E. John Harris Jr.

All Publications

• Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA network open Aslakson, R. A., Rickerson, E., Fahy, B., Waterman, B., Siden, R., Colborn, K., Smith, S., Verano, M., Lira, I., Hollahan, C., Siddiqi, A., Johnson, K., Chandrashekaran, S., Harris, E., Nudotor, R., Baker, J., Heidari, S. N., Poultsides, G., Conca-Cheng, A. M., Cook Chapman, A., Lessios, A. S., Holdsworth, L. M., Gustin, J., Ejaz, A., Pawlik, T., Miller, J., Morris, A. M., Tulsky, J. A., Lorenz, K., Temel, J. S., Smith, T. J., Johnston, F. 2023; 6 (5): e2314660

  Abstract

  Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations.To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers.From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients.Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation.The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed.In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99).To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers.ClinicalTrials.gov Identifier: NCT03611309.

  View details for DOI 10.1001/jamanetworkopen.2023.14660

  View details for PubMedID 37256623

• Real-world Experience With Drug-coated Balloon Angioplasty in Dysfunctional Arteriovenous Fistulae Martinez-Singh, K., Harris, E., Lee, J. T., Stern, J. R., Ross, E. MOSBY-ELSEVIER. 2022: E302

  View details for Web of Science ID 000798307600339

• Systematic review and meta-analysis of the management of incompetent perforators in patients with chronic venous insufficiency. Journal of vascular surgery. Venous and lymphatic disorders Ho, V. T., Adkar, S. S., Harris, E. J. 2022

  Abstract

  OBJECTIVE: Incompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurement, size, and Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification. The objective of this study was to systematically review and synthesize current literature regarding surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation (EVLA), ultrasound guided sclerotherapy (USGS), and radiofrequency ablation (RFA).METHODS: English-language literature published prior to November 2021 was reviewed from the PubMed, EMBASE, and MEDLINE databases for primary literature reporting safety and efficacy outcomes in the surgical treatment of incompetent perforating veins. Study quality and risk of bias was assessed using the Cochrane risk-of-bias tool for comparative studies and a modified version of the Newcastle-Ottawa Scale for non-comparative studies. A random effects model was used to pool effect sizes for efficacy outcomes of wound healing and freedom from wound recurrence.RESULTS: A total of 81 studies were included for qualitative synthesis representing 7010 patients with a mean age of 54.7 years. Overall evidence quality was low to intermediate, with moderate to high risk of bias in comparative studies. There was an 11.3% complication rate across interventions, with no reported incidences of stroke or air embolism. With regards to efficacy, pooled estimates for short-term (up to 1-year) wound healing were 99.9% for USGS (95% CI 0.81 - 1), 72.2% for ligation (95% CI 0.04, 0.94) and 96.0% for SEPS (95% CI 0.79 -0.99). For short-term freedom from wound recurrence, the pooled estimate for SEPS is 91.0% (95% CI 0.3 - 0.99).CONCLUSION: Current evidence regarding treatment of incompetent perforator veins is limited due to low adherence to reporting standards in observational studies and lack of randomization, blinding, and allocation concealment in comparative studies. Additional comparative studies are needed to guide clinical decision-making regarding invasive treatment options for incompetent perforator veins.

  View details for DOI 10.1016/j.jvsv.2021.12.088

  View details for PubMedID 35217217

• Validity of the Global Vascular Guidelines in Predicting Outcomes in a Comprehensive Wound Care Program Lou, V., Tran, K., Dossabhoy, S. S., Yawary, F., Ross, E. G., Stern, J. R., Lee, J. T., Harris, E., Dalman, R. L., Chandra, V. MOSBY-ELSEVIER. 2021: E405-E406

  View details for Web of Science ID 000707158200193

• Validity of the Global Vascular Guidelines in Predicting Outcomes in a Comprehensive Wound Care Program Lou, V., Tran, K., Dossabhoy, S. S., Yawary, F., Ross, E. G., Stern, J. R., Lee, J. T., Harris, E., Dalman, R. L., Chandra, V. MOSBY-ELSEVIER. 2021: E250-E251

  View details for Web of Science ID 000691401100388

• Analysis of Medicare Payments and Patient Outcomes with Pre-Operative Imaging for Carotid Endarterectomy. Annals of vascular surgery Itoga, N. K., Martinez-Singh, K., Lee, J. T., John Harris, E., Baker, L. C., Garcia-Toca, M. 2021

  Abstract

  OBJECTIVE: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in pre-operative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease.METHODS: We used a 20% Medicare sample from 2006-2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated pre-operative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use.RESULTS: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8±7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4±1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5±2.1 ultrasounds, 0.95±0.86 neck CTs and 0.47±0.7 MRIs per patient. The average payment for ultrasound was $140±40, $282±94 for CT and $410±146 for MRI. The average inpatient reimbursements were $7,413±4,215 for patients without CSI compared with $7,792±3,921 for patients with CSI, P<.001. The average LOS during CEA admission was 2.5±3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by post-operative day two compared with ultrasound alone (88.9% vs. 91.5%, respectively, P<.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups.CONCLUSIONS: Our analysis found pre-operative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.

  View details for DOI 10.1016/j.avsg.2021.06.001

  View details for PubMedID 34153493

• Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review. Surgical oncology Zhou, M., Javadi, C., Charville, G. W., Bui, N. Q., Harris, E. J., Poultsides, G. A., Norton, J. A., Visser, B., Lee, B., Dua, M. M., Ganjoo, K. N. 2021; 39: 101670

  Abstract

  We review our institution's experience in treating leiomyosarcomas involving the inferior vena cava, and we offer guidance on the management.A text-based search was performed to identify all patients who underwent surgical resection between January 2002 and October 2020. Clinicopathologic data, intraoperative variables, and outcomes were extracted from chart review.Twelve of 16 patients (75%) had localized disease; the remaining had limited metastatic disease. Seven of 16 patients (44%) received neoadjuvant chemotherapy or radiation; three patients had partial responses, and four patients had stable disease using RECIST 1.1 criteria. IVC reconstruction was performed in 14 of 16 patients (88%); IVC was ligated for the remaining two patients. Half of all patients had R0 resection on final pathology; the remaining had R1 resections. Progression-free survival (PFS) and overall survival (OS) were not statistically different between patients with R0 and R1 resection. Median PFS was 1.8 years (95% CI 0.89 - not reached); median OS was 6.5 years (1.8 - not reached). Only one patient (6%) experienced local disease recurrence; 4 of 16 patients (25%) experienced disease recurrence distally without local recurrence.Resection of IVC leiomyosarcomas at a sarcoma referral center with experience in vascular reconstruction can lead to many years of recurrence-free survival. Surgical resection should be offered to patients with a low volume of metastatic disease to reduce local complications from the primary tumor, many of which exert significant mass effect on surrounding organs. For patients with metastatic disease or large, high-risk tumors, neoadjuvant chemotherapy can provide a biologic test of disease stability prior to resection.

  View details for DOI 10.1016/j.suronc.2021.101670

  View details for PubMedID 34710646

• Paclitaxel exposure and long-term mortality of patients treated with the Zilver PTX drug-eluting stent. Vascular Stern, J. R., Tran, K., Chandra, V., Harris, E. J., Lee, J. T. 2020: 1708538120964371

  Abstract

  OBJECTIVES: Paclitaxel-eluting stents have demonstrated improved patency over balloon angioplasty and bare metal stenting for endovascular interventions in the femoral-popliteal segment. Recently, concerns have arisen regarding the safety of paclitaxel use and its association with mortality. This study aims to examine real-world, long-term mortality, and patency of patients treated with the Zilver PTX drug-eluting stent.METHODS: Patients treated with the PTX stent after FDA approval between 2013 and 2015 were identified from an institutional database. Demographic, procedural, and device information was collected and initial- and lifetime-exposure dose of paclitaxel was calculated. The primary outcome was all-cause mortality and its association with paclitaxel exposure. Long-term patency was also evaluated.RESULTS: Seventy-nine procedures involving PTX placement were performed on 64 individual patients during the study period, with 15 (23.4%) having bilateral procedures. Average age was 70 years, and 71.9% were male. Forty-five patients (70.3%) were claudicants, and 19 (29.7%) had chronic, limb-threatening ischemia. An average of 2.3 PTX stents, totaling 203 mm in length, were placed per procedure. Paclitaxel exposure was 1.87mg/procedure initially (range 0.38-4.03mg), and average lifetime exposure was 4.65mg/patient (range 0.38-27.91mg). Average follow-up was 59.6 months. Kaplan-Meier estimated survival was 96.9%, 81.2% and 71.7% at one , three, and five years. On multivariate analysis, no specific factors were associated with overall morality including initial paclitaxel dose (HR 0.99, 95% CI 0.99-1.00) and lifetime paclitaxel exposure (HR 0.98, 95% CI 0.89-1.08). Kaplan-Meier primary patency was 76.2%, 60.1%, and 29.3% at one, two, and five years, respectively. Secondary patency was 92.2%, 85.4%, and 75.2% at the same intervals.CONCLUSIONS: At a mean follow-up of five years, exposure to higher doses of paclitaxel from Zilver PTX does not appear to be associated with increased mortality compared to lower doses in real-world patients. Long-term patency rates confirm the efficacy of Zilver PTX, and further investigation may be warranted before abandoning paclitaxel use altogether.

  View details for DOI 10.1177/1708538120964371

  View details for PubMedID 33054678

• Evaluation of Outcomes Following Surgery for Locally Advanced Pancreatic Neuroendocrine Tumors. JAMA network open Titan, A. L., Norton, J. A., Fisher, A. T., Foster, D. S., Harris, E. J., Worhunsky, D. J., Worth, P. J., Dua, M. M., Visser, B. C., Poultsides, G. A., Longaker, M. T., Jensen, R. T. 2020; 3 (11): e2024318

  Abstract

  Although outcome of surgical resection of liver metastases from pancreatic neuroendocrine tumors (PNETs) has been extensively studied, little is known about surgery for locally advanced PNETs; it was listed recently by the European neuroendocrine tumor society as a major unmet need.To evaluate the outcome of patients who underwent surgery for locally aggressive PNETs.This retrospective single-center case series reviewed consecutive patients who underwent resection of T3/T4 PNETs at a single academic institution. Data collection occurred from 2003 to 2018. Data analysis was performed in August 2019.Disease-free survival (primary outcome) and overall mortality (secondary outcome) were assessed with Kaplan-Meier analysis. Recurrence risk (secondary outcome, defined as identification of tumor recurrence on imaging) was assessed with Cox proportional hazard models adjusting for covariates.In this case series, 99 patients with locally advanced nondistant metastatic PNET (56 men [57%]) with a mean (SEM) age of 57.0 (1.4) years and a mean (SEM) follow-up of 5.3 (0.1) years underwent surgically aggressive resections. Of those, 4 patients (4%) underwent preoperative neoadjuvant treatment (including peptide receptor radionuclide therapy and chemotherapy); 18 patients (18%) underwent pancreaticoduodenectomy, 68 patients (69%) had distal or subtotal pancreatic resection, 10 patients (10%) had total resection, and 3 patients (3%) had other pancreatic procedures. Additional organ resection was required in 86 patients (87%): spleen (71 patients [71%]), major blood vessel (17 patients [17%]), bowel (2 patients [2%]), stomach (4 patients [4%]), and kidney (2 patients [2%]). Five-year disease-free survival was 61% (61 patients) and 5-year overall survival was 91% (91 patients). Of those living, 75 patients (76%) had an Eastern Cooperative Oncology Group score of less than or equal to 1 at last followup. Lymph node involvement (HR, 7.66; 95% CI, 2.78-21.12; P < .001), additional organ resected (HR, 6.15; 95% CI, 1.61-23.55; P = .008), and male sex (HR, 3.77; 95% CI, 1.68-8.97; P = .003) were associated with increased risk of recurrence. Functional tumors had a lower risk of recurrence (HR, 0.23; CI, 0.06-0.89; P = .03). Required resection of blood vessels was not associated with a significant increase recurrence risk.In this case series, positive lymph node involvement and resection of organs with tumor involvement were associated with an increased recurrence risk. These subgroups may require adjuvant systemic treatment. These findings suggest that patients with locally advanced PNETs who undergo surgical resection have excellent disease-free and overall survival.

  View details for DOI 10.1001/jamanetworkopen.2020.24318

  View details for PubMedID 33146734

• Factors Affecting Intervention Rates and Time to Intervention for Lower Extremity Venous Disease in the Private Insurance Market Itoga, N. K., Rothenberg, K. A., George, E. L., Deslarzes-Dubuis, C., Rapanos, T., Harris, E. J. MOSBY-ELSEVIER. 2019: E255–E256

  View details for DOI 10.1016/j.jvs.2019.04.386

  View details for Web of Science ID 000469220300378

• Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure. Journal of vascular surgery McFarland, G., Tran, K., Virgin-Downey, W., Sgroi, M. D., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2019; 69 (2): 385–93

  Abstract

  OBJECTIVE: Endovascular aneurysm repair (EVAR) has become the standard of care for infrarenal aneurysms. Endografts are commercially available in proximal diameters up to 36mm, allowing proximal seal in necks up to 32mm. We sought to further investigate clinical outcomes after standard EVAR in patients requiring large main body devices.METHODS: We performed a retrospective review of a prospectively maintained database for all patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms at a single institution from 2000 to 2016. Only endografts with the option of a 34- to 36-mm proximal diameter were included. Requisite patient demographics, anatomic and device-related variables, and relevant clinical outcomes and imaging were reviewed. The primary outcome in this study was proximal fixation failure, which was a composite of type IA endoleak and stent graft migration >10mm after EVAR. Outcomes were stratified by device diameter for the large-diameter device cohort (34-36mm) and the normal-diameter device cohort (<34mm).RESULTS: There were 500 patients treated with EVAR who met the inclusion criteria. A total of 108 (21.6%) patients received large-diameter devices. There was no difference between the large-diameter cohort and the normal-diameter cohort in terms of 30-day (0.9% vs 0.95%; P= .960) or 1-year mortality (9.0% vs 6.2%; P= .920). Proximal fixation failure occurred in 24 of 392 (6.1%) patients in the normal-diameter cohort and 26 of 108 (24%) patients in the large-diameter cohort (P<.001). There were 13 (3.3%) type IA endoleaks in the normal-diameter cohort and 16 (14.8%) in the large-diameter cohort (P< .001). Stent graft migration (>10mm) occurred in 15 (3.8%) in the normal-diameter cohort and 16 (14.8%) in the large-diameter cohort (P< .001). After multivariate analysis, only the use of Talent (Medtronic, Minneapolis, Minn) endografts (odds ratio [OR], 4.50; 95% confidence interval [CI], 1.18-17.21) and neck diameter ≥29mm (OR, 2.50; 95% CI, 1.12-5.08) remained significant independent risk factors for development of proximal fixation failure (OR, 3.99; 95% CI, 1.75-9.11).CONCLUSIONS: Standard EVAR in patients with large infrarenal necks ≥29mm requiring a 34- to 36-mm-diameter endograft is independently associated with an increased rate of proximal fixation failure. This group of patients should be considered for more proximal seal strategies with fenestrated or branched devices vs open repair. Also, this group likely needs more stringent radiographic follow-up.

  View details for PubMedID 30686336

• Infrarenal endovascular aneurysm repair with large device (34-to 36-mm) diameters is associated with higher risk of proximal fixation failure McFarland, G., Tran, K., Virgin-Downey, W., Sgroi, M. D., Chandra, V., Mell, M. W., Harris, E., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2019: 385–93

  View details for DOI 10.1016/j.jvs.2018.02.054

  View details for Web of Science ID 000456316700012

• Preprocedural Cross-Sectional Imaging Prior to Percutaneous Peripheral Arterial Disease Interventions. Vascular and endovascular surgery Itoga, N. K., Ho, V. T., Tran, K. n., Chandra, V. n., Dalman, R. L., Harris, E. J., Lee, J. T., Mell, M. W. 2019: 1538574419887585

  Abstract

  Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.

  View details for DOI 10.1177/1538574419887585

  View details for PubMedID 31746279

• Incidence and Risk Factors for Deep Vein Thrombosis after Radiofrequency and Laser Ablation of the Lower Extremity Veins. Annals of vascular surgery Itoga, N. K., Rothenberg, K. A., Deslarzes-Dubuis, C. n., George, E. L., Chandra, V. n., Harris, E. J. 2019

  Abstract

  The rates of thromboembolic complications such as deep venous thrombosis (DVT) after venous ablation procedures for symptomatic superficial venous insufficiency are controversial. We sought to describe the risk factors for, and incidence of DVT after radiofrequency ablation (RFA) and laser ablation (LA).We queried the Truven Health Marketscan Database from 2007-16 for patients who underwent RFA or LA and had a follow-up duplex ultrasound within 30 days of the ablation procedure. The primary outcome was DVT at 7- and 30-days identified by ICD-9 and ICD-10 codes. Multivariable regression was used to evaluate the patient and procedural variables associated with a DVT at 30-days, expressed as odds ratios with a 95% confidence interval (OR 95%CI). Patients and procedures with a previous DVT diagnosis were excluded.A total of 256,999 patients underwent 433,286 ablation procedures: 192,195 (44.4%) RFA and 241,091 LA. Of these, 8,203 (1.9%) had a newly diagnosed DVT within 7-days and 13,347 (3.1%) within 30-days of the procedure. The incidence of DVT decreased over the study period. LA (2.8%) demonstrated a lower incidence of DVT at 30-days compared to RFA (3.4%), p<0.001. On multivariable regression, LA (OR 0.82, 95%CI 0.80-0.85) was again associated with a decreased risk for 30-day DVT, as was female gender (OR 0.74, 95%CI 0.71-0.77) and sclerotherapy performed on the same day (OR 0.91, 95%CI 0.85-0.98). A diagnosis of peripheral artery disease (OR 1.23, 95%CI 1.16-1.31) and concomitant stab phlebectomy (OR 1.43, 95%CI 1.37-1.49) was associated with an increased risk of DVT within 30-days.The incidence of newly diagnosed DVT within 30-days of an ablation procedure was 3.2%. The risk for DVT decreased in recent years and LA was associated with a 18% decreased risk compared to RFA.

  View details for DOI 10.1016/j.avsg.2019.04.008

  View details for PubMedID 31201974

• Comparison of Bovine Carotid Xenograft Versus Expanded Polytetrafluoroethylene Grafts for Forearm Loop Hemodialysis Access Colvard, B., Lavignia, K., Ho, V. T., Itoga, N., Dua, A., Harris, E., Me, M., Sorial, E., Garcia-Toca, M. MOSBY-ELSEVIER. 2018: E35

  View details for Web of Science ID 000442339800065

• Long-Term Outcomes After Repair of Symptomatic Nonruptured Abdominal Aortic Aneurysms Trang, K., Chandra, V., Virgin-Downey, W., Lee, J. T., Harris, E., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2017: E52

  View details for Web of Science ID 000412559500018

• Standard EVAR in Patients With Dilated Infrarenal Necks Requiring a 34-36 mm Endograft Is Associated With Increased Risk of Type la Endoleak and Stent Migration McFarland, G. E., Tran, K., Virgin-Downey, W., Chandra, V., Mell, M. W., Harris, E., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2017: 43S–44S

  View details for DOI 10.1016/j.jvs.2017.03.080

  View details for Web of Science ID 000403108000072

• New predictors of complications in carotid body tumor resection JOURNAL OF VASCULAR SURGERY Kim, G. Y., Lawrence, P. F., Moridzadeh, R. S., Zimmerman, K., Munoz, A., Luna-Ortiz, K., Oderich, G. S., de Francisco, J., Ospina, J., Huertas, S., de Souza, L. R., Bower, T. C., Farley, S., Gelabert, H. A., Kret, M. R., Harris, J., De Caridi, G., Spinelli, F., Smeds, M. R., Liapis, C. D., Kakisis, J., Papapetrou, A. P., Debus, E. S., Behrendt, C., Kleinspehn, E., Horton, J. D., Mussa, F. F., Cheng, S. K., Morasch, M. D., Rasheed, K., Bennett, M. E., Bismuth, J., Lumsden, A. B., Abularrage, C. J., Farber, A. 2017; 65 (6): 1673–79

  Abstract

  This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury.Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination.There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92).This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

  View details for PubMedID 28527929

• Long-Term Outcomes After Repair of Symptomatic Abdominal Aortic Aneurysms Trang, K., Chandra, V., Virgin-Dodwney, W., Harris, E., Lee, J. T., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2017: 151S–152S

  View details for DOI 10.1016/j.jvs.2017.03.287

  View details for Web of Science ID 000403108000274

• Management and outcomes of symptomatic abdominal aortic aneurysms during the past 20 years. Journal of vascular surgery Chandra, V. n., Trang, K. n., Virgin-Downey, W. n., Tran, K. n., Harris, E. J., Dalman, R. L., Lee, J. T., Mell, M. W. 2017; 66 (6): 1679–85

  Abstract

  We compared the management of patients with symptomatic, unruptured abdominal aortic aneurysms (AAAs) treated at a tertiary care center between two decades. This 20-year period encapsulated a shift in surgical approach to aortic aneurysms from primarily open to primarily endovascular, and we sought to determine the effect of this shift in the evaluation, treatment, and clinical outcomes of patients with symptomatic AAA.We reviewed 1429 consecutive patients with unruptured AAAs treated at a tertiary care hospital by six staff surgeons between 1995 and 2004 (era 1) and between 2005 and 2014 (era 2). Of those patients, 160 (11%) were symptomatic from their aneurysm and were included in our study. Patient demographics, operative approach, and outcomes were analyzed and compared for each period.Era 1 included 75 patients (71% men; average age, 73.1 ± 10.0 years) treated for symptomatic AAA (91.9% infrarenal, 4.0% juxtarenal, and 4.0% pararenal); of these, 68% were treated with open repair and 32.0% were treated with an endovascular repair. Perioperative mortality during this period was 5.3% (7.8% for the open cohort and 0% for the endovascular cohort). Era 2 included 85 patients (72.9% men; average age 72.0 ± 9.5 years) treated for symptomatic AAA (90.1% infrarenal, 7.5% juxtarenal, and 2.4% pararenal); of these, 29% were treated open and 71% underwent endovascular repair. Perioperative mortality was 5.9% (8.0% for the open cohort and 5.0% for the endovascular cohort). Era 2 had a significantly higher rate of endovascular repair compared with era 1 (71% vs 32%; P < .0001) and a trend toward decreased long-term mortality. The length of stay for era 2 was significantly reduced compared with era 1 (4 days vs 6 days; P = .005).To our knowledge, this is the largest single-institution cohort of symptomatic AAAs, which comprise 10% to 11% of overall aneurysms. As expected, we found a significant shift over time in the approach to these patients from a primarily open to a primarily endovascular technique. The modern era was also associated with decreased lengths of stay and fewer gastrointestinal and wound complications but no significant differences in overall perioperative mortality.

  View details for PubMedID 28619644

• Predictive models for mortality after ruptured aortic aneurysm repair do not predict futility and are not useful for clinical decision making JOURNAL OF VASCULAR SURGERY Thompson, P. C., Dalman, R. L., Harris, E. J., Chandra, V., Lee, J. T., Mell, M. W. 2016; 64 (6): 1617-1622

  Abstract

  The clinical decision-making utility of scoring algorithms for predicting mortality after ruptured abdominal aortic aneurysms (rAAAs) remains unknown. We sought to determine the clinical utility of the algorithms compared with our clinical decision making and outcomes for management of rAAA during a 10-year period.Patients admitted with a diagnosis rAAA at a large university hospital were identified from 2005 to 2014. The Glasgow Aneurysm Score, Hardman Index, Vancouver Score, Edinburgh Ruptured Aneurysm Score, University of Washington Ruptured Aneurysm Score, Vascular Study Group of New England rAAA Risk Score, and the Artificial Neural Network Score were analyzed for accuracy in predicting mortality. Among patients quantified into the highest-risk group (predicted mortality >80%-85%), we compared the predicted with the actual outcome to determine how well these scores predicted futility.The cohort comprised 64 patients. Of those, 24 (38%) underwent open repair, 36 (56%) underwent endovascular repair, and 4 (6%) received only comfort care. Overall mortality was 30% (open repair, 26%; endovascular repair, 24%; no repair, 100%). As assessed by the scoring systems, 5% to 35% of patients were categorized as high-mortality risk. Intersystem agreement was poor, with κ values ranging from 0.06 to 0.79. Actual mortality was lower than the predicted mortality (50%-70% vs 78%-100%) for all scoring systems, with each scoring system overestimating mortality by 10% to 50%. Mortality rates for patients not designated into the high-risk cohort were dramatically lower, ranging from 7% to 29%. Futility, defined as 100% mortality, was predicted in five of 63 patients with the Hardman Index and in two of 63 of the University of Washington score. Of these, surgery was not offered to one of five and one of two patients, respectively. If one of these two models were used to withhold operative intervention, the mortality of these patients would have been 100%. The actual mortality for these patients was 60% and 50%, respectively.Clinical algorithms for predicting mortality after rAAA were not useful for predicting futility. Most patients with rAAA were not classified in the highest-risk group by the clinical decision models. Among patients identified as highest risk, predicted mortality was overestimated compared with actual mortality. The data from this study support the limited value to surgeons of the currently published algorithms.

  View details for DOI 10.1016/j.jvs.2016.07.121

  View details for PubMedID 27871490

• Management of Symptomatic Unruptured Aortic Aneurysms Over the Past 20 Years 31st Annual Meeting of the Western-Vascular-Society Trang, K., Harris, E. J., Dalman, R. L., Lee, J. T., Mell, M. W., Chandra, V. MOSBY-ELSEVIER. 2016: 553–53

  View details for Web of Science ID 000380753300077

  View details for PubMedID 27763319

• Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition JAMA SURGERY Ullery, B. W., Tran, K., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2015; 150 (11): 1058-1065

  Abstract

  Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated.To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes.Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center.Early mortality, perioperative morbidity, discharge disposition, and overall survival.A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively.Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

  View details for DOI 10.1001/jamasurg.2015.1861

  View details for Web of Science ID 000367987100011

• Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition. JAMA surgery Ullery, B. W., Tran, K., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2015; 150 (11): 1058-65

  Abstract

  Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated.To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes.Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center.Early mortality, perioperative morbidity, discharge disposition, and overall survival.A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively.Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

  View details for DOI 10.1001/jamasurg.2015.1861

  View details for PubMedID 26244272

• Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study ANNALS OF SURGERY Poultsides, G. A., Tran, T. B., Zambrano, E., Janson, L., Mohler, D. G., Mell, M. W., Avedian, R. S., Visser, B. C., Lee, J. T., Ganjoo, K., Harris, E. J., Norton, J. A. 2015; 262 (4): 632-640

  Abstract

  To examine the impact of major vascular resection on sarcoma resection outcomes.En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described.Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival.From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion.Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

  View details for DOI 10.1097/SLA.0000000000001455

  View details for Web of Science ID 000367999800009

• Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study. Annals of surgery Poultsides, G. A., Tran, T. B., Zambrano, E., Janson, L., Mohler, D. G., Mell, M. W., Avedian, R. S., Visser, B. C., Lee, J. T., Ganjoo, K., Harris, E. J., Norton, J. A. 2015; 262 (4): 632-40

  Abstract

  To examine the impact of major vascular resection on sarcoma resection outcomes.En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described.Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival.From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion.Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

  View details for DOI 10.1097/SLA.0000000000001455

  View details for PubMedID 26366542

• Factors impacting follow-up care after placement of temporary inferior vena cava filters 27th Annual Meeting of the Western-Vascular-Society Gyang, E., Zayed, M., Harris, E. J., Lee, J. T., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2013: 440–45

  Abstract

  Rates of inferior vena cava (IVC) filter retrieval have remained suboptimal, in part because of poor follow-up. The goal of our study was to determine demographic and clinical factors predictive of IVC filter follow-up care in a university hospital setting.We reviewed 250 consecutive patients who received an IVC filter placement with the intention of subsequent retrieval between March 2009 and October 2010. Patient demographics, clinical factors, and physician specialty were evaluated. Multivariate logistic regression analysis was performed to identify variables predicting follow-up care.In our cohort, 60.7% of patients received follow-up care; of those, 93% had IVC filter retrieval. Major indications for IVC filter placement were prophylaxis for high risk surgery (53%) and venous thromboembolic event with contraindication and/or failure of anticoagulation (39%). Follow-up care was less likely for patients discharged to acute rehabilitation or skilled nursing facilities (P < .0001), those with central nervous system pathology (eg, cerebral hemorrhage or spinal fracture; P < .0001), and for those who did not receive an IVC filter placement by a vascular surgeon (P < .0001). In a multivariate analysis, discharge home (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.99-8.2; P < .0001), central nervous system pathology (OR, 0.46; 95% CI, 0.22-0.95; P = .04), and IVC filter placement by the vascular surgery service (OR, 4.7; 95% CI, 2.3-9.6; P < .0001) remained independent predictors of follow-up care. Trauma status and distance of residence did not significantly impact likelihood of patient follow-up.Service-dependent practice paradigms play a critical role in patient follow-up and IVC filter retrieval rates. Nevertheless, specific patient populations are more prone to having poorer rates of follow-up. Such trends should be factored into institutional quality control goals and patient-centered care.

  View details for DOI 10.1016/j.jvs.2012.12.085

  View details for PubMedID 23588109

• Vascular Reconstruction During Major Oncologic Pancreatic Resections Pineda, C., Chandra, V., Krampitz, G., Poultsides, G. A., Norton, J. A., Harris, E. J. MOSBY-ELSEVIER. 2013: 559

  View details for DOI 10.1016/j.jvs.2013.05.065

  View details for Web of Science ID 000322759500065

• EVAR Deployment in Anatomically Challenging Necks Outside the IFU 63rd Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) Lee, J. T., Ullery, B. W., Zarins, C. K., Olcott, C., Harris, E. J., Dalman, R. L. W B SAUNDERS CO LTD. 2013: 65–73

  Abstract

  Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points.A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU).IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all p < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs. 2.1%, p = .003), and needed increased fluoroscopy time (31 vs. 25 minutes, p = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, p = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05).EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.

  View details for DOI 10.1016/j.ejvs.2013.03.027

  View details for Web of Science ID 000321883200013

  View details for PubMedID 23628325

• Iliocaval and aortoiliac reconstruction following en bloc retroperitoneal leiomyosarcoma resection. Journal of vascular surgery Ohman, J. W., Chandra, V., Poultsides, G., Harris, E. J. 2013; 57 (3): 850-?

  View details for DOI 10.1016/j.jvs.2012.01.048

  View details for PubMedID 23446129

• Idiopathic true brachial artery aneurysm in an 18-month-old girl JOURNAL OF VASCULAR SURGERY Greenberg, J. I., Salamone, L., Chang, J., Harris, E. J. 2012; 56 (5): 1426-1426

  View details for DOI 10.1016/j.jvs.2011.09.055

  View details for Web of Science ID 000310428200043

  View details for PubMedID 23083666

• Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair 26th Annual Meeting of the Western-Vascular-Society Greenberg, J. I., Dorsey, C., Dalman, R. L., Lee, J. T., Harris, E. J., Hernandez-Boussard, T., Mell, M. W. MOSBY-ELSEVIER. 2012: 291–97

  Abstract

  Current information regarding coverage of accessory renal arteries (ARAs) during endovascular aneurysm repair (EVAR) is based on small case series with limited follow-up. This study evaluates the outcomes of ARA coverage in a large contemporary cohort.Consecutive EVAR data from January 2004 to August 2010 were collected in a prospective database at a University Hospital. Patient and aneurysm-related characteristics, imaging studies, and ARA coverage versus preservation were analyzed. Volumetric analysis of three-dimensional reconstruction computed tomography scans was used to assess renal infarction volume extent. Long-term renal function and overall technical success of aneurysm exclusion were compared.A cohort of 426 EVARs was identified. ARAs were present in 69 patients with a mean follow-up of 27 months (range, 1 to 60 months). Forty-five ARAs were covered in 40 patients; 29 patients had intentional ARA preservation. Patient and anatomic characteristics were similar between groups except that ARA coverage patients had shorter aneurysm necks (P = .03). Renal infarctions occurred in 84% of kidneys with covered ARAs. There was no significant deterioration in long-term glomerular filtration rate when compared with patients in the control group. No difference in the rate of endoleak, secondary procedures, or the requirement for antihypertensive medications was found.This study is the largest to date with the longest follow-up relating to ARA coverage. Contrary to previous reports, renal infarction after ARA coverage is common. Nevertheless, coverage is well tolerated based upon preservation of renal function without additional morbidity. These results support the long-term safety of ARA coverage for EVAR when necessary.

  View details for DOI 10.1016/j.jvs.2012.01.049

  View details for PubMedID 22480767

• Factors Impacting Follow-up Care after Placement of Temporary Inferior Vena Cava Filters William J. Von Liebig Forum at the Rapid Session of the Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) / Peripheral-Vascular-Surgery-Society Session Gyang, E., Zayed, M., Harris, E. J., Lee, J. T., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2012: 60–60

  View details for Web of Science ID 000304398900115

• Selective Use of Percutaneous Endovascular Aneurysm Repair in Women Leads to Fewer Groin Complications 35th Annual Spring Meeting of the Peripheral-Vascular-Surgery-Society Al-Khatib, W. K., Zayed, M. A., Harris, E. J., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012: 476–82

  Abstract

  Endovascular aneurysm repair (EVAR) in women is often technically limited by smaller access vessel anatomy, particularly at the femoral and iliac artery levels. Percutaneous femoral artery access and closure using the "Preclose" technique (PERC) is a less invasive alternative to open surgical femoral arterial exposure and has been reported to be technically feasible, particularly in male cohorts. The purpose of this study was to evaluate the efficacy and access-related outcomes of PERC in women undergoing EVAR.We identified female patients in a prospectively maintained EVAR database from 2000 to 2009. An all-percutaneous approach was adopted in 2007 if technically feasible, based on preoperative computed tomography angiogram criteria including a femoral diameter >7 mm, <25% posterior plaque and lack of circumferential calcification/disease. All percutaneous EVAR procedures were performed using two Perclose Proglide devices in a standardized manner for sheath sizes ranging between 12F and 26F.In period 1 (2000-2006), most cases were performed with open femoral exposure. In period 2 (2007-2009), our group adopted a percutaneous-first approach. Of 736 EVARs performed during the study period, 120 (16.3%) were in women, leading to 178 femoral arteries requiring large sheath access. Period 1 included 90 women and period 2 included 30 women who were evaluated for percutaneous access. During period 2, of the 47 eligible femoral arteries for possible PERC, 24 (51%) met appropriate criteria, and the Preclose technique was employed. The remaining 23 femoral arteries during period 2 were accessed with surgical exposure (OPEN). Technical success rate of PERC in period 2 was 96%, with one device pulling through a thin anterior arterial wall requiring open femoral conversion. During period 2, the OPEN cohort had a higher rate of total wound complications compared with PERC (34.8% vs. 8.3%, P = 0.02), including hematomas (8.7% vs. 0%), wound breakdowns (8.7% vs. 0%), and pseudoaneurysms (4.3% vs. 0%). There were two cases of femoral artery thrombosis in the PERC group requiring repair in the immediate postoperative period; however, this was not significantly different compared with the OPEN group (8.7% vs. 8.3%).Selective percutaneous access of the femoral arteries for EVAR is safe and effective in the female population, with fewer wound complications than open exposure. Approximately one-half of femoral arteries in women are eligible for PERC access, and complications can be limited with careful selection based on preoperative imaging.

  View details for DOI 10.1016/j.avsg.2011.11.026

  View details for PubMedID 22437069

• Cost Impact of Extension Cuff Utilization During Endovascular Aneurysm Repair 21st Annual Winter Meeting of the Peripheral-Vascular-Surgery-Society Chandra, V., Greenberg, J. I., Al-Khatib, W. K., Harris, E. J., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012: 86–92

  Abstract

  Modular stent-graft systems for endovascular aneurysm repair (EVAR) most often require two to three components, depending on the device. Differences in path lengths and availability of main body systems often require additional extensions for appropriate aneurysm exclusion. These additional devices usually result in added expenses and can affect the financial viability of an EVAR program within a hospital. The purpose of this study was to analyze the use of extensions during EVAR, focusing on incidence, clinical impact, and financial impact, as well as determining the associated cost differences between two- and three-component EVAR device systems.We reviewed available clinical data, images, and follow-up of 218 patients (203 males and 15 females, mean age: 74 ± 9 years) who underwent elective EVAR at a single academic center from 2004 to 2007. Patients were divided into two groups: patients undergoing EVAR using the standard number of pieces, that is, no extensions used (group A, n = 98), and those needing proximal or distal extensions during the index procedure (group B, n = 120).Both groups were similar in terms of demographics; preoperative characteristics, including aneurysm morphology; as well as intraoperative, postoperative, and midterm outcomes. Overall, 30-day operative mortality was 1.4%, with a mean follow-up of 24 months. Group A patients underwent repair with two-piece modular devices 41% of the time and three-piece systems 59% of the time, whereas group B patients underwent repair with two-piece modular systems 82% of the time and three-piece modular systems 18% of the time. The number of additional extensions per patient ranged from one to four (median: one piece). There was a 30% cost increase in overall mean device-related cost when using extensions versus the standard number of pieces (group A: $13,220 vs. group B: $17,107, p < 0.01).Clinical midterm aneurysm-related outcomes after EVAR in patients who required additional extensions was comparable with those treated with the standard number of pieces. An increased number of extensions led to increased costs and could have potentially been minimized with appropriate preoperative planning or device selection. Consideration should be made toward per-case pricing instead of per-piece pricing to further improve cost efficiency without compromising long-term patient outcomes.

  View details for DOI 10.1016/j.avsg.2011.10.003

  View details for PubMedID 22176878

• Pancreatic Endocrine Tumors With Major Vascular Abutment, Involvement, or Encasement and Indication for Resection ARCHIVES OF SURGERY Norton, J. A., Harris, E. J., Chen, Y., Visser, B. C., Poultsides, G. A., Kunz, P. C., Fisher, G. A., Jensen, R. T. 2011; 146 (6): 724-732

  Abstract

  Surgery for pancreatic endocrine tumors (PETs) with blood vessel involvement is controversial.Resection of PETs with major blood vessel involvement can be beneficial.The combined databases of the National Institutes of Health and Stanford University hospitals were queried.Operation, pathologic condition, complications, and disease-free and overall survival.Of 273 patients with PETs, 46 (17%) had preoperative computed tomography evidence of major vascular involvement. The mean size for the primary PET was 5.0 cm. The involved major vessel was as follows: portal vein (n = 20), superior mesenteric vein or superior mesenteric artery (n = 16), inferior vena cava (n = 4), splenic vein (n = 4), and heart (n = 2). Forty-two of 46 patients had a PET removed: 12 (27%) primary only, 30 (68%) with lymph nodes, and 18 (41%) with liver metastases. PETs were removed by either enucleation (n = 7) or resection (n = 35). Resections included distal or subtotal pancreatectomy in 23, Whipple in 10, and total in 2. Eighteen patients had concomitant liver resection: 10 wedge resection and 8 anatomic resections. Nine patients had vascular reconstruction: each had reconstruction of the superior mesenteric vein and portal vein, and 1 had concomitant reconstruction of the superior mesenteric artery. There were no deaths, but 12 patients had complications. Eighteen patients (41%) were immediately disease free, and 5 recurred with follow-up, leaving 13 (30%) disease-free long term. The 10-year overall survival was 60%. Functional tumors were associated with a better overall survival (P < .001), and liver metastases decreased overall survival (P < .001).These findings suggest that surgical resection of PETs with vascular abutment/invasion and nodal or distant metastases is indicated.

  View details for PubMedID 21690450

• Pancreatic Mass Resection and Revascularization Tedesco, M. M., Norton, J. A., Cisco, R. M., Song, T. K., Harris, E. MOSBY-ELSEVIER. 2010: 530

  View details for DOI 10.1016/j.jvs.2010.05.046

  View details for Web of Science ID 000280455900073

• Major Blood Vessel Reconstruction During Sarcoma Surgery ARCHIVES OF SURGERY Song, T. K., Harris, E. J., Raghavan, S., Norton, J. A. 2009; 144 (9): 817-822

  Abstract

  To evaluate the outcomes of major vessel reconstruction as part of surgery to remove sarcomas.Retrospective review.Tertiary academic medical center.Fourteen patients (10 female) with retroperitoneal or extremity sarcomas and major blood vessel involvement who underwent surgery to remove the tumor and had blood vessel reconstruction between 2003 and 2008. Each patient underwent computed tomography angiography.Early (<30 days) and late (>30 days) operative morbidity and mortality, freedom from disease, and graft patency.Seven patients had retroperitoneal sarcomas and 7, extremity sarcomas. Thirteen tumors were malignant (7 high grade and 6 low grade) and 1, benign (leiomyoma). Seven patients had replacement of artery and vein; 5, artery only; and 2, vein only. In all, 16 arteries were reconstructed (2 common femoral; 5 iliac; 2 superficial femoral; 1 brachial; 1 popliteal; and 2 aorta, one with implantation of both iliac arteries and the other with implantation of the left renal, superior mesenteric, and hepatic arteries). Eight patients (57%) had 9 veins reconstructed (3 external iliac, 3 superficial femoral, 2 vena cava, and 1 popliteal). Primary arterial patency was 58% and primary-assisted patency was 83%. Venous patency was 78%. Local recurrence occurred in 3 patients (21%). Five-year disease-free and overall survival were 52% and 68%, respectively. Limb salvage was achieved in 93%.Involvement of vascular structures is not a contraindication for resection of sarcomas, but appropriate planning is necessary to optimize outcome.

  View details for PubMedID 19797105

• Anatomic Suitability of Ruptured Abdominal Aortic Aneurysms for Endovascular Repair 18th Annual Winter Meeting of the Peripheral-Vascular-Surgical-Society Slater, B. J., Harris, E. J., Lee, J. T. ELSEVIER SCIENCE INC. 2008: 716–22

  Abstract

  Mortality from ruptured abdominal aortic aneurysms (rAAAs) remains high despite improvements in anesthesia, postoperative intensive care, and surgical techniques. Recent small series and single-center experiences suggest that endovascular aneurysm repair (EVAR) for rAAAs is feasible and may improve short-term survival. However, the applicability of EVAR to all cases of rAAA is unknown. The purpose of this study was to investigate the anatomical suitability of ruptured aneurysms for EVAR as determined by preoperative cross-sectional imaging. A contemporary consecutive series of rAAAs presenting to a tertiary academic center was retrospectively reviewed. Preoperative radiographic imaging was reviewed and assessed for endovascular compatibility based on currently available EVAR devices. Patients with aneurysm morphology demonstrating neck diameter >32 mm, neck length <10 mm, neck angulation >60 degrees, severe iliac tortuosity, or external iliac diameter <6 mm were deemed noncandidates for EVAR. Forty-seven rAAAs were treated over a 10-year period, with 47% of patients presenting with free rupture and 60% of patients transferred from outside hospitals. Five (11%) patients were treated with EVAR, all over the past 2 years, while the remaining 42 patients underwent open repair. Preoperative imaging was available for review in 43 (91%) patients, and morphological measurements indicated that 49% would have been candidates for EVAR with currently available devices. Criteria precluding EVAR in this cohort were inadequate neck length in 73%, unsuitable iliac access in 23%, large neck diameter in 18%, and severe neck angulation in 14%. Overall 30-day mortality was 34%, and 1-year mortality was 42%. Candidates for EVAR were more likely than non-EVAR candidates to be male (95% vs. 68%, p = 0.046) and to have smaller sac diameters (7.0 vs. 8.5 cm, p = 0.02) and longer neck lengths (24.1 vs. 8.6 mm, p < 0.0001); less likely to have a >60 degree angulated neck (10% vs. 45%, p = 0.0002), larger external iliac diameter (8.9 vs. 7.3 mm, p = 0.015), and less blood loss during surgical repair (2.4 vs. 6.0 L, p = 0.02); and more likely to be discharged home (71% vs. 25%, p = 0.05). There were no differences in 30-day, 1-year, or overall mortality between candidates for EVAR and noncandidates. Only 49% of patients with rAAAs in this consecutive series were found to be candidates for EVAR with conventional stent-graft devices. Differences in demographics, aneurysm morphology, and outcomes between candidates and noncandidates undergoing open repair suggest that differential risks apply to ruptured aneurysm patients. Protocols and future reports of EVAR for rAAAs should be tailored to these results. Device and technique modifications are necessary to increase the applicability of EVAR for rAAAs.

  View details for DOI 10.1016/j.avsg.2008.06.001

  View details for PubMedID 18657385

• Simulation-based endovascular skills assessment: The future of credentialing? 22nd Annual Meeting of the Western-Vascular-Society Tedesco, M. M., Pak, J. J., Harris, E. J., Krummel, T. M., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2008: 1008–14

  Abstract

  Simulator-based endovascular skills training measurably improves performance in catheter-based image-guided interventions. The purpose of this study was to determine whether structured global performance assessment during endovascular simulation correlated well with trainee-reported procedural skill and prior experience level.Fourth-year and fifth-year general surgery residents interviewing for vascular fellowship training provided detailed information regarding prior open vascular and endovascular operative experience. The pretest questionnaire responses were used to separate subjects into low (<20 cases) and moderate (20 to 100) endovascular experience groups. Subjects were then asked to perform a renal angioplasty/stent procedure on the Procedicus Vascular Intervention System Trainer (VIST) endovascular simulator (Mentice Corporation, Gothenburg, Sweden). The subjects' performance was supervised and evaluated by a blinded expert interventionalist using a structured global assessment scale based on angiography setup, target vessel catheterization, and the interventional procedure. Objective measures determined by the simulator were also collected for each subject. A postsimulation questionnaire was administered to determine the subjects' self-assessment of their performance.Seventeen surgical residents from 15 training programs completed questionnaires before and after the exercise and performed a renal angioplasty/stent procedure on the endovascular simulator. The beginner group (n = 8) reported prior experience of a median of eight endovascular cases (interquartile range [IQR], 6.5-17.8; range, 4-20), and intermediate group (n = 9) had previously completed a median of 42 cases (IQR, 31-44; range, 25-89, P = .01). The two groups had similar prior open vascular experience (79 cases vs 75, P = .60). The mean score on the structured global assessment scale for the low experience group was 2.68 of 5.0 possible compared with 3.60 for the intermediate group (P = .03). Scores for subcategories of the global assessment score for target vessel catheterization (P = .02) and the interventional procedure (P = .05) contributed more to the differentiation between the two experience groups. Total procedure time, fluoroscopy time, average contrast used, percentage of lesion covered by the stent, placement accuracy, residual stenosis rates, and number of cine loops utilized were similar between the two groups (P > .05).Structured endovascular skills assessment correlates well with prior procedural experience within a high-fidelity simulation environment. In addition to improving endovascular training, simulators may prove useful in determining procedural competency and credentialing standards for endovascular surgeons.

  View details for DOI 10.1016/j.jvs.2008.01.007

  View details for PubMedID 18372149

• Intraoperative monitoring of elephant trunk kinking with transesophageal echocardiography JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Oakes, D. A., Sze, D. Y., Frisoli, J. K., Mitchell, R. S., Harris, E. J., Thu, C., van der Starre, P. J. 2007; 21 (4): 584-586

  View details for DOI 10.1053/j.jvca.2006.11.002

  View details for Web of Science ID 000248766100023

  View details for PubMedID 17678793

• Intraoperative colon mucosal oxygen saturation during aortic surgery 1st Annual Academic Surgical Congress of the Association-for-Academic-Surgery Lee, E. S., Bass, A., Arko, F. R., Heikkinen, M., Harris, E. J., Zarins, C. K., van der Starre, P., Olcott, C. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2006: 19–24

  Abstract

  Colonic ischemia after aortic reconstruction is a devastating complication with high mortality rates. This study evaluates whether Colon Mucosal Oxygen Saturation (CMOS) correlates with colon ischemia during aortic surgery.Aortic reconstruction was performed in 25 patients, using a spectrophotometer probe that was inserted in each patient's rectum before the surgical procedure. Continuous CMOS, buccal mucosal oxygen saturation, systemic mean arterial pressure, heart rate, pulse oximetry, and pivotal intra-operative events were collected.Endovascular aneurysm repair (EVAR) was performed in 20 and open repair in 5 patients with a mean age of 75 +/- 10 (+/-SE) years. CMOS reliably decreased in EVAR from a baseline of 56% +/- 8% to 26 +/- 17% (P < 0.0001) during infrarenal aortic balloon occlusion and femoral arterial sheath placement. CMOS similarly decreased during open repair from 56% +/- 9% to 15 +/- 19% (P < 0.0001) when the infrarenal aorta and iliac arteries were clamped. When aortic circulation was restored in both EVAR and open surgery, CMOS returned to baseline values 56.5 +/- 10% (P = 0.81). Mean recovery time in CMOS after an aortic intervention was 6.4 +/- 3.3 min. Simultaneous buccal mucosal oxygen saturation was stable (82% +/- 6%) during aortic manipulation but would fall significantly during active bleeding. There were no device related CMOS measurement complications.Intra-operative CMOS is a sensitive measure of colon ischemia where intraoperative events correlated well with changes in mucosal oxygen saturation. Transient changes demonstrate no problem. However, persistently low CMOS suggests colon ischemia, thus providing an opportunity to revascularize the inferior mesenteric artery or hypogastric arteries to prevent colon infarction.

  View details for DOI 10.1016/j.jss.2006.05.014

  View details for Web of Science ID 000242202300004

  View details for PubMedID 16978651

• Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome 20th Annual Meeting of the Western-Vascular-Society Lee, J. T., Karwowski, J. K., Harris, E. J., Haukoos, J. S., Olcott, C. MOSBY-ELSEVIER. 2006: 1236–43

  Abstract

  The purpose of this study was to determine the clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with nonoperative management of patients with primary subclavian vein thrombosis.Sixty-four patients treated for Paget-Schroetter syndrome from 1996 to 2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First-rib resection was performed in 29 patients (45%) within the first 3 months, with a success rate of 93%. The remaining 35 patients (55%) were treated nonoperatively and constitute this study's population.Of the 35 patients with successful nonoperative management, 8 (23%) developed recurrent thrombotic events of the same extremity at a mean follow-up time of 13 months after thrombolysis (range, 6-33 months). These eight patients subsequently underwent first-rib resection with a 100% success rate without further sequelae at a mean follow-up time of 51 months (range, 2-103 months). The other 27 patients remained symptom free at a mean follow-up interval of 55 months (range, 10-110 months). Bivariate analyses determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P = .05). The recurrence group was also significantly younger than the asymptomatic group (22 vs 36 years; P = .01). Sex, being a competitive athlete, a history of trauma, whether the dominant arm was affected, time of delay to lysis, initial clot burden, response to original lysis, use of adjunctive balloons or mechanical thrombectomy devices, residual stenosis on venography, length of time on warfarin, and patency of the vein on follow-up duplex examination were all characteristics not associated with long-term recurrence after nonoperative management.Conservative nonoperative management of primary subclavian vein thrombosis can be successfully used with acceptable long-term results. A younger age (<28 years old) and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.

  View details for DOI 10.1016/j.jvs.2006.02.005

  View details for PubMedID 16765247

• Selective shunting during carotid endarterectomy VASCULAR Nguyen, T. Q., Lind, L., Harris, E. J. 2005; 13 (1): 23-27

  Abstract

  Carotid endarterectomy (CEA) is an effective treatment for significant carotid atherosclerosis. Perioperative stroke, a devastating complication, may be partially circumvented by shunting. However, routine shunt use is not without complications and does not benefit every patient. Our study is designed to determine whether CEA under general anesthesia, without cerebral monitoring, can be safely done with shunting only in the presence of poor internal carotid artery back-bleeding or contralateral carotid occlusion or critical stenosis. The medical records of 995 carotid operations were reviewed. A subset of 117 operations was performed on 112 patients using selective shunting. Data were analyzed and outcomes compared. For the selective shunt group, indications for redo operations (n=13) were recurrent asymptomatic high-grade stenosis in 69% and amaurosis fugax or transient ischemic attack in 31%. Indications for primary CEA (n=104) were asymptomatic high-grade stenosis in 59%, amaurosis fugax or transient ischemic attack in 36%, previous stroke in 3%, and global ischemia in 2%. A selective shunt was used in 29% of all symptomatic and 11% of all asymptomatic patients. No cerebral monitoring was used. There were no perioperative deaths and no permanent cranial nerve injuries, and there was one stroke (0.8%) from postoperative carotid thrombosis in a shunted patient. The average length of stay was 1.6 days for the non-shunt group and 2.2 days for the shunt group. The routine shunt group (n=878) had an overall stroke rate of 0.7%, no permanent cranial nerve deficits, and a mean hospital stay of 2.6 days. CEA under general anesthesia with selective shunting can be performed safely without cerebral monitoring.

  View details for Web of Science ID 000231147800004

  View details for PubMedID 15895671

• Early and late functional outcome assessments following endovascular and open aneurysm repair 16th Annual Meeting of the Western-Vascular-Society Arko, F. R., Hill, B. B., Reeves, T. R., Olcott, C., Harris, E. J., Fogarty, T. J., Zarins, C. K. ALLIANCE COMMUNICATIONS GROUP DIVISION ALLEN PRESS. 2003: 2–9

  Abstract

  To compare early and late functional outcomes, as well as survival and recovery, following endovascular or open repair of abdominal aortic aneurysm (AAA).Between 1996 and 2000, 294 patients underwent AAA repair (141 open and 153 endovascular); 57 patients from each group had 12-month follow-up for functional outcome assessment. Recovery was measured as hospital length of stay, skilled nursing requirement, and hospital readmission within 1 year to determine cumulative hospital utilization. Early (<6 months) functional outcomes were measured by activity level and convalescence days following surgery. Late (>6 months) functional outcomes were measured as ambulation, independent living, and employment status pre- and postoperatively.Operative mortality for open repair was 5 (3.5%) compared to 1 (0.6%) after an endovascular procedure (p<0.05). The endovascular group had a shorter hospital stay (2.8+/-2.8 versus 8.3+/-4.5 days) and fewer skilled nursing requirements (0% versus 26%; p<0.001). Cumulative hospital utilization over 12 months was 3.8 days for endovascular patients and 13.8 days for open repair (p<0.001). Recovery time was 99.3+/-84.1 days (range 14-365) in conventionally treated patients and 32.1+/-43.5 days (range 7-180) in the stent-graft group (p<0.001). At 6 months, 43 (75%) open and 54 (95%) endovascular patients had full recovery (p<0.01). Activity levels decreased in 13 (23%) open and 3 (5%) endovascular patients after surgery (p<0.01). There were no differences in ambulation, independent living, or employment status before and after treatment.Periprocedural survival following aneurysm repair is improved with endovascular grafting compared to open surgery, and recovery is more rapid, with a 78% reduction in total hospital days. Early functional outcomes are markedly improved with endovascular repair, while there is no difference in late functional outcomes between the procedures.

  View details for Web of Science ID 000183272900002

  View details for PubMedID 12751922

• Endovascular repair reduces early and late morbidity compared to open surgery for abdominal aortic aneurysm Annual Meeting of the Western-Surgical-Society Arko, F. R., Hill, B. B., Olcott, C., Harris, E. J., Fogarty, T. J., Zarins, C. K. ALLIANCE COMMUNICATIONS GROUP DIVISION ALLEN PRESS. 2002: 711–18

  Abstract

  To compare systemic complications between standard surgery and endovascular repair of abdominal aortic aneurysms (AAA) for both primary and late secondary procedures.At a single center between July 1993 and May 2000, 297 patients (255 men; mean age 73.4 +/- 8.1 years, range 50-93) were treated with open surgical repair; beginning in 1996, 200 (166 men; mean age 73.6 +/- 8.0 years, range 45-96) patients were treated with the AneuRx stent-graft. In a comparison of the cohorts, which were similar in terms of age, gender, and aneurysm diameter, the main outcomes were early major systemic morbidity following the primary procedure to treat the aneurysm and late (>30 days) organ system morbidity for any secondary procedures.Mean length of follow-up for open patients was 20.1 +/- 17.1 months (range 1-150) compared to 12.4 +/- 9.6 months (range 1-60) after endovascular repair (p<0.05). There were 36 (12.1%) systemic complications after the primary open surgery and 15 (7.5%) after endovascular repair (p=NS). There were 43 (14.5%) combined primary and secondary morbidities in the open surgery group versus 15 (7.5%) for patients undergoing endovascular repair (p<0.01). The need for invasive procedures to treat these primary and secondary systemic complications was 4 times greater in the open group (17, 5.7%) than in endograft patients (3, 1.5%) (p<0.05). After secondary procedures (32 in the open group and 30 in the endovascular patients) for graft-related complications, there were 7 (21.9%) adverse events in the open group versus none (0%) for endograft patients (p<0.01). Hospital lengths of stay following both primary and secondary procedures were lower for the endograft patients (p<0.01 and p<0.001, respectively).Endovascular stent-graft repair compared to open surgery has reduced the early and late morbidity by half. Complications that require invasive or secondary surgical procedures and hospitalization are reduced with endovascular repair.

  View details for Web of Science ID 000181102400001

  View details for PubMedID 12546569

• Transition to all-autogenous hemodialysis access: The role of preoperative vein mapping 12th Annual Winter Meeting of the Peripheral-Vascular-Surgery-Society Dalman, R. L., Harris, E. J., Victor, B. J., Coogan, S. M. ELSEVIER SCIENCE INC. 2002: 624–30

  Abstract

  Safe, reliable, and efficient hemodialysis access (DA) remains an unrealized ideal. Autogenous dialysis access (ADA) may improve outcome for renal failure patients. We now place ADA in 9 out of 10 new patients in an effort to maximize primary patency and minimize access-related complications. We reviewed our recent DA experience to determine whether our increased reliance on autogenous access (ADA) has improved outcomes, and to evaluate the impact of preoperative duplex venous imaging (vein mapping) on early and intermediate results. We conducted a retrospective database review of 108 consecutive patients undergoing initial permanent DA between 10/97 and 8/01. Mean follow-up was 13.1 months. Our results showed that increased ADA utilization decreases the need for secondary access procedures. The functional superiority of ADA vs. prosthetic dialysis access (PDA) in this series may be due to optimal autogenous conduit selection facilitated by preoperative vein mapping.

  View details for DOI 10.1007/s10016-001-0268-4

  View details for Web of Science ID 000178871800018

  View details for PubMedID 12203002

• Aneurysm-related death: Primary endpoint analysis for comparison of open and endovascular repair Joint Annual Meeting of the American-Association-for-Vascular-Surgery/Society-for-Vascular-Surgery Arko, F. R., Lee, W. A., Hill, B. B., Olcott, C., Dalman, R. L., Harris, E. J., Cipriano, P., Fogarty, T. J., Zarins, C. K. MOSBY-ELSEVIER. 2002: 297–304

  Abstract

  The purpose of this study was to utilize an objective endpoint analysis of aneurysm treatment, which is based on the primary objective of aneurysm repair, and to apply it to a consecutive series of patients undergoing open and endovascular repair.Aneurysm-related death was defined as any death that occurred within 30 days of primary aneurysm treatment (open or endovascular), within 30 days of a secondary aneurysm or graft-related treatment, or any death related to the aneurysm or graft at any time following treatment. We reviewed 417 consecutive patients undergoing elective infrarenal aortic aneurysm repair: 243 patients with open repair and 174 patients with endovascular repair.There was no difference between the groups (open vs endovascular) with regard to mean age +/- standard deviation (73 +/- 8 years vs 74 +/- 8 years) or aneurysm size (64 +/- 2 mm vs 58 +/- 10 mm) (P = not significant [NS]). The 30-day mortality for the primary procedure after open repair was 3.7% (9/243) and after endovascular repair was 0.6% (1/174, P <.05). The 30-day mortality for secondary procedures after open repair was 14% (6/41) compared to 0% after endovascular repair (P <.05). The aneurysm-related death rate was 4.1% (10/243) after open surgery and 0.6% (1/174) after endovascular repair (P <.05). Mean follow-up was 5 months longer following open repair (P <.05). Secondary procedures were performed in 41 patients following open surgery and 27 patients following endovascular repair (P = NS). Secondary procedures following open repair were performed for anastomotic aneurysms (n = 18), graft infection (n = 6), aortoenteric fistula (n = 5), anastomotic hemorrhage (n = 4), lower extremity amputation (n = 4), graft thrombosis (n = 3), and distal revascularization (n = 1). Secondary procedures following endovascular repair consisted of proximal extender cuffs (n = 11), distal extender cuffs (n = 11), limb thrombosis (n = 3), and surgical conversion (n = 2). The magnitude of secondary procedures following open repair was greater with longer operative time 292 +/- 89 minutes vs 129 +/- 33 minutes (P <.0001), longer length of stay 13 +/- 10 days vs 2 +/- 2 days (P <.0001) and greater blood loss 3382 +/- 4278 mL vs 851 +/- 114 mL (P <.0001).The aneurysm-related death rate combines early and late deaths and should be used as the primary outcome measure to objectively compare the results of open and endovascular repair in the treatment of infrarenal abdominal aortic aneurysms. In our experience, endovascular aneurysm repair reduced the overall aneurysm-related death rate when compared to open repair. Secondary procedures are required after both open and endovascular repair. However, the magnitude, morbidity, and mortality of secondary procedures are reduced significantly with endovascular repair.

  View details for DOI 10.1067/mva.2002.126314

  View details for Web of Science ID 000177489000015

  View details for PubMedID 12170210

• Duplex ultrasound criteria for defining the severity of carotid stenosis ANNALS OF VASCULAR SURGERY Filis, K. A., Arko, F. R., Johnson, B. L., Pipinos, I. I., Harris, E. J., Olcott, C., Zarins, C. K. 2002; 16 (4): 413-421

  Abstract

  Duplex ultrasound scan (DUS) criteria for grading >50% carotid artery stenosis is typically divided into broad categories such as 50-79% stenosis, 80-99% stenosis, and occlusion. The purpose of this study is to validate DUS criteria for stratifying 50 to 100% carotid stenosis into 10% intervals using digital substraction cerebral angiography (DSCA) as the standard of comparison. Between 1996 and 2001, 163 patients were evaluated with duplex ultrasound and angiography. A total of 326 carotid arteries were studied using DUS in an accredited ICAVL vascular laboratory. Threshold velocity criteria for determining the degree of carotid stenosis was defined according to seven categories: <50%, 50-59%, 60-69%, 70-79%, 80-89%, 90-99%, and occlusion. Treatment decisions were based on the angiographic findings. In cases where the degree of stenosis as defined by duplex velocity criteria did not correlate with angiographically defined stenosis, each record was reviewed to determine whether the angiographic findings altered the surgeon's treatment decision. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for DUS-defined degree of stenosis as compared to angiographically defined stenosis were determined. There was a high correlation (R = 0.96) between duplex scan and angiography in 93% (302/326) of the cases. Clinical management was altered in only 3% (10/326) of the cases because of the results of angiography. The DUS velocity criteria to grade the severity of carotid disease in 10% intervals is reliable and accurate. Clinical management of patients with carotid stenosis can be based solely on carotid DUS in 97% of patients considered for treatment of carotid artery disease.

  View details for DOI 10.1007/s10016-001-0175-8

  View details for Web of Science ID 000177802500003

  View details for PubMedID 12118345

• Endovascular obliteration of saphenous vein reflux: A perspective JOURNAL OF VASCULAR SURGERY Harris, E. J. 2002; 35 (6): 1292-1294

  View details for DOI 10.1067/mva.2002.124624

  View details for Web of Science ID 000176178500045

  View details for PubMedID 12042745

• Open versus endovascular AAA repair in patients who are morphological candidates for endovascular treatment JOURNAL OF ENDOVASCULAR THERAPY Hill, B. B., Wolf, Y. G., Lee, W. A., Arko, F. R., Olcott, C., Schubart, P. J., Dalman, R. L., Harris, E. J., Fogarty, T. J., Zarins, C. K. 2002; 9 (3): 255-261

  Abstract

  To compare the outcomes of open versus endovascular repair of abdominal aortic aneurysm (AAA) in a cohort of patients who fulfill morphological criteria for endovascular repair.A retrospective review of 229 consecutive AAA patients treated over a 3-year period identified 149 patients who were candidates for endovascular repair based on preoperative computed tomography and angiography. Of the 149 patients, 79 (68 men; mean age 74 +/- 8 years) underwent endovascular repair with the AneuRx stent-graft; the remaining 70 (56 men; mean age 72 +/- 8 years) had open repair. Short-term outcome measures were 30-day mortality and procedure-related morbidity, length of stay in the intensive care unit and hospital, intraoperative blood loss, interval to oral diet, and time to ambulation. Long-term outcome measures included death and secondary procedures.There was no difference in the 30-day mortality between endovascular repair (2, 2.5%) and open repair (2, 2.9%), even though endovascular patients had more comorbidities (p<0.05). Overall length of stay was reduced for endovascular patients (3.9 +/- 2.4 days versus 7.7 +/- 3.1 days for surgical patients, p<0.0001). Fewer endograft patients had complications (24% versus 40% for open repair, p<0.05), and the severity of these complications was less, as evidenced by the shorter hospital stays for endovascular patients with complications compared to conventionally treated patients with complications (6.7 +/- 2.4 days versus 22.5 +/- 35.2 days, p<0.05). There were no aneurysm ruptures or late surgical conversions in either group.Patients with AAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. Despite increased comorbidities in the endograft patients, there was no increase in mortality compared to open repair. Both treatments required secondary procedures and appeared to be equally effective in preventing aneurysm rupture up to 3 years.

  View details for Web of Science ID 000176993800001

  View details for PubMedID 12096937

• Gender differences in endovascular abdominal aortic aneurysm repair with the AneuRx stent graft 25th Annual Meeting of the Midwestern-Vascular-Surgical-Society Wolf, Y. G., Arko, F. R., Hill, B. B., Olcott, C., Harris, E. J., Fogarty, T. J., Zarins, C. K. MOSBY-ELSEVIER. 2002: 882–86

  Abstract

  The objective of this study was to evaluate gender differences in the selection, procedure, and outcome of endovascular abdominal aortic aneurysm repair (EVAR).Between October 1996 and January 2001, 378 patients were evaluated for EVAR and 189 patients underwent EVAR with the Medtronic AneuRx stent graft at a single center.Women constituted 17% of patients considered for EVAR. Their eligibility rate (49%) did not differ significantly from that of men (57%), and they constituted 14% of patients who underwent EVAR (26/189). Women who underwent EVAR were older (77.9 +/- 6.3 years versus 73.1 +/- 8.1 years; P <.005) with a higher rate of chronic obstructive lung disease (50% versus 28%; P <.05). Maximal aneurysm diameter (57.2 +/- 10.9 mm versus 57.8 +/- 9.4 mm; not significant) did not differ between men and women. Mean diameters of the proximal neck (20.4 +/- 2.3 mm versus 22.3 +/- 2.0 mm; P <.01), common iliac arteries (11.4 +/- 1.2 mm versus 13.5 +/- 3.6 mm; P <.001), and external iliac arteries (7.9 +/- 0.7 mm versus 9.4 +/- 1.4 mm; P <.001) were all smaller in women, and abdominal aortic aneurysm/neck diameter ratio was larger (2.82 +/- 0.59 versus 2.60 +/- 0.49; P <.05). The length of the proximal aortic neck was shorter in women (20.7 +/- 8.2 mm versus 24.5 +/- 11.8 mm; P <.05). Women had significantly more intraoperative complications (31% versus 13%; P <.05), primarily related to arterial access, and needed more frequent arterial reconstruction (42% versus 21%; P <.05), without a difference in postoperative mortality rate (0/26 versus 2/163; not significant) and complication rate (23% versus 20%: not significant). During a follow-up period of 13.8 +/- 11.7 months, no gender-related difference was found in survival rate, endoleak rate, or reintervention rate or in the rate of change in aneurysm diameter or volume.Eligibility rates of women for EVAR are similar to those of men. Women are at an increased risk for access-related complications during EVAR, but outcome is equivalent to that of men.

  View details for DOI 10.1067/mva.2002.123754

  View details for Web of Science ID 000175919100014

  View details for PubMedID 12021702

• Radiofrequency ablation of the long saphenous vein without high ligation versus high ligation and stripping for primary varicose veins: pros and cons. Seminars in vascular surgery Harris, E. J. 2002; 15 (1): 34-38

  Abstract

  Primary varicose vein disease is prevalent in our society, and although it is infrequently the cause of serious venous insufficiency, it often is associated with symptoms of local discomfort. These symptoms eventually may outweigh any cosmetic concerns of patients with this disease. Greater saphenous vein (GSV) reflux is the most important pathophysiologic component of primary venous insufficiency. To date, the surgical treatment of GSV reflux has evolved into 1 of 3 procedures: high ligation of the saphenofemoral junction, with or without perforator ligation; high ligation and stripping of the GSV; and high ligation with retrograde sclerotherapy of the GSV. High ligation and stripping of the GSV to below the knee enjoys the most durable success yet is associated with significant perioperative morbidity. A new treatment, radiofrequency ablation of the GSV without high ligation, recently has been described and promises a less invasive alternative to stripping with decreased morbidity and increased patient acceptance. The results of high ligation and stripping of the GSV will be compared with those with radiofrequency ablation of the GSV without high ligation.

  View details for PubMedID 11840424

• Impact of endovascular repair on open aortic aneurysm surgical training 13th Annual Meeting of the American-Venous-Forum Arko, F. R., Lee, W. A., Hill, B. B., Olcott, C., Harris, E. J., Dalman, R. L., Fogarty, T. J., Zarins, C. K. MOSBY-ELSEVIER. 2001: 885–90

  Abstract

  The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery.The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training.Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 +/- 4.9 (range, 68-77) and increased to 124.7 +/- 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 +/- 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 +/- 6.6 (range, 48-56) before endovascular repair versus 47.0 +/- 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 +/- 1.0 (range, 9-11) before endovascular repair compared with 19.0 +/- 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 +/- 3.0 (range, 4-11) before endovascular repair compared with 7.6 +/- 2.3 (range, 5-9) after.Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training.

  View details for DOI 10.1067/mva.2001.118816

  View details for Web of Science ID 000172305700035

  View details for PubMedID 11700491

• Vascular complications in high-performance athletes 15th Scientific Meeting of the Western-Vascular-Society Arko, F. R., Harris, E. J., Zarins, C. K., Olcott, C. MOSBY-ELSEVIER. 2001: 935–42

  Abstract

  The purpose of this study was to evaluate our experience with the diagnosis and management of vascular injuries in a group of high-performance athletes.Between June 1994 and June 2000, we treated 26 patients who sustained vascular complications as a result of athletic competition. Clinical presentation, type of athletic competition, location of injury, type of therapy, and degree of rehabilitation were analyzed retrospectively.The mean age of the patients was 23.8 years (range, 17-40). Twenty-one (81%) patients were men, and five (19%) were women. Athletes included 8 major-league baseball players, 7 football players, 2 world-class cyclists, 2 rock climbers, 2 wind surfers, 1 swimmer, 1 kayaker, 1 weight lifter, 1 marksman, and 1 volleyball player. There were 14 (54%) arterial and 12 (46%) venous complications. Arterial injuries included 7 (50%) axillary/subclavian artery or branch artery aneurysms with secondary embolization, 6 (43%) popliteal artery injuries, and 1 (7%) case of intimal hyperplasia and stenosis involving the external iliac artery. Subclavian vein thrombosis (SVT) accounted for all venous complications. Five of the seven patients with axillary/subclavian branch artery aneurysms required lytic therapy for distal emboli, and six required operative intervention. All popliteal artery injuries were treated by femoropopliteal bypass graft with autogenous saphenous vein. The external iliac artery lesion, which occurred in a cyclist, was repaired with limited resection and vein patch angioplasty. All 12 patients with SVT were treated initially with lytic therapy and anticoagulation. Eight patients required thoracic outlet decompression and venolysis of the subclavian vein. Thirteen arterial reconstructions have remained patent at an average follow-up of 31.9 months (range, 2-74). One patient with a popliteal artery injury required reoperation at 2 months for occlusion of his bypass graft. Eleven of the patients with an arterial injury were able to return to their prior level of competition. All of the patients with SVT have remained stable without further venous thrombosis and have returned to their usual level of activity.Athletes are susceptible to a variety of vascular injuries that may not be easily recognized. A high level of suspicion, a thorough workup including noninvasive studies and arteriography/venography, and prompt treatment are important for a successful outcome.

  View details for Web of Science ID 000168687300004

  View details for PubMedID 11331831

• Will endovascular repair replace open surgery for abdominal aortic aneurysm repair? 120th Annual Meeting of the American-Surgical-Association Zarins, C. K., Wolf, Y. G., Lee, W. A., Hill, B. B., Olcott, C., Harris, E. J., Dalman, R. L., Fogarty, T. J. LIPPINCOTT WILLIAMS & WILKINS. 2000: 501–5

  Abstract

  To evaluate of the impact of endovascular aneurysm repair on the rate of open surgical repair and on the overall treatment of abdominal aortic aneurysms (AAAs).All patients with AAA who were treated during two consecutive 40-month periods were reviewed. During the first period, only open surgical repair was performed; during the subsequent 40 months, endovascular repair and open surgical repair were treatment options.A total of 727 patients with AAA were treated during the entire period. During the initial 40 months, 268 patients were treated with open surgical repair, including 216 infrarenal (81%), 43 complex (16%), and 9 ruptured (3%) aortic aneurysms. During the subsequent 40 months, 459 patients with AAA were treated (71% increase). There was no significant change in the number of patients undergoing open surgical repair and no significant difference in the rate of infrarenal (238 [77%]) and complex (51 [16%]) repairs. A total of 353 patients were referred for endovascular repair. Of these, 190 (54%) were considered candidates for endovascular repair based on computed tomography or arteriographic morphologic criteria. Analyzing a subgroup of 123 patients, the most common primary reasons for ineligibility for endovascular repair were related to morphology of the neck in 80 patients (65%) and of the iliac arteries in 35 patients (28%). A total of 149 patients underwent endovascular repair. Of these, the procedure was successful in 147 (99%), and 2 (1%) patients underwent surgical conversion. The hospital death rate was 0%, and the 30-day death rate was 1%. During a follow-up period of 1 to 39 months (mean 12 +/- 9), 21 secondary procedures to treat endoleak (20) or to maintain graft limb patency (1) were performed in 17 patients (11%). There were no aneurysm ruptures or aneurysm-related deaths.Endovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA. Patients who previously were not candidates for repair because of medical comorbidity may now be safely treated with endovascular repair.

  View details for Web of Science ID 000089602400009

  View details for PubMedID 10998648

• Endovascular repair of abdominal aortic aneurysms: Eligibility rate and impact on the rate of open repair JOURNAL OF VASCULAR SURGERY Wolf, Y. G., Fogarty, T. J., Olcott, C., Hill, B. B., Harris, E. J., Mitchell, R. S., Miller, D. C., Dalman, R. L., Zarins, C. K. 2000; 32 (3): 519-523

  Abstract

  The purpose of this study was to determine the rate of eligibility among patients with abdominal aortic aneurysms (AAAs) considered for endovascular repair and to examine the effect of an endovascular program on the institutional pattern of AAA repair.All patients evaluated for endovascular AAA repair since the inception of an endovascular program were reviewed for determination of eligibility rates and eventual treatment. Open AAA repairs were categorized as simple (uncomplicated infrarenal), complex (juxtarenal, suprarenal, thoracoabdominal, infected), or ruptured, and their rates before and after initiation of an endovascular program were compared.Over 3 years, 324 patients were considered for endovascular AAA repair; 176 (54%) were candidates, 138 (43%) were not candidates, and 10 (3%) did not complete the evaluation. The rate of eligibility increased significantly from 45% (66/148 patients) during the first half of this period to 63% (110/176 patients) during the second half (P <. 001). Candidates were significantly younger (74.4 +/- 7.6 years) than noncandidates (78.3 +/- 6.7 years) (P <.01), and their aneurysm diameter tended to be smaller (57.6 +/- 9.2 mm compared with 60.8 +/- 12.3 mm; P =.06). The most common reason for ineligibility was an inadequate proximal aortic neck. Of 176 candidates, 78% underwent endovascular repair, and 6% underwent open repair. Of 138 noncandidates, 56% underwent surgical repair. Over a period of 6 years, 542 patients with AAAs (429 simple, 86 complex, 27 ruptured) underwent open repair. The total number and ratio of simple to complex open repairs for nonruptured aneurysms during the 3 years before the initiation of the endovascular program (213 simple, 44 complex) were not significantly different from the repairs over the subsequent 3-year period (216 simple, 42 complex). Similarly, no difference in the total number and the ratio of simple to complex open repairs was found between the first and the second 18-month periods since the initiation of the endovascular program.The rate of eligibility of patients with AAA for endovascular repair appears to be higher than previously reported. The presence of an active endovascular program has not decreased the number or shifted the distribution of open AAA repair.

  View details for PubMedID 10957658

• Surgical intervention is not required for all patients with subclavian vein thrombosis 14th Annual Meeting of the Western-Vascular-Society Lee, W. A., Hill, B. B., Harris, E. J., Semba, C. P., Olcott, C. MOSBY-ELSEVIER. 2000: 57–64

  Abstract

  The role of thoracic outlet decompression in the treatment of primary axillary-subclavian vein thrombosis remains controversial. The timing and indications for surgery are not well defined, and thoracic outlet procedures may be associated with infrequent, but significant, morbidity. We examined the outcomes of patients treated with or without surgery after the results of initial thrombolytic therapy and a short period of outpatient anticoagulation.Patients suspected of having a primary deep venous thrombosis underwent an urgent color-flow venous duplex ultrasound scan, followed by a venogram and catheter-directed thrombolysis. They were then converted from heparin to outpatient warfarin. Patients who remained asymptomatic received anticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptoms of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent thoracic outlet decompression and postoperative anticoagulation for 1 month.Twenty-two patients were treated between June 1996 and June 1999. Of the 18 patients who received catheter-directed thrombolysis, complete patency was achieved in eight patients (44%), and partial patency was achieved in the remaining 10 patients (56%). Nine of 22 patients (41%) did not require surgery, and the remaining 13 patients underwent thoracic outlet decompression through a supraclavicular approach with scalenectomy, first-rib resection, and venolysis. Recurrent thrombosis developed in only one patient during the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surgery sustained durable relief of their symptoms and a return to their baseline level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging.Not all patients with primary axillary-subclavian vein thrombosis require surgical intervention. A period of observation while patients are receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persistent symptoms and venous obstruction should be offered thoracic outlet decompression. Chronic anticoagulation is not required in these patients.

  View details for Web of Science ID 000088172500013

  View details for PubMedID 10876207

• Open saphenectomy complications following lower extremity revascularization CARDIOVASCULAR SURGERY Dalman, R. L., Abbruzzese, T., Bushnik, T., Harris, E. J. 2000; 8 (1): 51-57

  Abstract

  A review of saphenectomy site complications following lower extremity revascularization was conducted. Leg incisions used for 133 consecutive infrainguinal bypass procedures were categorized by location. Patient and procedural risk factors were analyzed for risk of wound complications. Procedure, limb and patient outcome were reported via life table analysis. Incisional wound complications followed 32/133 procedures (24%), including 15 groin, eight saphenectomy, five distal and four vein/distal incisions. There were five grade I and three grade II saphenectomy complications. Only weight (body mass index) predicted the likelihood of wound complication (P < 0.05). The 6-month primary patency rate was 79% (mean follow-up 22 months). Four-year assisted primary patency, limb salvage and survival rates were 75, 87 and 57%, respectively. Most bypass-related wound complications (24/32, 75%) involve arterial access incisions. Incisional complications are related to body mass index. Only 6% of GS vein bypass procedures develop saphenectomy site complications. Limiting saphenectomy size may not significantly reduce incisional morbidity following bypass grafting.

  View details for Web of Science ID 000084649000008

  View details for PubMedID 10661704

• Modular systems in the treatment of abdominal aortic aneurysms: lessons learned in the development of designer endografts. Seminars in vascular surgery Harris, E. J. 1999; 12 (3): 170-175

  Abstract

  Treatment of abdominal aortic aneurysms with endoluminal stent-grafts is gaining increased interest. Since the original home-made stent-graft was developed in 1991, a multitude of devices have been developed for this treatment. Modular endografts have evolved during this time and offer several significant advantages. Thorough preoperative imaging and assessment is critical to the success of this new therapy for abdominal aortic aneurysms. Lessons learned during the development of the Medtronic AneuRx endograft and its early clinical trials are discussed.

  View details for PubMedID 10498259

• Reoperation for carotid stenosis is as safe as primary carotid endarterectomy 13th Annual Meeting of the Western-Vascular-Society Hill, B. B., Olcott, C., Dalman, R. L., Harris, J., Zarins, C. K. MOSBY-ELSEVIER. 1999: 26–34

  Abstract

  Patients with recurrent carotid artery stenosis are sometimes referred for carotid angioplasty and stenting because of reports that carotid reoperation has a higher complication rate than primary carotid endarterectomy. The purpose of this study was to determine whether a difference exists between outcomes of primary carotid endarterectomy and reoperative carotid surgery.Medical records were reviewed for all carotid operations performed from September 1993 through March 1998 by vascular surgery faculty at a single academic center. The results of primary carotid endarterectomy and operation for recurrent carotid stenosis were compared.A total of 390 operations were performed on 352 patients. Indications for primary carotid endarterectomy (n = 350) were asymptomatic high-grade stenosis in 42% of the cases, amaurosis fugax and transient ischemic symptoms in 35%, global symptoms in 14%, and previous stroke in 9%. Indications for reoperative carotid surgery (n = 40) were symptomatic recurrent lesions in 50% of the cases and progressive high-grade asymptomatic stenoses in 50%. The results of primary carotid endarterectomy were no postoperative deaths, an overall stroke rate of 1.1% (three postoperative strokes, one preoperative stroke after angiography), and no permanent cranial nerve deficits. The results of operations for recurrent carotid stenosis were no postoperative deaths, no postoperative strokes, and no permanent cranial nerve deficits. In the primary carotid endarterectomy group, the mean hospital length of stay was 2.6 +/- 1. 1 days and the mean hospital cost was $9700. In the reoperative group, the mean length of stay was 2.6 +/- 1.5 days and the mean cost was $13,700. The higher cost of redo surgery is accounted for by a higher preoperative cerebral angiography rate (90%) in redo cases as compared with primary endarterectomy (40%).In this series of 390 carotid operations, the procedure-related stroke/death rate was 0.8%. There were no differences between the stroke-death rates after primary carotid endarterectomy and operation for recurrent carotid stenosis. Operation for recurrent carotid stenosis is as safe and effective as primary carotid endarterectomy and should continue to be standard treatment.

  View details for Web of Science ID 000081410700007

  View details for PubMedID 10394151

• Aortic aneurysmorrhaphy: Establishing concurrent results for comparison with endoluminal therapies VASCULAR SURGERY Harris, E. J., Dalman, R. L. 1998; 32 (6): 595-602

  View details for Web of Science ID 000076946200010

• Thrombosis with outflow obstruction delays thrombolysis and results in chronic wall thickening of rat veins 12th Annual Meeting of the Western-Vascular-Society See-Tho, K., Harris, E. J. MOSBY-ELSEVIER. 1998: 115–23

  Abstract

  An in vivo model of acute deep venous thrombosis was developed in rats to assess the role of venous thrombosis and outflow obstruction in recanalization and development of secondary wall changes.The left femoral veins of male Sprague-Dawley rats were thrombosed either by means of proximal ligation (obstruction, group A, n = 38) or by means of temporary 24-hour occlusion with a microvascular clamp (unobstructed, group B, n = 20). Right femoral veins served as controls. The rats were killed at intervals over 5 weeks. Wall thickness was compared among groups by means of counting of cells on representative sections through the midvein area. Thrombi were indirectly quantitated with a radiolabeled fibrinogen assay in a parallel series of rats.Control veins showed no evidence of cellular or structural changes. Early thrombus extension was seen in group A (peak at day 4) followed by recanalization after 2 weeks. Group A veins had marked wall thickening (27 +/- 7 vs 6 +/- 2 cells, p < 0.01, peak at 10 days) consisting of smooth muscle-type, neointimal, and medial cellular proliferations. Within 2 to 3 weeks, local neovascular channels had grown to bypass the outflow obstruction, and resumption of normal cephalad flow was seen. At the same time neointimal proliferation regressed, but medial cellular growth persisted, resulting in chronic wall thickening (11 +/- 3 vs 5 +/- 1 cells, p < 0.01, after 21 days). In contrast, group B veins exhibited no thrombus extension, had significantly less wall thickening (13 +/- 2 vs 5 +/- 1 cells, p < 0.01, peak at 4 days), and did not induce growth of local collateral blood vessels. Within 2 weeks, group B veins regained normal appearance and resumed normal flow.Thrombosis of rat femoral veins without chronic obstruction results in rapid lysis of thrombus and transient proliferative changes. In contrast, thrombosis with chronic outflow obstruction results in delayed recanalization, early extension of thrombus, and development of vigorous and persistent proliferative cellular responses. Thrombus-induced chronic wall thickening may be an important factor in development of postthrombotic venous insufficiency.

  View details for Web of Science ID 000074830100013

  View details for PubMedID 9685137

• Color Duplex evaluation of endoluminal Aortic Stent Grafts J Vasc Technology Johnson BL, Harris EJJr, Fogarty TJ, Olcott C, IV, Zarins CK 1998; 22: 97-104
• Limb salvage surgery in spinal cord injury patients 11th Annual Meeting of the Western-Vascular-Society Dalman, R. L., Harris, E. J., Walker, M. T., Perkash, I. ELSEVIER SCIENCE INC. 1998: 60–64

  Abstract

  Advances in the care and rehabilitation of patients with spinal cord injuries (SCI) have resulted in extended survival following injury. Increasingly, we are faced with difficult chronic lower extremity ischemic complications in SCI patients. Recognizing limitations associated with amputation in these nonambulatory patients, we report the preliminary results of a program of selective limb salvage via arterial reconstructive surgery. Retrospective chart review was performed on the records of the Veterans Affairs Palo Alto Health Care System SCI unit. Since 1989, 15 revascularization procedures were identified in 10 SCI patients. All patients suffered from ischemic ulceration and/or gangrene. Procedures performed included femorotibial bypass (8), aortofemoral bypass (4), femoro-femoral bypass (2), and axillobifemoral bypass (AXF) (1). All patients were men. The mean age was 56 (range 43-73). Follow-up was available on 10 procedures performed in seven patients since 1992. Mean follow-up was 17 months. One patient died 3 months following distal bypass. The AXF occluded within 1 month. One distal bypass occluded in the immediate postoperative period and could not be salvaged. All other grafts remain patent, and all wounds have healed following successful bypass. One patient developed pressure ulceration following AXF grafting due to postoperative upper extremity limitations. No other complications were encountered. Standard arterial reconstructive procedures can be performed safely and successfully in SCI patients, despite diminished limb blood flow due to inactivity, and atrophic arteries, muscle, and fascia. Axillobifemoral bypass grafting may not be suitable in SCI due to requirements for upper extremity-based mobility. Confirmation of benefit of limb salvage versus amputation awaits comparison between patients eligible for either procedure.

  View details for Web of Science ID 000071300900010

  View details for PubMedID 9451998

• Operative repair for aortic aneurysms: The gold standard JOURNAL OF ENDOVASCULAR SURGERY Zarins, C. K., Harris, E. J. 1997; 4 (3): 232-241

  Abstract

  Surgical treatment of abdominal aortic aneurysm (AAA) is being challenged by newer, minimally invasive therapies. Such new treatment strategies will need to prove themselves against concurrent results of standard operative AAA repair, within defined medical risk and aneurysm morphological categories. We review the natural history of AAAs, the medical risk levels for elective AAA repair, aneurysm morphology and its impact on operative mortality, the issue of high-risk patient treatment, and the current standard of care for AAAs based on single-center, multicenter, and population-based statistics. In good-risk patients, aneurysms > 5 cm in diameter are best treated by replacement with a prosthetic graft. Operative mortality should be < 5% 1-year survival > 90%. Aortic endograft techniques must meet or exceed these standards if they are to supplant standard surgical repair.

  View details for Web of Science ID A1997XU68300002

  View details for PubMedID 9291048

• Quantitative assessment of human aortic blood flow during exercise Surgical Forum Schalet BJ, Taylor CA, Harris EJ Jr, Herfkins RJ, Zarins CK 1997: XLVIII: 359-62
• Bilateral forefoot ischemia as a premonitory symptom of mixed cryoglobulinemia. journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Griffiths, T. A., Daniel, C. J., Harris, E. J. 1996; 35 (3): 213-217

  Abstract

  Cryoglobulins are composed of cold-sensitive immunoglobulins that precipitate upon cooling. As the cutaneous vasculature of the extremities is commonly exposed to colder temperatures than the body core, this precipitation often occurs in cutaneous, or even digital vessels. Hyperviscosity from the precipitated proteins can incite local thrombosis in otherwise normal vessels, which is manifested clinically as ischemic ulceration. In previously injured vessels, as seen with atherosclerotic occlusive disease, cryoglobulin precipitation can lead to thrombosis of larger vessels, with the consequence being more severe ischemic necrosis. A case of bilateral forefoot ischemia is presented where the precipitating cause of the gangrenous changes appears to be the development of a mixed cryoglobulinemia and a B-cell lymphoma. Tibial angioplasty, plasmaphoresis, and chemotherapy directed at the B-cell lymphoma allowed limb salvage with bilateral transmetatarsal amputations.

  View details for PubMedID 8807479

• Is completion arteriography mandatory after reversed-vein bypass grafting? JOURNAL OF VASCULAR SURGERY Dalman, R. L., Harris, E. J., Zarins, C. K. 1996; 23 (4): 637-644

  Abstract

  Many surgeons advocate uniform performance of operative completion arteriography after leg bypass surgery to ensure technical success and to optimize short- and intermediate-term graft patency. To determine the impact of this practice on the outcome of reversed-vein bypass surgery and associated patient charges, we reviewed our series of consecutive nonemergent leg bypass procedures. Ninety-three infrainguinal bypass procedures were performed in 80 patients (76 men and 4 women) from September 1991 to August 1994. The patients' average age was 67 years (range, 30 to 92 years). Follow-up (mean, 113.1 months; range, 1 to 36 months) was available on 91 grafts (97%). Indications for surgery included limb salvage in 75 cases, claudication in 12 cases, and popliteal aneurysm exclusion in 6 cases. All patients survived surgery. Primary graft patency rates as determined by life-table analysis were 87%, 81%, 78%, and 78% at 6 months and at 1, 2, and 3 years, respectively. Limb-salvage rates were 95%, 91%, 87% and 87% at the same intervals. Bypass procedures were divided into two groups. The 25 grafts in group 1 were evaluated with inspection, continuous-wave Doppler insonation, and routine completion arteriography. The 68 grafts in group 2 were evaluated by inspection and insonation alone. Fourteen grafts occluded after surgery (average, 5 months; range, 1 to 12 months), five in group 1 and nine in group 2. The likelihood of graft occlusion was similar in both groups (p = 0.42). The optimal method of confirming technical adequacy after bypass surgery in the clinically satisfactory graft remains uncertain. Charges for completion arteriography at our institution average $700, including 15 minutes of additional operative time. In our experience, these charges do not appear to be justified by improved short- or intermediate-term graft patency rates in reversed-vein grafts when completion arteriography is performed.

  View details for Web of Science ID A1996UJ12600016

  View details for PubMedID 8627900

• Endoluminal aortic grafting: A preliminary animal study of graft healing JOURNAL OF SURGICAL RESEARCH Harris, E. J., Harris, E. J., Berry, G. J., Mitchell, R. S. 1996; 61 (2): 404-412

  Abstract

  Our purpose was to evaluate the placement, long term performance, and healing of a transluminally delivered endoluminal graft and attachment system, in an animal model using large adult sheep. Nineteen sheep in the weight range of 105-125 kg were entered into this study. Under fluoroscopic guidance in anesthetized animals, an endoluminal delivery system was inserted through a common femoral arteriotomy into the infrarenal aorta, and the graft and attachment system were deployed. Fixation of the proximal and distal ends of the graft to the aortic wall was achieved by hooks on the self expanding attachment system, and seated by balloon expansion. Explantation of the prosthesis was performed prior to euthanasia at 1-, 3-, and 6-month intervals. Aortograms were obtained before and after implantation and before explantation for evaluation of placement, patency, anastomotic seal, migration, and graft infolding. In situ gross examination of the prosthesis under anesthesia prior to sacrifice was performed in all animals. Histologic sections were obtained from both attachment sites ("anastomoses"), from the midgraft and hook insertion sites, and from normal aorta inferior and superior to the endoluminal prosthesis. Scanning electron microscopy was performed randomly on specimens derived from the superior and inferior anastomotic sites at each time point. Selected intervals of healing were 1 month (N=5), 3 months (N=5), and 6 months (N=8). One sheep was euthanized at 1 week due to paraplegia. At all intervals, all prostheses were patent, were well incorporated at the aortic wall-anastomotic sites, and were without mural thrombus. The attachment hooks penetrated the aortic adventitia in all animals. There was no graft migration. At one month, initial pannus formation covered the anastomoses and the entire luminal graft, yet the endothelial-like surface coverage was incomplete. At 3 months and at 6 months, the anastomoses and luminal surfaces displayed more uniform pannus and endothelial-like surface coverage. We conclude that this endoluminal delivery system, passed through a femoral arteriotomy, can effectively deploy an endoluminal graft with self expanding attachment system having consistent patency, secure fixation, and incorporation of the anastomoses with the aortic wall in this animal model.

  View details for Web of Science ID A1996TZ90100018

  View details for PubMedID 8656616

• PHLEGMASIA COMPLICATING PROPHYLACTIC PERCUTANEOUS INFERIOR VENA-CAVAL INTERRUPTION - A WORD OF CAUTION 7th Annual Meeting of the American-Venous-Forum Harris, E. J., Kinney, E. V., Harris, E. J., Olcott, C., Zarins, C. K. MOSBY-YEAR BOOK INC. 1995: 606–11

  Abstract

  The purpose of this study was to evaluate the incidence of thrombotic complications in patients with deep vein thrombosis (DVT) who were treated with percutaneous inferior vena caval interruption in place of anticoagulation.A retrospective review of all percutaneously placed inferior vena cava filters for 1 year, August 1993 through July 1994, was performed.Thirty-three percutaneous inferior vena cava filters were placed in 32 patients. The underlying disease was pulmonary embolism in 15 (47%) and DVT in 17 (53%) patients. Of patients with pulmonary embolism, 11 had a documented DVT, and four were not evaluated for DVT. There were 14 men and 18 women, with a mean age of 63.5 years (range 24 to 93 years). Indications for vena caval interruption were recurrent pulmonary embolism with therapeutic anticoagulation (n = 2 [6%]), prophylactic insertion with documented pulmonary embolism and therapeutic anticoagulation (n = 8 [25%]), documented pulmonary embolism and absolute contraindication to anticoagulation (n = 5 [16%]), documented DVT and absolute contraindication to anticoagulation (n = 2 [6%]), prophylactic insertion with documented DVT and therapeutic anticoagulation (n = 5 [16%]), and documented DVT with relative contraindication to anticoagulation (n = 10 [31%]). Of the 32 patients with inferior vena cava filters, 17 were not given anticoagulants (7 absolute contraindications, 10 relative contraindications), and 15 were given anticoagulants. Insertion of a percutaneous inferior vena cava filter in patients who were not given anticoagulants was followed by the development of phlegmasia cerulea dolens in four patients (24%), which was bilateral in two patients; one patient eventually died. No patients treated with inferior vena cava filter and anticoagulation had development of phlegmasia.Percutaneous inferior vena caval interruption effectively prevents pulmonary embolism in patients with DVT but does not impact the underlying thrombotic process and in fact may contribute to progressive thrombosis in patients who are not given anticoagulants. Anticoagulation with intravenous heparin in safe and effective therapy for DVT in most patients. We believe that percutaneous insertion of vena cava filters should not replace anticoagulation in routine proximal DVT, and those patients who require an inferior vena cava filter for failure of anticoagulation should continue to receive heparin to treat the primary thrombotic process. We caution that relative contraindications to anticoagulation should be carefully scrutinized before recommending vena cava interruption as a primary therapy for DVT.

  View details for Web of Science ID A1995TF30600016

  View details for PubMedID 7494363

• PHASE-CONTRAST MRI ASSESSMENT OF PEDAL BLOOD-FLOW EUROPEAN RADIOLOGY Debatin, J. F., Dalman, R., Herfkens, R. J., Harris, E. J., Pelc, N. J. 1995; 5 (1): 36-42

  View details for Web of Science ID A1995QK12800007

• Genetic and metabolic causes of arterial disease. Annals of vascular surgery Fann, J. I., Dalman, R. L., Harris, E. J. 1993; 7 (6): 594-604

  View details for PubMedID 8123465

• OUTCOME OF INFRAINGUINAL ARTERIAL RECONSTRUCTION IN WOMEN 8TH ANNUAL MEETING OF THE WESTERN-VASCULAR-SOC Harris, E. J., Taylor, L. M., Moneta, G. L., Porter, J. M. MOSBY-ELSEVIER. 1993: 627–36

  Abstract

  The outcome of leg bypass in women is unknown. To date, most series of lower extremity bypass have included few women, and the results in women compared with those in men have not been reported. The experience with infrainguinal arterial reconstruction in women treated at the Oregon Health Sciences University has been greater than previously reported. We have reviewed our recent experience with lower extremity bypass to determine whether results in women differ significantly from those in men.In the past 11 years we have performed 823 infrainguinal arterial reconstructions for lower extremity ischemia in 585 patients, of which 357 procedures were performed in women and 466 procedures were performed in men. The mean ages were 65 years for men and 68 years for women. Diabetes was present in 59% of the men and 48% of the women. Among men, 84% had a history of tobacco use compared with 66% of the women. Bypasses in men were performed for limb salvage in 73%, claudication in 22%, and a failing bypass graft in 5% of cases. Bypasses in women were performed for limb salvage in 79%, claudication in 15%, and a failing graft in 6% of cases. Previous revascularizations had been performed in 63% of the men and 71% of the women. Autogenous vein was used in 97% of the bypasses in men and 96% of bypasses in women. Graft distribution among infrainguinal arterial target sites was similar between the groups. Bypasses in men were femoral to above-knee popliteal in 11%, femoral to below-knee popliteal in 40%, femoral to tibial in 38%, popliteal to tibial in 10%, and tibial to tibial in 1% of cases. Bypasses in women were femoral to above-knee popliteal in 14%, femoral to below-knee popliteal in 43%, femoral to tibial in 33%, popliteal to tibial in 9%, and tibial to tibial in 1% of cases.Perioperative 30-day mortality rates were 3.7% overall, 4.3% in men, and 2.9% in women. Long-term survival at 1, 3, and 5 years in men was 80%, 59%, and 44%, respectively. Long-term survival at 1, 3, and 5 years in women was 83%, 69%, and 44%, respectively. Life-table primary patency rates at 1, 3, and 5 years were 86%, 77%, and 71% for men and 87%, 74%, and 67% for women. Limb-salvage results at 1 and 5 years were 93% and 91% for men and 96% and 96% for women.These results indicate that long-term graft patency and limb salvage results in women are identical to those obtained in men in this experience with autogenous vein. Infrainguinal arterial reconstruction can be performed in women with mortality rates similar to those of men. In this series long-term survival was similar for both men and women.

  View details for PubMedID 8411470

• Extra-anatomic bypass. Annals of vascular surgery Fann, J. I., Harris, E. J., Dalman, R. L. 1993; 7 (4): 378-383

  View details for PubMedID 8268081

• Arteritis. Seminars in vascular surgery Harris, E. J., Nehler, M. R., Porter, J. M. 1993; 6 (1): 2-13

  View details for PubMedID 7902765

• Extra-anatomic bypass: a new look (supporting view). Advances in surgery Porter, J. M., Harris, E. J., Taylor, L. M., Moneta, G. L., Yeager, R. A. 1993; 26: 133-149

  View details for PubMedID 8418560

• UPPER EXTREMITY ARTERIAL BYPASS DISTAL TO THE WRIST 7TH ANNUAL MEETING OF THE WESTERN VASCULAR SOC Nehler, M. R., Dalman, R. L., Harris, E. J., Taylor, L. M., Porter, J. M. MOSBY-YEAR BOOK INC. 1992: 633–42

  Abstract

  Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold.(ABSTRACT TRUNCATED AT 250 WORDS)

  View details for PubMedID 1404683

• NEUROLOGIC DEFICITS FOLLOWING NONCAROTID VASCULAR-SURGERY 78TH ANNUAL MEETING OF THE NORTH PACIFIC SURGICAL ASSOC Harris, E. J., Moneta, G. L., Yeager, R. A., Taylor, L. M., Porter, J. M. CAHNERS PUBL CO. 1992: 537–40

  Abstract

  Neurologic events following noncarotid vascular surgery (NCVS) are considered unpredictable. To test this hypothesis, we reviewed our vascular registry for a 3-year period and identified all patients with new postoperative focal neurologic events (stroke, hemispheric transient ischemic attack [TIA]) within 2 weeks of a category I or II vascular procedure as defined by the American Board of Surgery, exclusive of carotid surgery and arterial trauma. Thirteen of 1,390 NCVS procedures (0.9%) in 13 patients were associated with focal neurologic events. There were 2 TIAs, 10 anterior circulation strokes, and 1 posterior circulation stroke. Twenty-seven percent of strokes were fatal. The neurologic deficit developed in the immediate postoperative period in 31%, more than 4 hours but less than 72 hours postoperatively in 54%, and within 3 to 14 days postoperatively in 15%. Patients with anterior circulation events (group A, n = 12) were compared for variables potentially influencing postoperative stroke with case controls who were selected using a table of random numbers (group B, n = 12). Controls were derived from a pool of all category I or II NCVS procedures recorded in our vascular registry sequentially during the same time period and who were without new neurologic deficits postoperatively. Using Fisher's exact test, comparisons between groups A and B revealed that new anterior circulation neurologic events in vascular surgical patients tended to be associated with intra-abdominal procedures (p less than 0.05), perioperative hypotension (p less than 0.05), and the presence of a greater than or equal to 50% internal carotid artery stenosis ipsilateral to the neurologic event (p less than 0.001). Such information may prove useful in the management of selected patients prior to arterial reconstruction and in operated NCVS patients with postoperative neurologic events.

  View details for PubMedID 1575315

• THE ASSOCIATION OF ELEVATED PLASMA HOMOCYST(E)INE WITH PROGRESSION OF SYMPTOMATIC PERIPHERAL ARTERIAL-DISEASE 44 ANNUAL MEETING OF THE SOC FOR VASCULAR SURGERY Taylor, L. M., DEFRANG, R. D., Harris, E. J., Porter, J. M. MOSBY-ELSEVIER. 1991: 128–36

  Abstract

  Plasma homocyst(e)ine (the sum of free and bound homocysteine, homocystine, and the mixed disulfide homocysteine-cysteine, expressed as homocysteine) levels were determined by high performance liquid chromatography in 214 patients with symptomatic (claudication, rest pain, gangrene, amputation) lower extremity arterial occlusive disease and/or symptomatic (stroke, cerebral transient ischemic attacks) cerebral vascular disease and in 103 control persons. Mean plasma homocyst(e)ine was significantly higher in patients than in controls (14.37 +/- 6.89 nmol/ml vs 10.10 +/- 2.16, p less than 0.05). Thirty-nine percent of patients (83 of 214) had plasma homocyst(e)ine values greater than control mean + 2 standard deviations. Plasma homocyst(e)ine values were contrasted to age, male sex, diabetes, hypertension, smoking, renal failure, and plasma cholesterol. No difference was found in the incidence and/or level of any of these risk factors when patients with normal plasma homocyst(e)ine were compared to those with elevated plasma homocyst(e)ine, both by univariate and multivariate analysis. Patients with elevated plasma homocyst(e)ine were more likely to demonstrate clinical progression of lower extremity disease and of coronary artery disease, but not of cerebral vascular disease than were patients with normal plasma homocyst(e)ine, and the rate of progression was more rapid (p = 0.002). Progression of lower extremity disease as assessed in the vascular laboratory was also more common in patients with elevated plasma homocyst(e)ine (p = 0.01). We conclude that elevated plasma homocyst(e)ine is an independent risk factor for symptomatic lower extremity disease or cerebral vascular disease or both. Symptomatic patients with lower extremity disease and with elevated plasma homocyst(e)ine also appear to have more rapid progression of disease.

  View details for PubMedID 1987384

• CLINICAL-RESULTS OF AXILLOBIFEMORAL BYPASS USING EXTERNALLY - SUPPORTED POLYTETRAFLUOROETHYLENE 5TH ANNUAL MEETING OF THE WESTERN VASCULAR SOC Harris, E. J., Taylor, L. M., McConnell, D. B., Moneta, G. L., Yeager, R. A., Porter, J. M. MOSBY-YEAR BOOK INC. 1990: 416–21

  Abstract

  Seventy-six axillobifemoral grafts with externally supported polytetrafluoroethylene prostheses were performed since 1983. The indications for operation were absolute (aortic sepsis) in 20 (26%) patients and relative (excessive operative risk or technical difficulty) in 56 (74%) patients. The life-table primary patency for these operations at 4 years follow-up (mean follow-up, 2 years, 4 months) was 85%. We conclude that the patency results achieved in this patient series are sufficiently satisfactory to warrant use of axillobifemoral grafts in an expanded number of patients with high operative risk and need for bypass of aortoiliac occlusive disease.

  View details for Web of Science ID A1990EE58200005

  View details for PubMedID 2145447

• THE IMPORTANCE OF ROUTINE SURVEILLANCE OF DISTAL BYPASS GRAFTS WITH DUPLEX SCANNING - A STUDY OF 379 REVERSED VEIN GRAFTS 5TH ANNUAL MEETING OF THE WESTERN VASCULAR SOC Mills, J. L., Harris, E. J., Taylor, L. M., BECKETT, W. C., Porter, J. M. MOSBY-YEAR BOOK INC. 1990: 379–89

  Abstract

  To assess the utility of routine duplex surveillance, 379 infrainguinal reversed vein grafts performed at two independent teaching hospitals were prospectively entered into a surveillance protocol from March 1986 through August 1989. An average of 3.2 postoperative duplex graft flow velocity (GFV) measurements per graft was obtained during a mean follow-up interval of 21 1/2 months. Only 2.1% of 280 grafts with GFV measurements greater than 45 cm/sec failed within 6 months of a normal surveillance examination. GFV measurements less than 45 cm/sec in 99 grafts led to arteriography in 75 grafts, identifying 50 stenotic lesions in 48 bypasses (12.6% of series). Inflow lesions were present in 5%, outflow stenoses in 2%, and intrinsic graft stenoses in only 6% of bypasses. Only 29% of grafts identified as failing by duplex scan were associated with a reduction in ankle-brachial index of greater than 0.15. Secondary reconstructions were performed in 48 grafts based on detection of a reduced GFV measurement; all such reconstructions are patent after a mean follow-up of 5 months. Duplex surveillance is more reliable in identification of failing vein grafts than is determination of ankle-brachial index.

  View details for Web of Science ID A1990EE58200001

  View details for PubMedID 2214034

• THE EFFECTS OF COOLING ON HUMAN SAPHENOUS-VEIN REACTIVITY TO ADRENERGIC AGONISTS JOURNAL OF VASCULAR SURGERY HARKER, C. T., Ousley, P. J., Harris, E. J., Edwards, J. M., Taylor, L. M., Porter, J. M. 1990; 12 (1): 45-49

  Abstract

  Human saphenous veins were obtained at surgery and assayed immediately (n = 10). The veins were cut into rings, suspended in organ chambers, and connected to force transducers for the recording of isometric tension. One ring served as control whereas others were treated with the alpha 1-adrenoceptor antagonist prazosin (3 X 10(-7) mol/L), or the alpha 2-adrenoceptor antagonist rauwolscine (10(-7) mol/L). In quiescent rings cooling from 37 degrees C to 24 degrees C had no significant effect. Norepinephrine (10(-8)-10(-5) mol/L) caused concentration-dependent contractions with an EC20 (-log concentration of norepinephrine required to induce contractions 20% of maximal) = 6.97 +/- 0.10. The contractions were inhibited by prazosin (EC20 = 5.89 +/- 0.17, p less than 0.001) and rauwolscine (ED20 = 5.78 +/- 0.11, p less than 0.001). In control rings cooling potentiated contractions evoked at concentrations of norepinephrine below 10(-6) mol/L and inhibited those at higher concentrations. In rings treated with alpha-antagonists cooling depressed the maximal contractile responses. Contractions to the alpha 1-agonist, phenylephrine (10(-7)-10(-4) mol/L), were inhibited by cooling, whereas those to the alpha 2-specific agonist B-HT 920 (10(-7)-10(-4) mol/L) showed a pattern similar to that seen with norepinephrine. The data indicate that the human saphenous vein possesses both alpha 1- and alpha 2-adrenoceptors postjunctionally, and that both contribute to contractile responses. Cold augments saphenous vein reactivity to norepinephrine by an apparent increase in the responsiveness of alpha 2-adrenoceptors to agonists. The relationship between temperature and adrenoceptor responsiveness may be of pivotal importance in defining the mechanism of cold-induced vasospasm.

  View details for PubMedID 2165189

• SURGICAL-TREATMENT OF DISTAL ULNAR ARTERY ANEURYSM 76TH ANNUAL MEETING OF THE NORTH PACIFIC SURGICAL ASSOC Harris, E. J., Taylor, L. M., Edwards, J. M., Mills, J. L., Porter, J. M. CAHNERS PUBL CO. 1990: 527–30

  Abstract

  In the past 7 years, we have encountered six patients with finger ischemia as a result of digital artery occlusion associated with seven distal ulnar artery aneurysms. Our experience with the management of these patients forms the basis of this report. All patients were men, with a mean age of 29 years, and all experienced repetitive trauma to the involved upper extremity. Each patient presented with the acute onset of cool and painful digits, with no previous history of cold sensitivity or Raynaud's syndrome. None of the patients had any serologic or clinical evidence of autoimmune disease. Angiography revealed occlusion of the ulnar artery on the affected side in two patients and patent ulnar artery aneurysms in the remaining five patients. There was occlusion of multiple common and proper digital arteries in all patients. One patient with bilateral ulnar artery aneurysms underwent operative repair consisting of aneurysm excision and replacement with autogenous vein grafts from the lower extremity. All patients have improved symptoms, and the grafts remained patent over a mean follow-up of 24 months (range: 13 to 57 months). Based on these results, we recommend that excision and grafting be considered for patients with symptomatic patent ulnar artery aneurysms. Selected patients with thrombosed aneurysms with ongoing digital ischemia may also benefit from surgical intervention.

  View details for PubMedID 2334021

• IMPROVING SURVIVAL AND LIMB SALVAGE IN PATIENTS WITH AORTIC GRAFT INFECTION 76TH ANNUAL MEETING OF THE NORTH PACIFIC SURGICAL ASSOC Yeager, R. A., Moneta, G. L., Taylor, L. M., Harris, E. J., McConnell, D. B., Porter, J. M. CAHNERS PUBL CO. 1990: 466–69

  Abstract

  A 15-year experience with 38 aortic graft infections, including 15 patients with graft enteric fistulas, is reviewed in order to analyze modern-day surgical results utilizing extra-anatomic bypass and aortic graft excision. Perioperative mortality was 14% during the most recent 7-year interval, which was a notable improvement compared with the earlier time interval (p = 0.06). Extended follow-up of the perioperative survivors demonstrated a 77% cumulative 5-year survival and a 76% cumulative 5-year limb salvage rate. Subsequent axillofemoral graft infection occurred in 22% of survivors and resulted in a significantly higher amputation rate compared with those patients with no axillofemoral graft infection (p less than 0.001). The results suggest good perioperative and long-term survival in patients with aortic graft infection, with excellent limb salvage if subsequent axillofemoral graft infection can be avoided.

  View details for PubMedID 2334008

• THROMBOLYTIC THERAPY AND MODERN VASCULAR-SURGERY - AN OVERVIEW SYMP ON CURRENT CRITICAL PROBLEMS AND NEW HORIZONS IN VASCULAR SURGERY Harris, E. J., Porter, J. M. QUALITY MEDICAL PUBLISHING INC. 1990: 307–321

  View details for Web of Science ID A1990BS66L00050

• EPITHELIOID HEMANGIOENDOTHELIOMA OF THE EXTERNAL ILIAC VEIN - A PRIMARY VASCULAR TUMOR PRESENTING AS TRAUMATIC VENOUS OBSTRUCTION JOURNAL OF VASCULAR SURGERY Harris, E. J., Taylor, L. M., Porter, J. M. 1989; 10 (6): 693-699

  Abstract

  A 32-year-old man employed as a laborer presented with the signs and symptoms of iliofemoral venous obstruction of 1 months' duration. Results of initial phlebography from the ankle to the femoral area were normal. No iliac vein anatomy was seen. This led to a group of tests directed toward neuromuscular function, which were unrewarding. On referral to our institution a noninvasive venous vascular laboratory examination was performed, which clearly indicated iliac vein obstruction/stenosis, with a normally patent distal venous system. Subsequent repeat phlebography, including direct femoral vein injection, visualized a mass lesion partially occluding the iliac vein. This lesion was treated with primary excision and segmental venous replacement with an interposition graft of autogeneous internal jugular vein. The excised lesion proved to be an epithelioid hemangioendothelioma of the iliac vein.

  View details for PubMedID 2585659