Double cobra head technique of distal coronary anastomosis

In 1967, Dr. René Favaloro introduced the use of reversed greater saphenous vein graft for coronary artery bypass grafting, since then a lot of efforts were made to improve the venous graft patency rate. We introduce a novel double cobra head technique of distal coronary anastomosis for better distal runoff. We expect our technique will help in difficult situations such as limited conduit availability and target vessel with bifurcation lesions. Refining our surgical techniques is essential to keep ourselves well equipped to compete with the rapidly evolving stent culture.

Comparative study on the effect of aspirin, TP receptor antagonist and TxA2 synthase inhibitor on the vascular tone of human saphenous vein and internal mammary artery

AIMS

Thromboxane (TxA₂) is synthesized from arachidonic acid (AA) via thromboxane synthase (TxS) enzyme and induces vasoconstriction via TP receptor. Our aim is to compare the effects of aspirin, TxS inhibitor and TP receptor antagonist on vascular reactivity of bypass grafts (saphenous vein and internal mammary artery).

MAIN METHODS

Using isolated organ bath, saphenous vein and internal mammary artery preparations were incubated with TP receptor antagonist, TxS inhibitor, aspirin, IP or EP4 receptor antagonist. Then prostaglandin (PG)E₂, PGF_2α, phenylephrine and AA were administered in concentration-dependent manner. The expression of prostanoid receptor and PGI₂ synthase (PGIS) enzyme was determined by Western Blot.

KEY FINDINGS

TP receptor antagonist inhibited the contraction induced by PGE₂, PGF_2α, and AA but not that induced by phenylephrine in both types of vessels. Aspirin increased phenylephrine-induced contraction only in internal mammary artery and decreased AA-induced contraction in saphenous vein. TxS inhibitor decreased both PGE₂ and AA-induced contraction in both types of vessels. This decrease was reversed by co-incubation of TxS inhibitor and IP/EP4 receptor antagonists. The expressions of EP3 receptor and PGIS enzyme were greater in internal mammary artery compared to saphenous vein while IP and TP receptors expressed at similar levels.

SIGNIFICANCE

TP receptor antagonist and TxS inhibitor are more effective to reduce contraction induced by different spasmogens in comparison to aspirin. Our results suggest that TP receptor antagonist and TxS inhibitor might have an advantage over aspirin due to their preventive effect on increased vascular reactivity observed in post-operative period of coronary artery bypass grafting.

In the VEST trial: are we missed to address the pathology incurred by the external stent?

In the VEST IV trial, the author concluded that external stenting of saphenous vein graft mitigates its remodeling and also significantly reduces the diffuse intimal hyperplasia and development of lumen irregularities at 4.5 years after coronary artery bypass grafting surgery. We also have valuable a suggestion in addition to external stenting that might nullify the pathology caused by the stent and might enhances graft patency.

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

OBJECTIVES

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 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 (VCSS), and quality of life (QoL) using the Aberdeen Varicose Vein Questionnaire (AVVQ) 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 (EGIT). 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. Mean age was 56.2±11.5 years (range, 19 to 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, VCSS, and QoL were improved (P<.001). EGIT developed in 5.8% of patients. There was a 1.53-fold linear increase in the stump length by 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.

CONCLUSION

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 stump length.

Safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms: a single-centre long-term retrospective study

Background

To summarize the safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms.

Methods

The data of complex intracranial aneurysms patients for high flow extracranial to intracranial saphenous vein bypass grafting from January 2008 to January 2020 were retrospectively collected and analyzed. Eighty-two patients (31 men and 51 women) with 89 aneurysms underwent 82 saphenous vein bypass grafts followed by immediate parent vessel occlusion. The aneurysm was located at the internal carotid artery, middle cerebral artery, and basilar artery in 75, 11, and 3 cases, respectively.

Results

The patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions. The main postoperative complications were transient hemiparesis and hemianopsia. 3 patients died due to bypass complications and poor physical condition.

Conclusions

High flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the saphenous vein can meet the requirements of brain blood supply. A high rate of graft patency and adequate cerebral blood flow can be achieved.

Highlights

A single-centre long-term retrospective study was conducted to assess the safety and effectiveness of high flow EC-IC saphenous vein bypass grafting in the treatment of complex intracranial aneurysms. The data of 82 patients from January 2008 to January 2020 were retrospectively collected and analysed.

We found the patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions.

Finally, we conclude that high flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the selected blood supply vessels can meet the requirements of blood supply.

As far as we know, this study is one of the maximum number of cases in the treatment of complex intracranial aneurysms with saphenous vein bypass.

Eighteen Years of Follow-up after Resection of a Giant Coronary Artery Aneurysm and Reconstruction with a Vein Graft

Giant coronary artery aneurysms are rare and challenging to treat because of variation in the presenting symptoms and the lack of established management guidelines. We report the case of a patient with a 6-cm-wide giant coronary artery aneurysm that was resected, followed by reconstruction using a saphenous vein graft and 18 years of follow-up.

Saphenous vein size as a surrogate marker for mortality of patients with chronic limb-threatening ischemia undergoing endovascular therapy

BACKGROUND

The size of the autologous vein graft is an important determinant of prognosis in patients with chronic limb-threatening ischemia (CLTI) undergoing bypass surgery. However, it is unclear whether reconstruction using a small vein graft would directly affect prognosis, or a subgroup having small veins would be subject to a poor prognosis. If the latter is true, having small veins would work as a marker for a poor prognosis even in patients with CLTI undergoing endovascular therapy (EVT). Therefore, we investigated the association between the size of saphenous veins and prognosis in patients with CLTI undergoing EVT.

METHODS

This study included 209 consecutive patients with CLTI who primarily underwent EVT between January 2017 and December 2018. The diameter of the saphenous vein was measured at three locations (saphenous-femoral junction, knee, and ankle joint) per limb before EVT by ultrasonography. A small saphenous vein was defined as the mean diameter <3.0 mm.

RESULTS

All-cause mortality rate was significantly higher in patients with a small saphenous vein than in those with non-small one (46.3% versus 10.7% at 2 years, p<0.001). The multivariate Cox regression analysis revealed that a small saphenous vein was independently associated with an increased risk of all-cause mortality.

CONCLUSIONS

Having a small saphenous vein was an independent marker for all-cause mortality in patients with CLTI undergoing EVT.

What is the impact of preserving the endothelium on saphenous vein graft performance? Comments on the 'NO' touch harvesting technique

Saphenous veins used for coronary artery bypass surgery are subjected to considerable vascular trauma when harvested by conventional methods. This vascular damage is responsible, at least in part, for the inferior patency of the saphenous vein when compared with the internal thoracic artery. The performance of saphenous vein grafts is improved when this conduit is harvested atraumatically using the no-touch technique. There is growing evidence that the success of the no-touch technique is due to the preservation of a number of vascular structures including the endothelium, vasa vasorum and perivascular fat. There is conflicting evidence regarding the degree of endothelial damage to the endothelium of conventional versus no-touch saphenous vein grafts. In general, it has been shown that this single layer of cells lining the lumen exhibits considerable damage associated with a combination of vascular trauma and high pressure intraluminal distension. Increased platelet aggregation and thrombus formation at the exposed subendothelial membrane is due to a local reduction of endothelium-derived factors including nitric oxide. In addition, damage to the vasa vasorum of conventionally-harvested veins will reduce transmural blood flow, a condition shown to promote neointimal hyperplasia and atheroma formation. By stripping off the perivascular fat during conventional harvesting, mechanical support of the graft is reduced and the source of adipocyte-derived factors potentially beneficial for graft patency removed. While most agree that endothelial damage to the saphenous vein affects graft patency, the contribution of other tissue-derived factors affected by vascular damage at harvesting need to be considered.

Successful Treatment of a Huge Thrombotic Saphenous Vein Graft Occlusion with Aspiration Thrombectomy: A Case Report

Saphenous vein grafts (SVGs) are widely used conduits for the surgical revascularization of coronary arteries, but they are associated with poor long-term patency rates. Acute SVG thromboses often present as acute coronary syndrome and have an extensive atherosclerotic and thrombotic burden. Percutaneous coronary intervention (PCI) is the first treatment option; however, it carries a high risk of distal embolization, no-reflow, and periprocedural myocardial infarction. Reducing the thrombus burden and preventing distal embolization during PCI can be achieved by using some pharmacological strategies (e.g., glycoprotein IIb/IIIa antagonists) and devices (e.g., thrombectomy and filter devices). There are yet no better therapeutic options for patients undergoing PCI of SVG occlusions. Here, we introduce a 52-year-old male patient admitted with a typical acute chest pain of 1 hour’s duration. Electrocardiography showed signs of acute inferoposterior myocardial infarction. A thrombotic SVG occlusion was detected in primary PCI, and a huge thrombus content was aspirated. After the thrombus aspiration with stent implantation, the chest pain was relieved and the ST-segment elevation was improved. The patient has been followed without any symptoms for 10 months.

First Results of the Single Heartstring Aortotomy for Multiple Off-Pump Vein Grafts: A Case Series

To validate the technique of the single Heartstring aortotomy for multiple off-pump venous bypass grafts (described in 2015), the results of a 38-month follow-up study of 18 patients, including high-risk patients, are presented. No early deaths or cardiac or cerebral complications occurred. During the follow-up period, 2 patients died of non-cardiac causes, and 3 developed coronary ischemia. Ischemia occurred due to late graft occlusion in 2 patients, both of whom had normal postoperative courses and correct graft flow. The presence of acute symptoms 24 months after surgery in these patients indicated that technical graft failure was unlikely. This safe technique combines the advantages of simple and reproducible revascularization, the off-pump approach, and minimal aortic manipulation.

The proximity of the superficial epigastric vein to the saphenofemoral junction is associated with endovenous heat-induced thrombosis after radiofrequency ablation for varicose veins

OBJECTIVE

To elucidate the risk factors of endovenous heat-induced thrombosis (EHIT) after radiofrequency ablation (RFA) for varicose veins in association with the superficial epigastric vein (SEV) position to the saphenofemoral junction (SFJ).

METHODS

We examined 125 legs from 218 patients (mean age, 67 years; 80 female legs) with great saphenous veins (GSVs) in association with the SEV proximity to the SFJ using the duplex ultrasound test. According to the Clinical, Etiology, Anatomy and Pathophysiology classification (CEAP; C1-C6), there were 62, 38, and 25 legs in the C2, C3, and C4-C6 categories, respectively. The postoperative duplex ultrasound tests, focused on EHIT, were conducted on days 1, 7, 30, and 90 after RFA. The EHIT analysis was based on Kabnick's classification (class 1-4). We compared the GSV diameter and the SEV-SFJ distance between the EHIT positive (n = 32) and negative groups (n = 93) using the Student t-test. The risk factors (age >75, male sex, ≥C3 classification, adjunctive phlebectomy, prior venous surgery history, GSV diameter of >7.5 mm, and short SEV-SFJ distance [<4 mm]) were examined using univariate and multiple logistic regression analyses.

RESULTS

The EHIT ratio after RFA was 25.6% (24, five, three, and no legs in classes 1, 2, 3, and 4, respectively). In the EHIT positive group, the mean GSV diameter and the SEV-SFJ distance were larger (8.0 ± 2.3 vs 6.4 ± 2.0 mm; P < .001) and shorter (5.2 ± 4.0 vs 6.8 ± 3.7 mm; P = .05) than the negative group. Using univariate analysis, the risk factors of EHIT after RFA were as follows: ≥C3 classification (odds ratio [OR], 4.15; P = .002), GSV diameter >7.5 mm (OR, 3.50; P = .003), and short SEV-SFJ distance (OR, 2.92; P = .01). Multiple logistic regression analysis showed that a classification of ≥C3 (OR, 3.39; 95% confidence interval [CI], 1.30-8.86; P = .013), GSV of >7.5 mm (OR, 3.32; 95% CI, 1.33-8.25; P = .010), and short SEV-SFJ distance (OR, 2.71; 95% CI, 1.09-6.71; P = .032) were also significant risk factors.

CONCLUSIONS

RFA treatment for patients with varicose veins should be considered postoperatively in combination with a classification of ≥C3, GSV diameter of >7.5 mm, and a history of deep venous thrombosis and concomitant procedures, because it is related with greater chances of EHIT development.

Saphenous vein characteristics evaluated using three-dimensional contrastless computed tomography before coronary artery bypass grafting

OBJECTIVE

Saphenous vein (SV) grafts are occasionally unsuitable for grafting owing to anatomic variants. However, there is some concern regarding preoperative SV evaluation. We used contrastless 3D-CT to investigate the anatomical SV characteristics before CABG.

METHODS

Contrastless 3D-CT was used to preoperatively evaluate the SV anatomy in 102 consecutive patients undergoing elective first-time CABG. The external diameter of the SV was measured at the mid-level of the thigh and calf segments on both sides. Abnormal branches of the SV were classified into three categories; (1) partial duplication, which was defined as double SVs; (2) large accessory SVs, which were larger than the great SV; and (3) complicated branches of the SV, which resulted in the great SV being undetected. The existence of varicose veins was assessed.

RESULTS

The size distribution of the SV (< 3 mm/3-5 mm/5 mm <) was 9/142/53 and 17/154/33 in the thigh and calf segments, respectively. Abnormal branches of the SV were found in 47 patients (46%): (1) partial duplication was noted in 40 patients; (2) large accessory SV was observed in eight patients; and (3) complicated branches were identified in five patients. Varicose veins were detected in 15 patients. SV was harvested in 74 patients, and no additional skin incision was required.

CONCLUSIONS

Contrastless 3D-CT is an objective, less time-consuming modality to preoperatively evaluate the SV, and may be less invasive in terms of avoiding unnecessary skin incision. This technique is useful for defining atypical anatomical variations, such as partial duplications, large accessory SVs, and varicose veins.

Three-year follow-up results of the prospective European Multicenter Cohort Study on Cyanoacrylate Embolization for treatment of refluxing great saphenous veins

OBJECTIVE

Cyanoacrylate closure of refluxing saphenous veins has demonstrated excellent safety and effectiveness results in feasibility and pivotal studies. This article provides the 36-month follow-up results of a prospective, multicenter, nonrandomized cohort study.

METHODS

A total of 70 patients were enrolled in a prospective, multicenter study conducted at seven centers in four European countries and underwent treatment of a solitary refluxing great saphenous vein with endovenous cyanoacrylate embolization without the use of tumescent anesthesia or postprocedure compression stockings. The primary effectiveness end point was freedom from recanalization (closure rate) of the great saphenous vein at 6 months. Safety was assessed by occurrence of adverse events after the procedure and during the 6-month follow-up period. Quality of life and clinical improvement parameters were measured before and after the procedure and through a 12-month follow-up period. Anatomic success and clinical improvement were assessed through 36 months after the procedure.

RESULTS

Of 70 treated patients, 64 (91%) were available for the 3-year follow-up. The closure rates by Kaplan-Meier life table methods at 6-, 12-, 24-, and 36-month time points were 91.4%, 90.0%, 88.5%, and 88.5%, respectively. Through 36 months, the improvement in change of the mean venous clinical severity score over time was statistically significant by dropping from 4.3 at baseline to 0.9 at the 36-month follow-up (P < .001).

CONCLUSIONS

The 3-year follow-up results of the prospective, multicenter eSCOPE study demonstrated the continued anatomic and clinical effectiveness of cyanoacrylate embolization over an extended follow-up period.

Expression profiles of the internal jugular and saphenous veins: Focus on hemostasis genes

INTRODUCTION

Venous bed specificity could contribute to differential vulnerability to thrombus formation, and is potentially reflected in mRNA profiles.

MATERIALS AND METHODS

Microarray-based transcriptome analysis in wall and valve specimens from internal jugular (IJV) and saphenous (SV) veins collected during IJV surgical reconstruction in patients with impaired brain outflow. Multiplex antigenic assay in paired jugular and peripheral plasma samples.

RESULTS

Most of the top differentially expressed transcripts have been previously associated with both vascular and neurological disorders. Large expression differences of HOX genes, organ patterning regulators, pinpointed the vein positional identity. The "complement and coagulation cascade" emerged among enriched pathways. In IJV, upregulation of genes for coagulation inhibitors (TFPI, PROS1), activated protein C pathway receptors (THBD, PROCR), fibrinolysis activators (PLAT, PLAUR), and downregulation of the fibrinolysis inhibitor (SERPINE1) and of contact/amplification pathway genes (F11, F12), would be compatible with a thromboprotective profile in respect to SV. Further, in SV valve the prothrombinase complex genes (F5, F2) were up-regulated and the VWF showed the highest expression. Differential expression of several VWF regulators (ABO, ST3GAL4, SCARA5, CLEC4M) was also observed. Among other differentially expressed hemostasis-related genes, heparanase (HPSE)/heparanase inhibitor (HPSE2) were up-/down-regulated in IJV, which might support procoagulant features and disease conditions. The jugular plasma levels of several proteins, encoded by differentially expressed genes, were lower and highly correlated with peripheral levels.

CONCLUSIONS

The IJV and SV rely on differential expression of many hemostasis and hemostasis-related genes to balance local hemostasis, potentially related to differences in vulnerability to thrombosis.

Results of polidocanol endovenous microfoam in clinical practice

BACKGROUND

Initial phase III clinical studies with polidocanol endovenous microfoam (PEM) demonstrated its safety and efficacy in the treatment of superficial venous reflux. In those studies, the primary outcome requirement was to assess the improvement in symptoms related to superficial venous disease. The goal of the present study was to evaluate the efficacy of PEM technology in routine clinical practice-specifically, the closure rates after treatment.

METHODS

We performed an observational study during which data were prospectively collected from 2 vein centers using an electronic database. Patients with CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥2 and symptomatic superficial axial reflux (great saphenous vein, anterior accessory saphenous vein, and small saphenous vein) were included and followed up prospectively. PEM was used to treat the saphenous vein and varicosities. The CEAP classification was used to classify chronic venous disease, and the venous clinical severity score (VCSS) was applied to measure the disease severity. Pain and discomfort were assessed using a visual analog scale, and the residual veins were assessed by physical examination.

RESULTS

PEM was used to treat superficial reflux in 60 patients. The CEAP classification was C2 for 32 patients, C3 for 14, C4 for 10, and C5 for 4 patients. The average pretreatment VCSS was 7.3. The saphenous vein diameter was 6.5 mm, and the average length was 31 cm. The average volume of PEM used to treat the saphenous veins was 9.3 mL. The closure rate at 3 and 6 months was 93% (54 of 58) and 93% (51 of 55), respectively. The VCSS had improved from 7.3 to 1.4. Complications included 1 case of deep vein thrombosis (1.7%), 5 patients (8.3%) with thrombophlebitis, and 4 patients (6.6%) with skin pigmentation.

CONCLUSIONS

PEM is safe and effective for the treatment of saphenous reflux and varicosities. The early closure rates using PEM were maintained at 6 months and are comparable to the results reported with nonthermal, nontumescent technologies and thermal tumescent technologies.

Patency of conduits in patients who received internal mammary artery, radial artery and saphenous vein grafts

Background

Where each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period.

Methods

Research protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or “string sign” conduits. Perfect patency was present in patent grafts if there was no lumen irregularity.

Results

Fifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P < 0.001. Patency RA 93.5% was also not different to IMA 96.8%, P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032.

When both arterial conduits were combined, perfect patency, P < 0.001, and patency, P = 0.017, were superior to SVG.

Conclusions

All but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perfect patency and overall patency compared to saphenous vein grafts.

Long-Term Patency Rate of Radial Artery Conduits in Chinese Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Consensus has yet to emerge among experts as to whether the radial artery (RA) conduit was superior to the saphenous vein (SV) graft for coronary artery bypass grafting (CABG) in terms of long-term patency. This study aimed to evaluate long-term patency of the RA conduit compared to the SV conduit for off-pump CABG, and to screen the independent predictors of long-term RA graft failure.Patients < 80 years of age with graftable triple-vessel disease undergoing non-emergent, primary, isolated off-pump CABG, using both the RA and the SV conduits, were reviewed. Graft patency, all-cause mortality and repeat revascularization were followed-up. The independent predictors of long-term RA graft failure were identified.A total of 296 out of 320 eligible patients (42 females, 61.3 ± 9.9 years old) received follow-up with an observed period of 93.4 ± 16.5 months. All-cause mortality was 14.5%, and repeat revascularization was conducted on 6 RA grafts and 9 SV grafts. Superior patency of the RA grafts compared to the SV grafts was observed (84.4% versus 78.5%, P = 0.035). Independent predictors of long-term RA graft failure included proximal stenosis of target right coronaries < 90% (OR = 2.35, 95%CI 1.41-5.82) and diabetes mellitus (OR = 1.66, 95%CI 1.17-4.26).The RA graft had a superior long-term patency than the SV graft. Long-term patency of the RA graft may be poor in diabetics or in the case of proximal stenosis of target right coronary <90%. (Trial registration: ChiCTR-OCH-1200212).

Avoiding disease mongering: A checklist for vascular physicians and researchers

Disease mongering is an expression created in 1992 by a medical journalist, Lynn Payer, to qualify the "selling of sickness that widens the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments". This interesting concept led us to question whether, as researchers with publication and career interests in superficial vein thrombosis, we were not shaping a benign condition into a disease. Since the publication of the CALISTO trial in 2010, anticoagulant management of superficial vein thrombosis remains debated. Issues raised, such as the cost-effectiveness of the treatment strategy, the use of a composite endpoint including death, the low event rate without mortality reduction and conflict of interest due to industrial funding. We searched Embase, Medline, Web of science, and Opengrey databases to review all aspects about disease mongering raised in the literature and created a checklist with seventeen items. We used this checklist as support for a narrative review, questioning known literature on superficial vein thrombosis. The main issues pointing towards disease mongering concerned definition and promotion; whereas management seemed rather spared. Many arguments could be counterbalanced, but researchers should pay particular attention to three major points: exaggeration of the severity of the disease and potential adverse outcomes without treatment, promotion by opinion leaders, and an openly declared, yet undoubtedly present, conflict of interest situation.

Safety and Effectiveness of Endovenous Thermal Ablation for Incompetent Saphenous Veins with an Aneurysm Close to the Junction

OBJECTIVE

The aim was to evaluate the safety and effectiveness of endovenous thermal ablation (EVTA) with or without adding high ligation (HL) for the treatment of incompetent saphenous veins with an aneurysm (>20 mm for the great saphenous vein, >15 mm for the small saphenous vein) close to the junction.

METHODS

This was a prospective observational cohort study in a single centre. All patients presenting with saphenous aneurysms close to the junction were included. Those with a venous aneurysm more distally, at >2 cm from the junction, or with associated deep venous aneurysms were excluded. Patients were treated with EVTA alone or combined with HL in cases of an aneurysm with a diameter >30 mm. Phlebectomies were performed during the same treatment session. Patients were followed up one and six weeks, and one year after treatment. Duplex ultrasound (DUS) was performed to evaluate occlusion of the vein and aneurysm as well as possible complications such as endovenous heat induced thrombosis (EHIT) or deep vein thrombosis (DVT). Venous clinical severity scores (VCSS) were registered before and one year after treatment.

RESULTS

Thirteen patients (15 limbs) were included between February 2012 and January 2015. Eleven limbs were treated with EVTA alone, the remaining four limbs with EVTA and HL. No severe adverse events occurred (no EHIT, no DVT). After one year none of the aneurysms was still visible on DUS and the truncal obliteration rate was 80% (two partial, one segmental recanalisation). Both treatment strategies showed significant improvement of the VCSS at the one year follow up, from a median score of 6 (interquartile range [IQR] 5-7) to 2 (IQR 1-3) (p = .001).

CONCLUSION

EVTA with or without HL appeared to be a safe and effective treatment for patients presenting with incompetent saphenous veins with an aneurysm close to the junction.

Outcome of ClosureFAST radiofrequency ablation for large-diameter incompetent great saphenous vein

Purpose

There is limited data on the outcomes of radiofrequency ablation (RFA) for large diameter saphenous veins. This study aimed to determine whether the large-diameter great saphenous vein (GSV) affected closure rate, complications, and clinical and quality of life (QoL) improvement.

Methods

From January 2012 to September 2016, a total of 722 limbs were treated with ClosureFAST RFA in a single center. Patients were divided into 2 groups according to the vein diameter measured 3 cm below the saphenofemoral junction (group A ≤ 12 mm, group B > 12 mm). Vein closure was evaluated with duplex scan at 3–5 days, 1, 3, 6, and 12 months postoperatively. The incidence of complications, improvements in symptoms (measured by the Venous Clinical Severity Score [VCSS]) and QoL (measured by the Aberdeen Varicose Vein Symptom Severity Score [AVSS]) were evaluated.

Results

Groups consisted of 663 GSVs in group A (mean diameter, 6.00 ± 1.74 mm) and 59 in group B (mean diameter, 13.17 ± 1.28 mm). Vein closure rates at 12 months were 98.9% in group A and 100% in group B (P = 0.428). There was no significant difference in the incidence of complications. Both groups showed marked improvements in the VCSS and the AVSS with no significant differences.

Conclusion

For large-diameter veins, RFA showed comparable outcomes in terms of closure rate, complications, clinical and QoL improvements.

Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambulatory conservative hemodynamic correction of chronic venous insufficiency

OBJECTIVE

Preoperative mapping of great saphenous vein (GSV) escape points to tributary veins (TVs) and targeted intervention of escape points may reduce recurrence rates of varicose veins (VVs) after endovascular treatment of saphenous veins and prevent saphenous nerve complications. The aim of this study was to perform an analysis of cartography after Doppler ultrasound mapping of escape points in patients with VVs and to suggest one point that may prevent recurrence and nerve complications.

METHODS

Ultrasound assessment of VVs was performed from March 4, 2016, to July 15, 2016, specifically focusing on the locations of escape points from the saphenous vein to TVs. The collected data were reviewed retrospectively. The topographic distribution of escape points was as follows: from inguinal ligament to midthigh; from midthigh to knee; from knee to midcalf; and from midcalf to heel.

RESULTS

Thirty patients (41 legs) with VVs underwent ultrasound examination. All VVs were characterized by reflux at the GSV. Topographic analysis revealed a total of 79 escape points in all patients. The most common location for escape points was the third part of the leg (from knee to midcalf), where 65.8% of escape points were located; 82.3% of all escape points were located below the knee. The mean diameter of the GSV at 3 cm and 15 cm from the saphenofemoral junction was 6.8 ± 1.6 cm and 5.5 ± 1.5 cm, respectively. Mean diameter of TVs was 5.1 ± 1.9 cm. The diameter was not significantly different between saphenous veins and TVs. The mean number of escape points in each leg was 1.9 ± 1.0.

CONCLUSIONS

Most escape points (65.8%) are located from knee to midcalf (third part of the leg), and 82.3% of all escape points are located below the knee. The diameter of TVs near the escape point is about 90% of that of the GSV. Thermal ablations of below-knee saphenous vein have potential nerve damage. Ablation of saphenous veins above the knee alone may result in residual shunting and formation of persistent reservoirs in TVs. These persistent reservoirs may be removed effectively with sclerotherapy or miniphlebectomy, especially trying to remove TVs near the escape point. Direct ligation of a TV near the escape point from the saphenous vein, just like saphenofemoral junction ligation, could be performed. These approaches may be able to prevent residual shunting and may reduce recurrence rates and nerve injury.

[Plaque features in saphenous vein graft evaluated by virtual histology intravascular ultrasound]

Objective: To investigate the features of plaques of saphenous venous graft (SVG) with virtual histology intravascular ultrasound (VH-IVUS) in patients underwent coronary artery bypass graft surgery. Methods: From March 2016 to March 2018, a total of 45 patients ((64.4±7.9) years old, 88.9% male (40 cases)) with ischemic symptoms after coronary artery bypass graft surgery and with coronary artery angiography evidenced SVG stenosis greater than or equal to 50%, who received percutaneous coronary intervention in Tianjin chest hospital were continuously included in this study, and the clinical data were retrospectively analyzed. VH-IVUS was performed before PCI to analyze plaque composition. The patients were divided into no smoking group (21 cases) and smoking group (24 cases), no diabetes group (30 cases) and diabetes group (15 cases), normal very low density lipoprotein cholesterin (VLDL-C) group (24 cases) and elevated VLDL-C group (21 cases), stable angina pectoris group (5 cases) and acute coronary syndrome group (40 cases), plaque burden (PB) < 70% group (11 cases) and PB ≥ 70% group (34 cases), without thin-cap fibroatheroma group (35 cases) and thin-cap fibroatheroma group (10 cases), and plaque features were compared between different groups. Results: The graft age was (8.9±3.7) years.The stenosis degree of SVG lesions was 90 (90, 98) %. The minimum lumen diameter was 1.6 (1.5, 1.8) mm. The vessel cross-sectional area was (12.1±4.0) mm(2). The plaque area was 8.6 (5.7,12.0) mm(2). The minimum lumen area was 2.5 (2.1,3.3) mm(2). The plaque burden was (75.3±8.3)%. The fibrotic tissue (FI) ratio was (65.1±10.1)%, fibrofatty plaque (FF) ratio was 13.8 (5.4,25.3) %, necrotic core tissue (NC) ratio was 12.0 (5.4,24.0)%, and dense calcium tissue (DC) ratio was1.0 (0.2,3.8)% in SVG lesions. There were no significant differences in SVG plaque area, FI area,FF area,NC area,and DC area between no smoking group and smoking group, no diabetes group and diabetes group, and normal VLDL-C group and elevated VLDL-C group. SVG plaque volume was significantly higher in acute coronary syndrome group than in stable angina pectoris group (262.2 (148.5,401.2) mm(3) vs. 93.1 (50.6,155.9) mm(3),P=0.006), and plaque area (10.1 (6.6,13.3) mm(2) vs. 5.0 (3.6,6.9) mm(2), P<0.001), FI area(4.8 (3.2,6.8) mm(2) vs. 2.8 (1.9,3.0) mm(2), P<0.001),and FF area (1.15 (0.60, 2.07) mm(2) vs. 0.30 (0.10,0.90) mm(2), P=0.009) were significantly larger in PB ≥ 70% group than in PB < 70% group.The NC area (1.75(0.40,2.78) mm(2) vs. 0.60 (0.20,1.30) mm(2), P=0.030) and DC area (0.35 (0.10,0.50) mm(2) vs. 0.00 (0.00,0.10) mm(2), P=0.006) were significantly larger in thin-cap fibroatheroma group than that in without thin-cap fibroatheroma group. Spearman correlation analysis showed that the plaque area of SVG lesion was positively correlated with FF area (r=0.64, P<0.001) and NC area (r=0.43, P=0.003). PB was positively correlated with FF area (r=0.50, P<0.001) and NC area (r=0.33, P=0.028). Graft age was positively correlated with FF area (r=0.30, P=0.047). Conclusions: The main components of SVG plaque are fibrotic tissue, conversely, calcified tissue is rare in patients with SVG stenosis after coronary artery bypass graft surgery. Fibrofatty tissue is increased in the plaque in patients with PB ≥ 70%. The necrotic component is also increased in patients with thin-cap fibroatheroma. The fibrofatty component increases and the plaque tends to be unstable in proportion with increaing age of the graft in this patient cohort.