Mark Lesney

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

World-renowned cardiologist Dr. Bernadine Healy has died from recurrent brain cancer; she was 67 years old.

Dr. Healy was always on the cutting edge of women's leadership. One of the first female presidents of the American Heart Association, Dr. Healy was appointed as the first woman director of the National Institutes of Health by President George H.W. Bush in 1991. She was the creator of the $625 million Women's Health Initiative - the first long-term governmental research study of women's health issues.

Dr. Healy went on to become the first woman dean of the Ohio State Medical School, at a time when only 5% of medical school deans in the U. S. were female.

Following Elizabeth Dole as president of the American Red Cross, Dr. Healy oversaw the development of a Weapons of Mass Destruction Response Program, and then led the Red Cross response during the September 11th terrorist attack. She instituted many health care policies to improve upon strategies for dealing with national emergencies and terrorist calamities. Criticism around these initiatives was associated with her departure from the American Red Cross.

Dr. Healy was a summa cum laude graduate of Vassar College and a cum laude graduate of Harvard Medical School, where she was one of ten women in a class of 120. Dr. Healy completed her residency at Johns Hopkins School of Medicine. There, she was a professor of medicine and the first woman to serve as assistant dean for postdoctoral programs and faculty development.

In addition to being a leading physician, educator and health administrator, Dr. Healy had a sterling reputation as a skilled cardiovascular researcher specializing in the pathology and treatment of heart attacks, focusing on women.

An author as well as a policy maker and physician, Dr. Healy wrote or co-authored over 220 peer-reviewed published manuscripts on cardiovascular research and health and science policy. She was a health editor and columnist for the U. S. News and World Report, a medical contributor to MSNBC.com and a panelist on the PBS show, To the Contrary.

In addition to her milestone book, A New Prescription for Women's Health, Dr. Healy published a book titled Livingtime about her cancer experience from the perspective of both the physician and the patient.

World-renowned cardiologist Dr. Bernadine Healy has died from recurrent brain cancer; she was 67 years old.

Dr. Healy was always on the cutting edge of women's leadership. One of the first female presidents of the American Heart Association, Dr. Healy was appointed as the first woman director of the National Institutes of Health by President George H.W. Bush in 1991. She was the creator of the $625 million Women's Health Initiative - the first long-term governmental research study of women's health issues.

Dr. Healy went on to become the first woman dean of the Ohio State Medical School, at a time when only 5% of medical school deans in the U. S. were female.

Following Elizabeth Dole as president of the American Red Cross, Dr. Healy oversaw the development of a Weapons of Mass Destruction Response Program, and then led the Red Cross response during the September 11th terrorist attack. She instituted many health care policies to improve upon strategies for dealing with national emergencies and terrorist calamities. Criticism around these initiatives was associated with her departure from the American Red Cross.

Dr. Healy was a summa cum laude graduate of Vassar College and a cum laude graduate of Harvard Medical School, where she was one of ten women in a class of 120. Dr. Healy completed her residency at Johns Hopkins School of Medicine. There, she was a professor of medicine and the first woman to serve as assistant dean for postdoctoral programs and faculty development.

In addition to being a leading physician, educator and health administrator, Dr. Healy had a sterling reputation as a skilled cardiovascular researcher specializing in the pathology and treatment of heart attacks, focusing on women.

An author as well as a policy maker and physician, Dr. Healy wrote or co-authored over 220 peer-reviewed published manuscripts on cardiovascular research and health and science policy. She was a health editor and columnist for the U. S. News and World Report, a medical contributor to MSNBC.com and a panelist on the PBS show, To the Contrary.

In addition to her milestone book, A New Prescription for Women's Health, Dr. Healy published a book titled Livingtime about her cancer experience from the perspective of both the physician and the patient.

World-renowned cardiologist Dr. Bernadine Healy has died from recurrent brain cancer; she was 67 years old.

Dr. Healy was always on the cutting edge of women's leadership. One of the first female presidents of the American Heart Association, Dr. Healy was appointed as the first woman director of the National Institutes of Health by President George H.W. Bush in 1991. She was the creator of the $625 million Women's Health Initiative - the first long-term governmental research study of women's health issues.

Dr. Healy went on to become the first woman dean of the Ohio State Medical School, at a time when only 5% of medical school deans in the U. S. were female.

Following Elizabeth Dole as president of the American Red Cross, Dr. Healy oversaw the development of a Weapons of Mass Destruction Response Program, and then led the Red Cross response during the September 11th terrorist attack. She instituted many health care policies to improve upon strategies for dealing with national emergencies and terrorist calamities. Criticism around these initiatives was associated with her departure from the American Red Cross.

Dr. Healy was a summa cum laude graduate of Vassar College and a cum laude graduate of Harvard Medical School, where she was one of ten women in a class of 120. Dr. Healy completed her residency at Johns Hopkins School of Medicine. There, she was a professor of medicine and the first woman to serve as assistant dean for postdoctoral programs and faculty development.

In addition to being a leading physician, educator and health administrator, Dr. Healy had a sterling reputation as a skilled cardiovascular researcher specializing in the pathology and treatment of heart attacks, focusing on women.

An author as well as a policy maker and physician, Dr. Healy wrote or co-authored over 220 peer-reviewed published manuscripts on cardiovascular research and health and science policy. She was a health editor and columnist for the U. S. News and World Report, a medical contributor to MSNBC.com and a panelist on the PBS show, To the Contrary.

In addition to her milestone book, A New Prescription for Women's Health, Dr. Healy published a book titled Livingtime about her cancer experience from the perspective of both the physician and the patient.

Endovenous thermal ablations with heat have revolutionized the treatment of patients with chronic venous disease. Both radiofrequency and laser ablations have been equally effective in causing early occlusion of the saphenous vein in more than 90% of patients in most studies, according to Dr. Peter Gloviczki.

The main reasons for anatomical failure of endothermal saphenous ablations are persistent patency of the vein after treatment and recanalization of the vein after primary occlusion. Reflux through saphenous tributaries and accessory saphenous veins is another cause of ablation failure. This occurs despite persistent occlusion of the great saphenous vein since the strategy of laser and radiofrequency (RF) treatment is saphenous ablation distal to groin tributaries, a method that corresponds to "low" ligation using a traditional open surgical technique, Dr. Gloviczki said at the Veith symposium on vascular medicine, which was sponsored by the Cleveland Clinic.

The development of recurrent varicose veins, deterioration of quality of life, and worsening of the patient’s VCSS (Venous Clinical Severity Scores) after the procedure are considered clinical failures. Any ablation procedure could also be considered a failure if there is a high risk of complications and if the cost is excessive, said Dr. Gloviczki, the Joe M. and Ruth Roberts Professor of Surgery at the Gonda Vascular Center at the Mayo Clinic in Rochester, Minn.

The common theme for anatomical failure is saphenous recanalization in 5%-26% of cases, which occurs after a very high rate of immediate early occlusion (reaching greater than 95% for the latest-generation laser and RF ablation). Anatomical failure, however, does not translate into clinical failure in most patients; more than three-fourths of those with recanalized saphenous veins remain asymptomatic at 1-2 years after intervention.

To illustrate this, Dr. Gloviczki discussed an important study of 185 limbs that grouped failures into the following three types:

Type 1 (nonocclusion). The treated vein failed to occlude initially and never occluded during follow-up (12%).

Type 2 (recanalization). The vein occluded after treatment but later recanalized partly or completely (70%).

Type 3 (groin reflux). The vein trunk occluded, but reflux was detected at the groin region, often involving an accessory vein (18%).

Most patients had symptomatic improvement despite anatomical failure, and 70%-80% of these "failed" patients remained asymptomatic, compared with 85%-94% of those with anatomical success. Varicose vein recurrence, however, was more frequent with type 2 and type 3 failures. The study investigators found that with the first-generation RF device, catheter pull-back speed and body mass index were the two risk factors associated with anatomical failures, Dr. Gloviczki said in an interview.

In Europe, steam has been used increasingly for thermal ablation, but whether this is more effective than RF and laser ablation remains to be seen, he stated.

Whatever the technique, endovenous thermal ablations are here to stay and clinical failure rates in the short- and midterms are comparable with those observed after open surgical treatment, he said. "So far, there is no convincing evidence that, of the currently used latest generation endothermal ablation techniques, one is better than the other or that any of them has a different failure rate than the traditional open surgery with high ligation and stripping," he added.

Endovenous thermal ablations with heat have revolutionized the treatment of patients with chronic venous disease. Both radiofrequency and laser ablations have been equally effective in causing early occlusion of the saphenous vein in more than 90% of patients in most studies, according to Dr. Peter Gloviczki.

The main reasons for anatomical failure of endothermal saphenous ablations are persistent patency of the vein after treatment and recanalization of the vein after primary occlusion. Reflux through saphenous tributaries and accessory saphenous veins is another cause of ablation failure. This occurs despite persistent occlusion of the great saphenous vein since the strategy of laser and radiofrequency (RF) treatment is saphenous ablation distal to groin tributaries, a method that corresponds to "low" ligation using a traditional open surgical technique, Dr. Gloviczki said at the Veith symposium on vascular medicine, which was sponsored by the Cleveland Clinic.

The development of recurrent varicose veins, deterioration of quality of life, and worsening of the patient’s VCSS (Venous Clinical Severity Scores) after the procedure are considered clinical failures. Any ablation procedure could also be considered a failure if there is a high risk of complications and if the cost is excessive, said Dr. Gloviczki, the Joe M. and Ruth Roberts Professor of Surgery at the Gonda Vascular Center at the Mayo Clinic in Rochester, Minn.

The common theme for anatomical failure is saphenous recanalization in 5%-26% of cases, which occurs after a very high rate of immediate early occlusion (reaching greater than 95% for the latest-generation laser and RF ablation). Anatomical failure, however, does not translate into clinical failure in most patients; more than three-fourths of those with recanalized saphenous veins remain asymptomatic at 1-2 years after intervention.

To illustrate this, Dr. Gloviczki discussed an important study of 185 limbs that grouped failures into the following three types:

Type 1 (nonocclusion). The treated vein failed to occlude initially and never occluded during follow-up (12%).

Type 2 (recanalization). The vein occluded after treatment but later recanalized partly or completely (70%).

Type 3 (groin reflux). The vein trunk occluded, but reflux was detected at the groin region, often involving an accessory vein (18%).

Most patients had symptomatic improvement despite anatomical failure, and 70%-80% of these "failed" patients remained asymptomatic, compared with 85%-94% of those with anatomical success. Varicose vein recurrence, however, was more frequent with type 2 and type 3 failures. The study investigators found that with the first-generation RF device, catheter pull-back speed and body mass index were the two risk factors associated with anatomical failures, Dr. Gloviczki said in an interview.

In Europe, steam has been used increasingly for thermal ablation, but whether this is more effective than RF and laser ablation remains to be seen, he stated.

Whatever the technique, endovenous thermal ablations are here to stay and clinical failure rates in the short- and midterms are comparable with those observed after open surgical treatment, he said. "So far, there is no convincing evidence that, of the currently used latest generation endothermal ablation techniques, one is better than the other or that any of them has a different failure rate than the traditional open surgery with high ligation and stripping," he added.

Endovenous thermal ablations with heat have revolutionized the treatment of patients with chronic venous disease. Both radiofrequency and laser ablations have been equally effective in causing early occlusion of the saphenous vein in more than 90% of patients in most studies, according to Dr. Peter Gloviczki.

The main reasons for anatomical failure of endothermal saphenous ablations are persistent patency of the vein after treatment and recanalization of the vein after primary occlusion. Reflux through saphenous tributaries and accessory saphenous veins is another cause of ablation failure. This occurs despite persistent occlusion of the great saphenous vein since the strategy of laser and radiofrequency (RF) treatment is saphenous ablation distal to groin tributaries, a method that corresponds to "low" ligation using a traditional open surgical technique, Dr. Gloviczki said at the Veith symposium on vascular medicine, which was sponsored by the Cleveland Clinic.

The development of recurrent varicose veins, deterioration of quality of life, and worsening of the patient’s VCSS (Venous Clinical Severity Scores) after the procedure are considered clinical failures. Any ablation procedure could also be considered a failure if there is a high risk of complications and if the cost is excessive, said Dr. Gloviczki, the Joe M. and Ruth Roberts Professor of Surgery at the Gonda Vascular Center at the Mayo Clinic in Rochester, Minn.

The common theme for anatomical failure is saphenous recanalization in 5%-26% of cases, which occurs after a very high rate of immediate early occlusion (reaching greater than 95% for the latest-generation laser and RF ablation). Anatomical failure, however, does not translate into clinical failure in most patients; more than three-fourths of those with recanalized saphenous veins remain asymptomatic at 1-2 years after intervention.

To illustrate this, Dr. Gloviczki discussed an important study of 185 limbs that grouped failures into the following three types:

Type 1 (nonocclusion). The treated vein failed to occlude initially and never occluded during follow-up (12%).

Type 2 (recanalization). The vein occluded after treatment but later recanalized partly or completely (70%).

Type 3 (groin reflux). The vein trunk occluded, but reflux was detected at the groin region, often involving an accessory vein (18%).

Most patients had symptomatic improvement despite anatomical failure, and 70%-80% of these "failed" patients remained asymptomatic, compared with 85%-94% of those with anatomical success. Varicose vein recurrence, however, was more frequent with type 2 and type 3 failures. The study investigators found that with the first-generation RF device, catheter pull-back speed and body mass index were the two risk factors associated with anatomical failures, Dr. Gloviczki said in an interview.

In Europe, steam has been used increasingly for thermal ablation, but whether this is more effective than RF and laser ablation remains to be seen, he stated.

Whatever the technique, endovenous thermal ablations are here to stay and clinical failure rates in the short- and midterms are comparable with those observed after open surgical treatment, he said. "So far, there is no convincing evidence that, of the currently used latest generation endothermal ablation techniques, one is better than the other or that any of them has a different failure rate than the traditional open surgery with high ligation and stripping," he added.

Endovenous thermal ablations with heat have revolutionized the treatment of patients with chronic venous disease. Both radiofrequency and laser ablations have been equally effective in causing early occlusion of the saphenous vein in more than 90% of patients in most studies, according to Dr. Peter Gloviczki.

The main reasons for anatomical failure of endothermal saphenous ablations are persistent patency of the vein after treatment and recanalization of the vein after primary occlusion. Reflux through saphenous tributaries and accessory saphenous veins is another cause of ablation failure. This occurs despite persistent occlusion of the great saphenous vein since the strategy of laser and radiofrequency (RF) treatment is saphenous ablation distal to groin tributaries, a method that corresponds to "low" ligation using a traditional open surgical technique, Dr. Gloviczki said at the Veith symposium on vascular medicine, which was sponsored by the Cleveland Clinic.

The development of recurrent varicose veins, deterioration of quality of life, and worsening of the patient’s VCSS (Venous Clinical Severity Scores) after the procedure are considered clinical failures. Any ablation procedure could also be considered a failure if there is a high risk of complications and if the cost is excessive, said Dr. Gloviczki, the Joe M. and Ruth Roberts Professor of Surgery at the Gonda Vascular Center at the Mayo Clinic in Rochester, Minn.

The common theme for anatomical failure is saphenous recanalization in 5%-26% of cases, which occurs after a very high rate of immediate early occlusion (reaching greater than 95% for the latest-generation laser and RF ablation). Anatomical failure, however, does not translate into clinical failure in most patients; more than three-fourths of those with recanalized saphenous veins remain asymptomatic at 1-2 years after intervention.

To illustrate this, Dr. Gloviczki discussed an important study of 185 limbs that grouped failures into the following three types:

Type 1 (nonocclusion). The treated vein failed to occlude initially and never occluded during follow-up (12%).

Type 2 (recanalization). The vein occluded after treatment but later recanalized partly or completely (70%).

Type 3 (groin reflux). The vein trunk occluded, but reflux was detected at the groin region, often involving an accessory vein (18%).

Most patients had symptomatic improvement despite anatomical failure, and 70%-80% of these "failed" patients remained asymptomatic, compared with 85%-94% of those with anatomical success. Varicose vein recurrence, however, was more frequent with type 2 and type 3 failures. The study investigators found that with the first-generation RF device, catheter pull-back speed and body mass index were the two risk factors associated with anatomical failures, Dr. Gloviczki said in an interview.

In Europe, steam has been used increasingly for thermal ablation, but whether this is more effective than RF and laser ablation remains to be seen, he stated.

Whatever the technique, endovenous thermal ablations are here to stay and clinical failure rates in the short- and midterms are comparable with those observed after open surgical treatment, he said. "So far, there is no convincing evidence that, of the currently used latest generation endothermal ablation techniques, one is better than the other or that any of them has a different failure rate than the traditional open surgery with high ligation and stripping," he added.

Endovenous thermal ablations with heat have revolutionized the treatment of patients with chronic venous disease. Both radiofrequency and laser ablations have been equally effective in causing early occlusion of the saphenous vein in more than 90% of patients in most studies, according to Dr. Peter Gloviczki.

The main reasons for anatomical failure of endothermal saphenous ablations are persistent patency of the vein after treatment and recanalization of the vein after primary occlusion. Reflux through saphenous tributaries and accessory saphenous veins is another cause of ablation failure. This occurs despite persistent occlusion of the great saphenous vein since the strategy of laser and radiofrequency (RF) treatment is saphenous ablation distal to groin tributaries, a method that corresponds to "low" ligation using a traditional open surgical technique, Dr. Gloviczki said at the Veith symposium on vascular medicine, which was sponsored by the Cleveland Clinic.

The development of recurrent varicose veins, deterioration of quality of life, and worsening of the patient’s VCSS (Venous Clinical Severity Scores) after the procedure are considered clinical failures. Any ablation procedure could also be considered a failure if there is a high risk of complications and if the cost is excessive, said Dr. Gloviczki, the Joe M. and Ruth Roberts Professor of Surgery at the Gonda Vascular Center at the Mayo Clinic in Rochester, Minn.

The common theme for anatomical failure is saphenous recanalization in 5%-26% of cases, which occurs after a very high rate of immediate early occlusion (reaching greater than 95% for the latest-generation laser and RF ablation). Anatomical failure, however, does not translate into clinical failure in most patients; more than three-fourths of those with recanalized saphenous veins remain asymptomatic at 1-2 years after intervention.

To illustrate this, Dr. Gloviczki discussed an important study of 185 limbs that grouped failures into the following three types:

Type 1 (nonocclusion). The treated vein failed to occlude initially and never occluded during follow-up (12%).

Type 2 (recanalization). The vein occluded after treatment but later recanalized partly or completely (70%).

Type 3 (groin reflux). The vein trunk occluded, but reflux was detected at the groin region, often involving an accessory vein (18%).

Most patients had symptomatic improvement despite anatomical failure, and 70%-80% of these "failed" patients remained asymptomatic, compared with 85%-94% of those with anatomical success. Varicose vein recurrence, however, was more frequent with type 2 and type 3 failures. The study investigators found that with the first-generation RF device, catheter pull-back speed and body mass index were the two risk factors associated with anatomical failures, Dr. Gloviczki said in an interview.

In Europe, steam has been used increasingly for thermal ablation, but whether this is more effective than RF and laser ablation remains to be seen, he stated.

Whatever the technique, endovenous thermal ablations are here to stay and clinical failure rates in the short- and midterms are comparable with those observed after open surgical treatment, he said. "So far, there is no convincing evidence that, of the currently used latest generation endothermal ablation techniques, one is better than the other or that any of them has a different failure rate than the traditional open surgery with high ligation and stripping," he added.

Endovenous thermal ablations with heat have revolutionized the treatment of patients with chronic venous disease. Both radiofrequency and laser ablations have been equally effective in causing early occlusion of the saphenous vein in more than 90% of patients in most studies, according to Dr. Peter Gloviczki.

The main reasons for anatomical failure of endothermal saphenous ablations are persistent patency of the vein after treatment and recanalization of the vein after primary occlusion. Reflux through saphenous tributaries and accessory saphenous veins is another cause of ablation failure. This occurs despite persistent occlusion of the great saphenous vein since the strategy of laser and radiofrequency (RF) treatment is saphenous ablation distal to groin tributaries, a method that corresponds to "low" ligation using a traditional open surgical technique, Dr. Gloviczki said at the Veith symposium on vascular medicine, which was sponsored by the Cleveland Clinic.

The development of recurrent varicose veins, deterioration of quality of life, and worsening of the patient’s VCSS (Venous Clinical Severity Scores) after the procedure are considered clinical failures. Any ablation procedure could also be considered a failure if there is a high risk of complications and if the cost is excessive, said Dr. Gloviczki, the Joe M. and Ruth Roberts Professor of Surgery at the Gonda Vascular Center at the Mayo Clinic in Rochester, Minn.

The common theme for anatomical failure is saphenous recanalization in 5%-26% of cases, which occurs after a very high rate of immediate early occlusion (reaching greater than 95% for the latest-generation laser and RF ablation). Anatomical failure, however, does not translate into clinical failure in most patients; more than three-fourths of those with recanalized saphenous veins remain asymptomatic at 1-2 years after intervention.

To illustrate this, Dr. Gloviczki discussed an important study of 185 limbs that grouped failures into the following three types:

Type 1 (nonocclusion). The treated vein failed to occlude initially and never occluded during follow-up (12%).

Type 2 (recanalization). The vein occluded after treatment but later recanalized partly or completely (70%).

Type 3 (groin reflux). The vein trunk occluded, but reflux was detected at the groin region, often involving an accessory vein (18%).

Most patients had symptomatic improvement despite anatomical failure, and 70%-80% of these "failed" patients remained asymptomatic, compared with 85%-94% of those with anatomical success. Varicose vein recurrence, however, was more frequent with type 2 and type 3 failures. The study investigators found that with the first-generation RF device, catheter pull-back speed and body mass index were the two risk factors associated with anatomical failures, Dr. Gloviczki said in an interview.

In Europe, steam has been used increasingly for thermal ablation, but whether this is more effective than RF and laser ablation remains to be seen, he stated.

Whatever the technique, endovenous thermal ablations are here to stay and clinical failure rates in the short- and midterms are comparable with those observed after open surgical treatment, he said. "So far, there is no convincing evidence that, of the currently used latest generation endothermal ablation techniques, one is better than the other or that any of them has a different failure rate than the traditional open surgery with high ligation and stripping," he added.

Diagnosing and treating congenital heart disease outside of developed countries remain major problems for pediatric health across the world, despite some recent improvements in strategies and infrastructure in selected nations.

The disparity is tremendous, with about one facility capable of performing open-heart surgery for every 120,000 people in America, compared with one similarly capable center for every 33 million people in Africa, or for every 16 million people in Asia. This means that “the majority [of children with congenital and acquired heart diseases] will never receive the treatment they need,” according to a release by the Children's HeartLink, an international medical charity founded in 1969. The charity produced a report entitled “Linked by a Common Purpose: Global Efforts for Improving Pediatric Heart Health,” available at www.childrensheartlink.org

The report details the incidence and prevalence of congenital and acquired heart disease. Although congenital heart problems occur at similar rates in both the developed and developing world, diagnosis and treatment are often delayed in the poorer countries, which creates a significant backlog of cases for treatment centers, even when treatment is available.

Diagnosing and treating congenital heart disease outside of developed countries remain major problems for pediatric health across the world, despite some recent improvements in strategies and infrastructure in selected nations.

The disparity is tremendous, with about one facility capable of performing open-heart surgery for every 120,000 people in America, compared with one similarly capable center for every 33 million people in Africa, or for every 16 million people in Asia. This means that “the majority [of children with congenital and acquired heart diseases] will never receive the treatment they need,” according to a release by the Children's HeartLink, an international medical charity founded in 1969. The charity produced a report entitled “Linked by a Common Purpose: Global Efforts for Improving Pediatric Heart Health,” available at www.childrensheartlink.org

The report details the incidence and prevalence of congenital and acquired heart disease. Although congenital heart problems occur at similar rates in both the developed and developing world, diagnosis and treatment are often delayed in the poorer countries, which creates a significant backlog of cases for treatment centers, even when treatment is available.

Diagnosing and treating congenital heart disease outside of developed countries remain major problems for pediatric health across the world, despite some recent improvements in strategies and infrastructure in selected nations.

The disparity is tremendous, with about one facility capable of performing open-heart surgery for every 120,000 people in America, compared with one similarly capable center for every 33 million people in Africa, or for every 16 million people in Asia. This means that “the majority [of children with congenital and acquired heart diseases] will never receive the treatment they need,” according to a release by the Children's HeartLink, an international medical charity founded in 1969. The charity produced a report entitled “Linked by a Common Purpose: Global Efforts for Improving Pediatric Heart Health,” available at www.childrensheartlink.org

The report details the incidence and prevalence of congenital and acquired heart disease. Although congenital heart problems occur at similar rates in both the developed and developing world, diagnosis and treatment are often delayed in the poorer countries, which creates a significant backlog of cases for treatment centers, even when treatment is available.

A new certification program for the implantation of left ventricular assist devices was released for review by the Joint Commission on Accreditation of Healthcare Organizations.

The certification will be conducted within the Disease‐Specific Care Certification program. Organizations seeking certification will have to meet the standards, practice guidelines, and performance measurements of the specific‐care program, as well as left ventricular assist device (LVAD)‐specific requirements based on those used in the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial, according to the Association for the Advancement of Medical Instrumentation (AAMI). The AAMI expects the requirements to be ready for Centers for Medicare and Medicaid Services review by April.

A new certification program for the implantation of left ventricular assist devices was released for review by the Joint Commission on Accreditation of Healthcare Organizations.

The certification will be conducted within the Disease‐Specific Care Certification program. Organizations seeking certification will have to meet the standards, practice guidelines, and performance measurements of the specific‐care program, as well as left ventricular assist device (LVAD)‐specific requirements based on those used in the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial, according to the Association for the Advancement of Medical Instrumentation (AAMI). The AAMI expects the requirements to be ready for Centers for Medicare and Medicaid Services review by April.

A new certification program for the implantation of left ventricular assist devices was released for review by the Joint Commission on Accreditation of Healthcare Organizations.

The certification will be conducted within the Disease‐Specific Care Certification program. Organizations seeking certification will have to meet the standards, practice guidelines, and performance measurements of the specific‐care program, as well as left ventricular assist device (LVAD)‐specific requirements based on those used in the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial, according to the Association for the Advancement of Medical Instrumentation (AAMI). The AAMI expects the requirements to be ready for Centers for Medicare and Medicaid Services review by April.