Doug Brunk

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to 70 years of age, results from a large Canadian study showed.

Although observational studies have suggested that bilateral internal thoracic artery grafting (BITA) can be ideal for this population of patients, it is used in just 4% of coronary artery bypass graft (CABG) cases in North America and 12% of CABG cases in Europe, Dr. Teresa M. Kieser said at the annual meeting of the Society of Thoracic Surgeons.

"Why is it not used more often?" asked Dr. Kieser, a cardiac surgeon at the University of Calgary (Alta.). "Longer OR times, technical demands, and risks to patients. BITA today is reserved for the young, but who are the young? Currently there are no age guidelines for the performance of CABG with BITA. We set out to determine if there is an age cutoff point until which BITA is better."

She and her associates studied 5,601 consecutive patients who underwent isolated primary CABG between April 1995 and March 2008 and were followed to March 2009. The patients were linked to the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), an ongoing initiative that captures detailed clinical information on all patients undergoing cardiac catheterization and subsequent intervention in the province of Alberta since 1995.

The researchers used a Cox model to compare survival by type of internal thoracic artery graft used (bilateral, single, or none), and they adjusted for baseline clinical and demographic differences. The primary outcome was all-cause mortality, which included operative mortality. Secondary outcomes included cardiac catheterization, percutaneous coronary intervention, repeat CABG, and death within 1 year.

The mean age of the 5,601 patients was 64 years; 18.5% underwent BITA, 72% had single internal thoracic artery grafting (SITA), and 9.5% underwent CABG with vein only.

Dr. Kieser reported that, compared with patients in the other treatment groups, those in the BITA group were younger and more often male; had less comorbidity, lower European System for Cardiac Operative Risk Evaluation scores, and a higher ejection fraction; and underwent cardiac catheterization more often for stable angina.

The proportion of repeat procedures within 1 year of CABG was similar among all groups. However, those who underwent BITA had significantly lower mortality at 1 year, compared with their counterparts in the SITA and vein-only groups (2.4% vs. 4.3% and 8.2%, respectively).

During a mean follow-up of 7 years, 1,233 patients (22%) died. Patients in the BITA group had significantly lower crude long-term mortality, compared with those in the SITA and vein-only groups (16.7% vs. 40.1% and 42%, respectively). "This survival difference appeared to increase over prolonged follow-up," Dr. Kieser said.

After multivariable adjustment, the survival advantage for patients in the BITA groups was no longer statistically significant. "Perhaps a longer period of follow-up will clarify the presence or absence of a BITA advantage," she said.

A spline analysis that plotted hazard ratio for BITA relative to SITA across ages showed a trend toward a survival benefit of BITA, compared with SITA, in patients up to the age of 70 years. Age therefore appeared to be a modifier of the BITA effect.

"As the benefits of BITA become more obvious over time, a longer period of follow-up will be needed to confirm or deny the advantage of a BITA strategy," Dr. Kieser said. "We must advise caution in use of BITA in patients older than 70 years until more is known about BITA in this age group."

Dr. Kieser said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women's Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study's primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women's Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study's primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women's Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study's primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women’s Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study’s primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women’s Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study’s primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women’s Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study’s primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women’s Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study’s primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women’s Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study’s primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – Foam sclerotherapy alone was just as effective as ultrasound-guided foam sclerotherapy for the treatment of great saphenous vein reflux, results from a single-center study showed.

Dr. Takashi Yamaki, a vascular surgeon, and his associates in the department of plastic and reconstructive surgery at Tokyo Women’s Medical University conducted a randomized study between January and July 2010 in which 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy and 52 limbs in 49 patients were treated with foam sclerotherapy alone.

Patients in the combined-treatment group received less than 0.5 mL of 1% polidocanol foam per injection to minimize any foam migration beyond the target vein, said Dr. Yamaki at the annual meeting of the American Venous Forum.

Patients in the foam-only treatment group received more than 0.5 mL of 1% polidocanol foam per injection, but the amount never exceeded 1.0 mL.

The researchers conducted ultrasonographic inspection of the foam in the greater saphenous vein for 5 minutes before compression was applied. They also conducted postsclerotherapy surveillance at 1, 3, and 6 months. The study’s primary end point was elimination of greater saphenous vein reflux at 6 months.

The mean age of patients was 66 years, and 71% were female. There were no differences between the groups in terms of CEAP clinical classification (which is based on clinical severity, etiology or cause, anatomy, and pathophysiology) or venous clinical severity scores.

Dr. Yamaki reported that the mean greater saphenous vein diameter was 0.6 cm in the combined-treatment group and 0.57 cm in the foam-only treatment group, a difference that was not significant. The mean injected volume of foam for varicose tributary veins was significantly lower in the combined-treatment group than in the foam-only group (3.9 mL vs. 5.8 mL, respectively). However, the mean total amount of injected foam was significantly higher in the combined-treatment group than in the foam-only group (6.5 mL vs. 5.8 mL).

Ultrasonic evaluation revealed complete spasm of the greater saphenous vein in 73% of limbs that underwent combined treatment, compared with 56% of limbs that underwent foam-only treatment, a difference that was not significant.

At 6 months the researchers observed absence of reflux in 59% of limbs that underwent combined treatment, compared with 71% of limbs that underwent foam-only treatment, a difference that was not significant.

No serious complications occurred in either group.

"Further studies are required in order to define the predictive factors for successful outcome, especially in patients with uncomplicated varicose veins, including factors such as foam production, the optimal volume of foam, the use of physiologic gases, injection techniques, and the optimal period of use of compression stockings," said Dr. Yamaki.

Zeria Pharmaceutical provided the 1% polidocanol used in the study. Dr. Yamaki said that he had no relevant financial disclosures.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – No differences in clinical outcomes or angiographic results were observed in off-pump coronary artery bypass patients who received bilateral internal thoracic arteries as in situ vs. as Y-composite grafts, a long-term single-center study showed.

"There have been reports that bilateral internal thoracic artery grafting [BITA] may improve long-term survival and freedom from reintervention," Dr. Ho Young Hwang said at the annual meeting of the Society of Thoracic Surgeons. "Previous studies have suggested that clinical results might be better with in situ BITA. Other studies have suggested that 8-year survival and 8-year event-free survival are similar between BITA as in situ vs. BITA as Y-composite grafts."

The purpose of the current study was to compare 5-year angiographic patency rates and long-term clinical outcomes in 398 patients who underwent off-pump coronary artery bypass at Seoul National University Hospital, Korea, between June 1998 and December 2003. Of the 398 patients, 164 received BITA as in situ grafts and 234 received BITA as Y-composite grafts. The mean age of patients at baseline was 62 years. The researchers selected 220 propensity score–matched patients for analysis (110 in the in situ graft group and 110 in the Y-composite graft group).

Dr. Hwang, of the hospital’s department of thoracic and cardiovascular surgery, reported that the rates of early mortality were similar between the in situ graft group and the Y-composite graft group (1.8% vs. 0.9%, respectively). The rates of postoperative complications were also similar between groups, with atrial fibrillation being the most common complication (13.6% vs. 17.3%, respectively).

The researchers performed early, 1-year, and 5-year postoperative angiographies in 217, 202, and 167 patients, respectively. They observed no significant differences in patency rates of BITA between the groups at 5 years (92.5% in the in situ graft group vs. 92.4% in the Y-composite graft group) or in the rate of overall 10-year survival (85.6% vs. 81.6%, respectively), 10-year freedom from cardiac death (95.1% vs. 94.2%), reintervention-free survival (86.3% vs. 82.5%), and freedom from major adverse cardiac events (83.2% vs. 80.3%).

Dr. Hwang said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Caval angulation and filter tilt complicate removal of inferior vena cava filters, results from a large single-center study demonstrated.

"The use of retrievable IVC filters has increased significantly over the past 10 years," Jennifer Stevens said at the annual meeting of the American Venous Forum. "However, these filters have become permanent in many cases, with retrieval rates ranging anywhere from 15% to 59%. In one multicenter study, the retrieval rate was only 21%."

In an effort to examine patient characteristics and anatomic predictors associated with nonretrieval of IVC filters, Ms. Stevens, a fourth-year medical student at the University of Pittsburgh, and her associates reviewed all retrievable IVC filters that were placed in 404 patients at the university’s medical center between 2004 and 2009. Caval angulation at the lowest renal vein was categorized as straight, less than 30 degrees, 30-60 degrees, and greater than 60 degrees. Filter tilt was classified as none, less than 45 degrees, and 45-90 degrees. Filter thrombus was classified as less than one-third or greater than one-third.

Ms. Stevens reported that the majority of filters (65%) were placed in trauma patients, with prophylactic indications for insertion (57%). More than one-third of patients (41%) were between the ages of 26 and 50 years, and 61% were male.

Of the 404 filters placed, 166 (41%) were not retrieved. "These patients were more likely to be middle-aged males with a therapeutic indication for insertion," she said.

The most common reasons for nonretrieval were physician oversight (38%) and patient noncompliance (20%). Other reasons included significant thrombus that precluded removal (5%), a medical decision to leave the filter permanently placed (11%), and mechanical inability to remove the filter (12%).

The majority of the 24 cases of attempted but failed retrieval were in female trauma patients aged 51-75 years with a history of prior deep vein thrombosis requiring prophylactic filter insertion. "All of these retrievals had more than one separate attempt made before retrieval was aborted," Ms. Stevens said.

Dwell time was higher in patients who had failed retrieval (mean of 67 days vs. 30 days in patients whose filters were successfully retrieved), and 29% were still on warfarin. "Of note, 71% of these patients were categorized with a less than 30-degree angulation at the level of the renal vein," she said.

Ms. Stevens also presented findings from a subset of 39 cases of difficult filter retrievals that required adjunctive maneuvers, most commonly an extra snare (55%). More than half of these cases (62%) involved the Tulip filter.

Of all filters placed, 82 (20%) had apposition of the hook into the caval wall. Of those filters, 9 (11%) were difficult to retrieve.

Predictors of failed or difficult retrieval included any filter tilt or angulation at the renal veins (odds ratio 3.99) and longer dwell time (OR 1.02). Caval penetration by a filter strut was not a significant predictor of failed or difficult retrieval.

"From an anatomic standpoint, caval angulation and filter tilt complicate IVC filter retrieval," Ms. Stevens concluded. "Consideration should be given to deploying in a straight segment of the IVC even if not flush with the renal veins in order to optimize retrieval. Dwell time adversely affects retrieval success, and the overall retrieval rate continues to be moderate, suggesting physician prompts and patient follow-up reminders as possible future targets for improvement."

The study’s principal investigator was Dr. Rabih A. Chaer, a vascular surgeon at the university.

Ms. Stevens and Dr. Chaer had no relevant financial disclosures.

SAN DIEGO – Caval angulation and filter tilt complicate removal of inferior vena cava filters, results from a large single-center study demonstrated.

"The use of retrievable IVC filters has increased significantly over the past 10 years," Jennifer Stevens said at the annual meeting of the American Venous Forum. "However, these filters have become permanent in many cases, with retrieval rates ranging anywhere from 15% to 59%. In one multicenter study, the retrieval rate was only 21%."

In an effort to examine patient characteristics and anatomic predictors associated with nonretrieval of IVC filters, Ms. Stevens, a fourth-year medical student at the University of Pittsburgh, and her associates reviewed all retrievable IVC filters that were placed in 404 patients at the university’s medical center between 2004 and 2009. Caval angulation at the lowest renal vein was categorized as straight, less than 30 degrees, 30-60 degrees, and greater than 60 degrees. Filter tilt was classified as none, less than 45 degrees, and 45-90 degrees. Filter thrombus was classified as less than one-third or greater than one-third.

Ms. Stevens reported that the majority of filters (65%) were placed in trauma patients, with prophylactic indications for insertion (57%). More than one-third of patients (41%) were between the ages of 26 and 50 years, and 61% were male.

Of the 404 filters placed, 166 (41%) were not retrieved. "These patients were more likely to be middle-aged males with a therapeutic indication for insertion," she said.

The most common reasons for nonretrieval were physician oversight (38%) and patient noncompliance (20%). Other reasons included significant thrombus that precluded removal (5%), a medical decision to leave the filter permanently placed (11%), and mechanical inability to remove the filter (12%).

The majority of the 24 cases of attempted but failed retrieval were in female trauma patients aged 51-75 years with a history of prior deep vein thrombosis requiring prophylactic filter insertion. "All of these retrievals had more than one separate attempt made before retrieval was aborted," Ms. Stevens said.

Dwell time was higher in patients who had failed retrieval (mean of 67 days vs. 30 days in patients whose filters were successfully retrieved), and 29% were still on warfarin. "Of note, 71% of these patients were categorized with a less than 30-degree angulation at the level of the renal vein," she said.

Ms. Stevens also presented findings from a subset of 39 cases of difficult filter retrievals that required adjunctive maneuvers, most commonly an extra snare (55%). More than half of these cases (62%) involved the Tulip filter.

Of all filters placed, 82 (20%) had apposition of the hook into the caval wall. Of those filters, 9 (11%) were difficult to retrieve.

Predictors of failed or difficult retrieval included any filter tilt or angulation at the renal veins (odds ratio 3.99) and longer dwell time (OR 1.02). Caval penetration by a filter strut was not a significant predictor of failed or difficult retrieval.

"From an anatomic standpoint, caval angulation and filter tilt complicate IVC filter retrieval," Ms. Stevens concluded. "Consideration should be given to deploying in a straight segment of the IVC even if not flush with the renal veins in order to optimize retrieval. Dwell time adversely affects retrieval success, and the overall retrieval rate continues to be moderate, suggesting physician prompts and patient follow-up reminders as possible future targets for improvement."

The study’s principal investigator was Dr. Rabih A. Chaer, a vascular surgeon at the university.

Ms. Stevens and Dr. Chaer had no relevant financial disclosures.

SAN DIEGO – Caval angulation and filter tilt complicate removal of inferior vena cava filters, results from a large single-center study demonstrated.

"The use of retrievable IVC filters has increased significantly over the past 10 years," Jennifer Stevens said at the annual meeting of the American Venous Forum. "However, these filters have become permanent in many cases, with retrieval rates ranging anywhere from 15% to 59%. In one multicenter study, the retrieval rate was only 21%."

In an effort to examine patient characteristics and anatomic predictors associated with nonretrieval of IVC filters, Ms. Stevens, a fourth-year medical student at the University of Pittsburgh, and her associates reviewed all retrievable IVC filters that were placed in 404 patients at the university’s medical center between 2004 and 2009. Caval angulation at the lowest renal vein was categorized as straight, less than 30 degrees, 30-60 degrees, and greater than 60 degrees. Filter tilt was classified as none, less than 45 degrees, and 45-90 degrees. Filter thrombus was classified as less than one-third or greater than one-third.

Ms. Stevens reported that the majority of filters (65%) were placed in trauma patients, with prophylactic indications for insertion (57%). More than one-third of patients (41%) were between the ages of 26 and 50 years, and 61% were male.

Of the 404 filters placed, 166 (41%) were not retrieved. "These patients were more likely to be middle-aged males with a therapeutic indication for insertion," she said.

The most common reasons for nonretrieval were physician oversight (38%) and patient noncompliance (20%). Other reasons included significant thrombus that precluded removal (5%), a medical decision to leave the filter permanently placed (11%), and mechanical inability to remove the filter (12%).

The majority of the 24 cases of attempted but failed retrieval were in female trauma patients aged 51-75 years with a history of prior deep vein thrombosis requiring prophylactic filter insertion. "All of these retrievals had more than one separate attempt made before retrieval was aborted," Ms. Stevens said.

Dwell time was higher in patients who had failed retrieval (mean of 67 days vs. 30 days in patients whose filters were successfully retrieved), and 29% were still on warfarin. "Of note, 71% of these patients were categorized with a less than 30-degree angulation at the level of the renal vein," she said.

Ms. Stevens also presented findings from a subset of 39 cases of difficult filter retrievals that required adjunctive maneuvers, most commonly an extra snare (55%). More than half of these cases (62%) involved the Tulip filter.

Of all filters placed, 82 (20%) had apposition of the hook into the caval wall. Of those filters, 9 (11%) were difficult to retrieve.

Predictors of failed or difficult retrieval included any filter tilt or angulation at the renal veins (odds ratio 3.99) and longer dwell time (OR 1.02). Caval penetration by a filter strut was not a significant predictor of failed or difficult retrieval.

"From an anatomic standpoint, caval angulation and filter tilt complicate IVC filter retrieval," Ms. Stevens concluded. "Consideration should be given to deploying in a straight segment of the IVC even if not flush with the renal veins in order to optimize retrieval. Dwell time adversely affects retrieval success, and the overall retrieval rate continues to be moderate, suggesting physician prompts and patient follow-up reminders as possible future targets for improvement."

The study’s principal investigator was Dr. Rabih A. Chaer, a vascular surgeon at the university.

Ms. Stevens and Dr. Chaer had no relevant financial disclosures.