- Vascular and Endovascular Surgery
MD, Yale School of Medicine, Doctor of Medicine (2020)
MHS, Yale School of Medicine, Translational Research (2020)
MS, Yale Graduate School of Arts and Sciences, Molecular Biology (2015)
BS, Yale College, Molecular, Cellular and Developmental Biology (2015)
Comparison of Atherectomy to Balloon Angioplasty and Stenting for Isolated Femoropopliteal Revascularization.
Annals of vascular surgery
The use of atherectomy for lower extremity revascularization is increasing despite concerning reports about its long-term safety and effectiveness. This study compares the outcomes of atherectomy to percutaneous transluminal angioplasty (PTA) and stenting for treatment of isolated femoropopliteal disease.All patients undergoing endovascular treatment of isolated femoropopliteal lesions in the Vascular Quality Initiative (2009-2018) were identified. Patients with concomitant open surgery, acute limb ischemia, or iliac or tibial intervention were excluded. Patients were divided into 3 treatment groups: atherectomy with or without PTA, PTA alone and stenting alone. Propensity matching was performed based on age, gender, race, ambulatory-status, diabetes, smoking, hypertension, coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, dialysis, prior inflow bypass and intervention, prior major ipsilateral amputation, indication, length of treated lesion, American Society of Anesthesiologists class, and TASC II classification. The perioperative and one-year outcomes of the matched groups were compared.A total of 10,007 atherectomy, 22,000 PTA and 27,579 stenting of isolated femoropopliteal disease were identified. After matching, there were 6,372 procedures in atherectomy and PTA groups respectively. Atherectomy was associated with higher likelihood of technical success (98.3% vs 97.5%; P<.001) and shorter length of stay (1.8 ± 8.2 days vs 2.7 ± 15.7 days; P<.001), but had increased rate of distal embolization (2% vs 1.1%; P<.001) compared to PTA. At one year, atherectomy was associated with improved primary patency (84.2% vs 82%; P=.047) and survival rate (91.1% vs 90%; P=.044), but was also associated with a higher reintervention rate (15.7% vs 13.6%; P=0.033) compared to PTA. There was no difference in the rates of major amputation, ambulatory-status improvement or ABI improvement. In the second analysis, after matching, there were 6,877 procedures in the atherectomy and stenting groups respectively. Atherectomy was associated with lower rate of dissection (3.7% vs 8.2% <.001), lower rate of perforation (0.6% vs 1.2%; P<.001) and a shorter length of stay (1.9 ± 8.1 vs 2.9 ± 9.8 days; P<.001) compared to stenting. However, patients treated with atherectomy had a lower rate of technical success (98.3% vs 99.2%; P<.001) and a higher rate of distal embolization (2% vs 1.2%; P<.001) compared to stenting. At one year, atherectomy was associated with a higher rate of major ipsilateral amputation (5.3% vs 4.1%; P=.046) and less improvement in ABI (0.19 ± 0.42 vs 0.25 ± 0.4; P<.001) compared to stenting. There was no difference in rates of primary patency, survival, reintervention, ambulatory-status improvement at one year.Atherectomy does not seem to confer any significant additional clinical benefit compared to balloon angioplasty or stenting. Further research is needed to justify its additional cost over other endovascular modalities.
View details for DOI 10.1016/j.avsg.2020.05.019
View details for PubMedID 32512112
Using the epidemiology of critical limb ischemia to estimate the number of patients amenable to endovascular therapy.
Vascular medicine (London, England)
2020; 25 (1): 78–87
Critical limb ischemia represents the advanced stage of peripheral artery disease, a health problem with increasing prevalence. Critical limb ischemia is associated with significant mortality, limb loss, pain, and diminished health-related quality of life. Public awareness and early diagnosis are necessary for an effective treatment with early risk factor modification, smoking cessation, and exercise therapy. Herein, we present an overview of the epidemiology as well as the clinical stages of the disease, and estimate that there are 6.5 million patients with critical limb ischemia in the US, Europe, and Japan based on global population-based studies. At least 75% of these patients, accounting for approximately 4.8 million patients, are amenable to endovascular therapy.
View details for DOI 10.1177/1358863X19878271
View details for PubMedID 31621531
Endovascular Revascularization Incorporating Infrapopliteal Coronary Drug-Eluting Stents Improves Clinical Outcomes in Patients with Critical Limb Ischemia and Tissue Loss.
Annals of vascular surgery
2020; 63: 234–40
Critical limb ischemia (CLI) involving infrapopliteal arterial atherosclerosis and tissue loss remains a formidable clinical scenario with significant morbidity and mortality. Despite level IA evidence, tibial revascularization with coronary drug-eluting stents (DES) remains a seldom-used technique in the United States due, in part, to lack of a Food and Drug Administration-approved indication and dedicated stent technology for infrapopliteal application. Furthermore, follow-up data beyond 1 year remain scarce, and further evidence for improvement in clinical outcomes using this technique is needed. Herein, we present our multi-institutional experience with endovascular revascularization of patients with CLI and tissue loss using coronary DES for infrapopliteal lesions of appropriate dimensions and the Wound, Ischemia, and foot Infection (WIfI) score as supportive evidence for improvement in clinical outcomes.In this retrospective study, 40 sequential tibial revascularization procedures performed in 32 patients with CLI were reviewed. Outcomes including changes in WIfI scores, patency rates, freedom from major amputation, target lesion recurrence, and all-cause mortality were analyzed. Average follow-up duration was 19.3 months (interquartile range: 7-27.1 months).Freedom from major amputation was 88.6%. One-year primary patency was 90.3%. Mean ankle-brachial indices increased after revascularization (0.57 ± 0.26 to 0.97 ± 0.26; P = 0.03). All components of the WIfI score significantly improved after revascularization (W: 1.9 to 1.1, P = 0.03; I: 2.0 to 0.6, P = 0.001; and fI: 1.5 to 0.8, P = 0.01). WIfI risk of major amputation score before revascularization was 3.58 ± 0.75 (high risk), which was reduced to 2.04 ± 1.31 (low risk; P < 0.001). One-year survival rate was 90.6%.Coronary DES continue to demonstrate promising primary patency and limb salvage rates in appropriately selected patients undergoing multilevel endovascular revascularization for CLI and tissue loss. In addition to its value as a predictor for major amputation and revascularization benefit, the WIfI score can also serve as a multicomponent tool for objective assessment of outcomes after revascularization.
View details for DOI 10.1016/j.avsg.2019.07.011
View details for PubMedID 31563654
Use of neuraxial anesthesia for hybrid lower extremity revascularization is associated with reduced perioperative morbidity.
Journal of vascular surgery
2020; 71 (4): 1296–1304.e7
Recent advances in endovascular technology have allowed complex peripheral arterial disease (PAD) to be treated with less invasive hybrid procedures under neuraxial anesthesia. This study investigates the perioperative outcomes of hybrid lower extremity revascularization (LER) performed under neuraxial anesthesia (NAA) vs general anesthesia (GA). We hypothesize that the use of NAA is associated with improved outcomes.The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program dataset was used to identify patients who underwent hybrid LER for PAD. Based on the primary anesthetic technique, patients were divided into two groups: GA and NAA, which included spinal or epidural anesthesia. Baseline characteristics of the two groups were compared. A group of patients treated under GA were matched (2:1) to patients in the NAA group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease, wound infection, American Society of Anesthesiologists classification, emergent surgery, preoperative sepsis, indication, and type of hybrid procedure. Patient characteristics and 30-day outcomes were compared.Of 9430 patients who underwent hybrid LER, only 452 (4.8%) received NAA. Patients who received NAA were older (mean age, 68 ± 8.4 vs 72.3 ± 9.2; P = .004) and were more likely to be white (70.9% vs 85.6%; P < .0001), have dependent functional status (7.6% vs 13.1%; P < .0001), chronic obstructive pulmonary disease (24.3% vs 17.5%; P = .001), and a diagnosis of wound infection (15% vs 23.5%; P < .0001). After propensity matching, 904 patients in the GA group were compared with 452 patients in the NAA group with no difference in baseline characteristics. NAA was associated with reduced rate of more than 48 hours' ventilator requirement (2.4% vs 0.2%; P = .0014), bleeding requiring transfusion (17.5% vs 8%; P < .0001), and overall morbidity (29.3% vs 19%; P < .0001), as well as shorter length of hospital stay (6.8 ± 9.3 vs 5.3 ± 6.1 days; P = .0026) and total operating time (237.8 ± 109 vs 202.4 ± 113 minutes; P < .0001) compared with GA.NAA is an infrequently used anesthesia technique during hybrid LER and is primarily used for older patients with chronic obstructive pulmonary disease. NAA is associated with decreased perioperative morbidity and length of hospital stay compared with GA and may be considered in this sicker patient population.
View details for DOI 10.1016/j.jvs.2019.07.072
View details for PubMedID 31708304
Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization.
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
2020; 27 (1): 94–101
Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.
View details for DOI 10.1177/1526602819887382
View details for PubMedID 31746264
- Transcarotid Artery Revascularization With Flow Reversal-Reply. JAMA surgery 2020
Rapid increase in hybrid surgery for the treatment of peripheral artery disease in the Vascular Quality Initiative database.
Journal of vascular surgery
Advances in technology have increased the use of endovascular therapy for lower extremity revascularization (LER), but the impact on hybrid surgery has not been studied. This study aims to (1) investigate the contemporary national trends in frequency of hybrid LER and (2) compare the outcomes of open bypass (BYP) and hybrid surgery for isolated femoropopliteal revascularization.Using the national Vascular Quality Initiative database from 2010 to 2017, all patients receiving bypass or hybrid LER for PAD were identified. A trend of all hybrid LER compared with open LER was obtained. Next, only patients who underwent hybrid or open isolated femoropopliteal LER were identified. Patients treated with hybrid surgery underwent femoral endarterectomy and antegrade endovascular intervention of the femoropopliteal vessels (HYB), whereas patients treated with BYP underwent femoral endarterectomy and femoropopliteal bypass. These two groups of patients were matched based on age, gender, race, indication, ambulatory status, emergency status, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and hemodialysis. Patient characteristics and the perioperative and 1-year outcomes of the two groups were compared.The overall rate of hybrid LER procedures increased from 6.1% in 2010 to 32% in 2017 (P = .03). Hybrid LER was significantly more commonly used in patients with claudication (47%) and BYP surgery was used in patients with tissue loss (38.5%; P = .019). There were 456 HYB and 2665 BYP for isolated femoropopliteal revascularization. After propensity matching, the cohort comprised 425 patients in each group. HYB was associated with lower rate of myocardial infarction (1.9% vs 5.7%; P = .005) and renal complications (2.1% vs 6.7%; P = .003), length of stay (4.7 vs 6.1 days; P = .001), and higher rate of discharge to home (90.8% vs 81.4%; P < .001) compared with BYP. There was no significant difference in 30-day mortality (HYB 1.5% vs BYP, 2.5%; P = .44). The 1-year outcomes comparison suggested that patients in the BYP group had a higher likelihood of improvement in ambulatory status compared with patients in HYB group (16.7% vs 7.7%; P = .044). However, Kaplan-Meier analysis showed no difference in overall survival (P = .13) or amputation-free survival (P = .057) between the two groups. There was no statistical difference in graft patency, limb loss, or secondary interventions.Hybrid LER for PAD has been increasingly used and accounts for up to one-third of open LER in the Vascular Quality Initiative. Hybrid femoropopliteal revascularization improves perioperative outcomes compared with femoropopliteal bypass. However, the 1-year outcomes between the two procedures are comparable, suggesting that hybrid femoropopliteal revascularization should be favored in high-risk patients because of its perioperative advantages.
View details for DOI 10.1016/j.jvs.2019.11.041
View details for PubMedID 32067877
Evaluation and management of the lateral marginal vein in Klippel-Trénaunay and other PIK3CA-related overgrowth syndromes.
Journal of vascular surgery. Venous and lymphatic disorders
The lateral marginal vein is an anomalous clinical entity found in association with Klippel-Trénaunay and other PIK3CA-related overgrowth syndromes. Although it is reported to affect <20% of patients with Klippel-Trénaunay syndrome, this venous anomaly has been associated with significant morbidity and mortality attributable to venous hypertension and potentially lethal thromboembolic events. Limited literature exists on the diagnosis and management of this rare anomaly, with most of the reports focusing on retrospective clinical experience at a few centers of excellence. Despite these limitations, a systematic approach to diagnosis and treatment of this anomaly is warranted and expounded on herein. When plausible, clinical recommendations based on best available literature are made.
View details for DOI 10.1016/j.jvsv.2019.12.003
View details for PubMedID 32089498
- Lipiodol as an Imaging Biomarker of Tumor Response After Conventional Transarterial Chemoembolization: Prospective Clinical Validation in Patients with Primary and Secondary Liver Cancer. Translational oncology 2020; 13 (3): 100742
Induced pluripotent stem cell-derived smooth muscle cells increase angiogenesis and accelerate diabetic wound healing.
Aim: To assess the potential of human induced pluripotent stem cell-derived smooth muscle cells (hiPSC-SMC) to accelerate diabetic wound healing. Methods: hiPSC-SMC were embedded in 3D collagen scaffolds and cultured in vitro for 72 h; scaffolds were then applied to diabetic, nude mouse, splinted back wounds to assess in vivo healing. Cultured medium after scaffold incubation was collected and analyzed for expression of pro-angiogenic cytokines. Results: hiPSC-SMC secrete increased concentration of pro-angiogenic cytokines, compared with murine adipose derived stem cells. Delivery of hiPSC-SMC-containing collagen scaffolds accelerates diabetic wound healing and is associated with an increased number of total and M2 type macrophages. Conclusion: hiPSC-SMC promote angiogenesis and accelerate diabetic wound healing, making them a promising new candidate for treatment of diabetic wounds.
View details for DOI 10.2217/rme-2019-0086
View details for PubMedID 32228292
Technical and Ethical Challenges in the Care of an Independent Nonagenarian with Critical Limb Ischemia.
Archives of Clinical and Medical Case Reports
2020; 4 (1): 130-137
View details for DOI 10.26502/acmcr.96550178
Altered hemodynamics during arteriovenous fistula remodeling leads to reduced fistula patency in female mice
Journal of Vascular Surgery. Vascular Science
View details for DOI 10.1016/j.jvssci.2020.03.001
Mechanochemical and surgical ablation of an anomalous upper extremity marginal vein in CLOVES syndrome identifies PIK3CA as the culprit gene mutation
Journal of vascular surgery cases and innovative techniques
2020; 6 (3): 438-442
View details for DOI 10.1016/j.jvscit.2020.05.013
Distinct subsets of T-cells and macrophages impact venous remodeling during arteriovenous fistula maturation
Journal of Vascular Surgery. Vascular Science
2020; 1 (1)
View details for DOI 10.1016/j.jvssci.2020.07.005
Stem Cell Delivery Techniques for Stroke and Peripheral Artery Disease
Stem Cell Therapy for Vascular Diseases
Springer Nature. 2020
View details for DOI 10.1007/978-3-030-56954-9_3
A national post-Match webinar panel improves knowledge and preparedness of medical students interested in vascular surgery training.
Journal of vascular surgery
BACKGROUND: The current shortage of vascular surgeons is projected to worsen. Compared with other surgical residency programs, integrated vascular surgery residency (IVSR) offers fewer training positions and attracts fewer applicants. As a result, only a few medical students from each school match into the specialty, and conventional resources like Match panels are not available to students interested in vascular surgery. We hypothesize that a national post-Match panel webinar will improve medical students' knowledge of the IVSR application process.METHODS: A panel of four recently matched medical students shared their experiences on their successful Match into an IVSR through a 65-minute-long national webinar. Data were collected from students who attended the webinar through anonymous online surveys before and after the panel discussion. The participants' self-reported understanding of the IVSR was assessed using a 5-point Likert scale for 11 questions. Objective knowledge of the IVSR Match process was assessed using five data-based questions. All prewebinar and postwebinar responses were paired and compared using bivariate analysis.RESULTS: A total of 76 participants completed both the prewebinar and postwebinar surveys. The majority of respondents were first-year medical students (51.3%) and attended medical school in the Northeast (38.2%). Among these respondents, 57.6% indicated that their home institution had an IVSR program, 44.7% had an active vascular surgery interest group (VSIG), 14.5% had previously attended a vascular surgery conference, and 28.9% were very likely to apply into an IVSR. After the webinar, more students correctly identified the number of currently existing IVSR training positions (76.3% vs 89.5%; P= .002), duration of IVSR (56.6% vs 85.5%; P< .001), and median Step 1 score (50% vs 84.2%; P< .001) and minimum number of applications (38.2% vs 65.8%; P< .001) recommended for a successful Match into IVSR. Students who had a VSIG at their home institution were found to have a better baseline knowledge of the IVSR based on their higher aggregate scores on the data-based questions (3.4± 1 vs 1.9± 1.2; P< .001) compared with those without one.CONCLUSIONS: A national webinar run by recently matched students can effectively improve medical students' understanding of the IVSR application process. Students with a VSIG at their institutions have a better baseline knowledge of IVSR. In addition to expanding the VSIG, instituting an annual national postmatch webinar may help students become better prepared applicants and improve the overall application pool.
View details for DOI 10.1016/j.jvs.2019.08.282
View details for PubMedID 31843302
Inhibition of the Akt1-mTORC1 Axis Alters Venous Remodeling to Improve Arteriovenous Fistula Patency
2019; 9: 11046
Arteriovenous fistulae (AVF) are the most common access created for hemodialysis, but up to 60% do not sustain dialysis within a year, suggesting a need to improve AVF maturation and patency. In a mouse AVF model, Akt1 regulates fistula wall thickness and diameter. We hypothesized that inhibition of the Akt1-mTORC1 axis alters venous remodeling to improve AVF patency. Daily intraperitoneal injections of rapamycin reduced AVF wall thickness with no change in diameter. Rapamycin decreased smooth muscle cell (SMC) and macrophage proliferation; rapamycin also reduced both M1 and M2 type macrophages. AVF in mice treated with rapamycin had reduced Akt1 and mTORC1 but not mTORC2 phosphorylation. Depletion of macrophages with clodronate-containing liposomes was also associated with reduced AVF wall thickness and both M1- and M2-type macrophages; however, AVF patency was reduced. Rapamycin was associated with improved long-term patency, enhanced early AVF remodeling and sustained reduction of SMC proliferation. These results suggest that rapamycin improves AVF patency by reducing early inflammation and wall thickening while attenuating the Akt1-mTORC1 signaling pathway in SMC and macrophages. Macrophages are associated with AVF wall thickening and M2-type macrophages may play a mechanistic role in AVF maturation. Rapamycin is a potential translational strategy to improve AVF patency.
View details for DOI 10.1038/s41598-019-47542-5
View details for Web of Science ID 000477858900022
View details for PubMedID 31363142
View details for PubMedCentralID PMC6667481
Molecular Targets for Improving Arteriovenous Fistula Maturation and Patency.
Vascular investigation and therapy
2019; 2 (2): 33–41
The increasing prevalence of chronic and end-stage renal disease creates an increased need for reliable vascular access, and although arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access, 60% fail to mature and only 50% remain patent at one year. Fistulae mature by diameter expansion and wall thickening; this outward remodeling of the venous wall in the fistula environment relies on a delicate balance of extracellular matrix (ECM) remodeling, inflammation, growth factor secretion, and cell adhesion molecule upregulation in the venous wall. AVF failure occurs via two distinct mechanisms with early failure secondary to lack of outward remodeling, that is insufficient diameter expansion or wall thickening, whereas late failure occurs with excessive wall thickening due to neointimal hyperplasia (NIH) and insufficient diameter expansion in a previously functional fistula. In recent years, the molecular basis of AVF maturation and failure are becoming understood in order to develop potential therapeutic targets to aide maturation and prevent access loss. Erythropoietin-producing hepatocellular carcinoma (Eph) receptors, along with their ligands, ephrins, determine vascular identity and are critical for vascular remodeling in the embryo. Manipulation of Eph receptor signaling in adults, as well as downstream pathways, is a potential treatment strategy to improve the rates of AVF maturation and patency. This review examines our current understanding of molecular changes occurring following fistula creation, factors predictive of fistula success, and potential areas of intervention to decrease AVF failure.
View details for DOI 10.4103/VIT.VIT_9_19
View details for PubMedID 31608322
View details for PubMedCentralID PMC6788624
Uterine Fibroid Embolization.
View details for DOI 10.5772/intechopen.86937
Endovascular Aortic Aneurysm Repair in Patients with Aortoiliac Occlusive Disease.
Vascular Access Surgery - Tips and Tricks
View details for DOI 10.5772/intechopen.83848
Reduced patency in left-sided arteriovenous grafts in a porcine model.
Journal of vascular surgery
The porcine arteriovenous graft model is commonly used to study hemodialysis vascular access failure, with most studies using a bilateral, paired-site approach in either the neck or femoral vessels. In humans, left- and right-sided central veins have different anatomy and diameters, and left-sided central vein catheters have worse outcomes. We assessed the effect of laterality on arteriovenous prosthetic graft patency and hypothesized that left-sided carotid-jugular arteriovenous prosthetic grafts have reduced patency in the porcine model.Arteriovenous polytetrafluoroethylene grafts were placed ipsilaterally or bilaterally in 10 Yorkshire male pigs from the common carotid artery to the internal jugular vein. Ultrasound measurements of blood flow velocities and diameters were assessed before graft placement. Animals were sacrificed at 1 week, 2 weeks, or 3 weeks. Patency was determined clinically; grafts and perianastomotic vessels were excised and analyzed with histology and immunostaining.At baseline, left- and right-sided veins and arteries had similar blood flow velocities. Although internal jugular veins had similar diameters at baseline, left-sided carotid arteries had 11% smaller outer diameters (P = .0354). There were 10 left-sided and 8 right-sided polytetrafluoroethylene grafts placed; only 4 of 10 (40%) grafts were patent on the left compared with 7 of 8 (88%) grafts patent on the right (P = .04). Left-sided grafts had increased macrophages at the arterial anastomosis (P = .0007). Left-sided perianastomotic arteries had thicker walls (0.74 vs 0.60 mm; P = .0211) with increased intima-media area (1.14 vs 0.77 mm2; P = .0169) as well as a trend toward 38% smaller luminal diameter (1.6 vs 2.5 mm; P = .0668) and 20% smaller outer diameter (3.0 vs 3.7 mm; P = .0861). Left- and right-sided perianastomotic veins were similar histologically, but left-sided veins had decreased expression of phosphorylated endothelial nitric oxide synthase (P = .0032) and increased numbers of α-actin-positive smooth muscle cells (P = .0022).Left-sided arteriovenous grafts are associated with reduced short-term patency compared with right-sided grafts in the Yorkshire pig preclinical model of arteriovenous prosthetic grafts. Laterality must be considered in planning and interpreting surgical preclinical models.
View details for DOI 10.1016/j.jvs.2019.06.221
View details for PubMedID 31699515
Coil embolization of bilateral internal mammary artery aneurysms in the setting of a heterozygous missense variant of unknown significance in COL5A1 and fibromuscular dysplasia.
Journal of vascular surgery cases and innovative techniques
2019; 5 (4): 410–14
Internal mammary artery aneurysms are rare but serious clinical entities. Rupture results in hemothorax and can be life threatening. Most reported cases are pseudoaneurysms secondary to iatrogenic or traumatic causes. Noniatrogenic, nontraumatic, true internal mammary artery aneurysms have most commonly been associated with vasculitides or connective tissue disorders; rare cases have been deemed idiopathic. We describe a rare case of bilateral internal mammary artery aneurysms-successfully treated with coil embolization-in the setting of heterozygosity for a missense variant of unknown significance in the COL5A1 gene and multifocal fibrodysplastic changes on angiography.
View details for DOI 10.1016/j.jvscit.2019.07.002
View details for PubMedID 31660461
View details for PubMedCentralID PMC6806644
Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systematic Review.
Thromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack.To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack.This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine.Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy.Crescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.
View details for DOI 10.1001/jamasurg.2019.2952
View details for PubMedID 31483458
Raising the bar for appropriateness in the care of patients with peripheral artery disease.
Journal of vascular surgery cases and innovative techniques
2019; 5 (3): 345–49
Advances in endovascular therapy have exponentially increased the number of procedures performed for peripheral artery disease, but public concerns of overuse have placed the vascular community under scrutiny. The appropriateness of care has thus become a focus of discussion within several professional societies, but literature on the topic is limited. This report presents two cases of patients with peripheral artery disease, one patient who did not need revascularization and underwent an intervention and the other who required additional intervention that was not recognized owing to an incomplete diagnostic workup.
View details for DOI 10.1016/j.jvscit.2019.03.009
View details for PubMedID 31334415
View details for PubMedCentralID PMC6614600
On-table modification of self-expanding covered stents for hybrid aortobifemoral revascularization.
Journal of vascular surgery cases and innovative techniques
2019; 5 (2): 179–82
Femoral endarterectomy with iliac stenting is a safe and effective minimally invasive alternative to aortobifemoral bypass. However, TransAtlantic Inter-Society Consensus D lesions with contiguous iliofemoral occlusion are challenging cases for hybrid repair. Herein, we present a unique approach for iliofemoral revascularization by on-table modification of self-expanding covered stents.
View details for DOI 10.1016/j.jvscit.2018.12.013
View details for PubMedID 31193649
View details for PubMedCentralID PMC6536774
Bifurcated unibody aortic endografts can overcome unfavorable aortoiliac anatomy for deployment of bilateral iliac branch endoprostheses.
Journal of vascular surgery cases and innovative techniques
2019; 5 (2): 174–78
In conjunction with traditional modular bifurcated aortic endografts, bilateral iliac branch endoprostheses have been safely and effectively used for treatment of bilateral iliac artery aneurysms. However, anatomic constraints, such as inadequate renal artery to iliac bifurcation lengths and unfavorable aortic anatomy, can preclude deployment in certain configurations and limit use in many patients. We present an innovative technique to overcome such anatomic constraints and to extend the reach of iliac branch endoprosthesis technology in patients with iliac artery aneurysms.
View details for DOI 10.1016/j.jvscit.2019.01.004
View details for PubMedID 31193591
View details for PubMedCentralID PMC6536773
- National trends of hybrid lower extremity revascularization in the ACS-NSQIP database. Vascular 2019; 27 (6): 653–62
Regulation of axon growth by myosin II-dependent mechanocatalysis of cofilin activity.
The Journal of cell biology
2019; 218 (7): 2329–49
Serotonin (5-HT) is known to increase the rate of growth cone advance via cofilin-dependent increases in retrograde actin network flow and nonmuscle myosin II activity. We report that myosin II activity is regulated by PKC during 5-HT responses and that PKC activity is necessary for increases in traction force normally associated with these growth responses. 5-HT simultaneously induces cofilin-dependent decreases in actin network density and PKC-dependent increases in point contact density. These reciprocal effects facilitate increases in traction force production in domains exhibiting decreased actin network density. Interestingly, when PKC activity was up-regulated, 5-HT treatments resulted in myosin II hyperactivation accompanied by catastrophic cofilin-dependent decreases in actin filament density, sudden decreases in traction force, and neurite retraction. These results reveal a synergistic relationship between cofilin and myosin II that is spatiotemporally regulated in the growth cone via mechanocatalytic effects to modulate neurite growth.
View details for DOI 10.1083/jcb.201810054
View details for PubMedID 31123185
View details for PubMedCentralID PMC6605792
- Anomalous course of the left common iliac vein anterior to the right common iliac artery with resultant May-Thurner syndrome. Journal of vascular surgery. Venous and lymphatic disorders 2019; 7 (3): 450–51
Molecular changes associated with vascular malformations.
Journal of vascular surgery
2019; 70 (1): 314–26.e1
Vascular anomalies are typically classified into two major categories, vascular tumors and vascular malformations. Most vascular malformations are caused sporadically by somatic mosaic gene mutations, and genetic analyses have advanced our understanding of the biomolecular mechanisms involved in their pathogenesis. Culprit gene mutations typically involve two major signaling pathways; the RAS/MAPK/ERK pathway is typically involved in fast-flow arteriovenous malformations, whereas the PI3K/AKT/mTOR pathway is typically mutated in slow-flow venous and lymphatic malformations. These findings suggest new therapeutic approaches to vascular malformations, focusing on targeting the etiologic mutated pathways. This review summarizes the currently available literature reflecting the updated International Society for Study of Vascular Anomalies classification system with emphasis on potential therapeutic targets that will provide vascular surgeons with an updated perspective on the etiologic basis of vascular malformations, allowing improved multidisciplinary collaboration.
View details for DOI 10.1016/j.jvs.2018.12.033
View details for PubMedID 30922748
The potential and limitations of induced pluripotent stem cells to achieve wound healing.
Stem cell research & therapy
2019; 10 (1): 87
Wound healing is the physiologic response to a disruption in normal skin architecture and requires both spatial and temporal coordination of multiple cell types and cytokines. This complex process is prone to dysregulation secondary to local and systemic factors such as ischemia and diabetes that frequently lead to chronic wounds. Chronic wounds such as diabetic foot ulcers are epidemic with great cost to the healthcare system as they heal poorly and recur frequently, creating an urgent need for new and advanced therapies. Stem cell therapy is emerging as a potential treatment for chronic wounds, and adult-derived stem cells are currently employed in several commercially available products; however, stem cell therapy is limited by the need for invasive harvesting techniques, immunogenicity, and limited cell survival in vivo. Induced pluripotent stem cells (iPSC) are an exciting cell type with enhanced therapeutic and translational potential. iPSC are derived from adult cells by in vitro induction of pluripotency, obviating the ethical dilemmas surrounding the use of embryonic stem cells; they are harvested non-invasively and can be transplanted autologously, reducing immune rejection; and iPSC are the only cell type capable of being differentiated into all of the cell types in healthy skin. This review focuses on the use of iPSC in animal models of wound healing including limb ischemia, as well as their limitations and methods aimed at improving iPSC safety profile in an effort to hasten translation to human studies.
View details for DOI 10.1186/s13287-019-1185-1
View details for PubMedID 30867069
View details for PubMedCentralID PMC6416973
Irinotecan-Eluting 75-150-μm Embolics Lobar Chemoembolization in Patients with Colorectal Cancer Liver Metastases: A Prospective Single-Center Phase I Study.
Journal of vascular and interventional radiology : JVIR
2018; 29 (12): 1646–53.e5
The primary end point of this trial was to determine the feasibility and safety of transarterial chemoembolization with the use of 75-150-μm drug-eluting embolics loaded with irinotecan (DEE-IRI) for the treatment of metastatic colorectal cancer (CRC) refractory to systemic chemotherapy.Fourteen patients (mean age 57.9 years) with liver-dominant metastatic disease (14.3% unilobar, 85.7% bilobar), who had failed at least 1 line of chemotherapy, were enrolled and received up to 4 (mean 2.3) cycles of DEE-IRI lobar transarterial chemoembolization. Technical complications and adverse events were recorded, and response was assessed by means of imaging-based criteria. Levels of irinotecan and angiogenesis biomarkers in the serum were measured at multiple time points.Thirty-two DEE-IRI transarterial chemoembolizations were successfully performed, and the full dose (100 mg) was delivered in all cases. The only grade 3-4 toxicity was abdominal pain (29%). One patient had objective response according to the Response Evaluation Criteria in Solid Tumors and World Health Organization, and 3 patients had objective response according to the European Association for the Study of the Liver. The median overall survival was 18.14 months, and the 1-year survival was 65%. The average plasma Cmax of the active metabolite was 41.5 ± 26.1 ng/mL, with average Tmax of 1.3 ± 0.5 hours. The treatment significantly reduced levels of vascular endothelial growth factor receptor 1 (VEGFR1) at 24 hours.Lobar transarterial chemoembolization with the use of DEE-IRI is a technically feasible and well tolerated palliative treatment for patients with refractory liver-predominant CRC metastatic disease and has acceptable pharmacokinetics. VEGFR1 is a potential biomarker for predicting treatment efficacy and risk of adverse events.
View details for DOI 10.1016/j.jvir.2018.08.010
View details for PubMedID 30337148
Computer-assisted 3D bowel length measurement for quantitative laparoscopy.
2018; 32 (9): 4052–61
This study aimed at developing and evaluating a tool for computer-assisted 3D bowel length measurement (BMS) to improve objective measurement in minimally invasive surgery. Standardization and quality of surgery as well as its documentation are currently limited by lack of objective intraoperative measurements. To solve this problem, we developed BMS as a clinical application of Quantitative Laparoscopy (QL).BMS processes images from a conventional 3D laparoscope. Computer vision algorithms are used to measure the distance between laparoscopic instruments along a 3D reconstruction of the bowel surface. Preclinical evaluation was performed in phantom, ex vivo porcine, and in vivo porcine models. A bowel length of 70 cm was measured with BMS and compared to a manually obtained ground truth. Afterwards 70 cm of bowel (ground truth) was measured and compared to BMS.Ground truth was 66.1 ± 2.7 cm (relative error + 5.8%) in phantom, 65.8 ± 2.5 cm (relative error + 6.4%) in ex vivo, and 67.5 ± 6.6 cm (relative error + 3.7%) in in vivo porcine evaluation when 70 cm was measured with BMS. Using 70 cm of bowel, BMS measured 75.0 ± 2.9 cm (relative error + 7.2%) in phantom and 74.4 ± 2.8 cm (relative error + 6.3%) in ex vivo porcine evaluation. After thorough preclinical evaluation, BMS was successfully used in a patient undergoing laparoscopic Roux-en-Y gastric bypass for morbid obesity.QL using BMS was shown to be feasible and was successfully translated from studies on phantom, ex vivo, and in vivo porcine bowel to a clinical feasibility study.
View details for DOI 10.1007/s00464-018-6135-y
View details for PubMedID 29508142