.5% had thrombi detected with six in deep and two in superficial veins. Only 18 of 105 symptomatic patients with an incomplete study had a repeat study with 71% of follow-up studies for screening patients (P < .001). DVT diagnosis rates were similar between initial complete LEVDUSs (8.7%) and repeat LEVDUSs performed after an initial incomplete examination (8.2%; P = .65). Almost one-half of incomplete LEVDUSs are ordered in symptomatic patients. However, the large majority of patients with incomplete LEVDUS, even those with symptoms, do not have a follow-up examination but patients with repeat studies have a DVT diagnosis rate equivalent to patients with an initial complete examination, suggesting the need for quality assurance programs to ensure repeat studies are performed after incomplete LEVDUS, particularly in symptomatic patients.

Day of Week, Site of Service, and Patient Complexity Differences in Venous Ultrasound Interpreted by Radiologists Versus Nonradiologists

ObjectiveNationally, nonradiologists interpret an increasing proportion of lower extremity venous duplex ultrasound (LEVDU) examinations. We aimed to study day of week, site of service, and patient complexity differences in LEVDU services interpreted by radiologists versus nonradiologists. Materials and MethodsUsing carrier claims files for a 5% national sample of Medicare beneficiaries from 2012 to 2015, we retrospectively classified all LEVDU examinations by physician specialty (radiologist versus nonradiologist), day of week (weekday versus weekend), site of service, and patient Charlson Comorbidity Index (CCI) scores. Pearson’s χ2 was used to test statistical significance. ResultsOf 760,433 LEVDU examinations for which provider specialty could be determined, 439,964 (58%) were interpreted by radiologists and 320,469 (42%) by nonradiologists. On weekends, radiologists interpreted 75% (66,094 of 88,244) and nonradiologists 25% (22,150 of 88,244) (P < .0001). Of LEVDU examinations interpreted by radiologists, 57% were performed in the inpatient or emergency department settings, and 70% of LEVDU examinations interpreted by nonradiologists were performed in the private office or outpatient hospital setting. Radiologists interpreted a slightly larger proportion (17%) of their examinations on patients with more comorbidities (CCI of ≥3) than nonradiologists (15%) (P < .0001). ConclusionCompared with nonradiologists, radiologists interpret a disproportionately larger share of weekend (versus weekday) LEVDU examinations and a considerably larger proportion in higher acuity settings. Additionally, the patients on whom they render services have more comorbidities. To optimize around-the-clock patient access to necessary imaging, emerging quality payment programs should consider the timing and sites of service, as well as patient complexity.

Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency.

Reflux in the ovarian veins, with or without an obstructive venous outflow component, is reported to be the primary cause of pelvic venous insufficiency (PVI). The degree to which venous outflow obstruction plays a role in PVI is currently ill-defined. We retrospectively reviewed the charts of 227 women with PVI who presented to the Center for Vascular Medicine from January 2012 to September 2015. Assessments and interventions consisted of an evaluation for other causes of chronic pelvic pain by a gynecologist; preintervention and postintervention visual analog scale (VAS) pain score; complete venous duplex ultrasound examination; and Clinical, Etiology, Anatomy, and Pathophysiology classification. All patients underwent diagnostic venography of their pelvic and left ovarian veins as well as intravascular ultrasound of their iliac veins. Patients were treated in one of six ways: ovarian vein embolization (OVE) alone (chemical± coils), OVE with staged iliac vein stenting, OVE with simultaneous iliac vein stenting, iliac vein stenting alone, OVE with venoplasty, and venoplasty alone. Of the 227 women treated, the average age and number of pregnancies was 46.4± 10.4years and 3.36± 1.99, respectively. Treatment distribution was the following: OVE, n= 39; OVE with staged stenting, n= 94; OVE with simultaneous stenting, n= 33; stenting alone, n= 50; OVE with venoplasty, n= 8; and venoplasty alone, n= 3. Seven patients in the OVE and stenting groups (staged) and one patient in the OVE+ venoplasty group required a second embolization of the left ovarian vein. Eighty percent (181/227) of patients demonstrated an iliac stenosis >50% by intravascular ultrasound. Average VAS scores for the entire cohort before and after intervention were 8.45± 1.11 and 1.86± 1.61 (P ≤ .001). In the staged group, only 9 of 94 patients reported a decrease in the VAS score with OVE alone. VAS score decreased from 8.6±0.89 before OVE to 7.97± 2.10 after OVE. After the planned staged stenting, VAS score decreased to 1.33± 2.33 (P≤.001). Similarly, in the simultaneous group, preintervention scores were 8.63± 1.07 and decreased to 2.36± 2.67 after OVE+ stenting (P ≤ .001). The majority of patients in our series (80%) demonstrated a significant iliac vein stenosis. These observations indicate that the incidence of iliac vein outflow obstruction in PVI is greater than previously reported. In patients with combined ovarian vein reflux and iliac vein outflow obstruction, our data suggest that pelvic venous outflow lesions should be treated first and that ovarian vein reflux should be treated only if symptoms persist. In women with an outflow lesion, ovarian vein reflux, and a large pelvic reservoir, we recommend simultaneous treatment.

Radiofrequency ablation with concomitant stab phlebectomy increases risk of endovenous heat-induced thrombosis.

Endovenous heat-induced thrombosis (EHIT) is a well-documented phenomenon that follows endovenous ablation, but the treatment, surveillance, and risk factors for EHIT have yet to be comprehensively elucidated. We sought to identify characteristics that may put patients at higher risk for development of EHIT after radiofrequency ablation (RFA) for the treatment of symptomatic superficial venous insufficiency. A retrospective review was performed of all consecutive patients undergoing treatment with RFA to the great saphenous vein by a single surgeon from July 2013 through October 2015. On postprocedural day 2, a surveillance venous duplex ultrasound examination was obtained and the presence of EHIT was recorded. Demographics of the patients, venous thromboembolism (VTE) risk factors, and procedural details were compared between patients with EHIT and those with no EHIT using multivariable logistic regression for risk adjustment. As a sensitivity analysis, propensity score matching on the basis of 18 demographic and perioperative variables was then used to confirm significant findings. There were 299 patients who underwent RFA for symptomatic chronic venous insufficiency (median age, 55years; 65% female; 46% right lower extremity). Concomitant stab phlebectomy was performed in 71%. EHIT occurred in 12% (n= 35) of patients (class 1, 5%; class 2, 4%; class 3, 1%; class 4, 2%). The incidence of EHIT was significantly higher after RFA with concomitant stab phlebectomy vs RFA alone (14% vs 6%; P= .04). There were also nonsignificant trends toward a higher incidence of EHIT in patients with a history of VTE (20% vs 10%; P= .06), worsening venous disease (Clinical, Etiology, Anatomy, Pathophysiology [CEAP] class >2, 37% vs 26%; P= .13), and history of tobacco use (43% vs 31%; P= .18). On multivariable analysis, RFA with concomitant stab phlebectomy (odds ratio, 3.46; 95% confidence interval, 1.36-10.8) and history of VTE (odds ratio, 3.48; 95% confidence interval, 1.22-9.25) were independently associated with EHIT (P ≤ .02). After propensity matching of 60 pairs of similar patients, RFA with concomitant stab phlebectomy had a persistently higher incidence of EHIT compared with RFA alone (23% vs 7%; relative risk, 3.48; P= .01). Concomitant stab phlebectomy and the patient's history of VTE are independent risk factors for EHIT after endovenous ablation with RFA. History of tobacco use and advanced stages of venous disease may also play a role. For patients with these high-risk features, care should be taken to prevent, identify, and treat EHIT early.

Iliac Vein Stenosis: An Underdiagnosed Cause of Pelvic Venous Insufficiency

Pelvic venous insufficiency (PVI) is a common cause of chronic pelvic pain in women. Reflux in the ovarian veins, with or without an obstructive venous outflow component, is reported to be the primary cause of PVI. The degree to which venous outflow obstruction plays a role in PVI is currently ill-defined. We retrospectively reviewed the charts of 220 women who underwent 227 procedures for PVI at the Center for Vascular Medicine from January 2012 to September 2015. Assessments and treatments consisted of an evaluation for other causes of chronic pelvic pain by a gynecologist; visual analog scale (VAS) for pain score before and after intervention; complete venous duplex ultrasound examination; and clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification. All patients underwent diagnostic venography of their pelvic and left ovarian veins as well as intravascular ultrasound (IVUS) examination of their iliac veins. Patients were treated in one of six ways: ovarian vein embolization (OVE) alone (chemical ± coils), OVE with staged iliac vein stenting, OVE with simultaneous iliac vein stenting, iliac vein stenting alone, OVE with venoplasty, and venoplasty alone. In patients with ovarian vein reflux and iliac vein stenosis, it was our policy to treat the ovarian veins first and to stage the iliac vein stenting. In patients with travel restrictions, OVE and stenting were performed simultaneously. In addition to VAS scores before and after intervention, symptoms were also assessed in terms of complete, partial, or no symptom resolution. Of the 220 women treated, the average age and number of pregnancies were 44.8 ± 10.4 years and 3.08 ± 2.21, respectively. CEAP class for 181 patients was documented as follows: C0, 16; C1, 62; C2, 45; C3, 42; C4, 13; C5, 2; and C6, 1. Treatment distribution was the following: OVE, n = 39; OVE with staged stenting, n = 88; OVE with simultaneous stenting, n = 32; stenting alone, n = 50; OVE with venoplasty, n = 8; and venoplasty alone, n = 3. Seven patients in the OVE and stenting groups (staged) and one patient in the OVE with venoplasty group required a second embolization of the left ovarian vein. Eighty-two percent of patients (181/220) demonstrated an iliac stenosis >50% by IVUS. Average stent diameter was between 20 and 22 mm. Of the six therapies employed, complete, partial, and no symptom resolution was observed as follows: stenting alone, 70%, 20%, 10%; OVE with stenting, 58%, 36%, 5%; OVE alone, 35%, 54%, 5%; OVE with venoplasty, 50%, 50%, 0%; and venoplasty alone, 33%, 63%, 0%. Dyspareunia and fullness responded best to OVE with stenting and worst to OVE alone. Average VAS scores before and after intervention for the entire cohort were 8.45 ± 1.11 and 1.86 ± 1.61 (P ≤ .001). Scores before and after intervention between groups did not differ except for venoplasty alone (P ≤ .01). To assess the role of stenting for alleviation of pain in patients with ovarian vein reflux and iliac vein occlusive disease, we analyzed the OVE staged and simultaneous groups separately. In the staged group, only 9 of 88 patients reported a decrease in the VAS score with OVE alone. The remaining 79 reported no improvement. After stenting, a significant decrease in VAS score was reported. The VAS score decreased from 8.6 ± 0.89 before OVE to 7.97 ± 2.10 after OVE (P ≤ .01). After the planned staged stenting, VAS score decreased to 1.33 ± 2.33 (P ≤ .001). Similarly, in the simultaneous group, preintervention scores were 8.63 ± 1.07 and decreased to 2.36 ± 2.67 after OVE with stenting (P ≤ .001). The postintervention scores between the staged and simultaneous groups were significantly different (P ≤ .04). The majority of patients in our series (82%) demonstrated a significant iliac vein stenosis. These observations indicate that the incidence of iliac vein outflow obstruction in PVI is greater than previously reported. In patients with combined ovarian vein reflux and iliac vein outflow obstruction, our data suggest that pelvic venous outflow lesions should be treated first and that ovarian vein reflux should be treated only if symptoms persist. We recommend that during pelvic venography, IVUS should be performed routinely as part of the diagnostic evaluation.