Jason T. Lee, MD

All Publications

• Patient-specific computational flow simulation reveals significant differences in paravisceral aortic hemodynamics between fenestrated and branched endovascular aneurysm repair. JVS-vascular science Tran, K., Deslarzes-Dubuis, C., DeGlise, S., Kaladji, A., Yang, W., Marsden, A. L., Lee, J. T. 2024; 5: 100183

  Abstract

  Endovascular aneurysm repair with four-vessel fenestrated endovascular aneurysm repair (fEVAR) or branched endovascular aneurysm repair (bEVAR) currently represent the forefront of minimally invasive complex aortic aneurysm repair. This study sought to use patient-specific computational flow simulation (CFS) to assess differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR.Patients from two institutions who underwent four-vessel fEVAR with the Cook Zenith Fenestrated platform and bEVAR with the Jotec E-xtra Design platform were retrospectively selected. Patients in both cohorts were treated for paravisceral and extent II, II, and V thoracoabdominal aortic aneurysms. Three-dimensional finite element volume meshes were created from preoperative and postoperative computed tomography scans. Boundary conditions were adjusted for body surface area, heart rate, and blood pressure. Pulsatile flow simulations were performed with equivalent boundary conditions between preoperative and postoperative states. Postoperative changes in hemodynamic parameters were compared between the fEVAR and bEVAR groups.Patient-specific CFS was performed on 20 patients (10 bEVAR, 10 fEVAR) with a total of 80 target vessels (40 renal, 20 celiac, 20 superior mesenteric artery stents). bEVAR was associated with a decrease in renal artery peak flow rate (-5.2% vs +2.0%; P < .0001) and peak pressure (-3.4 vs +0.1%; P < .0001) compared with fEVAR. Almost all renal arteries treated with bEVAR had a reduction in renal artery perfusion (n = 19 [95%]), compared with 35% (n = 7) treated with fEVAR. There were no significant differences in celiac or superior mesenteric artery perfusion metrics (P = .10-.27) between groups. Time-averaged wall shear stress in the paravisceral aorta and branches also varied significantly depending on endograft configuration, with bEVAR associated with large postoperative increases in renal artery (+47.5 vs +13.5%; P = .002) and aortic time-averaged wall shear stress (+200.1% vs -31.3%; P = .001) compared with fEVAR. Streamline analysis revealed areas of hemodynamic abnormalities associated with branched renal grafts which adopt a U-shaped geometry, which may explain the observed differences in postoperative changes in renal perfusion between bEVAR and fEVAR.bEVAR may be associated with subtle decreases in renal perfusion and a large increase in aortic wall shear stress compared with fEVAR. CFS is a novel tool for quantifying and visualizing the unique patient-specific hemodynamic effect of different complex EVAR strategies.This study used patient-specific CFS to compare postoperative hemodynamic effects of four-vessel fenestrated endovascular aneurysm repair (fEVAR) and branched endovascular aneurysm repair (bEVAR) in patients with complex aortic aneurysms. The findings indicate that bEVAR may result in subtle reductions in renal artery perfusion and a significant increase in aortic wall shear stress compared with fEVAR. These differences are clinically relevant, providing insights for clinicians choosing between these approaches. Understanding the patient-specific hemodynamic effects of complex EVAR strategies, as revealed by CFS, can aid in future personalized treatment decisions, and potentially reduce postoperative complications in aortic aneurysm repair.

  View details for DOI 10.1016/j.jvssci.2023.100183

  View details for PubMedID 38314201

  View details for PubMedCentralID PMC10832507

• Preoperative Proteinuria is Independently Associated with Mortality after Fenestrated Endovascular Aneurysm Repair. Journal of vascular surgery Dossabhoy, S. S., Fisher, A. T., Chang, T. I., Owens, D. K., Arya, S., Stern, J. R., Lee, J. T. 2024

  Abstract

  Fenestrated endovascular aneurysm repair (FEVAR) has become mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in aneurysm patients is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR.A single-institution retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling.Among 181 patients undergoing standard FEVAR from 2012-2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Those with proteinuria were more likely to be Black (10.0% vs 1.3%) with lower estimated glomerular filtration rate ([eGFR] 52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8) (all P<.05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%, P=.03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%, log-rank P<.001). On multivariable analysis, preoperative proteinuria was independently associated with over three-fold higher hazard of mortality (hazard ratio [HR] 3.21, 95% confidence interval [CI] 1.66-6.20, P<.001), while preoperative eGFR was not predictive (HR 0.99, 95% CI 0.98-1.01, P=.28). Additional significant predictors included chronic obstructive pulmonary disease (HR 2.04), older age (HR 1.05), and larger maximal aneurysm diameter (HR 1.03, all P<.05).In our ten-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, while eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk stratifying patients prior to FEVAR.

  View details for DOI 10.1016/j.jvs.2024.01.013

  View details for PubMedID 38219966

• Expansion of Abdominal Aortic Aneurysm Screening and Ultrasound Utilization and Diagnosis. JAMA surgery Ho, V. T., Cabot, J. H., George, E. L., Garcia-Toca, M., Chen, J. H., Asch, S. M., Lee, J. T. 2023

  View details for DOI 10.1001/jamasurg.2023.4662

  View details for PubMedID 37851462

  View details for PubMedCentralID PMC10585488

• Utilizing an induced pluripotent stem cell platform to model arterial calcification resulting from deficiency of CD73 Noishiki, C., Alsaigh, T., Wu, D., Adkar, S., Chandra, V., Klarin, D., Lee, J., Fukaya, E., Leeper, N., Sayed, N. SAGE PUBLICATIONS LTD. 2023: 499-500

  View details for Web of Science ID 001083593400024

• Preoperative Proteinuria Independently Predicts Mortality After Fenestrated Endovascular Aneurysm Repair Dossabhoy, S. S., Fisher, A. T., Chang, T. I., Stern, J. R., Lee, J. T. MOSBY-ELSEVIER. 2023: E14

  View details for Web of Science ID 001054512000003

• Association of Baseline Chronic Kidney Disease Stage with Short- and Long-term Outcomes after Fenestrated Endovascular Aneurysm Repair. Annals of vascular surgery Dossabhoy, S. S., Sorondo, S. M., Fisher, A. T., Ho, V. T., Stern, J. R., Lee, J. T. 2023

  Abstract

  Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR.We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury. Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography scans, and CKD stage progression were assessed at latest follow up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics.From 2012-2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3 months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs 73.0 years, P=.04), had increased preoperative creatinine (1.6 vs 0.9 mg/dL, P<.01) and demonstrated increased renal artery ostial calcification (37.7% vs 21.5%, P=.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs 228 ml, P=.01), longer operative times (186 vs 162 min, P=.04), and longer length of stay (3 vs 2 days, P<.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs 95.1%, P<.01 and 55.4% vs 70.8%, P=.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1 year (94.4% vs 100%, P=.015) and 5 years (84.7% vs 100%, P<.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs CKD 3-5 14.3%, P=.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scans between groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P=.17). On multivariable modeling, age (HR 1.05, 95%CI 1.01-1.09, P=.02) and CKD stage 4-5 (HR 6.39, 95%CI 2.26-18.05, P<.01) were independently associated with mortality.Preoperative CKD status did not negatively impact the durability nor technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.

  View details for DOI 10.1016/j.avsg.2023.07.102

  View details for PubMedID 37586562

• Assessing Differences in Aortic Haemodynamics Between Two- Versus Four-Vessel Fenestrated Endovascular Aneurysm Repair using Patient-Specific Computational Flow Simulation. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery Tran, K., Kaladji, A., Yang, W., Marsden, A. L., Lee, J. T. 2023

  View details for DOI 10.1016/j.ejvs.2023.07.050

  View details for PubMedID 37536515

• Cardiac Pulsatile Helical Deformation of the Thoracic Aorta Before and After Thoracic Endovascular Aortic Repair of Type B Dissections. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists Bondesson, J., Suh, G., Dake, M. D., Lee, J. T., Cheng, C. P. 2023: 15266028231179592

  Abstract

  PURPOSE: Type B aortic dissections propagate with either achiral (nonspiraling) or right-handed chiral (spiraling) morphology, have mobile dissection flaps, and are often treated with thoracic endovascular aortic repair (TEVAR). We aim to quantify cardiac-induced helical deformation of the true lumen of type B aortic dissections before and after TEVAR.MATERIAL AND METHODS: Retrospective cardiac-gated computed tomography (CT) images before and after TEVAR of type B aortic dissections were used to construct systolic and diastolic 3-dimensional (3D) surface models, including true lumen, whole lumen (true+false lumens), and branch vessels. This was followed by extraction of true lumen helicity (helical angle, twist, and radius) and cross-sectional (area, circumference, and minor/major diameter ratio) metrics. Deformations between systole and diastole were quantified, and deformations between pre- and post-TEVAR were compared.RESULTS: Eleven TEVAR patients (59.9±4.6 years) were included in this study. Pre-TEVAR, there were no significant cardiac-induced deformations of helical metrics; however, post-TEVAR, significant deformation was observed for the true lumen proximal angular position. Pre-TEVAR, cardiac-induced deformations of all cross-sectional metrics were significant; however, only area and circumference deformations remained significant post-TEVAR. There were no significant differences of pulsatile deformation from pre- to post-TEVAR. Variance of proximal angular position and cross-sectional circumference deformation decreased after TEVAR.CONCLUSION: Pre-TEVAR, type B aortic dissections did not exhibit significant helical cardiac-induced deformation, indicating that the true and false lumens move in unison (do not move with respect to each other). Post-TEVAR, true lumens exhibited significant cardiac-induced deformation of proximal angular position, suggesting that exclusion of the false lumen leads to greater rotational deformations of the true lumen and lack of true lumen major/minor deformation post-TEVAR means that the endograft promotes static circularity. Population variance of deformations is muted after TEVAR, and dissection acuity influences pulsatile deformation while pre-TEVAR chirality does not.CLINICAL IMPACT: Description of thoracic aortic dissection helical morphology and dynamics, and understanding the impact of thoracic endovascular aortic repair (TEVAR) on dissection helicity, are important for improving endovascular treatment. These findings provide nuance to the complex shape and motion of the true and false lumens, enabling clinicians to better stratify dissection disease. The impact of TEVAR on dissection helicity provides a description of how treatment alters morphology and motion, and may provide clues for treatment durability. Finally, the helical component to endograft deformation is important to form comprehensive boundary conditions for testing and developing new endovascular devices.

  View details for DOI 10.1177/15266028231179592

  View details for PubMedID 37300396

• Vascular Surgery Workforce Reductions Decrease Ambulatory Care Delivery for Carotid and Peripheral Arterial Disease Ho, V. T., George, E. L., Stern, J. R., Lee, J. T. MOSBY-ELSEVIER. 2023: E206-E207

  View details for Web of Science ID 001038870400203

• Controlled balloon false lumen obliteration for the endovascular management of chronic dissection in the descending thoracic aorta. JTCVS techniques Watkins, A. C., Dossabhoy, S., Dalal, A. R., Yasin, A., Leipzig, M., Colvard, B., Lee, J. T., Dake, M. D. 2023; 19: 1-9

  Abstract

  Retrograde false lumen perfusion has limited the utility of aortic stent grafting for chronic aortic dissection. It is unknown whether balloon septal rupture can improve the outcomes for endovascular management of chronic aortic dissection.Included patients underwent false lumen obliteration and creation of a single-lumen aortic landing zone using balloon aortoplasty during thoracic endovascular aortic repair. The distal thoracic stent graft was sized to the total aortic lumen diameter, and septal rupture was performed within the stent graft with a compliant balloon in the region 5 cm proximal to the distal fabric edge. Clinical and radiographic outcomes are reported.Forty patients, with an average age 56 years, underwent thoracic endovascular aortic repair with septal rupture. Seventeen patients (43%) had chronic type B dissections, 17 of 40 patients (43%) had residual type A dissections, and 6 of 40 patients (15%) had acute type B dissections. Nine cases were emergency, complicated by rupture or malperfusion. Perioperative complications included 1 death (2.5%) due to rupture of the descending thoracic aorta and 2 (5%) instances each of stroke (neither permanent) and spinal cord ischemia (1 permanent). Two (5%) stent graft-induced new injuries were seen. Average postoperative computed tomography follow-up was 1.4 years. Thirteen patients (33%) had a decrease in aortic size, 25 of 39 patients (64%) were stable, and 1 of 39 patients (2.6%) had an increased aortic size. Partial and complete false lumen thrombosis were achieved in 10 of 39 patients (26%) and 29 of 39 patients (74%), respectively. Midterm aortic-related survival was 97.5% at an average of 1.6 years.Controlled balloon septal rupture offers an effective endovascular method to treat aortic dissection in the distal thoracic aorta.

  View details for DOI 10.1016/j.xjtc.2023.01.010

  View details for PubMedID 37324349

  View details for PubMedCentralID PMC10267755

• Precocious rupture of abdominal aortic aneurysms below size criteria for repair: Risk factors and outcomes. Annals of vascular surgery George, E. L., Smith, J. A., Colvard, B., Lee, J. T., Stern, J. R. 2023

  Abstract

  INTRODUCTION: Practice guidelines recommend elective repair for abdominal aortic aneurysms (AAA) ≥5.5cm in men and ≥5cm in women to prevent rupture; however, some rupture at smaller diameters. We identify risk factors for rupture (rAAA) below this threshold and compare outcomes following rAAA repair above/below size criteria.METHODS: The Vascular Quality Initiative (2013-2019) was queried for patients undergoing repair for rAAA and stratified based on diameter into Small and Large cohorts [Small: <5.5cm (men), <5.0cm (women)]. Univariate analysis was performed, and Kaplan-Meier analysis compared overall survival, aneurysm-related mortality, and reintervention at 12-months.RESULTS: 5,162 rAAA were identified. Small rAAA patients [n = 588] were more likely to have hypertension (81.3% vs. 77.0%, p<0.02), diabetes (18.2% vs. 14.9%, p<0.04), and ESRD (2.9% vs. 0.9%, p<0.01), and be on optimal medical therapy (32.1% vs. 26.8%, p<0.01). Women were more likely to rupture at smaller diameters compared to men (p<0.01). Small rAAA patients were more likely to undergo EVAR (70.2% vs. 56.0%, p<0.01), and had lower in-hospital mortality (17.7% vs. 27.7%, p<0.01), and fewer perioperative complications across all categories. At 12-months, small rAAA patients had better overall survival, freedom from aneurysm-related mortality, and freedom from reintervention, largely driven by EVAR approach.CONCLUSION: More than 11% of patients presenting with ruptured AAA were below the recommended size threshold for repair, and they tended to be younger, non-white, and have hypertension, diabetes and/or renal failure. Patients with small rAAA experienced lower in-hospital morbidity and mortality and improved 1-year survival, and EVAR was associated with better outcomes than open repair. However, women more frequently rupture at smaller diameters compared to men. Given contemporary elective outcomes for women, a randomized controlled trial for EVAR vs. surveillance at a sex-specific size threshold is needed.

  View details for DOI 10.1016/j.avsg.2023.05.008

  View details for PubMedID 37247834

• Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine Olson, E. M., Dyrek, P., Harris, T., Fereydooni, A., Lee, J. T., Kussman, A., Roh, E. 2023

  Abstract

  Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions.Retrospective chart review.Single institution.Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded.Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided.Rate of return to play (RTP) to collegiate athletics.Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery.Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks.This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.

  View details for DOI 10.1097/JSM.0000000000001162

  View details for PubMedID 37207307

• Longitudinal Mapping of True Lumen Morphology for Accurate Endograft Oversizing in Patients with Type B Aortic Dissections Bondesson, J., Raja, S., Suh, G., Dake, M. D., Lee, J. T., Cheng, C. P. MOSBY-ELSEVIER. 2023: 64S-65S

  View details for Web of Science ID 000994639100142

• Percutaneous Bailout Technique for Trapping an Embolized Valve During Valve-in-Valve TAVR. The Journal of invasive cardiology Stathogiannis, K. E., MacArthur, J. W., Lee, J. T., Sharma, R. P. 2023; 35 (3): E160

  Abstract

  A complex 15-year treatment history of a 75-year-old man with New York Heart Association class III symptoms is presented via images and video. His treatment history was noteworthy of bicuspid aortic valve (AV) and a ventricular septal defect (VSD), for which he had an AV replacement and VSD closure in 2005. In 2015, he underwent redo AV replacement and root reconstruction. Echocardiography demonstrated severe bioprosthetic AV stenosis and moderate AV regurgitation. Valve-in-valve transcatheter aortic valve replacement with a Sentinel cerebral protection device was recommended. Pre-operative computed tomography scan showed dilated aortic root and descending aorta with evidence of pseudocoarcta- tion. This case highlights the need for multidisciplinary team approach and the in-depth knowledge of various devices and techniques available.

  View details for PubMedID 36884365

• Percutaneous Bailout Technique for Trapping an Embolized Valve During Valve-in-Valve TAVR JOURNAL OF INVASIVE CARDIOLOGY Stathogiannis, K. E., MacArthur, J. W., Lee, J. T., Sharma, R. P. 2023; 35 (3): E160

  View details for Web of Science ID 001033680000012

• A fenestrated, double-barrel technique for proximal reintervention after open or endovascular abdominal aortic aneurysm repair. Journal of vascular surgery cases and innovative techniques Stern, J. R., Tran, K., Dossabhoy, S. S., Sorondo, S. M., Lee, J. T. 2023; 9 (1): 101091

  Abstract

  Proximal endovascular reintervention after prior endovascular aortic repair (EVAR) or open abdominal aortic aneurysm repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow the use of the commercially available ZFEN device using a double-barrel, kissing-limb technique.Patients who underwent fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of the standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πDLIMB = πDZFEN + 2DZFEN.Of 235 patients who underwent repair using ZFEN from 2012 to 2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 treated using the double-barrel technique (8 EVAR, 5 OR). The distance from the flow divider to the lowest renal artery was 67 ± 24.4 mm (range, 39-128 mm), and the distance to the superior mesenteric artery (SMA) was 87 ± 30.5 mm (range, 60-164 mm). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal artery and SMA to accommodate a standard ZFEN build was 56 and 60 mm, respectively. Four patients required adjunctive snorkel grafts and two required laser fenestrations. Two patients had gutter leaks at 1 month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72%, and 48% at 1, 2, and 3 years, respectively.This double-barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.

  View details for DOI 10.1016/j.jvscit.2022.101091

  View details for PubMedID 36747609

  View details for PubMedCentralID PMC9898739

• Endovascular aortic arch repair with chimney technique for pseudoaneurysm. BMC cardiovascular disorders Luo, M., Zhang, X., Fang, K., Guo, Y., Chen, D., Lee, J. T., Shu, C. 2023; 23 (1): 86

  Abstract

  BACKGROUND: Aortic pseudoaneurysm is a life-threatening clinical condition, and thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones.METHODS: A retrospective study was conducted from October 2015 to August 2020, 32 patients with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, 12months and yearly thereafter.RESULTS: The median age of 32 patients was 68.0years (range, 28-81) with the mean max diameter of aneurysm of 47.9±12.0mm. Forty-four related supra-aortic branches were well preserved, and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The mean follow-up times was 46.5±14.3months. One patient died due to acute myocardial infarction just 10days after chimney TEVAR and the other 3 patients passed away at 1.5months, 20months, and 31months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred.CONCLUSION: For aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.

  View details for DOI 10.1186/s12872-023-03091-4

  View details for PubMedID 36782127

• Most Privately Insured Patients Do Not Receive Federally Recommended Abdominal Aortic Aneurysm Screening. Journal of vascular surgery Ho, V. T., Tran, K., George, E. L., Asch, S. M., Chen, J. H., Dalman, R. L., Lee, J. T. 2023

  Abstract

  Since 2005, the United States Preventative Services Task Force (USPSTF) has recommended abdominal aortic aneurysm (AAA) ultrasound screening for 65- to 75-year-old male ever-smokers. Integrated health systems such as Kaiser Permanente and the Veterans Affairs (VA) healthcare system report 74-79% adherence, but compliance rates in the private sector are unknown.The IBM Marketscan® Commercial and Medicare Supplemental databases (2006 -2017) were queried for male ever-smokers continuously enrolled from age 65 to 75. Exclusion criteria were previous history of abdominal aortic aneurysm, connective tissue disorder, and aortic surgery. Patients with abdominal computed tomographic or magnetic resonance imaging from ages 65 to 75 were also excluded. Screening was defined as a complete abdominal, retroperitoneal, or aortic ultrasound. A logistic mixed-effects model utilizing state as a random intercept was used to identify patient characteristics associated with screening.Of 35,154 eligible patients, 13,612 (38.7%, Table 1) underwent screening. Compliance varied by state, ranging from 24.4% in Minnesota to 51.6% in Montana (p <0.05, Figure 1). Screening activity increased yearly, with 0.7% of screening activity occurring in 2008 versus 22.2% in 2016 (p <0.05, Figure 2). In a logistic mixed-effects model adjusting for state as a random intercept, history of hypertension (OR 1.07, 95% CI [1.03 - 1.13]), coronary artery disease (OR 1.17, 95% CI [1.10, 1.22]), congestive heart failure (OR 1.14, 95% CI [1.01 - 1.22]), diabetes (OR 1.1, 95% CI [1.06 - 1.16]) and chronic kidney disease (OR 1.4 95% CI [1.24 - 1.53]) were associated with screening. Living outside of a census-designated metropolitan area was negatively associated with screening (OR 0.92, 95% CI [0.87 - 0.97], Table 2).In a private claims database representing 250 million claimants, 38.7% of eligible patients received UPSTF-recommended AAA screening. Compliance was nearly half that of integrated health systems and was significantly lower for patients living outside of metropolitan areas. Efforts to improve early detection of AAA should include targeting non-metropolitan areas and modifying Medicare reimbursement and incentivization strategies to improve guideline adherence.

  View details for DOI 10.1016/j.jvs.2023.01.202

  View details for PubMedID 36781115

• Utilizing Remote Access for Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents. Journal of vascular surgery Ho, V. T., Sgroi, M. D., Chandra, V., Asch, S. M., Chen, J. H., Lee, J. T. 2023

  Abstract

  Survey data suggests that surgical residents spend 20-30% of training time using the electronic medical record (EMR), raising concerns about burnout and insufficient operative experience. We characterize trainee EMR activity in the vascular surgery service of a quaternary care center to identify modifiable factors associated with high EMR use.Resident activity while on the Vascular Surgery service was queried from the EMR. Weekends and holidays were excluded to focus on typical staffing periods. Variables including daily time spent, post-graduate year (PGY), remote access via mobile device or personal laptop, and patient census including operative caseload were extracted. Univariate analysis was performed with t-tests and chi-squared tests where appropriate. We then fit a linear mixed-effects model with normalized daily EMR time as the outcome variable, random slopes for resident and patient census, and fixed effects of PGY level, academic year, and fractional time spent using remote access.EMR activity for 53 residents from July 2015 to June 2019 was included. The mean daily EMR usage was 1.6 hours, ranging from 3.6 hours per day in PGY1 residents to 1.1 hours in PGY4-5 residents. Across all post-graduate years, the most time-consuming EMR activities were chart review (43.0-46.6%) and notes review (22.4-27.0%). In the linear mixed-effects model, increased patient census was associated with increased daily EMR usage (Coefficient = 0.61, p-value < 0.001). Resident seniority (Coefficient = -1.2, p-value < 0.001) and increased remote access (Coefficient = -0.44, p-value < 0.001) were associated with reduced daily EMR usage. Over the study period, total EMR usage decreased significantly from the 2015-2016 academic year to 2018-2019 (mean difference 2.4 hours vs 1.78, p-value <0.001).In an audit of EMR activity logs on a vascular surgery service, mean EMR time was 1.6 hours a day, which is lower than survey estimates. Resident seniority and remote access utilization were associated with reduced time spent on the EMR, independent of patient census. While increasing EMR accessibility via mobile devices and personal computers have been hypothesized to contribute to poor work-life balance, our study suggests a possible time-saving effect by enabling expedient access for data review, which constitutes the majority of resident EMR activity. Further research in other institutions and specialties is needed for external validation and exploring implications for resident wellness initiatives.

  View details for DOI 10.1016/j.jvs.2023.01.198

  View details for PubMedID 36758909

• Midterm Outcomes in Type A Aortic Dissection Repair with and without Malperfusion in a Hybrid Operating Room. Seminars in thoracic and cardiovascular surgery Dalal, A. R., Dossabhoy, S., Heng, E., Yasin, A., Leipzig, M. M., Bonham, S. A., Fischbein, M. P., Lee, J. T., Woo, Y. J., Watkins, A. C. 2022

  Abstract

  Treatment approach to type A aortic dissection with malperfusion, immediate open aortic repair versus upfront endovascular treatment, remains controversial. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Starting in 2019, all type A aortic dissections were performed in a fixed-fluoroscopy, hybrid operating room. Propensity score matching was used to control baseline patient characteristics between traditional and hybrid operating room approaches. There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 41% (64/157) underwent intraoperative angiograms, and of those, 58% (37/64) received at least one endovascular intervention. Following propensity matching, 125 patients remained in each the traditional and hybrid groups. Thirty-day survival was significantly improved in the hybrid cohort at 96.7%% (122/125) as compared to the traditional cohort at 87.2% (109/125) (p=0.002). There were no significant differences in perioperative paralysis (1.6% vs. 1.6%, p>0.9), new hemodialysis (12% vs. 9.6%, p=0.5), fasciotomy (2.4% vs. 5.6%, p=0.20, and exploratory laparotomy (1.6% vs. 4.8%, p=0.3). The hybrid operating room approach to type A aortic dissection, provides the ability to immediately assess distal malperfusion and perform endovascular interventions at the time of open aortic repair, and is associated with significantly higher 30-day and 2-year survival when compared to a stepwise repair approach in a traditional operating room.

  View details for DOI 10.1053/j.semtcvs.2022.12.003

  View details for PubMedID 36567047

• Impact of Scalene Muscle Botulinum Toxin Injection With and Without Surgery in Neurogenic Thoracic Outlet Syndrome. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine Fereydooni, A., Ho, V. T., Olson, E. M., Dyrek, P., Harris, T., Kussman, A., Roh, E., Lee, J. T. 2022

  Abstract

  Scalene blocks are part of both the diagnostic and treatment algorithm for patients presenting with symptoms of neurogenic thoracic outlet syndrome (nTOS). However, there is a paucity of data on the utility of scalene botulinum toxin injection (BTI) before surgical decompression. We sought to determine the impact of BTI with and without surgery at a multidisciplinary referral center.Retrospective cohort study.Single institution tertiary academic center, 2011 to 2020.Seventy-seven consecutive patients.Scalene muscle BTI for nTOS with or without surgical decompression.Pain relief and Quick Disability of the Arm, Shoulder and Hand (QDASH) score.Seventy-seven patients, with a mean age of 31.4 years, had BTI for symptoms of nTOS. All patients underwent pretreatment physical therapy through the Edgelow protocol for a mean duration of 3.4 months. However, 72.7% had dynamic vascular compression on duplex ultrasound with provocative maneuvers and 85.7% had a positive physical examination finding. After BTI, 77.9% reported subjective relief, confirmed by an improved QDASH disability score. Thirty-one patients (40.3%) then went on to have further persistent symptoms and proceeded with first rib resection. After BTI + Surgery, 96.8% reported symptomatic relief and had a median QDASH score improvement of 21 (range: 10-40), with all reaching minimal clinically important differences in the QDASH score after combination therapy.In this reported series of chemodenervation in patients with nTOS, BTI is helpful in alleviating symptoms before definitive surgical decompression. BTI followed by first rib resection provides additional symptom improvement over BTI alone.

  View details for DOI 10.1097/JSM.0000000000001094

  View details for PubMedID 36367782

• Most Privately Insured Patients do not Receive Federally Recommended Abdominal Aortic Aneurysm Screening Ho, V., Tran, K., George, E., Asch, S., Chen, J., Dalman, R., Lee, J. MOSBY-ELSEVIER. 2022: E78

  View details for Web of Science ID 000868486600054

• Concurrent Diagnosis of Functional Popliteal Artery Entrapment Syndrome and Chronic Exertional Compartment Syndrome in Athletes. Current sports medicine reports Lawley, R. J., Kasitinon, D., Sisk, D., Lavingia, K. S., Lee, J. T., Fredericson, M. 2022; 21 (10): 366-370

  View details for DOI 10.1249/JSR.0000000000000999

  View details for PubMedID 36205428

• Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection: Pre- and Postprocedural Imaging. Radiographics : a review publication of the Radiological Society of North America, Inc Shen, J., Mastrodicasa, D., Al Bulushi, Y., Lin, M. C., Tse, J. R., Watkins, A. C., Lee, J. T., Fleischmann, D. 2022; 42 (6): 1638-1653

  Abstract

  Aortic dissection is a chronic disease that requires lifelong clinical and imaging surveillance, long after the acute event. Imaging has an important role in prognosis, timing of repair, device sizing, and monitoring for complications, especially in the endovascular therapy era. Important anatomic features at preprocedural imaging include the location of the primary intimal tear and aortic zonal and branch vessel involvement, which influence the treatment strategy. Challenges of repair in the chronic phase include a small true lumen in conjunction with a stiff intimal flap, complex anatomy, and retrograde perfusion from distal reentry tears. The role of thoracic endovascular aortic repair (TEVAR) remains controversial for treatment of chronic aortic dissection. Standard TEVAR is aimed at excluding the primary intimal tear to decrease false lumen perfusion, induce false lumen thrombosis, promote aortic remodeling, and prevent aortic growth. In addition to covering the primary intimal tear with an endograft, several adjunctive techniques have been developed to mitigate retrograde false lumen perfusion. These techniques are broadly categorized into false lumen obliteration and landing zone optimization strategies, such as the provisional extension to induce complete attachment (PETTICOAT), false lumen embolization, cheese-wire fenestration, and knickerbocker techniques. Familiarity with these techniques is important to recognize expected changes and complications at postintervention imaging. The authors detail imaging options, provide examples of simple and complex endovascular repairs of aortic dissections, and highlight complications that can be associated with various techniques. Online supplemental material is available for this article. ©RSNA, 2022.

  View details for DOI 10.1148/rg.220028

  View details for PubMedID 36190862

• Patient-Specific Computational Flow Simulation Reveals Significant Differences in Paravisceral Aortic Hemodynamics Between Fenestrated and Branched Endovascular Aneurysm Repair Tran, K., DeGlise, S., Deslarzes-Dubuis, C., Kaladji, A., Yang, W., Marsden, A., Lee, J. MOSBY-ELSEVIER. 2022: E83-E84

  View details for Web of Science ID 000868486600062

• Results of the North American Complex Abdominal Aortic Debranching (NACAAD) Registry. Circulation Escobar, G. A., Oderich, G. S., Farber, M., de Souza, L. R., Quinones-Baldrich, W. J., Patel, H. J., Eliason D, J. L., Upchurch, G. R., Timaran, C., Black, J. H., Ellozy, S. H., Woo, E. Y., Fillinger, M. F., Singh, M. J., Lee, J. T., Carlos Jimenez, J., Lall, P., Gloviczki, P., Kalra, M., Duncan, A. A., Lyden, S. P., Tenorio, E. R., NACAAD Investigators 2022: 101161CIRCULATIONAHA120045894

  Abstract

  BACKGROUND: Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting.METHODS: Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed.RESULTS: A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality (P<0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency (P<0.0001).CONCLUSIONS: Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

  View details for DOI 10.1161/CIRCULATIONAHA.120.045894

  View details for PubMedID 36148651

• Large Fenestrations Versus Scallops for the SMA During Fenestrated EVAR: Does it Matter? Annals of vascular surgery Sorondo, S. M., Ss, D., K, T., Vt, H., Jr, S., J, L. 2022

  Abstract

  FEVAR is an established customized treatment for aortic aneurysms with three current commercially available configurations for the superior mesenteric artery (SMA) - a single-wide scallop, large fenestration, or small fenestration, with the scallop or large fenestration most utilized. Outcomes comparing SMA single-wide scallops to large fenestrations with the ZFEN device are scarce. As large fenestrations have the benefit of extending the proximal seal zone compared to scalloped configurations, we sought to determine the differences in seal zone and sac regression outcomes between the two SMA configurations.We retrospectively reviewed our prospectively maintained complex EVAR database and included all patients treated with the Cook ZFEN device with an SMA scallop or large fenestration configuration at its most proximal build. All first post-operative CT scans (1-30 days) were analyzed on TeraRecon to determine precise proximal seal zone lengths, and standard follow-up anatomic and clinical metrics were tabulated.A total of 234 consecutive ZFEN patients from 2012-2021 were reviewed, and 137 had either a scallop or large fenestration for the SMA as the proximal-most configuration (72 scallops and 65 large fenestrations) with imaging available for analysis. Mean follow-up was 35 months. Mean proximal seal zone length was 19.5±7.9 mm for scallop vs 41.7±14.4 mm for large fenestration groups (P<.001). There was no difference in sac regression between scallop and large fenestration at one year (10.1±10.9 mm vs 11.0±12.1, P = 0.63). Overall, 30-day mortality (1.3% vs 2.5%, P=.51) and all-cause three-year mortality (72.5% vs 81.7%, P=.77) were not significantly different. Reinterventions within 30 days were primarily secondary to renal artery branch occlusions, with only one patient in the scallop group requiring reintervention for an SMA branch occlusion.Despite attaining longer proximal seal lengths, large SMA fenestrations were not associated with a difference in sac regression compared to scalloped SMA configurations at one-year follow up. There were no significant differences in reinterventions or overall long-term survival between the two SMA strategies.

  View details for DOI 10.1016/j.avsg.2022.07.013

  View details for PubMedID 36058451

• Factors associated with sac regression after F/BEVAR for complex abdominal and thoracoabdominal aneurysms. Seminars in vascular surgery Stern, J. R., Lee, J. T. 2022; 35 (3): 306-311

  Abstract

  The behavior and remodeling of the residual aneurysm sac after endovascular repair is predictive of long-term outcomes. Although persistent growth is clearly a harbinger of complications, only recently has the relative advantage of sac regression over sac stability been recognized. There is a growing literature examining the prognostic implications of sac regression after standard infrarenal endovascular aortic repair, and various factors associated with increased likelihood of regression have been identified. However, there is a relative paucity of data on sac regression after more complex aneurysm repairs using fenestrated and/or branched technology. In this article, we aim to review sac regression and its importance as a whole, and specifically examine the role of regression after fenestrated and/or branched endovascular aortic repair for more extensive abdominal and thoracoabdominal aneurysms.

  View details for DOI 10.1053/j.semvascsurg.2022.07.004

  View details for PubMedID 36153071

• Female sex is independently associated with reduced inpatient mortality after endovascular repair of blunt thoracic aortic injury. Journal of vascular surgery Ho, V. T., Sorondo, S., Forrester, J. D., George, E. L., Tran, K., Lee, J. T., Garcia-Toca, M., Stern, J. R. 2022

  Abstract

  Female sex has been associated with decreased mortality following blunt trauma, but whether sex influences outcomes of thoracic endovascular aortic repair (TEVAR) for traumatic blunt thoracic aortic injury (BTAI) is unknown.In this retrospective study of a prospectively maintained database, the Vascular Quality Initiative (VQI) registry was queried from 2013-2020 for patients undergoing TEVAR for BTAI. Univariate Student's t-tests and chi-squared tests were performed, followed by multivariate logistic regression for variables associated with inpatient mortality.211 (26.2%) of 806 patients were female. Female patients were older (47.9 vs. 41.8 years, p<0.0001) and less likely to smoke (38.3% vs. 48.2%, p=0.044). Most patients presented with grade III BTAI (54.5% female, 53.6% male,), followed by grade IV (19.0% female, 19.5% male). Mean Injury Severity Scores (30.9 + 20.3 female, 30.5 + 18.8 male) and regional Abbreviated Injury Score did not vary by sex. Postoperatively, female patients were less likely to die as inpatients (3.8% vs 7.9% , p=0.042) and to be discharged home (41.4% vs. 52.2%, p=0.008). On multivariate logistic regression, female sex (OR 0.05, p=0.002) was associated with reduced inpatient mortality. Advanced age (OR 1.06, p< 0.001), postoperative transfusion (OR 1.05, p=0.043), increased Injury Severity Score (OR 1.03, p=0.039), postoperative stroke (OR 9.09, p= 0.016), postoperative myocardial infarction (OR 9.9, p=0.017), and left subclavian coverage (OR 2.7, p= 0.029) were associated with inpatient death.Female sex is associated with lower odds of inpatient mortality following TEVAR for BTAI, independent of age, injury severity, BTAI grade, and postoperative complications. Further study of the influence of sex on post-discharge outcomes is needed.

  View details for DOI 10.1016/j.jvs.2022.07.178

  View details for PubMedID 35944732

• Five-year Outcomes from a Prospective, Multicenter Study of Endovascular Repair of Iliac Artery Aneurysms Using an Iliac Branch Device. Journal of vascular surgery Schneider, D. B., Matsumura, J. S., Lee, J. T., Peterson, B. G., Chaer, R. A., Oderich, G. S. 2022

  Abstract

  To report five-year results of a pivotal prospective, multicenter study conducted in the United States of a specifically-designed iliac branch device (IBE; W.L. Gore & Associates, Flagstaff, Ariz) for endovascular repair of aortoiliac aneurysms and common iliac artery aneurysms.Sixty-three patients (98.4% male, mean age 70 years) with aortoiliac or common iliac artery aneurysms were enrolled and underwent implantation of a single IBE device and a bifurcated aortoiliac stent graft. Patients with bilateral common iliac artery aneurysms (n=22; 34.9%) underwent either staged occlusion or surgical revascularization of the contralateral internal iliac artery prior to study enrollment. At 5 years, 36/63 patients completed the final study follow up; 35 had clinical examination and 32 had computed tomography imaging (evaluated by an independent core laboratory and adverse events adjudicated by clinical events committee).At 5 years, freedom from all-cause mortality was 85.7% and freedom from aneurysm-related mortality was 100%. The nine deaths that occurred (range 132 to 1898 days) were adjudicated as unrelated to the aneurysm or the procedure. Primary patency of the internal and external iliac artery IBE limbs was 95.1% and 100%, respectively. No patients experienced new onset buttock claudication on the IBE side or self-reported new onset erectile dysfunction. Common iliac artery diameter on the IBE side was either unchanged or decreased by ≥5 mm in 30/31 (96.8%) patients with a baseline (1 month) and a 5-year computed tomography scan (day 1641 to 2006). Of evaluable patients, 9/31 (29.0%) had an increase of ≥5 mm in aortic diameter, of which five patients had a concurrent Type II endoleak. There were no core laboratory-identified Type I or Type III endoleaks or device migrations. Six patients underwent a total of 8 secondary interventions which included 5 interventions for Type II endoleak. Freedom from secondary intervention was 90.5%.The 5-year results of this prospective, multicenter study confirm the safety, efficacy, and durability of the IBE device for treatment of aortoiliac and iliac artery aneurysms. The device effectively prevented common iliac artery aneurysm rupture while maintaining patency of the internal iliac artery and avoiding complications associated with internal iliac artery sacrifice. Although common iliac artery aneurysm enlargement was rare, abdominal aortic enlargement was more common, suggesting that outcomes of endovascular aneurysm repair may be different in patients with or without associated common iliac artery aneurysms.

  View details for DOI 10.1016/j.jvs.2022.07.006

  View details for PubMedID 35842202

• Implementation of the Vascular Surgery Board Virtual Certifying Examination. Journal of vascular surgery Huber, T. S., Brown, K. R., Lee, J. T., Barry, C. L., Ibanez, B., Jones, A. T., Perler, B. A., Upchurch, G. R. 2022

  Abstract

  COVID mandated postponement of the in-person Vascular Surgery Board 2020 certifying examination (CE). Vascular Surgery Virtual CEs (VVCEs) were developed for the scheduled 2020 (rescheduled 1/21) and 2021 (rescheduled 7/21) CEs to avoid postponing the certification testing. This study reports the development, implementation and outcome of the first two VVCEs.The VVCE was similar to the in-person format (3 - 30 min sessions, 2 examiners, 4 questions), but required a proctor and host. In contrast to the general surgery VCEs, VVCE also incorporated images. Candidates and examiners were instructed on the format, and technology checks were performed prior to the VVCE. Candidates were given the opportunity to invalidate their exam for technology-related reasons immediately post-examination. Post-examination surveys were administered to all participants.The VVCEs were completed by 99.7% (356/357) of the candidates. The pass rates for the 1/21 and 7/21 exams were 97.6% (first time - 99.4%, retake - 70%) and 94.7% (first time - 94.6%, retake - 100%), respectively, and were not significantly different from the 2019 in-person CE (χ2 = 2.30, p = 0.13 and χ2 = 0.01, p = 0.91, from the 1/21 and 7/21 exams, respectively). No candidates invalidated their exams. The candidates (162/356 - 46%), examiners (64/118 - 54%), proctors (25/27 - 93%), and hosts (8/9 - 89%) completing the survey were very satisfied with the exam (Likert score 4 or 5: candidates - 92.6% vs non-candidates - 96.9%) , and found the technology domains (Zoom, audio, video, viewing images) to be very good (Likert scores 4 or 5) with candidates and other responders scores of 73 - 84% and > 94%, respectively. Significantly more candidates favored a future VVCE compared to examiners (87% vs 32%, χ2 =67.1, p < .001). Free text responses from all responders commented favorably on the organization and implementation of the exam, but some candidates expressed concerns about image sizes, while some examiners expressed concern about time constraints of the question format. Candidates appreciated the convenience of an at-home exam, especially avoiding travel costs.The two Vascular Surgery Board virtual certifying examinations were psychometrically sound and overwhelmingly successful, demonstrating that imaged-based virtual examinations are feasible and may be the standard for the future.

  View details for DOI 10.1016/j.jvs.2022.06.022

  View details for PubMedID 35760241

• Reintervention Does Not Impact Long-term Survival After Fenestrated Endovascular Aneurysm Repair. Journal of vascular surgery Dossabhoy, S. S., Sorondo, S. M., Tran, K., Stern, J. R., Dalman, R. L., Lee, J. T. 2022

  Abstract

  OBJECTIVES: Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in the treatment of juxtarenal aortic aneurysms and short-neck infrarenal aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource utilization. We sought to determine if REIs impact long-term survival after FEVAR.METHODS: A single-institution retrospective review of all Cook ZFEN repairs was performed. Patients with ≥6 months follow-up and without adjunctive branch modifications were included. REI was defined as any aneurysm, device, target branch, or access-related intervention after the index procedure. REIs were categorized by early (<30 days) or late (≥30 days), indication (branch, endoleak, limb, access-related, or other), and target branch/device component. Patients were stratified into REI vs No REI and Branch REI vs Non-Branch REI.RESULTS: Of 219 consecutive ZFEN from 2012-2021, 158 patients met inclusion criteria. Forty-one (26%) patients underwent a total of 51 REIs (10 early, 41 late) over a mean follow-up of 33.9 months. The most common indication for REI was branch-related 61% (31/51), with the renal arteries most frequently affected 51% (26/51). The only differences found in baseline, aneurysm, or device characteristics were a higher mean SVS comorbidity score (9.6 vs 7.9, P=.04) and larger suprarenal neck angle (23.3 vs 17.1 degrees, P=.04) in No REI, while REI had larger mean proximal seal zone diameter (26.3 vs 25.1 mm, P=.03) and device diameter (31.9 vs 30.0 mm, P=.002) than No REI. Technical success and operative characteristics were similar between groups, except for longer mean fluoroscopy time (74.9 vs 60.8 min, P=.01) and longer median length of stay (2 vs 2 days, P=.006) in REI. While the rate of early major adverse events (<30 days) was higher in REI (24.4% vs 6.0%, P=.001), 30-day mortality was not statistically different (4.9% vs 0.9%, P=.10). On Kaplan-Meier analysis, freedom from REI at 1- and 5-years was 85.7% and 62.6%, respectively, in the overall cohort. There was no difference in estimated 5-year survival between REI and No REI (62.8% vs 63.5%, log-rank P=.87) and Branch REI and Non-Branch REI (71.8% vs 49.9%, log-rank P=.16). In multivariate analysis, REI did not predict mortality; age, the SVS comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (HR 1.07 95% CI 1.02-1.12, P=.007; HR 1.10, 95% CI 1.01-1.18, P=.02; HR 1.05, 95% CI 1.02-1.08, P=.003 respectively).CONCLUSIONS: Following ZFEN, 26% of patients required a total of 51 REIs with most occurring ≥30 days and 61% being branch-related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs do not influence 5-year post-procedural survival.

  View details for DOI 10.1016/j.jvs.2022.04.050

  View details for PubMedID 35709854

• Real-world Long-term Reinterventions After Fenestrated/Branched Endovascular Aneurysm Repair in the United States Ho, V., Tran, K., Chen, J. H., Stern, J. R., George, E., Dalman, R., Lee, J. T. MOSBY-ELSEVIER. 2022: E263-E264

  View details for Web of Science ID 000798307600287

• 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

• Remote Access to Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents Ho, V., Sgroi, M., Chandra, V., Asch, S., Chen, J. H., Lee, J. T. MOSBY-ELSEVIER. 2022: E135

  View details for Web of Science ID 000798307600104

• Anatomic factors contributing to external iliac artery endofibrosis in high performance athletes. Annals of vascular surgery Fisher, A. T., Tran, K., Dossabhoy, S. S., Sorondo, S., Fereydooni, A., Lee, J. T. 2022

  Abstract

  External iliac artery endofibrosis (EIAE) classically presents in cyclists with intimal thickening of the affected arteries. We investigated possible anatomical predisposing factors including psoas muscle hypertrophy, arterial tortuosity, inguinal ligament compression, and arterial kinking via case-control comparison of symptomatic and contralateral limbs.All patients with unilateral EIAE treated surgically at our institution were reviewed. Each patient's symptomatic side was compared with their contralateral side using paired t-tests. Psoas hypertrophy was quantified by transverse cross-sectional area (CSA) at L4, L5, and S1 vertebral levels, and inguinal ligament compression was measured as anterior-posterior distance between inguinal ligament and underlying bone. Tortuosity index for diseased segments and arterial kinking were measured on TeraRecon.Of 33 patients operated on for EIAE from 2004-2021, 27 with available imaging presented with unilateral disease, more commonly left-sided (63%). Most (96%) had external iliac involvement and 26% had ≥2 segments affected: 19% common iliac artery, 15% common femoral artery. The symptomatic limb had greater mean L5 psoas CSA (1450 mm2 vs. 1396 mm2, mean difference 54 mm2, P=0.039). There were no significant differences in L4 or S1 psoas hypertrophy, tortuosity, inguinal ligament compression, or arterial kinking. 63% underwent patch angioplasty and 85% underwent additional inguinal ligament release. 84% reported postoperative satisfaction, which was associated with greater difference in psoas hypertrophy at L4 (p=0.022).Psoas muscle hypertrophy is most pronounced at L5 and is associated with symptomatic EIAE. Preferential hypertrophy of the affected side correlates with improved outcomes, suggesting psoas muscle hypertrophy as a marker of disease severity.

  View details for DOI 10.1016/j.avsg.2022.05.011

  View details for PubMedID 35654289

• Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era. Journal of vascular surgery George, E. L., Arya, S., Ho, V. T., Stern, J. R., Sgroi, M. D., Chandra, V., Lee, J. T. 2022

  Abstract

  OBJECTIVE: Prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of and increased anatomic suitability of endovascular aortic repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees.METHODS: We examined ACGME case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aorto-iliac occlusive disease (AIOD) via aorto-iliac/femoral bypass (AFB) from integrated vascular surgery residents (VSR) and fellows (VSF) graduating 2006-2017 and compared them to national estimates of total OAR (open AAA repair + AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample based on ICD-9 and ICD-10 procedural codes. Changes over time were assessed using Chi-square test, Student's t-test, and linear regression.RESULTS: During the twelve-year study period, the national annual total OAR and open AAA repair estimates decreased: total OAR by 72.5% (2006: estimate (standard error) 24,255 (1185) vs. 2017: 6,690 (274); p<0.001) and open AAA repair by 84.7% (2006: 18,619 (924) vs. 2017: 2,850 (168); p<0.001); AFB estimates decreased by 33.0% (p<0.001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals significantly increased from 55 to 80% (all p<0.001). There was a 40.9% decrease in open AAA repairs logged by graduating VSF (mean 18.6 vs. 11) but only a 6.9% decrease in total OAR cases (mean 27.6 vs. 25.7) due to increasing AFB volumes (mean 9.0 vs. 14.7). VSR graduates consistently logged an average of 10 open AAA repairs and there was a 31.0% increase in total OAR (mean 23.2 vs. 30.4), again secondary to rising AFB volumes (mean 11.4 vs 17.5). Although there was an absolute decrease in open aortic experience for VSF, the rate of decline for total OAR case volumes was not significantly different after VSR programs were established (p=0.40).CONCLUSIONS: As incidence decreases nationally, OAR is shifting towards teaching hospitals. While open AAA procedures for trainees are declining due to EVAR, open aortic reconstruction for AIOD is rising and plays an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be top priority for vascular surgery program directors.

  View details for DOI 10.1016/j.jvs.2022.03.887

  View details for PubMedID 35598821

• In-situ Bypass Is Associated with Superior Infection-free Survival Compared to Extra-Anatomic Bypass for the Management of Secondary Aortic Graft Infections Without Enteric Involvement. Journal of vascular surgery Janko, M. R., Hubbard, G., Back, M., Shah, S. K., Pomozi, E., Szeberin, Z., DeMartino, R., Wang, L. J., Crofts, S., Belkin, M., Davila, V. J., Lemmon, G. W., Wang, S. K., Czerny, M., Kreibich, M., Humphries, M. D., Shutze, W., Joh, J. H., Cho, S., Behrendt, C., Setacci, C., Hacker, R. I., Sobreira, M. L., Yoshida, W. B., D'Oria, M., Lepidi, S., Chiesa, R., Kahlberg, A., Go, M. R., Rizzo, A. N., Black, J. H., Magee, G. A., Elsayed, R., Baril, D. T., Beck, A. W., McFarland, G. E., Gavali, H., Wanhainen, A., Kashyap, V. S., Stoecker, J. B., Wang, G. J., Zhou, W., Fujimura, N., Obara, H., Wishy, A. M., Bose, S., Liang, P., Schermerhorn, M., Conrad, M. F., Hsu, J. H., Patel, R., Lee, J. T., Liapis, C. D., Moulakakis, K. G., Farber, M. A., Motta, F., Ricco, J., Bath, J., Coselli, J. S., Aziz, F., Coleman, D. M., Davis, F. M., Fatima, J., Irshad, A., Shalhub, S., Zhang, Q., Lawrence, P. F., Woo, K., Chung, J. 2022

  Abstract

  OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI.METHODS: A retrospective, multi-institutional study of AGI from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed.RESULTS: 241 patients at 34 institutions from 7 countries presented with AGI during the study period (median age 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%) and 66 endografts (27%) and 3 unknown (2%). 172 (71%) of the patients underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (NAIS) (24%), and cryopreserved allograft (41%). 69 patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier (KM) estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB versus EAB, there was a significant difference in KM estimated infection-free survival (2910 days, IQR 391, 3771 versus 180 days, IQR 27, 3750 days; p<0.001). There were otherwise no significant differences in presentation, comorbidities, nor perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (HR 2.4, 95% CI 1.6-3.6; p<0.001), polymicrobial infection (HR 2.2, 95% CI 1.4-3.5; p=0.001), MRSA infection (HR 1.7, 95% CI 1.1-2.7; p=0.02), as well as the protective effect of omental/muscle flap coverage (HR 0.59, 95% CI 0.37-0.92; p=0.02).CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two-and-half fold higher re-infection/mortality compared to ISB. Omental and/or muscle flap coverage of the repair appear protective.

  View details for DOI 10.1016/j.jvs.2022.03.869

  View details for PubMedID 35470015

• Cost effectiveness of computed tomography versus ultrasound-based surveillance following endovascular aortic repair of intact infrarenal abdominal aortic aneurysms. Journal of vascular surgery Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. 2022

  Abstract

  BACKGROUND: While Society for Vascular Surgery guidelines recommend computed tomography angiography (CTA) or ultrasound for surveillance following infrarenal endovascular aortic repair (EVAR), there is a lack of consensus regarding optimal timing and modalities. We hypothesized that ultrasound-based approaches would be more cost-effective and developed a cost-effectiveness analysis to estimate the lifetime costs and outcomes of various strategies.METHODS: We developed a decision tree with nested Markov models to compare five surveillance strategies: yearly CTA, yearly CDU, yearly CEU, CTA at first year followed by CDU, and CTA at first year followed by CEU. The model accounted for differential sensitivity, specificity, and risk of acute kidney injury after CTA, and was implemented on a monthly cycle with a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) and 3% annual discounting.RESULTS: Under base case assumptions, the CTA-CDU strategy was cost effective with a lifetime cost of $77950 for 7.74 QALYs. In sensitivity analysis, the CTA-CDU approach remained cost-effective when CEU specificity was less than 95%, and risk of acute kidney injury following CTA was less than 20%. At diagnostic sensitivities below 75% for CEU and 55% for CDU, a yearly CTA strategy maximized QALYs.CONCLUSION: A hybrid strategy in which CTA is performed in the first year and CDU is performed annually thereafter is the most cost-effective strategy for infrarenal EVAR surveillance in patients with less than a 20% risk of contrast-induced nephropathy. If the sensitivity of CEU and CDU are at the lower end of plausible estimates, a yearly CTA strategy is reasonable. Further research should aim to identify patients who may benefit from alternative surveillance strategies.

  View details for DOI 10.1016/j.jvs.2022.02.057

  View details for PubMedID 35278655

• Comparison of Hemodynamic Changes Associated With Two-Versus Four-Vessel Fenestrated Endovascular Aneurysm Repair Using Patient-specific Computational Flow Modeling Tran, K., Kaladji, A., Yang, W., Marsden, A., Lee, J. MOSBY-ELSEVIER. 2022: E41-E42

  View details for Web of Science ID 000758691500053

• Reverse Cheese-Wire Septotomy to Create a Distal Landing Zone for Thoracic Endovascular Aortic Repair. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists Stern, J. R., Pham, X. D., Lee, J. T. 1800: 15266028211070966

  Abstract

  PURPOSE: The objective of this study is to describe a novel method for creating a distal landing zone for thoracic endovascular aortic repair (TEVAR) in chronic aortic dissection. The technique is described in a patient with prior total arch and descending aortic replacement, with false lumen expansion.TECHNIQUE: A cheese-wire endovascular septotomy was desired to create a single lumen above the celiac axis. To avoid dividing the septum caudally across the visceral segment, we performed a modified septotomy in a cephalad direction. Stiff wires were passed into the prior surgical graft, through true lumen on the right and false lumen on the left. An additional wire was passed across an existing fenestration at the level of the celiac axis, and snared and externalized. 7F Ansel sheaths were advanced and positioned tip-to-tip at the fenestration. Using the stiff wires as tracks, the through-wire was pushed cephalad to endovascularly cut the septum. Angiogram demonstrated successful septotomy, and TEVAR was performed to just above the celiac with successful aneurysm exclusion and no endoleak or retrograde false lumen perfusion. Follow-up computed tomography angiogram (CTA) showed continued exclusion without false lumen perfusion.CONCLUSIONS: This novel modification in a reverse direction provides an alternative method for endovascular septotomy, when traditional septotomy may threaten the visceral vessels.

  View details for DOI 10.1177/15266028211070966

  View details for PubMedID 35018867

• Fenestrated Aortic Aneurysm Repair in Patients Treated Inside Versus Outside of Instructions for Use. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists Stern, J. R., Deslarzes-Dubuis, C., Tran, K., Lee, J. T. 1800: 15266028211068762

  Abstract

  OBJECTIVES: The aim of this study was to compare outcomes of patients treated with the Cook Zenith Fenestrated (ZFEN) device for juxtarenal aortic aneurysms inside versus outside the IFU.METHODS: We retrospectively reviewed our institutional ZFEN database for cases performed between 2012 and 2018, with analysis performed in 2020 in order to report midterm outcomes. The cohort was stratified based on treatment inside (IFU group) and outside (non-IFU group) the IFU for criteria involving the proximal neck: neck length 4 to 14 mm, neck diameter 19 to 31 mm, and neck angulation ≤45°. Patients with thoracoabdominal aneurysms or concurrent chimney grafting were excluded. The primary outcomes in question were mortality, type 1a endoleak, and reintervention. Univariate and multivariate analyses were performed to determine associations between adherence to IFU criteria and outcomes.RESULTS: We identified 100 consecutive patients (19% female, mean age 73.6 years) for inclusion in this analysis. Mean follow-up was 21.6 months. Fifty-four patients (54%) were treated outside the IFU because of inadequate neck length (n=48), enlarged neck diameter (n=10), and/or excessive angulation (n=16). Eighteen patients were outside IFU for two criteria, and one patient was outside IFU for all three. Non-IFU patients were exposed to higher radiation doses (3652 vs 5445 mGy, p=0.008) and contrast volume (76 vs 95 mL, p=0.004). No difference was noted between IFU and non-IFU groups for 30-day mortality (0% vs 3.7%, p=0.18), or type 1a endoleak (0% vs 1.9%, p=0.41). Reintervention was also similar between cohorts (13% vs 27.8%, p=0.13). Being outside IFU for neck diameter or length was each borderline significant for higher reintervention on univariate analysis (p=0.05), but this was not significant on multivariate Cox proportional hazard modeling (HR 1.82 [0.53-6.25]; 2.03 [0.68-7.89]), respectively. No individual IFU deviations were associated with the primary outcomes on multivariate analysis, nor being outside IFU for multiple criteria.CONCLUSIONS: Patients with juxtarenal aortic aneurysms may be treated with the ZFEN device with moderate deviations from the IFU. While no differences were seen in mortality or proximal endoleak, larger studies are needed to examine the potential association between IFU nonadherence and reinterventions and close follow-up is warranted for all patients undergoing such repair.

  View details for DOI 10.1177/15266028211068762

  View details for PubMedID 34994244

• Patient-specific changes in aortic hemodynamics is associated with thrombotic risk after fenestrated endovascular aneurysm repair with large diameter endografts. JVS-vascular science Tran, K., Feliciano, K. B., Yang, W., Schwarz, E. L., Marsden, A. L., Dalman, R. L., Lee, J. T. 2022; 3: 219-231

  Abstract

  Background: The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. In the present study, we used patient-specific computational fluid dynamic (CFD) simulation to investigate the effect of the endograft diameter on hemodynamics after fEVAR and explore the hypothesis that diameter-dependent alterations in aortic hemodynamics can predict for thrombotic events.Methods: A single-institutional retrospective study was performed of patients who had undergone fEVAR for juxtarenal aortic aneurysms. The patients were stratified into large diameter (34-36mm) and small diameter (24-26mm) endograft groups. Patient-specific CFD simulations were performed using three-dimensional paravisceral aortic models created from computed tomographic images with allometrically scaled boundary conditions. Aortic time-averaged wall shear stress (TAWSS) and residence time (RT) were computed and correlated with future thrombotic complications (eg, renal stent occlusion, development of significant intraluminal graft thrombus).Results: A total of 36 patients (14 with a small endograft and 22 with a large endograft) were included in the present study. The patients treated with large endografts had experienced a higher incidence of thrombotic complications compared with small endografts (45.5% vs 7.1%; P= .016). Large endografts were associated with a lower postoperative aortic TAWSS (1.45± 0.76dynes/cm2 vs 3.16± 1.24dynes/cm2; P< .001) and longer aortic RT (0.78± 0.30second vs 0.34± 0.08second; P< .001). In the large endograft group, a reduction >0.39dynes/cm2 in aortic TAWSS demonstrated discriminatory power for thrombotic complications (area under the receiver operating characteristic curve, 0.77). An increased aortic RT of ≥0.05second had similar accuracy for predicting thrombotic complications (area under the receiver operating characteristic curve, 0.78). The odds of thrombotic complications were significantly higher if patients had met the hemodynamic threshold changes in aortic TAWSS (odds ratio, 7.0; 95% confidence interval, 1.1-45.9) and RT (odds ratio, 8.0; 95% confidence interval, 1.13-56.8).Conclusions: Patient-specific CFD simulation of fEVAR in juxtarenal aortic aneurysms demonstrated significant endograft diameter-dependent differences in aortic hemodynamics. A postoperative reduction in TAWSS and an increased RT correlated with future thrombotic events after large-diameter endograft implantation. Patient-specific simulation of hemodynamics provides a novel method for thrombotic risk stratification after fEVAR.

  View details for DOI 10.1016/j.jvssci.2022.04.002

  View details for PubMedID 35647564

• Objective Evaluation of Clock Face Suture Using the Objective Structured Assessment of Technical Skill (OSATS) Checklist. EJVES vascular forum Treil, L., Neumann, N., Chanes, N., Lejay, A., Bourcier, T., Bismuth, J., Lee, J. T., Sheahan, M., Rouby, A., Chakfe, N., Collaborators, Eidt, J., Georg, Y., Mitchell, E. L., Rigberg, D., Shames, M., Thaveau, F., Sheahan, C. 2022; 57: 5-11

  Abstract

  Objective: Assessment of the quality of the final product (QFP) is critical in simulation training, such as the clock face suture (CFS) exercise that is used to assess trainees' needle handling and suturing accuracy. Objective Structured Assessment of Technical Skill (OSATS) scores are the gold standard for the evaluation of trainees. The aim was to investigate variability in the use of OSATS checklists and to evaluate a semi-automatic method of suture analysis vs. OSATS scores.Methods: Details of 287 CFSs performed by trainees during Fundamentals in Vascular Surgery examinations were collected. All were rated according to a seven item OSATS checklist, including QFP score and an overall score by one or two expert surgeons immediately after completion. Interassessor variability was assessed for the CFS that were assessed by two assessors.In order to assess intra- and interassessor variability, 50 CFS pictures were chosen randomly and submitted to three expert surgeons to rate the QFP twice and to carry out a semi-automatic image analysis of each CFS and the estimated cumulative error (CE; mm) recorded. It was hypothesised that the CE correlates to OSATS checklist items or overall score. Variables were compared for correlation with OSATS results using a linear regression. A Pearson's test was used to confirm the proposed hypothesis.Results: Mean ± standard deviation overall score for the OSATS checklist was 20.61 ± 6.33. Inter- and intra-assessor correlation were statistically significant regarding OSATS checklist items. Both correlations presented a low coefficient of determination, indicating variability. The mean CE was 16.07 ± 4.84 mm, and the correlation between the QFP and CE was statistically significant, proving that CE is an objective metric by which to assess the QFP.Conclusion: OSATS score demonstrated intra- and interassessor variability, although there was a significant correlation between scores. CE is an objective metric that is not subject to assessor subjectivity or interassessor variability and is correlated with the gold standard of evaluation.

  View details for DOI 10.1016/j.ejvsvf.2022.10.001

  View details for PubMedID 36388464

• Xray Exposure Time in Dedicated Academic Simulation Programs Is Realistic of Patient Procedures. EJVES vascular forum Debucquois, A., Vento, V., Neumann, N., Mertz, L., Lejay, A., Rouby, A., Bourcier, T., Lee, J. T., Chakfe, N., Collaborators, Berard, X., Bonnin, E., Camin, A., Chenesseau, B., Cochennec, F., Corpateaux, J., Deglise, S., Delay, C., Deltatto, B., Duprey, A., Gaudric, J., Georg, Y., Ghariani, Z., Jean-Baptiste, E., Hertault, A., Meteyer, V., Roussin, M., Saucy, F., Schneider, F., Steinmetz, L., Thaveau, F. 2022; 55: 5-8

  Abstract

  Objective: To ascertain whether simulated endovascular procedures are comparable to real life operating room (OR) procedures, particularly with regard to irradiation time.Methods: This was a retrospective study comparing simulation with clinical data. Fluoroscopy time and overall operation time were compared between simulated abdominal aortic endovascular repair (EVAR) and iliac procedures that were performed, respectively, from 2016 to 2019 and from 2015 to 2019, and clinical EVAR and iliac procedures performed in the OR between January 2018 and November 2021.Results: Within the defined periods, 171 simulated procedures (91 EVAR, 80 iliac) and 199 clinical procedures (111 EVAR, 88 iliac) were performed. For both EVAR and iliac procedures, median total procedure time was much longer during real surgery (p < .001). However, median total fluoroscopy time remained the same, whether the procedure was real surgery or performed on the simulator, for iliac procedures (8.47 minutes in the OR, 8.35 minutes on the simulator, p= .61) and for EVAR procedures (14.80 minutes in the OR, 15.00 minutes on the simulator p= .474).Conclusion: Simulated endovascular procedures are comparable with real life OR procedures, particularly with regard to irradiation time when integrated in a dedicated curriculum.

  View details for DOI 10.1016/j.ejvsvf.2022.01.010

  View details for PubMedID 35252939

• Impact of renal chimney intra-aortic stent length on branch and end-stent angle in chimney endovascular aneurysm repair and endovascular aneurysm sealing configurations. Vascular Ullery, B. W., Suh, G., Thompson, P., Lee, J. T., Holden, A., Dalman, R. L., Cheng, C. P. 1800: 17085381211059978

  Abstract

  OBJECTIVE: Practice patterns and durability of parallel stent graft techniques in complex endovascular aneurysm repair (EVAR) remain poorly defined. We aimed to quantify and compare the impact of renal chimney intra-aortic stent length (IASL) on geometric deformations of renal arteries in complex EVAR.METHODS: Thirty-eight nonconsecutive patients underwent EVAR utilizing parallel stent graft techniques (chimney EVAR [chEVAR], n = 28; chimney endovascular aneurysm sealing [chEVAS], n = 10) between 2010 and 2016. A total of 59 renal chimney stent grafts were used. Geometric quantification was derived from three-dimensional model-based centerline extraction. Renal chimney intra-aortic stent length (IASL) was defined as the length of chimney stent that extended from the proximal edge of the chimney stent to the ostium of the corresponding renal artery.RESULTS: Mean IASL for both left and right renal arteries in the cohort was 35.7mm. Renal arteries containing chimney IASL <30mm trended toward a greater branch angle (135.4 vs. 127.8°, p = .06). Left renal arteries showed significantly greater branch angle among those with IASL <40mm (135.5 vs. 121.7°, p = .045). Mean IASL for renal arteries in chEVAR was significantly longer compared to chEVAS (39.2 vs. 26.3mm, p = .003). No difference was noted in overall branch angle or end-stent angle based on procedure type. ChEVAR with IASL <30mm had significantly greater end-stent angle (48.2 vs. 33.5°, p = .03). In contrast, chEVAS patients showed no difference in end-stent angle based on IASL thresholds, but did have significantly greater branch angle among those with IASL <30mm when grouped by both all renal arteries (133.5 vs. 113.5°, p = .004) and right renal arteries (134.3 vs. 111.6°, p = .02).CONCLUSIONS: Renal chimney stents with longer IASL appear to exhibit less renal artery deformation, suggesting a more gradual and perpendicular transition of the chimney stent across the renal ostium.

  View details for DOI 10.1177/17085381211059978

  View details for PubMedID 34963378

• Vascular Surgery Curriculum for Medical Students: A National Targeted Needs Assessment. Annals of vascular surgery Dorsey, C., McKenzie, N., Milner, R., Lee, J., Schindler, N. 2021

  Abstract

  OBJECTIVE: At present, neither theAmerican College of Surgeons (ACS) nor the Society for Vascular Surgery (SVS) provides curriculum recommendations for medical students rotating on a vascular surgery service. We sent a targeted needs assessment to vascular surgeons across the country in order to investigate the need for a structured curriculum for medical students participating in a vascular surgery rotation during their clinical clerkships.METHODS: The survey was developed with input from medical students, vascular surgeons, and medical educators. Respondents were identified from the Fellowship and Residency Electronic Interactive Database (FREIDA). The needs assessment was sent to program directors of vascular residencies and fellowships and to other vascular surgery educators. The survey collected data regarding the existing vascular surgery curriculum at the respondent's institution, the need for a standardized curriculum, desired experiences for medical students, and important vascular topics for medical students to cover while on rotation.RESULTS: Responses were obtained from 50 of the 146 surveyed individuals (response rate = 34.2%). Forty-eight respondents (96%) worked in an academic hospital or academic affiliated hospital. With regard to the existing vascular surgery curriculum, only twenty-eight respondents (61%) indicated that they had a curriculum approved by the surgery clerkship director. Thirty-seven respondents (77.1%) said there were at least goals and objectives for students on the vascular surgery service, and 29 respondents (60.4%) indicated that there was dedicated time for didactic sessions. Only 17 respondents (35.4%) indicated students gave a case presentation on the service. Twenty-nine respondents (63%) agreed or strongly agreed that there should be a standardized vascular curriculum for medical students. When asked to rank nine topics from most important to least important for students to learn, respondents ranked peripheral arterial disease, aortic disease, and carotid disease highest. Simulation experience was most frequently indicated as a desired addition to the curriculum, and only 16 respondents (33.3%) reported opportunities for vascular surgery specific simulation experiences.CONCLUSIONS: This study identified the lack of an existing structured curriculum for medical students, the desire for a standardized curriculum, and key topics and experiences that are felt to be important for students to cover. With this information in hand, vascular educators have the potential to enhance the learning experience of medical students rotating through the service by developing a standardized curriculum.

  View details for DOI 10.1016/j.avsg.2021.08.040

  View details for PubMedID 34688874

• Fenestrated endovascular repair with large device diameters (34- to 36-mm) is associated with type 1 and 3 endoleak and reintervention. Annals of vascular surgery Deslarzes-Dubuis, C., Stern, J. R., Tran, K., Colvard, B., Lee, J. T. 2021

  Abstract

  OBJECTIVES: Patients with abdominal aortic aneurysms undergoing EVAR with larger device diameters (34- to 36-mm) have worse outcomes due to proximal fixation failure and need for reintervention. We examine outcomes relating to standard fenestrated repair (FEVAR) with larger device diameters, and investigate whether a similar relationship exists.MATERIAL AND METHODS: Retrospective review of a prospectively maintained, single institution database of patients treated with the Cook ZFEN device between 2012-2017. Outcomes were stratified by device diameter into normal-diameter (ND,≤ 32 mm) and large-diameter (LD,34-36 mm). Primary endpoints were need for reintervention and composite type I/III endoleak.RESULTS: 100 consecutive patients treated were identified for inclusion. Overall mean age was 73.6 years and mean aortic diameter was 59.1 mm. Mean follow-up was 22 months. A total of 26 (26%) patients were treated with LD devices. Number of target vessels per patient was 2.8 in both groups. Infrarenal neck length and diameter were significantly different in the LD and ND patients, respectively (2.6 mm vs 4.7 mm (P<.01) and 30.1 mm vs 23.4 mm (P<.01)). Percent graft oversizing was lower in the LD cohort (19% vs 24%; P=.006). No difference was seen in overall mortality at 30-days (0% vs 2%; P=.4) or at latest follow up (6% vs 14%; P=.6). Reinterventions were not significantly different at 30 days, but were significantly higher over the follow-up period in the LD cohort (46.2 vs. 17.6%; P=.002). LD diameter was associated with reintervention on univariate (HR 1.19, 95% CI 1.04-1.37), but not multivariate analysis. The composite endpoint of type I/III endoleak was higher in the LD cohort (15.4% vs. 2.7%; P=.004).CONCLUSION: FEVAR requiring 34- or 36-mm device diameters is associated with an increased risk of composite type I/III endoleak and reintervention. Patients undergoing fenestrated repair requiring LD devices should be closely monitored, with consideration for proximal or open repair.

  View details for DOI 10.1016/j.avsg.2021.07.055

  View details for PubMedID 34656711

• Impact of Scalene Muscle Botulinum Toxin Injection with and without Surgery in Neurogenic Thoracic Outlet Syndrome Fereydooni, A., Ho, V. T., Olson, E., Dyrek, P., Harris, T., Kussman, A., Roh, E. Y., Lee, J. T. MOSBY-ELSEVIER. 2021: E410

  View details for Web of Science ID 000707158200201

• 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

• Open Abdominal Aortic Surgery in the Endovascular Era-Will we have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E418

  View details for Web of Science ID 000707158200214

• Reintervention Does Not Increase Long-term Mortality After Fenestrated Endovascular Aneurysm Repair Dossabhoy, S. S., Sorondo, S. M., Tran, K., Stern, J. R., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E399-E400

  View details for Web of Science ID 000707158200185

• Cost Effectiveness of Computed Tomography Versus Ultrasound-Based Surveillance Following Endovascular Aortic Repair of Intact Abdominal Aortic Aneurysms Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E414-E415

  View details for Web of Science ID 000707158200208

• Collagen Fibril Orientation in Tissue Specimens from Atherosclerotic Plaque Explored Using Small Angle X-Ray Scattering. Journal of biomechanical engineering Silva, H., Tassone, C., Ross, E. G., Lee, J. T., Zhou, W., Nelson, D. V. 2021

  Abstract

  Atherosclerotic plaques can gradually develop in certain arteries. Disruption of fibrous tissue in plaques can result in plaque rupture and thromboembolism, leading to heart attacks and strokes. Collagen fibrils are important tissue building blocks and tissue strength depends on how fibrils are oriented. Fibril orientation in plaque tissue may potentially influence vulnerability to disruption. While X-ray scattering has previously been used to characterize fibril orientations in soft tissues and bones, it has never been used for characterization of human atherosclerotic plaque tissue. This study served to explore fibril orientation in specimens from human plaques using small angle X-ray scattering. Plaque tissue was extracted from human femoral and carotid arteries, and each tissue specimen contained a region of calcified material. 3D collagen fibril orientation was determined along scan lines that started away from and then extended towards a given calcification. At locations several millimeters or more from a calcification, fibrils were found to be oriented predominantly in the circumferential direction of the plaque tissue. However, in a number of cases, the dominant fibril direction changed markedly near a calcification, from circumferential to longitudinal. Further study is needed to elucidate how these fibril patterns may change plaque tissue behavior.

  View details for DOI 10.1115/1.4052432

  View details for PubMedID 34529040

• Reintervention Does Not Increase Long-term Mortality After Fenestrated Endovascular Aneurysm Repair Dossabhoy, S. S., Sorondo, S. M., Tran, K., Stern, J. R., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E227

  View details for Web of Science ID 000691401100357

• Impact of the Veterans Affairs National Abdominal Aortic Screening Program Garcia-Toca, M., Hlatky, M. A., Dalman, R. L., Itoga, N., Kou, A., Mudumbai, S., Lee, J. T., Aalami, O. MOSBY-ELSEVIER. 2021: E48-E49

  View details for Web of Science ID 000691401100103

• 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

• Cost Effectiveness of Computed Tomography Versus Ultrasound-Based Surveillance After Endovascular Aortic Repair of Intact Abdominal Aortic Aneurysms Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E190-E191

  View details for Web of Science ID 000691401100304

• Open Abdominal Aortic Surgery in the Endovascular Era - Will We Have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V. T., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E259-E260

  View details for Web of Science ID 000691401100398

• Final 5-Year Results of the US Prospective, Multicenter Study of Endovascular Repair of Iliac Aneurysms Using the Gore Iliac Branch Endoprosthesis Schneider, D. B., Matsumura, J. S., Lee, J. T., Peterson, B. G., Chaer, R. A., Oderich, G. S. MOSBY-ELSEVIER. 2021: E89-E90

  View details for Web of Science ID 000691401100171

• Contemporary Outcomes After Partial Resection Of Infected Aortic Grafts. Annals of vascular surgery Janko, M., Hubbard, G., Woo, K., Kashyap, V. S., Mitchell, M., Murugesan, A., Chen, L., Gardner, R., Baril, D., Hacker, R. I., Szeberin, Z., ElSayed, R., Magee, G. A., Motta, F., Zhou, W., Lemmon, G., Coleman, D., Behrendt, C., Aziz, F., Black, J. H., Tran, K., Dao, A., Shutze, W., Garrett, H. E., De Caridi, G., Patel, R., Liapis, C. D., Geroulakos, G., Kakisis, J., Moulakakis, K., Kakkos, S. K., Obara, H., Wang, G., Stoecker, J., Rheaume, P., Davila, V., Ravin, R., DeMartino, R., Milner, R., Shalhub, S., Jim, J., Lee, J., Dubuis, C., Ricco, J., Coselli, J., Lemaire, S., Fatima, J., Sanford, J., Yoshida, W., Schermerhorn, M. L., Menard, M., Belkin, M., Blackwood, S., Conrad, M., Wang, L., Crofts, S., Nixon, T., Wu, T., Chiesa, R., Bose, S., Turner, J., Moore, R., Smith, J., Irshad, A., Hsu, J., Czerny, M., Cullen, J., Kahlberg, A., Setacci, C., Joh, J. H., Senneville, E., Garrido, P., Sarac, T. P., Rizzo, A., Go, M. R., Bjorck, M., Gavali, H., Wanhainen, A., D'Oria, M., Lepidi, S., Mastrorilli, D., Veraldi, G., Piazza, M., Squizzato, F., Beck, A., St John, R., Wishy, A., Humphries, M., Shah, S. K., Back, M., Chung, J., Lawrence, P. F., Bath, J., Smeds, M. R. 2021

  Abstract

  INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection.METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002-2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed.RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%.The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (p=0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; p=0.01) as well as aortoenteric fistula (HR 1.9, p=0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, p=0.04), as well as those with American Society of Anesthesiologists (ASA) classification less than 3 (HR 0.35, p=0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs 60 years, p=0.01) and less likely to have patent repairs during follow up (59% vs. 32%, p=0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs 29%, p<0.01) CONCLUSIONS: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

  View details for DOI 10.1016/j.avsg.2021.07.002

  View details for PubMedID 34437963

• Validity Evidence for Vascular Skills Assessment: The Feasibility of Fundamentals of Vascular Surgery in General Surgery Residency. Journal of surgical education Schmiederer, I. S., Kearse, L. E., Korndorffer, J. R., Lee, E., Sgroi, M. D., Lee, J. T. 2021

  Abstract

  OBJECTIVE: As the Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES) have been used for general surgery assessment, the Fundamentals of Vascular Surgery (FVS) has recently been developed to evaluate core operative skills for vascular trainees. This study examines the 3 year implementation of FVS for general surgery residents and it gathers validity evidence using Messick's framework. We hypothesized that the curriculum and assessment tool enhance general surgery resident training and assessment.DESIGN: This is a retrospective review of FVS assessments of residents using descriptive and multivariate analyses.SETTING: This study was conducted at an academic institution, where simulation-based teaching sessions occur in coordination between the general surgery and the integrated vascular surgery residency programs.PARTICIPANTS: Seventeen general surgery residents were assessed in FVS skills by an expert rater from 2018 to 2020.RESULTS: Overall, 86 assessments were completed.CONTENT: Assessment focuses on 3 open vascular skills (End-to-Side Anastomosis, Patch Angioplasty and Clockface Suturing). Response Process: 7 items comprise a graded rating for a skills score. Additionally, a global summary score is designated. Internal Structure: The assessment tool has a Cronbach's alpha of 0.87, demonstrating good internal consistency. Addition of the second rater correlated with Cohen's kappa -0.69 (p < 0.001), indicating poor interrater reliability. Relationships to other variables: The most significant improvement occurred in total scores between PGY2s (17.4 ± 2.37) and PGY4s (23.2 ± 3.00), p < 0.001, indicating adequate level discernment.CONCLUSIONS: The validity evidence of FVS assessment in this study supports its use in general surgery residency at a time when opportunities for open vascular skills assessment may be decreasing due to case availability and shifting paradigms. Further study into quality rater training is needed to optimize national implementation of FVS and ensure consistency in grading.

  View details for DOI 10.1016/j.jsurg.2021.07.009

  View details for PubMedID 34446383

• Predictors Of Relief Following Botulinum Injection For Thoracic Outlet Syndrome Olson, E., Dyrek, P., Fereydooni, A., Harris, T., Lee, J. T., Kussman, A., Roh, E. Y. LIPPINCOTT WILLIAMS & WILKINS. 2021: 377

  View details for Web of Science ID 000693955700413

• Predicting Return To Play In NCAA Division 1 Athletes With Neurogenic Thoracic Outlet Syndrome Dyrek, P., Olson, E., Fereydooni, A., Harris, T., Kussman, A., Roh, E., Lee, J. T., Segovia, N. LIPPINCOTT WILLIAMS & WILKINS. 2021: 390

  View details for Web of Science ID 000693955700448

• Reply. Journal of vascular surgery Lee, J. T. 2021; 74 (1): 344

  View details for DOI 10.1016/j.jvs.2021.02.019

  View details for PubMedID 34172195

• 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

• Addressing Contemporary Management of Vascular Trauma: Optimization of Patient Care Through Collaboration. Annals of surgery Smith, B. K., Sheahan, M. G., Sgroi, M., Weis, T., Singh, N., Rigberg, D., Coleman, D. M., Lee, J. T., Shames, M. L., Mitchell, E. L. 2021; 273 (5): e171–e172

  View details for DOI 10.1097/SLA.0000000000004861

  View details for PubMedID 33824252

• Influence of Thoracic Endovascular Aortic Repair on True Lumen Helical Morphology for Stanford Type B Dissections. Journal of vascular surgery Bondesson, J., Suh, G., Marks, N., Dake, M. D., Lee, J. T., Cheng, C. P. 2021

  Abstract

  OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) can change the morphology of the flow lumen in aortic dissections, which may affect aortic hemodynamics and function. This study characterizes how helical morphology of the true lumen in type B aortic dissections is altered by TEVAR.METHODS: Patients with type B aortic dissection who underwent computed tomography angiography pre- and post-TEVAR were retrospectively reviewed. Images were used to construct 3D stereolithographic (STL) surface models of the true lumen and whole aorta using custom software. STL models were segmented and co-registered to determine helical morphology of the true lumen with respect to the whole aorta. The true lumen region covered by the endograft was defined based on fiducial markers pre- and post-TEVAR. Helical angle, average helical twist, peak helical twist, and cross-sectional eccentricity, area, and circumference were quantified in this region for pre- and post-TEVAR geometries.RESULTS: Sixteen patients (61.3±8.0 years, 12.5% female) were treated successfully for type B dissection (five acute and eleven chronic) with TEVAR and scans pre- and post-TEVAR were retrospectively obtained (follow-up interval 52±91 days). From pre- to post-TEVAR, true lumen helical angle (-70.0±71.1 to -64.9±75.4 deg, p=0.782), average helical twist (-4.1±4.0 to -3.7±3.8 deg/cm, p=0.674) and peak helical twist (-13.2±15.2 to -15.4±14.2 deg/cm, p=0.629) did not change. However, true lumen helical radius (1.4±0.5 to 1.0±0.6 cm, p<0.05) and eccentricity (0.9±0.1 to 0.7±0.1, p<0.05) decreased, and cross-sectional area (3.0±1.1 to 5.0±2.0 cm2, p<0.05) and circumference (7.1±1.0 to 8.0±1.4 cm, p<0.05) increased significantly from pre- to post-TEVAR. The distinct bimodal distribution of chiral and achiral native dissections disappeared post-TEVAR, and subgroup analyses showed that the true lumen circumference of acute dissections increased with TEVAR, while it did not for chronic dissections.CONCLUSIONS: The unchanged helical angle and average and peak helical twists as a result of TEVAR suggest that angular positions of the true lumen are constrained and that the endografts were helically conformable in the angular direction. The decrease of helical radius indicated a straightening of the "corkscrew" shape of the true lumen, and in combination with more circular and expanded lumen cross-sections, TEVAR produced luminal morphology that theoretically allows for lower flow resistance through the endografted portion. The impact of TEVAR on dissection flow lumen morphology and the interaction between endografts and aortic tissue can provide insight for improving device design, implantation technique, and long-term clinical outcomes.

  View details for DOI 10.1016/j.jvs.2021.04.029

  View details for PubMedID 33940073

• Unique Complications and Failure Modes of Iliac Branch Devices. Annals of vascular surgery Stern, J. R., Tran, K., Li, M., Lee, J. T. 2021

  Abstract

  OBJECTIVES: Iliac branch devices (IBDs) are modular, bifurcated endografts designed to preserve hypogastric flow during endovascular aortoiliac aneurysm repair. We report our single center outcomes, and describe the unique complications of these devices: inability to cannulate the hypogastric artery (technical failure), occlusion of the internal branch, and type III endoleak from separation of components between the main body and IBD.METHODS: A prospectively maintained institutional database of patients undergoing IBD implantation between 2014 and 2019 was reviewed. Technical and clinical outcomes were evaluated. We then identified patients having one of the IBD-specific complications and patient, anatomic, and procedural data were analyzed to identify factors associated with these failures.RESULTS: 64 IBDs were placed in 59 patients during the study period. Mean age was 71.2±8.6, and 92% were male. 74.6% of patients had a current or prior abdominal aortic aneurysm, and 9.4% had a hypogastric aneurysm. Technical success was achieved in 60/64 cases (93.8%); prior EVAR was associated with technical failure (p=0.04). There were 5 instances of component separation between the main body and the IBD: 3 occurred intraoperatively and were repaired with additional bridging components, and 2 occurred on late follow-up and required reintervention. Increased tortuosity index of both aortoiliac (1.7±0.4 vs. 1.3±02, p=0.04) and iliac-specific (3.9±2.4 vs. 1.9±0.9, p=0.03) segments were significantly associated with component separation, as was the use of larger internal iliac components (13.9±2.4 vs. 11.1±2.3 mm, p=0.04). Internal branch occlusions occurred in 4 patients (6.7%). Two were successfully reopened with endovascular procedures, with two being asymptomatic. No specific factors were found to be predictive of branch occlusion.CONCLUSIONS: IBD-specific complications occur rarely. History of prior EVAR is associated with technical failure, while increased aortic and iliac tortuosity are predictive of component separation and type III endoleak. Severe tortuosity should be carefully considered when planning for IBD.

  View details for DOI 10.1016/j.avsg.2021.03.008

  View details for PubMedID 33836229

• Bicycle Exercise Ankle-Brachial Index Recovery Time as a Novel Metric for Evaluating the Hemodynamic Significance of External Iliac Endofibrosis in Competitive Cyclists Tran, K., Dossabhoy, S., Sorondo, S., Lee, J. T. MOSBY-ELSEVIER. 2021: E50

  View details for Web of Science ID 000630898900027

• Interview Experience, Postinterview Communication, and Gender-Based Differences in the Integrated Vascular Surgery Residency Match Fereydooni, A., Ramirez, J. L., Morrow, K. L., Sorondo, S., Lee, J. T., Coleman, D. M., Chandra, V. MOSBY-ELSEVIER. 2021: E46

  View details for Web of Science ID 000630898900020

• Patient-specific computational flow modelling for assessing hemodynamic changes following fenestrated endovascular aneurysm repair. JVS-vascular science Tran, K., Yang, W., Marsden, A., Lee, J. T., Stanford, C. 2021; 2: 53-69

  Abstract

  Objective: This study aimed to develop an accessible patient-specific computational flow modelling pipeline for evaluating the hemodynamic performance of fenestrated endovascular aneurysm repair (fEVAR), with the hypothesis that computational flow modelling can detect aortic branch hemodynamic changes associated with fEVAR graft implantation.Methods: Patients who underwent fEVAR for juxtarenal aortic aneurysms with the Cook ZFEN were retrospectively selected. Using open-source SimVascular software, preoperative and postoperative visceral aortic anatomy was manually segmented from computed tomography angiograms. Three-dimensional geometric models were then discretized into tetrahedral finite element meshes. Patient-specific pulsatile in-flow conditions were derived from known supraceliac aortic flow waveforms and adjusted for patient body surface area, average resting heart rate, and blood pressure. Outlet boundary conditions consisted of three-element Windkessel models approximated from physiologic flow splits. Rigid wall flow simulations were then performed on preoperative and postoperative models with the same inflow and outflow conditions. We used SimVascular's incompressible Navier-Stokes solver to perform blood flow simulations on a cluster using 72 cores.Results: Preoperative and postoperative flow simulations were performed for 10 patients undergoing fEVAR with a total of 30 target vessels (20 renal stents, 10 mesenteric scallops). Postoperative models required a higher mean number of mesh elements to reach mesh convergence (3.2 ± 1.8 * 106 vs 2.6 ± 1.1 * 106; P = .005) with a longer mean computational time (10.3 ± 6.3 hours vs 7.8 ± 3.5 hours; P = .04) compared with preoperative models. fEVAR was associated with small but statistically significant increases in mean peak proximal aortic arterial pressure (140.3 ± 11.0 mm Hg vs 136.9 ± 8.7 mm Hg; P = .02) and peak renal artery pressure (131.6 ± 14.8 mm Hg vs 128.9 ± 11.8 mm Hg; P = .04) compared with preoperative simulations. No differences were observed in peak pressure in the celiac, superior mesenteric, or distal aortic arteries (P = .17-.96). When measuring blood flow, the only observed difference was an increase in peak renal flow rate after fEVAR (17.5 ± 3.8 mL/s vs 16.9 ± 3.5 mL/s;P =.04). fEVAR was not associated with changes in the mean pressure or the mean flow rate in the celiac, superior mesenteric, or renal arteries (P = .06-.98). Stenting of the renal arteries did not induce significant changes time-averaged wall shear stress in the proximal renal artery (23.4 ± 8.1 dynes/cm2 vs 23.2 ± 8.4 dynes/cm2; P = .98) or distal renal artery (32.7 ± 13.9 dynes/cm2 vs 29.6 ± 11.8 dynes/cm2; P = .23). In addition, computational visualization of crosssectional velocity profiles revealed low flow disturbances associated with protrusion of renal graft fabric into the aortic lumen.Conclusions: In a pilot study involving a selective cohort of patients who underwent uncomplicated fEVAR, patient-specific flow modelling was a feasible method for assessing the hemodynamic performance of various two-vessel fenestrated device configurations and revealed subtle differences in computationally derived peak branch pressure and blood flow rates. Structural changes in aortic flow geometry after fEVAR do not seem to affect computationally estimated renovisceral branch perfusion or wall shear stress adversely. Additional studies with invasive angiography or phase contrast magnetic resonance imaging are required to clinically validate these findings.

  View details for DOI 10.1016/j.jvssci.2020.11.032

  View details for PubMedID 34258601

• Addressing Contemporary Management of Vascular Trauma: Optimization of Patient Care Through Collaboration. Annals of surgery Smith, B. K., Sheahan, M. G., Sgroi, M. n., Weis, T. n., Singh, N. n., Rigberg, D. n., Coleman, D. M., Lee, J. T., Shames, M. L., Mitchell, E. L. 2021

  Abstract

  The optimization of surgical care for traumatic vascular injuries has come under scrutiny. Important questions regarding the impact of endovascular techniques, as well as residency and fellowship training paradigms on the preparedness of acute care, trauma and vascular surgeons have been raised. Inter-specialty collaboration is critical to address these issues.

  View details for DOI 10.1097/SLA.0000000000004861

  View details for PubMedID 34009781

• Factors Influencing Medical Student Choices in the Integrated Vascular Surgery Match: Implications for Future Post-pandemic Residency Matches. Journal of vascular surgery Fereydooni, A., Ramirez, J. L., Morrow, K. L., Chandra, V., Coleman, D. M., Lee, J. T. 2021

  Abstract

  Integrated Vascular Surgery Residency (IVSR) is among the most competitive specialties, but little is known about the applicant perspective. The COVID-19 outbreak impacted the 2021 IVSR match due to travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process.An anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing VS, logistic of away rotations and interviews, and factors influencing students' rank lists.Seventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (25-41), 32.9% were female, 91.4% were US medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median 2; range 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range 1-70) and interviewed at 17 (range 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included: program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance.Successfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to COVID-19 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.

  View details for DOI 10.1016/j.jvs.2021.05.014

  View details for PubMedID 34023431

• Cancer-Associated Venous Thromboembolic Disease, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network : JNCCN Streiff, M. B., Holmstrom, B., Angelini, D., Ashrani, A., Elshoury, A., Fanikos, J., Fertrin, K. Y., Fogerty, A. E., Gao, S., Goldhaber, S. Z., Gundabolu, K., Ibrahim, I., Kraut, E., Leavitt, A. D., Lee, A., Lee, J. T., Lim, M., Mann, J., Martin, K., McMahon, B., Moriarty, J., Morton, C., Ortel, T. L., Paschal, R., Schaefer, J., Shattil, S., Siddiqi, T., Sudheendra, D., Williams, E., Hollinger, L., Nguyen, M. Q. 2021; 19 (10): 1181-1201

  Abstract

  NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Associated Venous Thromboembolic Disease focus on the prevention, diagnosis, and treatment of patients with cancer who have developed or who are at risk for developing venous thromboembolism (VTE). VTE is a significant concern among cancer patients, who are at heightened risks for developing as well as dying from the disease. The management of patients with cancer with VTE often requires multidisciplinary efforts at treating institutions. The NCCN panel comprises specialists from various fields: cardiology, hematology/hematologic oncology, internal medicine, interventional radiology, medical oncology, pharmacology/pharmacy, and surgery/surgical oncology. This article focuses on VTE prophylaxis for medical and surgical oncology inpatients and outpatients, and discusses risk factors for VTE development, risk assessment tools, as well as management methods, including pharmacological and mechanical prophylactics. Contraindications to therapeutic interventions and special dosing, when required, are also discussed.

  View details for DOI 10.6004/jnccn.2021.0047

  View details for PubMedID 34666313

• Interview Experience, Post-interview Communication and Gender-based Differences in the Integrated Vascular Surgery Residency Match. Journal of vascular surgery Fereydooni, A., Ramirez, J. L., Morrow, K. L., Sorondo, S., Lee, J. T., Coleman, D. M., Chandra, V. 2021

  Abstract

  Integrated vascular surgery residency (IVSR) applicant perspective about the Match process has been rarely studied, yet has important implications on trainee recruitment. We sought to better understand the nature of the interview process, and post-interview communication and its impact on students' ranking choices.A voluntary and anonymous survey was sent to students who matched to IVSR in 2020, inquiring about interviews, post-interview communications and factors influencing students' rank-lists.70 of the 73 matched students completed the survey (96% response rate; 23 female and 47 male). Applicants reported they were asked questions about other programs of interest (81.4%), top choice programs (65.7%), marital-status (32.9%), family-planning (7.1%) and religion (1.4%) during interviews. Female applicants were more frequently asked questions about family-planning (17.4% vs 2.1%; P<.01) and marital-status (52.5% vs 23.4%; P <.01) compared to male applicants. After interviews, 92.9% of applicants notified their top choice program of their ranking preference. 61.4% of applicants received post-interview communication with regards to ranking from at least one program, initiated by program directors in 81.3% of instances. Among these applicants, 58.1% reported that the post-interview communication had an impact on their rank-list and 46.5% matched at a program by which they were contacted. 5.7% of applicants were asked by a program to reveal their ranking of the program and 11.4% were promised by a program to be ranked first if the applicant reciprocally ranked them first. Female and male applicants weighed program culture, operative volume, mentorship and prestige equally in making their rank-list. Male applicants weighed the sub-internship experience more significantly; however, female applicants weighed the sub-internship experience, personal relationships in certain cities, dedicated professional development years and large female representation in the program more heavily (P<.02).This study provides insight into the interview experience and impactful factors for the vascular surgery match. Both female and male applicants were asked a high number of questions about personal matters unrelated to medical school performance. Female applicants, however, experienced a higher proportion of these instances, particularly regarding family-planning. These findings demonstrate the factors that are important to applicants in the match process and raises awareness of potential challenges in the interview and recruitment process.

  View details for DOI 10.1016/j.jvs.2021.05.060

  View details for PubMedID 34197947

• Multiaxial pulsatile dynamics of the thoracic aorta and impact of thoracic endovascular repair. European journal of radiology open Suh, G., Bondesson, J., Zhu, Y. D., Lee, J. T., Dake, M. D., Cheng, C. P. 2021; 8: 100333

  Abstract

  Purpose: The thoracic aorta is a highly mobile organ whose dynamics are altered by thoracic endovascular aorta repair (TEVAR). The aim of this study was to quantify cardiac pulsatility-induced multi-axial deformation of the thoracic aorta before and after descending aortic TEVAR.Methods: Eleven TEVAR patients (8 males and 3 females, age 57-89) underwent retrospective cardiac-gated CT angiography before and after TEVAR. 3D geometric models of the thoracic aorta were constructed, and lumen centerlines, inner and outer surface curves, and cross-sections were extracted to measure aortic arclength, centerline, inner surface, and outer surface longitudinal curvatures, as well as cross-sectional effective diameter and eccentricity for the ascending and stented aortic portions.Results: From pre- to post-TEVAR, arclength deformation was increased at the ascending aorta from 5.9 ± 3.1 % to 8.8 ± 4.4 % (P < 0.05), and decreased at the stented aorta from 7.5 ± 5.1 % to 2.7 ± 2.5 % (P < 0.05). Longitudinal curvature and diametric deformations were reduced at the stented aorta. Centerline curvature, inner surface curvature, and cross-sectional eccentricity deformations were increased at the distal ascending aorta.Conclusions: Deformations were reduced in the stented thoracic aorta after TEVAR, but increased in the ascending aorta near the aortic arch, possibly as a compensatory mechanism to maintain overall thoracic compliance in the presence of reduced deformation in the stiffened stented aorta.

  View details for DOI 10.1016/j.ejro.2021.100333

  View details for PubMedID 33748348

• Correction to: Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome. Digestive diseases and sciences Magee, G. A., Slater, B. J., Lee, J. T., Poultsides, G. A. 2021

  View details for DOI 10.1007/s10620-021-06880-z

  View details for PubMedID 33537922

• Risk of renal failure and death when renal arteries are involved in endovascular aortic aneurysm repair. Journal of vascular surgery Plotkin, A. n., Weaver, F. A., Abou-Zamzam, A. n., Malas, M. B., Lee, J. T., Han, S. M., Ding, L. n., Magee, G. A. 2021

  Abstract

  Endovascular abdominal aortic repair may involve incorporation of renal arteries. Revascularization after intentional or unintentional renal artery coverage is not always technically successful and loss of a single renal artery may result in the need for postoperative dialysis. To compare outcomes after endovascular aneurysm repair (EVAR) stratified by renal artery involvement (RAI).Patients in the Vascular Quality Initiative (VQI) registry were analyzed (2009-2018). Exclusion criteria were preoperative dialysis, missing RAI variable, and repair above the superior mesenteric artery. Repair type cohorts were defined as: 1) no RAI (NRAI), 2) RAI with revascularization (RAI-R), 3) RAI and no revascularization (RAI-NR). A sensitivity analysis was performed by excluding ruptured presentation. The primary outcome was postoperative dialysis. Secondary outcomes were 30-day mortality, dialysis at follow-up, postoperative renal function, and 2-year survival. Multivariate analysis was used to determine independent predictors of postoperative dialysis. Two-year survival analysis was performed using Kaplan-Meier log-rank test.Of 54,020 patients in the EVAR and TEVAR/complex EVAR modules in the VQI, 25,724 met criteria for inclusion (24,879 NRAI, 733 RAI-R, 112 RAI-NR). Demographics and comorbidities were similar between groups. RAI-NR were more frequently ruptured or symptomatic. Postoperative dialysis was higher in RAI-NR (0.7% NRAI vs. 2.2% RAI-R vs. 17% RAI-NR, p<.0001) as were 30-day mortality and dialysis at follow-up. On multivariate analysis, RAI-R (OR 2.2, p=.03) and RAI-NR (OR 5.9, p<.0001) were independent predictors of postoperative dialysis and remained so after excluding ruptures: RAI-R (OR 3, p=.003) and RAI-NR (OR 22.3, p<.0001). Other independent predictors of postoperative dialysis were worse preoperative renal function symptomatic presentation, any preoperative/intraoperative blood transfusion, and larger blood loss (≥200 mL). Excluding ruptures, overall survival at 2-years on Kaplan-Meier was lower in RAI-NR (92% NRAI vs. 89% RAI-R vs. 80% RAI-NR, p=.004).RAI is highly predictive of the need for postoperative and permanent dialysis following EVAR. RAI without revascularization is associated with lower overall survival. These risks should be taken into consideration with planning and performing EVAR and should be weighed against the risks of open repair when considering treatment options.

  View details for DOI 10.1016/j.jvs.2021.02.033

  View details for PubMedID 33684468

• Late Venous Thoracic Outlet Syndrome After Anatomic Fixation of a Diaphyseal Clavicle Fracture: A Case Report. JBJS case connector Fogel, N., Lee, J. T., Bishop, J. A. 2021; 11 (1)

  Abstract

  CASE: We report the case of a 29-year-old man with a displaced mid-diaphyseal clavicle fracture that healed in anatomic position without fracture callus after surgical treatment but developed symptoms of late venous thoracic outlet syndrome (TOS) 19 months postoperatively. He was diagnosed with proximal subclavian vein thrombosis and was treated with urgent thrombolysis and staged first rib resection with resolution of symptoms.CONCLUSIONS: Late venous TOS is a potential complication of clavicle fracture, even in the setting of anatomic reduction and primary bone healing. This entity has previously only been described in the setting of nonunion and malunion.

  View details for DOI 10.2106/JBJS.CC.20.00243

  View details for PubMedID 33690240

• Bicycle exercise ankle brachial index recovery time as a novel metric for evaluating the hemodynamic significance of external iliac endofibrosis in competitive cyclists. Journal of vascular surgery cases and innovative techniques Tran, K., Dossabhoy, S. S., Sorondo, S., Lee, J. T. 2021; 7 (4): 681-685

  Abstract

  Subtle radiographic findings can increase the challenge of diagnosing external iliac artery endofibrosis. We evaluated a new metric, the bicycle exercise ankle brachial index recovery time (BART), in a cohort of cyclists with symptomatic external iliac artery endofibrosis. BART was defined as the time required in minutes for the ankle brachial index to return to 0.9 after a period of exercise. Surgical correction resulted in an improvement in BART postoperatively (4.5 ± 4.1 vs 9.1 ± 4.3 minutes; P < .001), with improved values correlating with better patient satisfaction. Documentation of the BARTs before and after surgical treatment provides an additional measure of postoperative hemodynamic improvement.

  View details for DOI 10.1016/j.jvscit.2021.08.013

  View details for PubMedID 34746530

  View details for PubMedCentralID PMC8556481

• Female sex is independently associated with in-hospital mortality after endovascular aortic repair for ruptured aortic aneurysm. Annals of vascular surgery Ho, V. T., Rothenberg, K. A., George, E. L., Lee, J. T., Stern, J. R. 2021

  Abstract

  Endovascular aortic repair (EVAR) can treat anatomically compatible ruptured abdominal aortic aneurysms (rAAA), but registry data suggests that women undergo more open abdominal aneurysm repairs than men. We evaluate in-hospital outcomes of EVAR for rAAA by sex.The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 for rAAA patients treated with EVAR. Univariate analysis was performed with Student's t-test and chi-squared tests. Multivariable logistic regression was then performed to assess the association between female sex and inpatient mortality.1775 patients were included (23.8% female). Female rAAA patients were older (p < 0.01) and weighed less (p < 0.01). They were less likely to have smoked (p <. 001) and had lower creatinine (1.29 vs 1.43, p <0.01) and hemoglobin (10.7 vs 11.7, p < 0.01). Women had smaller maximum aortic diameters (74 vs 66 mm, p < 0.01) and were less likely to have iliac aneurysms (p <.001). Women were more likely to have concomitant femoral endarterectomy (8.5% vs 4.6%, p=.03). Despite having no significant difference in complication or reintervention rates, women had higher rates of in-hospital mortality (45.9% vs 34.5%, p < 0.01). In a logistic regression model for predictors of in-hospital mortality (χ2 < .01), increased age (OR 1.08, p < 0.01), female sex (OR 1.7, p=0.02), preoperative cardiac arrest (OR 5.29, p<0.01), concurrent iliac stenting (OR 2.38, p =0.02), postoperative mesenteric ischemia (OR 2.51, p<0.01) and postoperative transfusion (OR 1.06, p <0.01) were independently associated with in-hospital mortality. Increased preoperative hemoglobin was protective (OR 0.89, p < 0.01) CONCLUSIONS: Female sex is independently associated with in-hospital mortality after EVAR for rAAA, suggesting a relationship beyond anatomical, biochemical, and procedural covariates.

  View details for DOI 10.1016/j.avsg.2021.08.043

  View details for PubMedID 34752855

• Predictors of Sac Regression after Fenestrated Endovascular Aneurysm Repair. Journal of vascular surgery Li, M., Stern, J. R., Tran, K., Deslarzes-Dubuis, C., Lee, J. T. 2021

  Abstract

  Aneurysm sac regression after standard endovascular aortic repair is associated with improved outcomes, but similar data are limited after fenestrated endovascular aortic repair (FEVAR). We sought to evaluate sac regression after FEVAR, and identify any predictors of this favorable outcome.Patients undergoing elective FEVAR using the commercially available Zenith Fenestrated device (ZFEN; Cook Medical, Bloomington, IN) from 2012 to 2018 at a single institution were retrospectively reviewed. Maximal aortic diameter was compared between the preoperative scan and those obtained in follow-up. Patients with ≥5 mm sac regression were included in the REG group, with all others in the NON-REG group. Outcomes were compared between groups using univariate analysis, and logistic regression analysis was performed to identify any predictive factors for sac regression.132 FEVAR patients were included in the analysis. At a mean follow-up of 33.1 months, 65 patients (49.2%) had sac regression ≥5 mm and comprised the REG group (N=65, 49.2%). The REG group had smaller diameter devices, and were less likely to have had concomitant chimney grafts placed (P <0.05). The NON-REG group had a higher incidence of type II endoleak (35.8% vs. 12.3%; P=0.002). Sac regression was associated with a significant mortality benefit on Kaplan-Meier analysis (log rank; P=0.02). Multivariate analysis identified adjunctive parallel grafting (OR 0.01, 95% CI 0.03-0.36; P <0.01), persistent type II endoleak (OR 0.13, 95% CI 0.02-0.74; P <0.01), and increased number of target vessels (OR 0.25, 95% CI 0.10-0.62, P=0.002) as independent predictors of failure to regress.Sac regression after FEVAR occurred in nearly half of patients, but appears to be less common in patients with persistent type II endoleaks and those undergoing concomitant parallel grafting. Sac regression was associated with a significant survival advantage, and can be used as a clinical marker for success after FEVAR.

  View details for DOI 10.1016/j.jvs.2021.08.067

  View details for PubMedID 34506890

• Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury. Journal of vascular surgery Ho, V. T., George, E. L., Rothenberg, K. A., Lee, J. T., Garcia-Toca, M., Stern, J. R. 2020

  Abstract

  OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is an effective treatment for blunt thoracic aortic injury (BTAI), but the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications.METHODS: The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 to identify patients who underwent TEVAR for BTAI with or without administration of intraoperative heparin. Univariate analyses were performed with Student's t-test, Fisher exact, and chi-squared tests where appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality.RESULTS: 655 patients were included, of whom the majority presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) ≥ 15 (70.2% vs. 90.5%, p<0.0001), or major head or neck injury (39.6% vs. 62.9%, p<0.0001). Patients receiving heparin had lower incidence of inpatient death (5.1% vs. 12.9%, p<0.01). Across all injury grades, heparin use was not associated with intraoperative transfusion, postoperative transfusion, or hematoma. In patients with grade III BTAI, non-use of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%, P < 0.05). On multivariable logistic regression for inpatient mortality, intraoperative heparin use (OR = 0.31, 95% Confidence Interval [CI] 0.11 - 0.86, P < 0.05) and female gender (OR = 0.11, 95% CI 0.11 - 0.86, P < 0.05) were associated with better survival, even when controlling for head and neck trauma and injury grade. In contrast, increased age (OR = 1.06, 95% CI 1.03 - 1.1, P <0.001), postoperative transfusion (OR = 1.06, 95% CI 1.02 - 1.11, P < 0.01), Higher ISS (OR = 1.04, 95% CI 1.01 - 1.07, P < 0.05), postoperative dysrhythmia (OR = 4.48, 95% CI 1.10 - 18.18, P < 0.05), and postoperative stroke or transient ischemic attack (OR = 5.54, 95% CI 1.11 - 27.67, P < 0.05) were associated with increased odds of inpatient mortality.CONCLUSIONS: Intraoperative heparin use is associated with reduced inpatient mortality in patients undergoing during TEVAR for BTAI, including those with major head or neck trauma and high injury severity scores. Heparin did not increase risk of hemorrhagic complications across all injury grades, and in patients with grade III BTAI heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI, and should be administered when no specific contraindication exists.

  View details for DOI 10.1016/j.jvs.2020.12.068

  View details for PubMedID 33348003

• Renal stent complications and impact on renal function following standard fenestrated endovascular aneurysm repair. Annals of vascular surgery Deslarzes-Dubuis, C., Tran, K., Colvard, B. D., Lee, J. T. 2020

  Abstract

  OBJECTIVES: To report renal outcomes including long-term patency, secondary interventions, and related renal function following fenestrated endovascular aortic repair (fEVAR).MATERIALS AND METHODS: Single center retrospective review of patients undergoing fEVAR between 2012-2018 using the Cook-ZFEN device. Renal stent complications, defined as any stenosis, occlusion, kink, renal stent related endoleak, and reinterventions were tabulated. Estimated glomerular filtration rate (GFR) was estimated using the MDRD formula.RESULTS: During the study period, 114 patients underwent elective fEVAR. Of 329 total target vessels, 193 renal arteries were stented (133 Atrium iCAST, 60 Gore VBX). Technical success was achieved in 97.4% and the mean follow-up was 23.3 months. 17 renal complications occurred in 14 patients (12.3%), including 4 occlusions, 9 stenosis, 3 dislocations and 1 type 3 endoleak. All stent complications underwent endovascular reintervention with a median hospital stay of 1 day (0-10) and a technical success of 94.2%. One patient suffered renal hemorrhage that warranted embolization. Patients with occlusion were treated the day of diagnosis, and mean time from diagnosis to intervention for stenosis was 21.5 days. Estimated primary patency was 92.1 % and 81.5% at 24 and 48 months respectively. On multivariate analysis, larger native renal artery diameter was the only independent protective factor against patency loss (HR 0.23(0.09-0.59)). Secondary patency at latest follow-up was 99.4%. Mean eGFR was not significantly different at latest follow-up between patients with renal complications versus those without (43.75 vs 55.58 mL/min/1.73m2, p=.09). Comparing patients with and without renal stent complications, 81.4% and 72.7% of patients had stable or improved renal disease by CKD staging compared to baseline (P=.51).CONCLUSIONS: fEVAR is a durable option for the treatment of juxtarenal aortic aneurysms and is associated with excellent secondary patency. Renal stent complications have no significant impact on renal function, but smaller native renal arteries are at higher risk of stent graft complications.

  View details for DOI 10.1016/j.avsg.2020.10.020

  View details for PubMedID 33249133

• 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

• Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population Ho, V. T., Itoga, N. K., Tran, K., Lee, J. T., Stern, J. R. ELSEVIER SCIENCE INC. 2020: S347–S348

  View details for Web of Science ID 000582792300648

• Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population. Journal of the American College of Surgeons Ho, V. T., Itoga, N. K., Tran, K., Lee, J. T., Stern, J. R. 2020

  Abstract

  BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is indicated for treatment of aneurysms, dissections, and traumatic injury. We describe mid-term mortality and re-intervention rates in Medicare beneficiaries undergoing TEVAR.STUDY DESIGN: Patients who underwent TEVAR between 2006-2014 were identified by Current Procedural Terminology (CPT) codes in a 20% Medicare sample. Indication for aortic repair (aneurysm, dissection, trauma) was ascertained via International Classification of Diseases (ICD-9) codes. Follow-up was evaluated until 2015. Kaplan Meier survival analysis and Cox regression were used to compare mortality, with re-intervention and mortality rates expressed as a composite outcome in a hazard ratio with 95% confidence interval (HR 95%CI).RESULTS: 3095 patients underwent TEVAR during the study period: 1465 (47%) for aneurysm 1448 (47%) for dissection, and 182 (5.9%) for trauma. Mean patient age was 74.4 years, and 44.5% were female. Median follow-up was 2.7 years. The overall 30-day, 1-year, and 5-year, and 8-year survival was 93%, 78%, 49%, and 33%, respectively. 30-day mortality was highest in traumatic indications, but overall mortality was highest in patients undergoing TEVAR for aneurysm. Freedom from combined re-intervention and mortality at 30-days, 1-year, 5-years and 8-years was 89%, 73%, 43%, and 29% respectively. Reintervention was highest in patients undergoing TEVAR for dissection (12.8%), followed by aneurysm (10.0%) and trauma (5.5%). Advanced age (HR 1.03 per year, 95%CI 1.02-1.03), congestive heart failure (CHF) (HR 1.48, 95%CI 1.33-1.65), dementia (HR 1.40, 95%CI 1.14-1.28), and rupture (HR 1.38, 95%CI 1.24-1.54) were associated with mortality.CONCLUSION: Midterm survival is lower in patients who undergo TEVAR for dissection and aneurysm compared to trauma. Aneurysmal disease, advanced age, CHF, dementia and aortic rupture are associated with mortality and re-intervention in TEVAR.

  View details for DOI 10.1016/j.jamcollsurg.2020.09.011

  View details for PubMedID 33022404

• Analysis of Medicare Payments for Preoperative Imaging Before Carotid Endarterectomy Itoga, N. K., Martinez-Singh, K., Harris, J., Lee, J. T., Baker, L., Garcia-Toca, M. MOSBY-ELSEVIER. 2020: E17–E18

  View details for Web of Science ID 000544100700022

• The Fundamentals of Vascular Surgery: When Do Vascular Trainees Achieve Basic Open Surgical Competency? Sheahan, M., Lalani, A. M., Lee, J. T., Shames, M., Rigberg, D., Cass, B., Sheahan, C., Bismuth, J. MOSBY-ELSEVIER. 2020: E24–E25

  View details for Web of Science ID 000544100700032

• Factors Affecting 8-Year Mortality in the Endovascular Era of Abdominal Aortic Aneurysm Repair Itoga, N. K., Dossabhoy, S., Tran, K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2020: E96

  View details for Web of Science ID 000544100700151

• Vascular Surgery Program Director Work Hours and Compensation Do Not Align With Accreditation Council for Graduate Medical Education-Proposed Requirements Shames, M., Owens, K., Robinson, W. P., Reed, A. B., Lee, J. T., Jordan, W., Sheahan, M. MOSBY-ELSEVIER. 2020: E24

  View details for Web of Science ID 000544100700031

• The Effect of Interfacility Transfer in Patients With Blunt Thoracic Aortic Injury Rothenberg, K. A., George, E. L., Ho, V., Barreto, N. B., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E167

  View details for Web of Science ID 000544100700255

• Intraoperative Heparin Use Is Associated With Reduced Inpatient Mortality After Thoracic Endovascular Aortic Repair for Blunt Aortic Injury Ho, V., Rothenberg, K. A., George, E. L., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E99

  View details for Web of Science ID 000544100700156

• Patient-Specific Computational Flow Modelling for Assessing Hemodynamic Changes Following Fenestrated Endovascular Aneurysm Repair Tran, K., Yang, W., Marsden, A., Lee, J. T. MOSBY-ELSEVIER. 2020: E182–E183

  View details for Web of Science ID 000544100700286

• Current Status of Endoluminal Treatment of Descending Thoracic Aortic Aneurysms. Cardiovascular and interventional radiology Watkins, A. C., Dalal, A., Lee, J. T., Dake, M. D. 2020

  Abstract

  Thoracic endovascular aortic repair (TEVAR) was proved to be effective in thoracic descending aortic aneurysm (TDAA) repair in 1994 and approved by the FDA in 2005. Since then, TEVAR has become the first-line, recommended treatment for intact or ruptured DTAA or as a bridge to definitive open surgical repair in connective tissue disease. TEVAR has decreased perioperative morbidity and mortality compared to open surgery due to the lack of thoracotomy, aortic cross-clamping and left heart bypass. Improvement in materials, manufacturing and device delivery systems have allowed for the expansion of indications. Thoughtful and accurate pre-procedure planning is the hallmark of successful TEVAR. Familiarization and adherence to the instructions for use for an aortic device will give the best possible chance of success.

  View details for DOI 10.1007/s00270-020-02526-1

  View details for PubMedID 32449019

• Endovascular Treatment of Acute Carotid Stent Occlusion: Aspiration Thrombectomy and Angioplasty. Cureus Murray, N. M., Wolman, D. N., Marks, M., Dodd, R., Do, H. M., Lee, J. T., Heit, J. J. 2020; 12 (5): e7997

  Abstract

  Introduction Acute carotid stent occlusion (CSO) is a rare complication of endovascular carotid stent placement that requires emergent intervention. We describe angioplasty or combined angioplasty and aspiration thrombectomy as a new endovascular technique for CSO treatment. The technique is compared to others previously described in the literature. Methods We performed a retrospective cohort study of all patients who underwent endovascular treatment (ET) of acute symptomatic CSO from January 2008 to March 2018 at our neurovascular referral center. Patient demographics, endovascular treatment details, and outcome data were determined from the electronic medical record. Primary outcome was successful stent recanalization and cerebral reperfusion (modified thrombolysis in cerebral infarction (mTICI) score IIB-III). Secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) shift from presentation to discharge, mortality, and modified Rankin Scale (mRS) score at 3 months. Additionally, a literature review (years 2008-2019) was performed to characterize other techniques for ET of CSO. Results Four patients who underwent ET of acute CSO were identified. ET treatment by angioplasty (n = 1) or combined aspiration thrombectomy and angioplasty (n = 3) resulted in carotid stent recanalization in all patients. Tandem intracranial occlusions were present in three patients (75%), and successful cerebral reperfusion was achieved in all patients. Patient symptoms improved (mean NIHSS shift -5.3 ± 7.2 at discharge). One patient died of a symptomatic reperfusion hemorrhage and another died of cardiac complications by 3-month follow-up. The mRS scores of the surviving patients were 1 and 3. Previously described studies (n = 14) using different and varied techniques had moderate recanalization rates and outcomes. Conclusion Combined aspiration thrombectomy and angioplasty for the neurointerventional treatment of acute CSO leads to high rates of stent recanalization and cerebral reperfusion. The recanalization rate here is improved compared to previously reported techniques. Further multicenter studies are required to risk-stratify patients for specific ET interventions.

  View details for DOI 10.7759/cureus.7997

  View details for PubMedID 32523851

  View details for PubMedCentralID PMC7274505

• Endovascular Treatment of Acute Carotid Stent Occlusion: Aspiration Thrombectomy and Angioplasty CUREUS Murray, N. M., Wolman, D. N., Marks, M., Dodd, R., Do, H. M., Lee, J. T., Heit, J. J. 2020; 12 (5)

  View details for DOI 10.7759/cureus.7997

  View details for Web of Science ID 000530650700015

• Long-term Functional Outcomes Follow-Up After 188 Rib Resections in Patients with TOS. Annals of vascular surgery Dua, A., Rothenberg, K. A., Gologorsky, R., Lee, J. T. 2020

  Abstract

  INTRODUCTION: Short term outcomes in patients with all forms of TOS have been widely reported in the literature and have established that rib resection can be beneficial in decompressing the thoracic outlet and relieving pressure on traversing structures. We sought to determine long term functional outcomes using the QuickDASH survey in patients with TOS who underwent rib resection.METHODS: Clinical records for patients who underwent rib resection for TOS at a single institution were retrospectively reviewed. All patients were contacted via telephone and long-term functional outcome was assessed at latest follow-up via the 11-item version of the Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Demographics, TOS type, pre-operative QuickDASH score, and athletic status were recorded. Patients were asked if they returned to baseline activity since their surgery, would have the procedure again, and if they were subjectively better postoperatively.RESULTS: From 2000-2018, 261 patients underwent rib resection surgery. 170 (65.1%) were able to be contacted via telephone for long-term follow-up. A total of 188 surgeries (102 nTOS, 82 vTOS, 4 aTOS) were performed in these 170 patients. The mean follow-up time for the cohort was 5.3 years (range 1-18). Overall, 167 (88.9%) of patients returned to baseline activity post-operatively. Postop quickdash decreased to 12 from 44 pre-operatively for the cohort.CONCLUSION: First rib resection and thoracic outlet decompression for all forms of TOS is a durable surgical treatment which results in excellent long term functional outcomes as determined by both the QuickDASH score and subjective patient reporting.

  View details for DOI 10.1016/j.avsg.2020.04.033

  View details for PubMedID 32335257

• The Triple-Wire Technique for Delivery of Endovascular Components in Difficult Anatomy. Annals of vascular surgery Stern, J. R., Cheng, C. P., Colvard, B. D., Paranjape, H., Lee, J. T. 2020

  Abstract

  We describe a novel endovascular technique in which three 0.014" guidewires are placed in parallel through a 0.035" lumen catheter, in order to create a stiff platform to allow for delivery of 0.035" profile devices through challenging anatomy. Three illustrative cases are presented: a difficult aortic bifurcation during lower extremity intervention, a tortuous internal iliac artery during placement of an iliac branch device, and salvage of a renal artery after inadvertent coverage during proximal cuff deployment for type 1a endoleak. We also quantify the relative stiffness of the triple 0.014" wire configuration, using several well-known 0.035" wires for comparison. The "triple-wire technique" is an effective method for tracking endovascular devices through difficult tortuous anatomy, and can be used in a variety of clinical settings. The technique is especially useful when a traditional, stiff 0.035" wire will not track without "kicking out." Each 0.014" wire is reasonably soft and traverses the tortuous vessel easily, but when the three wires are used together as a rail it provides a stiff enough platform for delivery.

  View details for DOI 10.1016/j.avsg.2020.04.021

  View details for PubMedID 32335254

• Thoracic aortic geometry correlates with endograft bird-beaking severity. Journal of vascular surgery Frohlich, M. M., Suh, G., Bondesson, J., Leineweber, M., Lee, J. T., Dake, M. D., Cheng, C. P. 2020

  Abstract

  OBJECTIVE: Aortic geometry has been shown to influence the development of endograft malapposition (bird-beaking) in thoracic endovascular aortic repair (TEVAR), but the extent of this relationship lacks clarity. The aim of this study was to develop a reproducible method of measuring bird-beak severity and to investigate preoperative geometry associated with bird-beaking.METHODS: The study retrospectively analyzed 20 patients with thoracic aortic aneurysms or type B dissections treated with TEVAR. Computed tomography scans were used to construct three-dimensional geometric models of the preoperative and postoperative aorta and endograft. Postoperative bird-beaking was quantified with length, height, and angle; categorized into a bird-beak group (BBG; n= 10) and no bird-beak group (NBBG; n= 10) using bird-beak height ≥5mm as a threshold; and correlated to preoperative metrics including aortic cross-sectional area, inner curvature, diameter, and inner curvature*diameter as well as graft diameter and oversizing at the proximal landing zone.RESULTS: Aortic area (1002± 118mm2 vs 834± 248mm2), inner curvature (0.040± 0.014mm-1 vs 0.031± 0.012mm-1), and diameter (35.7± 2.1mm vs 32.2± 4.9mm) were not significantly different between BBG and NBBG; however, inner curvature*diameter was significantly higher in BBG (1.4± 0.5 vs 1.0± 0.3; P= .030). Inner curvature and curvature*diameter were significantly correlated with bird-beak height (R= 0.462, P= .041; R= 0.592, P= .006) and bird-beak angle (R= 0.680, P< .001; R= 0.712, P< .001).CONCLUSIONS: TEVAR bird-beak severity can be quantified and predicted with geometric modeling techniques, and the combination of high preoperative aortic inner curvature and diameter increases the risk for development of TEVAR bird-beaking.

  View details for DOI 10.1016/j.jvs.2019.11.045

  View details for PubMedID 32035770

• Even More Real World Data Regarding ChEVAR Continuing to Show Consistent Results. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery Tran, K., Lee, J. T. 2020

  View details for DOI 10.1016/j.ejvs.2020.01.003

  View details for PubMedID 32008932

• Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia. Annals of vascular surgery George, E. L., Colvard, B., Ho, V., Rothenberg, K. A., Lee, J. T., Stern, J. R. 2020

  Abstract

  OBJECTIVES: Ultrasound-enhanced catheter-directed thrombolysis (UET) using the EKOS device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process in order to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting.METHODS: We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALE; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications.RESULTS: 32 patients (mean age 67.4 ± 14.9 years; 25% female) underwent UET for acute limb ischemia between 2014-2018. Rutherford Acute Limb Ischemia Classification was R1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 ± 11.3 hours, and mean tissue plasminogen activator dose was 24.5 ± 15.3 mg. Major adverse limb events occurred in 16.7% of patients within the first 30-days and 38.9% experienced a MALE by 1-year. Limb salvage at 30-days and 1-year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30 days and 37.5% of patients within 1 year. Overall mortality was 6.2% at 30-days and 13.5% at 1-year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in pre- to post-op ABI (0.31+0.29 vs. 0.78+0.34, p<0.001) and number of patent tibial runoff vessels (1.31+1.20 vs. 1.96+0.86, p <0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%).CONCLUSIONS: UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared to traditional methods.

  View details for DOI 10.1016/j.avsg.2019.12.026

  View details for PubMedID 31917220

• Long-term chimney/snorkel EVAR experience for complex abdominal aortic pathologies within the PERICLES Registry. Journal of vascular surgery Taneva, G. T., Lee, J. T., Tran, K. n., Dalman, R. n., Torsello, G. n., Fazzini, S. n., Veith, F. J., Donas, K. P. 2020

  Abstract

  Early and short-term efficacy of the snorkel/chimney technique (ch-EVAR) have been previously reported. However, long-term ch-EVAR performance, vessel patency, and patient survival remain unknown. Our study aimed to evaluate the late outcomes and to identify possible predictors for failure within the PERICLES registry.Clinical and radiographic data from patients receiving ch-EVAR between 2008-2014 in the PERICLES registry were updated with extension of the follow-up. Regression models were used to evaluate relevant anatomic and operative characteristics as factors influencing late results focusing on patients with at least 30 months of follow-up (mean 46.6 months; range 30-120 months).517 patients from the initial PERICLES registry were included in this analysis, from which mean follow-up was updated from previously 17.1 to 28.2 months (range, 1-120 months). All-cause mortality at latest follow-up was 25.5% (n=132), with an estimated patient survival of 87.6%, 74.4% and 66.1% at one, three and five years, respectively. A sub-group of 244 patients with 387 chimney grafts placed (335 renal, 42 SMAs, 10 celiac arteries) and follow-up of at least 30 months was used to analyze specific anatomic and device predictors of adverse events. In the sub-group, the technical success was 88.9%, while primary patency was 94%, 92.8%, 92%, and 90.5% at 2.5 years, 3 years, 4 years and 5 years respectively. Mean aneurysm sack regression was 7.8±11.4 mm,p<.0001. Chimney graft occlusion occurred in 24 target vessels(6.2%). Late open conversion was required in 5 patients for endograft infection(n=2), persistent T1a endoleak (n=2) and endotension (n=1), The absence of infrarenal neck (OR 2.86 [1.32-6.19], p=.007) was significantly associated with long-term device-related complications. Sealing zone diameter > 30mm was significantly associated with persistent/late type Ia endoleak (T1a EL)(OR 4.86 [1.42-16.59], p=.012).The present analysis of the PERICLES registry provides the missing long-term experience on the ch-EVAR technique showing favorable results with more than half of the patients surviving for more than 5 years and chimney graft branch vessels patency of 92%. The absence of infrarenal neck and treatment with sealing zone diameter >30mm were the main anatomical long-term limits of the technique demanding adequate preoperative planning and indication.

  View details for DOI 10.1016/j.jvs.2020.10.086

  View details for PubMedID 33259893

• Molecular Imaging of Chimeric Antigen Receptor T Cells by ICOS-ImmunoPET Clinical cancer research: an official journal of the American Association for Cancer Research Alam*, I. S., Simonetta*, F. 2020: 1058–68

  Abstract

  Immunomonitoring of chimeric antigen receptor (CAR) T cells relies primarily on their quantification in the peripheral blood, which inadequately quantifies their biodistribution and activation status in the tissues. Noninvasive molecular imaging of CAR T cells by PET is a promising approach with the ability to provide spatial, temporal, and functional information. Reported strategies rely on the incorporation of reporter transgenes or ex vivo biolabeling, significantly limiting the application of CAR T-cell molecular imaging. In this study, we assessed the ability of antibody-based PET (immunoPET) to noninvasively visualize CAR T cells.After analyzing human CAR T cells in vitro and ex vivo from patient samples to identify candidate targets for immunoPET, we employed a syngeneic, orthotopic murine tumor model of lymphoma to assess the feasibility of in vivo tracking of CAR T cells by immunoPET using the 89Zr-DFO-anti-ICOS tracer, which we have previously reported.Analysis of human CD19-CAR T cells during activation identified the Inducible T-cell COStimulator (ICOS) as a potential target for immunoPET. In a preclinical tumor model, 89Zr-DFO-ICOS mAb PET-CT imaging detected significantly higher signal in specific bone marrow-containing skeletal sites of CAR T-cell-treated mice compared with controls. Importantly, administration of ICOS-targeting antibodies at tracer doses did not interfere with CAR T-cell persistence and function.This study highlights the potential of ICOS-immunoPET imaging for monitoring of CAR T-cell therapy, a strategy readily applicable to both commercially available and investigational CAR T cells.See related commentary by Volpe et al., p. 911.

  View details for DOI 10.1158/1078-0432.CCR-20-2770

  View details for PubMedCentralID PMC7887027

• Association of upper extremity and neck access with stroke in endovascular aortic repair. Journal of vascular surgery Plotkin, A. n., Ding, L. n., Han, S. M., Oderich, G. S., Starnes, B. W., Lee, J. T., Malas, M. B., Weaver, F. A., Magee, G. A. 2020

  Abstract

  Upper extremity and neck access is commonly used for complex endovascular aortic repairs. We sought to compare perioperative stroke and other complications of (1) arm/neck (AN) and femoral or iliac access versus femoral/iliac (FI) access alone, (2) right- versus left-sided AN, and (3) specific arm versus neck access sites.Patients entered in the thoracic endovascular aortic repair/complex endovascular aortic repair registry in the Vascular Quality Initiative from 2009 to 2018 were analyzed. Patients with a missing access variable and aortic arch proximal landing zone were excluded. The primary outcome was perioperative in-hospital stroke. Secondary outcomes were other postoperative complications and 1-year survival. Kaplan-Meier curves and log-rank test were used for survival analysis.Of 11,621 patients with 11,774 recorded operations, 6691 operations in 6602 patients met criteria for analysis (1418 AN, 5273 FI). AN patients had a higher rate of smoking history (83.6% vs 76.1%; P < .0001), and prior stroke (12.6% vs 10.1%; P = .01). Operative time (280 ± 124 minutes vs 157 ± 102 minutes; P < .0001), contrast load (141 ± 82 mL vs 103 ± 67 mL; P < .0001), and estimated blood loss (300 mL vs 100 mL; P < .0001) were larger in the AN group, indicative of greater complexity cases. Overall, AN had a higher rate of stroke (3.1% vs 1.8%; P = .003) compared with FI and on multivariable analysis AN access was found to be an independent risk factor for stroke (odds ratio, 1.97; P = .0003). There was no difference in stroke when comparing right- and left-sided AN access (2.8% vs 3.2%; P = .71). Stroke rates were similar between arm, axillary, and multiple access sites, but were significantly higher in patients with carotid access (2.6% vs 3.5% vs 13% vs 3.7%; P = .04). AN also had higher rates of puncture site hematoma, access site occlusion, arm ischemia, and in-hospital mortality (7.1% vs 4.2%; P < .0001). At 1 year, AN had a lower survival rate (85.1% vs 88.1%; P = .03).Upper extremity and neck access for complex aortic repairs has a higher risk of stroke compared with femoral and iliac access alone. Right-sided access does not have a higher stroke rate than left-sided access. Carotid access has a higher stroke rate than axillary, arm, and multiple arm/neck access sites.

  View details for DOI 10.1016/j.jvs.2020.02.017

  View details for PubMedID 32273227

• In-situ Bypass and Extra-anatomic Bypass Procedures Result in Similar Survival in Patients with Secondary Aorto-Enteric Fistulae. Journal of vascular surgery Janko, M. R., Woo, K. n., Hacker, R. I., Baril, D. n., Bath, J. n., Smeds, M. R., Kashyap, V. S., Szeberin, Z. n., Magee, G. n., Elsayed, R. n., Wishy, A. n., St John, R. n., Beck, A. n., Farber, M. n., Motta, F. n., Zhou, W. n., Lemmon, G. n., Coleman, D. n., Behrendt, C. A., Aziz, F. n., Black, J. n., Shutze, W. n., Garrett, H. E., de Caridi, G. n., Liapis, C. n., Kakkos, S. n., Obara, H. n., Wang, G. n., Rhéaume, P. n., Davila, V. n., Ravin, R. n., DeMartino, R. n., Milner, R. n., Shalhub, S. n., Jim, J. n., Lee, J. n., Dubuis, C. n., Ricco, J. B., Coselli, J. n., Lemaire, S. n., Fatima, J. n., Sanford, J. n., Yoshida, W. n., Schermerhorn, M. n., Menard, M. n., Belkin, M. n., Blackwood, S. n., Conrad, M. n., Wang, L. n., Crofts, S. n., Nixon, T. n., Wu, T. n., Chiesa, R. n., Bose, S. n., Turner, J. n., Moore, R. n., Smith, J. n., Ciocca, R. n., Hsu, J. n., Czerny, M. n., Cullen, J. n., Kahlberg, A. n., Setacci, C. n., Joh, J. H., Senneville, E. n., Garrido, P. n., Sarac, T. n., Rizzo, A. n., Go, M. n., Bjorck, M. n., Gavali, H. n., Wanhainen, A. n., Lawrence, P. F., Chung, J. n. 2020

  Abstract

  The optimal revascularization modality in secondary abdominal aorto-enteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF.A retrospective, multi-institutional study of SAEF from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed.182 patients at 34 institutions from 11 countries presented with SAEF during the study period (median age 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%) with 2 unknown. 102 of the SAEF (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (NAIS) (17), cryopreserved allograft (28), and untreated prosthetic grafts (4). 80 patients (44%) underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier (KM) estimated survival was 319 days (IQR 20, 2410) days. When stratified by EAB versus ISB, there was no significant difference in KM estimated survival (p=0.82). Comparing EAB versus ISB, EAB patients were older (age 74 vs. 70; p=0.01), had less operative hemorrhage (1200mL vs. 2000mL; p=0.04), were more likely to initiate dialysis within 30 days postoperatively (15% vs. 5%, p=0.02), and were less likely to experience aortic-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs. 11% anastomotic rupture, p=0.03). There were otherwise no significant differences in presentation, comorbidities, intra-operative or postoperative variables. Multivariable Cox regression showed the duration of antibiotic use (HR 0.92, 95% CI 0.86-0.98; p = 0.01) and rifampin use at time of discharge (HR 0.20, 0.05-0.86, p = 0.03) independently decreased mortality.These data suggest ISB does not offer a survival advantage compared to EAB and does not decrease the risk of postoperative aortic-related hemorrhage. Less than 50% of SAEF patients survive ten months after repair. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling are imperative for this population.

  View details for DOI 10.1016/j.jvs.2020.04.515

  View details for PubMedID 32445832

• Special Communication: Evaluation and Treatment of Thoracic Outlet Syndrome During the Global Pandemic Due to SARS-CoV-2 and COVID-19. Journal of vascular surgery Ohman, J. W., Annest, S. J., Azizzadeh, A. n., Burt, B. M., Caputo, F. J., Chan, C. n., Donahue, D. M., Freischlag, J. A., Gelabert, H. A., Humphries, M. D., Illig, K. A., Lee, J. T., Lum, Y. W., Meyer, R. D., Pearl, G. J., Ransom, E. F., Sanders, R. J., Teijink, J. A., Vaccaro, P. S., van Sambeek, M. R., Vemuri, C. n., Thompson, R. W. 2020

  Abstract

  The global SARS-CoV-2/COVID-19 pandemic has required a reduction in non-emergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the 3 defined types of TOS (neurogenic, venous, and arterial) and 3 phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources): (1) In-person evaluation and treatment for neurogenic TOS (interventional or surgical) is generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. (2) Venous TOS presenting with acute upper extremity deep vein thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. (3) Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

  View details for DOI 10.1016/j.jvs.2020.05.048

  View details for PubMedID 32497747

• Current role of the chimney technique in the treatment of complex abdominal aortic pathologies: A position paper from the PERICLES Registry investigators. Vascular Donas, K. P., Criado, F. n., Torsello, G. n., Riambau, V. n., Scali, S. n., Minion, D. n., Lee, J. T., Lachat, M. n., Woo, E. Y., Veith, F. J. 2020; 28 (6): 692–96

  View details for DOI 10.1177/1708538120914455

  View details for PubMedID 32408852

• Quantification of True Lumen Helical Morphology and Chirality in Type B Aortic Dissections. American journal of physiology. Heart and circulatory physiology Bondesson, J. n., Suh, G. Y., Lundh, T. n., Dake, M. D., Lee, J. T., Cheng, C. P. 2020

  Abstract

  Chirality is a fundamental property in many biologic systems. Motivated by previous observations of helical aortic blood flow, aortic tissue fibers, and propagation of aortic dissections, we introduce methods to characterize helical morphology of aortic dissections. After validation on computer generated phantoms, the methods were applied to patients with type B dissection. For this cohort, there was a distinct bimodal distribution of helical propagation of the dissection with either achiral or exclusively right-handed chirality, with no intermediate cases or left-handed cases. This clear grouping indicates that dissection propagation favors these two modes, potentially due to the right-handedness of helical aortic blood flow and cell orientation. The characterization of dissection chirality and quantification of helical morphology advances our understanding of dissection pathology and lays a foundation for applications in clinical research and treatment practice. For example, the chirality and magnitude of helical metrics of dissections may indicate risk of dissection progression, help define treatment and surveillance strategies, and enable development of novel devices that account for various helical morphologies.

  View details for DOI 10.1152/ajpheart.00778.2020

  View details for PubMedID 33382638

• Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Vascular Closure Device During Percutaneous EVAR and TEVAR Procedures. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists Krajcer, Z. n., Wood, D. A., Strickman, N. n., Bernardo, N. n., Metzger, C. n., Aziz, M. n., Bacharach, J. M., Nanjundappa, A. n., Campbell, J. n., Lee, J. T., Dake, M. D., Lumsden, A. n., Nardone, S. n. 2020: 1526602820912224

  Abstract

  Purpose: To evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device in patients undergoing percutaneous endovascular aneurysm repair (PEVAR) or thoracic endovascular aortic repair (TEVAR). Materials and Methods: The SAFE MANTA Study (ClinicalTrials.gov identifier NCT02908880) was a prospective, single-arm, multicenter trial in patients undergoing endovascular interventions using large-bore sheaths (transcatheter aortic valve replacement, PEVAR, or TEVAR) at 20 sites in North America. Patient selection intended to test the MANTA device in populations without morbid obesity, severe calcification, or a severely scarred femoral access area. Of the 263 patients enrolled in the primary analysis cohort, 53 (20.2%) patients (mean age 74.9±8.9 years; 41 men) underwent PEVAR (n=51) or TEVAR (n=2) procedures and form the cohort for this subgroup analysis. Per protocol a single MANTA device was deployed in all PEVAR/TEVAR cases. Results: The mean time to hemostasis in the PEVAR/TEVAR cohort was 35±91 seconds, with a median time of 19 seconds vs 24 seconds in the overall SAFE MANTA population. The MANTA device met the definition for technical success in 52 (98%) of 53 PEVAR/TEVAR cases compared with 97.7% in the overall SAFE MANTA population. One (1.9%) major complication (access-site stenosis) occurred in this subgroup compared to 14 (5.3%) events in the SAFE population. In the PEVAR/TEVAR group, 1 pseudoaneurysm was noted prior to discharge, another at 30-day follow-up, and one at 60 days. One (1.9%) of the 3 minor pseudoaneurysms was treated with ultrasound-guided compression and the other 2 required no treatment. Conclusion: The MANTA device demonstrated a short time to hemostasis and low complication rates compared with published literature results of other percutaneous closure devices. Time to hemostasis and complication rates were comparable between the PEVAR/TEVAR patients and the full SAFE MANTA study cohort. The MANTA device provides reliable closure with a single percutaneous device for PEVAR/TEVAR procedures.

  View details for DOI 10.1177/1526602820912224

  View details for PubMedID 32193971

• Thoracic Aortic Dilation Following Endovascular Repair of Blunt Traumatic Aortic Injury. Annals of vascular surgery Tran, K. n., Li, M. n., Stern, J. R., Lee, J. T. 2020

  Abstract

  Thoracic endovascular aneurysm repair (TEVAR) has become the current standard of care for emergent treatment of blunt traumatic aortic injuries (BTAI). Although aortic dilation of the infrarenal neck following EVAR for aortic aneurysms has been studied, changes in aortic diameter following TEVAR for BTAI is not well understood. This study aims to characterize changes in thoracic aortic diameter following stent graft placement in the setting of non-aneurysmal traumatic aortic injury.A single-center, retrospective review was performed involving patients presenting with BTAI treated with TEVAR. Only patients with at least 12 months follow-up were included. Aortic diameter, defined as the outer-to-outer diameter on 3D center-line imaging, was measured at six locations along the proximal and mid thoracic aorta. The first post-operative CT (≤1 month) served as a baseline from which interval measurements were compared.Twenty patients with BTAI treated from 2011-2017 had adequate imaging available for review and were included in this study cohort. Median follow-up time was 46.8 (12-80, range) months. At latest follow-up, aortic dilation (AD) occurred at all measured locations within the endograft, starting from the proximal graft edge (0.62±0.69mm, p=.027) to the distal graft edge (1.21±1.28mm, p=.003). AD was most pronounced in the distal graft segment 2cm proximal to the distal graft edge, with a mean AD of 1.32±1.59mm (+5.3%, p<.001). At this location, AD was found to increase in a linear manner with an estimated rate of 0.67±0.20mm /year (p=0.006). The native aorta proximal and distal to the endograft was not found to significantly dilate during follow-up (p=.280-.897). 70% of patients were found to have AD >5%. The amount of aortic dilation was not found to be associated with either graft oversizing (p=.151) or age (p=.340). There were no cases of graft migration, erosion or endoleak.Aortic dilation is a common benign finding after TEVAR for BTAI. AD is most pronounced at the near the distal end of the stent graft. In late-term follow-up, there are no known associated complications related to AD.

  View details for DOI 10.1016/j.avsg.2020.06.049

  View details for PubMedID 32603842

• Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States. Annals of vascular surgery George, E. L., Arya, S. n., Rothenberg, K. A., Hernandez-Broussard, T. n., Ho, V. T., Stern, J. R., Gelabert, H. A., Lee, J. T. 2020

  Abstract

  Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher- versus lower-volume centers.The National Inpatient Sample was queried using ICD-9 codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm [arterial (aTOS)], subclavian DVT [venous (vTOS)], or brachial plexus lesions [neurogenic (nTOS)]. Basic descriptive statistics, non-parametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher- and lower-volume hospitals, respectively.There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010-2015 (89.2% nTOS, 9.9% vTOS, 0.9% aTOS) with annual case volume increasing significantly over time (p=0.03). Higher-volume centers (≥10 cases/year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma or lymphatic leak) rates [adjusted Odds Ratio (OR) 0.71 (95% confidence interval 0.52-0.98); p=0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 (0.20-2.43); p=0.56) or vascular injuries/graft complications [aOR 0.71 (0.0.33=1.54); p=0.39]. Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (p=0.03). However, vTOS & aTOS had >2.5 times the odds of major complication compared to nTOS [OR 2.68 (1.88-3.82) & aOR 4.26 (1.78-10.17); p<0.001], and ∼10 times the odds of a vascular complication [aOR 10.37 (5.33-20.19) & aOR 12.93 (3.54-47.37); p<0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (p<0.001). Total hospital charges were on average higher when surgery was performed in lower-volume centers (< 10 cases/year) compared to higher-volume centers [mean $65,634 (standard deviation 98,796) vs. $45,850 (59,285), p<0.001].The annual number of TOS operations have increased in the United States from 2010-2015, while complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher-volume centers delivered higher-value care: less or similar operative morbidity with lower total hospital charges.

  View details for DOI 10.1016/j.avsg.2020.10.046

  View details for PubMedID 33340669

• Increased vertebral exposure in anterior lumbar interbody fusion associated with venous injury and deep venous thrombosis. Journal of vascular surgery. Venous and lymphatic disorders Ho, V. T., Martinez-Singh, K. n., Colvard, B. n., Lee, J. T., Chandra, V. n. 2020

  Abstract

  Published outcomes on anterior lumbar interbody fusion (ALIF) have focused on 1-2 level fusion with and without vascular surgery assistance. We examined the influence of multi-level fusion on exposure-related outcomes when performed by vascular surgeons.We retrospectively reviewed clinical and radiographic data for patients undergoing anterior lumbar interbody fusion (ALIF) with exposure performed by vascular surgeons at a single practice.From 2017-2018, 201 consecutive patients underwent vascular-assisted ALIF. Patients were divided by number of vertebral levels exposed (90 patients with 1 level exposed, 71 with 2, 40 with 3+). Demographically, 3+ level fusion patients were older (p=.0045) and more likely to have had prior ALIF (p=.0383). Increased vertebral exposure was associated with higher rates of venous injury (p=.0251), increased procedural time (p= .0116), length of stay (p=.0001), and incidence of postoperative DVT (p=.0032). There was a 6.5% rate of intraoperative vascular injury, comprised of 3 major and 10 minor venous injuries. In patients who experienced complications, 92.3% of injuries were repaired primarily. 23% of patients with venous injuries developed postoperative deep venous thrombosis. In a multivariate logistic regression model, increased levels of exposure (RR = 6.23, p = .026) and a history of degenerative spinal disease (RR = .033, p = .033) were predictive of intraoperative venous injury.Increased vertebral exposure in anterior lumbar interbody fusion is associated with increased risk of intraoperative venous injury and postoperative deep venous thrombosis, with subsequently greater lengths of procedure time and length of stay. Rates of arterial and sympathetic injury were not affected by exposure extent.

  View details for DOI 10.1016/j.jvsv.2020.08.006

  View details for PubMedID 32795618

• Quantification of suprarenal aortic neck dilation after fenestrated endovascular aneurysm repair. Journal of vascular surgery Tran, K. n., Deslarzes-Dubuis, C. n., Lee, J. T. 2020

  Abstract

  Suprarenal aortic neck dilation (AND) after fenestrated endovascular aneurysm repair (FEVAR) with commercially available devices has not yet been well characterized. The aim of this study was to measure diameter changes in the supravisceral aorta after FEVAR.This is a single-center retrospective review involving patients with juxtarenal aneurysms treated with Cook ZFEN devices (Cook Medical, Bloomington, Ind). Patients with at least 1 year of cross-sectional radiologic follow-up were included. AND was defined as ≥3 mm at any measured location. Aortic diameter, defined as the average outer to outer diameter on three-dimensional centerline imaging, was measured at seven locations along the length of the ZFEN device from the proximal fixation struts to the bottom of the second seal stent. The first postoperative CT scan (≤1 month) served as a baseline from which subsequent measurements at annual intervals were compared.A total of 43 patients who underwent FEVAR from 2012 to 2018 met inclusion criteria, with a total of 119 target vessels (83 renal stents, 41 superior mesenteric artery scallops or large fenestrations). Mean follow-up time was 30.3 months. Any AND was found to occur in 32 (74.4%) patients. Aortic diameter dilation at latest follow-up was found to occur at all measured locations from the top of the fixation struts (1.9 ± 2.4 mm; P < .0001) to the middle of the second seal stent (1.3 ± 3.8 mm; P < .01). Diameter growth was most pronounced in the middle of the first seal stent, with mean AND of 3.6 ± 3.2 mm. At this location, the aorta experienced nearly linear annual growth of 0.99 mm (95% confidence interval, 0.7-1.28 mm) per year. Increasing device oversizing relative to the native visceral aorta was the strongest predictor of postoperative neck diameter growth (1.34 mm per 10% increase in oversizing; P = .02), whereas increasing proximal seal length was protective of growth (-1.82 mm per 10-mm increase in seal length; P = .016). Proximal seal lengths ≥3 cm were associated with less neck dilation compared with <3 cm (2.6 mm vs 4.9 mm; P = .022). Type IA endoleak in this cohort was rare (n = 1) and not associated with AND (P = .256).Dilation of the suprarenal aorta is a common finding in midterm follow-up after FEVAR and not associated with proximal endoleak. Aggressive device oversizing is predictive of dilation, whereas longer seal lengths are associated with less dilation along the suprarenal seal zone. These results support the continued use of FEVAR for juxtarenal aneurysms, particularly in patients in whom ≥3 cm of healthy seal length can be obtained.

  View details for DOI 10.1016/j.jvs.2020.04.522

  View details for PubMedID 32445831

• Acute type A dissection causing impending rupture of abdominal aortic aneurysm previously treated with EVAR. Annals of vascular surgery Ogawa, Y., Watkins, A. C., Lee, A., Iwakoshi, S., Dua, A., Pedroza, A. J., Dake, M. D., Lee, J. T. 2019

  Abstract

  This report describes the rapid expansion of a previously excluded abdominal aortic aneurysm (AAA) following type A aortic dissection repair in a 74-year-old male. Following successful hemi-arch replacement, CT angiography (CTA) showed residual dissection throughout the thoracoabdominal aorta which had created a proximal endoleak at the prior endovascular stentgraft resulting in rapid growth of the residual AAA sac. Urgent thoracic endovascular aortic repair (TEVAR) did not fully obliterate false lumen flow allowing further unstable expansion of the AAA and abdominal pain. This was ultimately managed with an open replacement of the infrarenal neck with a Dacron interposition graft sewn to the prior EVAR. Post-op CTA showed resolution of the false lumen communication to the infrarenal AAA and no further endoleak. Open interposition AAA neck replacement is a possible treatment for new onset endoleak in patients with aortic dissection following prior infrarenal EVAR.

  View details for DOI 10.1016/j.avsg.2019.11.047

  View details for PubMedID 31863952

• Improved midterm outcomes after endovascular repair of nontraumatic descending thoracic aortic rupture compared with open surgery. The Journal of thoracic and cardiovascular surgery Ogawa, Y., Watkins, A. C., Lingala, B., Nathan, I., Chiu, P., Iwakoshi, S., He, H., Lee, J. T., Fischbein, M., Woo, Y. J., Dake, M. D. 2019

  Abstract

  BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become first-line treatment for descending thoracic aortic rupture (DTAR), but its midterm and long-term outcomes remain undescribed. This study evaluated whether TEVAR would improve midterm outcomes of nontraumatic DTAR relative to open surgical repair (OSR).METHODS: Between December 1999 and October 2018, 118 patients with DTAR were treated with either OSR (n=39) or TEVAR (n=79) at a single center. Primary end points were 30-day and long-term all-cause mortalities. Secondary end points included stroke, permanent spinal cord ischemia (SCI), prolonged ventilation support or tracheostomy, permanent hemodialysis, and aortic reintervention.RESULTS: Thirty-day mortality was significantly lower with TEVAR (OSR, 38.5%; TEVAR, 16.5%; P=.01). Stroke (15.6% vs 3.8%; P=.03), permanent SCI (15.6% vs 2.5%; P=.02), prolonged ventilation (30.8% vs 8.9%; P=.002), and tracheostomy (12.8% vs 2.5%; P=.04) were significantly lower after TEVAR than OSR. Need for hemodialysis trended higher after OSR (12.8% vs 5.1%; P=.2). Mean follow ups were 1048±1591days for OSR group and 828±1258days for TEVAR. All-cause mortality at last follow-up was significantly lower after TEVAR than OSR (35.4% vs 66.7%; P=.001). Aortic reintervention was required more frequently within 30days after TEVAR (15.2% vs 2.6%; P=.06). By multivariate analysis, TAAA was an independent predictor for mortality.CONCLUSIONS: TEVAR improves both early and midterm outcomes of DTAR relative to OSR. TAAA was a predictor of mortality. Endovascular approach to DTAR may provide the greatest chance at survival.

  View details for DOI 10.1016/j.jtcvs.2019.10.156

  View details for PubMedID 31926735

• Quantification of Suprarenal Aortic Neck Dilation After Fenestrated Endovascular Aneurysm Repair Tran, K., Deslarzes-Dubuis, C., Lee, J. T. MOSBY-ELSEVIER. 2019: E192–E193

  View details for Web of Science ID 000491272700185

• Surgical Management of Functional Popliteal Entrapment Syndrome in Athletes Lavingia, K. S., Dua, A., Rothenberg, K. A., Fredericson, M., Lee, J. T. MOSBY-ELSEVIER. 2019: E116–E117

  View details for Web of Science ID 000491272700005

• Automated Quantification of Diseased Thoracic Aortic Longitudinal Centerline and Surface Curvatures. Journal of biomechanical engineering Bondesson, J. H., Suh, G., Lundh, T., Lee, J. T., Dake, M. D., Cheng, C. 2019

  Abstract

  Precise description of vascular morphometry is crucial to support medical device manufacturers and clinicians for improving device development and interventional outcomes. A compact and intuitive method is presented to automatically characterize the surface geometry of tubular anatomic structures and quantify surface curvatures starting from generic stereolithographic surfaces. The method was validated with software phantoms and used to quantify the longitudinal surface curvatures of 37 human thoracic aortas with aneurysm or dissection. The quantification of surface curvatures showed good agreement with analytic solutions from the software phantoms, and demonstrated better agreement as compared to estimation methods using only centerline geometry and cross-sectional radii. For the human thoracic aortas, longitudinal inner surface curvature was significantly higher than centerline curvature (0.33±0.06 vs. 0.16±0.02 cm-1 for mean; 1.38±0.48 vs. 0.45±0.11 cm-1 for peak; both p<0.001). These findings show the importance of quantifying surface curvatures in order to better describe the geometry and biomechanical behavior of the thoracic aorta, which can assist in treatment planning and supplying device manufactures with more precise boundary conditions for mechanical evaluation.

  View details for DOI 10.1115/1.4045271

  View details for PubMedID 31633168

• "Cheese Wire" Fenestration of Dissection Intimal Flap to Facilitate Thoracic Endovascular Aortic Repair in Chronic Dissection. Journal of vascular and interventional radiology : JVIR Iwakoshi, S., Watkins, C. A., Ogawa, Y., Fischbein, M., Lee, A., Lee, J. T., Hiesinger, W., Dake, M. D. 2019

  Abstract

  Thoracic endovascular aortic repair (TEVAR) for aneurysmal chronic dissection is often complicated by retrograde filling of the false lumen and dissected distal landing zone. A "cheese wire"-style fenestration of the dissection intimal flap can create a landing zone facilitating TEVAR. This technique successfully aided TEVAR in 3 patients with an average age of 57.3 years. Complications included type III endoleak requiring relining and renal artery occlusion requiring stent placement. Average duration of clinical follow-up was 19 ± 4 months. Imaging follow-up was 8 ± 10 months. All patients have survived for more than 1 year without aneurysm enlargement.

  View details for DOI 10.1016/j.jvir.2019.06.004

  View details for PubMedID 31542270

• Association of Upper Extremity and Neck Access With Stroke in Endovascular Aortic Repair Plotkin, A., Ding, L., Hang, S. M., Oderich, G. S., Starnes, B. W., Lee, J. T., Malas, M. B., Weaver, F. A., Magee, G. MOSBY-ELSEVIER. 2019: E86

  View details for DOI 10.1016/j.jvs.2019.06.114

  View details for Web of Science ID 000482181500145

• Long Term Quality of Life Comparison between Supra and Infraclavicular Rib Resection in Patients with vTOS. Annals of vascular surgery Dua, A., Rothenberg, K. A., Gologorsky, R. C., Deslarzes-Dubuis, C., Lee, J. T. 2019

  Abstract

  INTRODUCTION: Rib resection in venous thoracic outlet syndrome (VTOS) may be approached via a transaxillary, supraclavicular, or infraclavicular approach based on surgeon preference. The purpose of this study was to evaluate long-term postoperative quality of life function after surgery for VTOS and to determine if there were long term patency differences associated with the surgical approach or whether prophylactic post-operative venography was performed METHODS: All patients with vTOS undergoing rib resection at a single institution were retrospectively reviewed. In 2012 we switched our approach to infraclavicular with postoperative venogram performed within two weeks of rib resection. Clinical records and imaging results were tabulated, and postoperative outcomes, complications, and long-term symptom follow up via QuickDASH surveys. The QuickDASH score range from 0-100 with lower numbers indicating better functional status (100 = worst).RESULTS: Over the 19-year study period we performed 109 rib resections in patients with vTOS (mean age 29.8 years). From 2000 to 2012, 54 patients were approached via a supraclavicular approach and from 2012-2018, 55 patients were approached via an infraclavicular approach. There was a significant decrease in the number of complications in the infraclavicular cohort compared to the supraclavicular group. There was no difference in patency between the two groups even with a higher rate of postoperative venogram in the infraclavicular cohort. There was no difference in long term QuickDASH scores. There was an increased rate of complications in the supraclavicular cohort as compared to the infraclavicular group (P<0.05).CONCLUSION: The infraclavicular approach in vTOS patients is associated with a lower rate of complications but long-term quality of life outcomes and patency are not different between groups.

  View details for DOI 10.1016/j.avsg.2019.08.071

  View details for PubMedID 31476427

• Early Experience with the Octopus Endovascular Strategy in the Management of Thoracoabdominal Aneurysms. Annals of vascular surgery Dua, A., Lavingia, K. S., Deslarzes-Dubuis, C., Dake, M. D., Lee, J. T. 2019

  Abstract

  OBJECTIVES: The Octopus endovascular strategy involves placement of multiple, stacked bifurcated grafts in the thoracic segment of a TAAA to facilitate deployment of multiple parallel covered stents for visceral perfusion. This study aimed to review early outcomes of the Octopus TAAA repair strategy at a tertiary, high volume referral center.METHODS: All patients who underwent this Octopus procedure from 2015 to 2018 were reviewed from a prospectively collected single institution registry. Demographics, comorbidities, aneurysm anatomy including side and extent, peri-operative data including blood loss, length of procedure length of stay (LOS), morbidity, and mortality up to 3 years post procedure were elevated.RESULTS: A total of 21 patients (48% female, age 72.9 years) underwent the Octopus procedure over the study period. Mean TAAA diameter was 6.7cm, with 14% dissection related and 86% degenerative TAAA. All patients had been turned down for open repair and three (14%) were done urgently of which two were ruptures. TAAA extent was 9% type 2, 62% type 3, 29% type 4. A mean of 3.04 branches were revascularized per patient, with the SMA (90%) perfused through its own limb, and both renals usually reconstructed in parallel graft fashion (left 90%, right 85.7%) with the distal abdominal extension though one of the limbs. Mean operative time was 8 hours, fluoroscopy time 164 minutes, contrast 182mL, and blood loss 807mL. We staged the thoracic and juxtavisceral portions of the cases in 24% of patients. 90% of cases were able to be completed with exclusion of the TAAA and all planned visceral branches cannulated. Perioperative complications included paraplegia (19%) [13.3% permanent, 26.6% temporary], acute kidney injury (24%), prolonged ventilation (19%), MI (4.9%), and ischemic bowel (4.8%). Median follow up was 13.5 months (range 1-26 months). At latest follow-up, type I endoleak rate was 9.5%, with all being treated with proximal cuffs. Other 2nd interventions included re-stenting of a right renal, angioplasty of an iliac limb kink, and type 2 endoleak coiling. Primary patency of visceral branches was 93.8% at latest follow up (celiac 100%, SMA 94.7%, right renal 88.9%, left renal 94.8%). In-hospital all-cause mortality rate was 14.2%, with 30-day survival being 90.5%, 6-month survival was 88.3%, one year survival 71.4% and 3 year survival was 52.1%.CONCLUSION: The Octopus procedure is a high-risk option for urgent or emergent endovascular TAAA repair with off the shelf devices in patients who are not candidates for open repair.

  View details for DOI 10.1016/j.avsg.2019.05.043

  View details for PubMedID 31394231

• Duplex ultrasound surveillance of renal branch grafts after fenestrated endovascular aneurysm repair. Journal of vascular surgery Tran, K., Mcfarland, G., Sgroi, M., Lee, J. T. 2019

  Abstract

  OBJECTIVE: The use of duplex ultrasound (DUS) examinations for surveillance after fenestrated endovascular aneurysm repair (FEVAR) is not well-studied. Our objective was to further characterize normal and abnormal duplex findings in renal branch grafts after FEVAR.METHODS: We retrospectively reviewed a single-center experience involving consecutive patients treated with Cook ZFEN devices between 2012 and 2017. Postoperative imaging consisted of a computed tomography (CT) scan at 1month, 6months, 1year, and annually thereafter. As experienced progressed, DUS examination with or without concurrent CT scans were obtained in a nonstandardized protocol, particularly for patients with decreased renal function. Renal patency loss was defined as occlusion or stenosis of greater than 50% evaluated on 3-day renal artery center-line imaging.RESULTS: A total of 116 patients were treated with FEVAR, of which 60 (51.7%) had concurrent CT and renal DUS images available for review. Six patients (10%) had limited ultrasound studies owing to bowel gas and were excluded. The study cohort therefore included 54 patients receiving of 94 renal fenestrated stents with a mean follow-up of 23months. Twelve cases of renal patency loss in 10 patients (9 stenoses, 3 occlusions) were found on CT scanning, 11 (91.6%) of which had concurrent abnormalities found on ultrasound examination. Stents with compression at the junction of the main body exhibited significantly elevated mean Peak systolic velocities (PSV) compared with nonstenosed stents (349.2cm/s vs 115.3cm/s; P= .003). Stenosis in the most proximal portion of the stent (ie, within the main body) showed no difference in proximal PSV (86.0cm/s vs 131.9cm/s; P= .257); however, dampened PSV showed significant differences in the mid (17.5cm/s vs 109.9cm/s; P= .027) and distal (19.0cm/s vs 78.3cm/s; P= .028) segments compared with nonstenosed stents. All occluded stents demonstrated no flow detection. Proximal PSV served as a strong classifier for junctional stenosis (area under the curve, 0.98). A combined criterion of proximal PSV of greater than 215cm/s or distal PSV of less than 25cm/s resulted in a sensitivity of 91.6% and specificity of 85.3% for detecting patency loss. All stents that were compromised underwent successful secondary reintervention and restoration of patency.CONCLUSIONS: DUS imaging is a clinically useful modality for surveillance of renal branch grafts after FEVAR. Patterns of segmental velocity elevation (proximal PSV, >215cm/s) and dampening in the distal renal indicate potential hemodynamic compromise and should prompt more aggressive workup or imaging and likely be considered for secondary intervention.

  View details for DOI 10.1016/j.jvs.2018.12.050

  View details for PubMedID 31327607

• Surgical management of functional popliteal entrapment syndrome in athletes. Journal of vascular surgery Lavingia, K. S., Dua, A., Rothenberg, K. A., Fredericson, M., Lee, J. T. 2019

  Abstract

  BACKGROUND: Functional popliteal artery entrapment syndrome (FPAES) is a rare disorder described in young, physically active adults that can be limb or performance threatening if untreated. We used provocative computed tomography angiography (CTA) in these patients to guide partial debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle for FPAES and reviewed the outcomes of this technique in this highly specialized cohort.METHODS: Athletes referred with symptoms of FPAES underwent a CTA protocol with provocative plantarflexion and dorsiflexion to confirm compression and were offered surgery. All patients underwent posterior approach operative exposure of the popliteal artery, adhesiolysis, side branch ligation, and partial excision of the gastrocnemius muscle with or without fasciotomies. Preoperative imaging, operative findings, and midterm follow-up, including return to baseline function and return to competitive function, as well as symptom recurrence, were retrospectively reviewed.RESULTS: Thirty-six athletes had a total of 56 limbs treated. The average patient age was 26.9years and the majority were female (56%). Thirty-one percent of patients were referred after already having undergone prior fasciotomies. Sports involved included track and field or running (47%), soccer (25%), water sports (8%), basketball (6%), lacrosse (6%), climbing (3%), skiing (3%), and gymnastics (3%). Of the patients, 27 (75%) had bilateral symptoms and evidence of entrapment; however, only 20 of the 36 (56%) underwent bilateral surgical treatment for symptom resolution. The mean amount of gastrocnemius muscle removed was 7.6cm3. Nine percent of limbs underwent a bypass along with debulking owing to arterial occlusion at presentation. Postoperatively, there were no nerve or vascular complications noted, although two patients had wound/seroma complications (6%). At the first follow-up, all patients reported mild symptom improvement, but at the midterm follow-up (mean follow-up time, 16months), six (17%) reported mild to moderate recurrence of symptoms. Of the patients, 78% were able to fully return to their previous competitive levels of sports. All patients were able to resume their athletic endeavor at a recreational level.CONCLUSIONS: More than three-fourths of athletes limited by FPAES demonstrate full return to prior competitive levels with fasciotomy and surgical debulking of the anterolateral quadrant of the medial gastrocnemius muscle. Provocative CTA protocols can help to guide the location of muscle debulking to alleviate the functional entrapment that occurs in these athletes with exercise. This technique is a viable option in athletes with FPAES looking to return to competitive athletics.

  View details for DOI 10.1016/j.jvs.2019.01.068

  View details for PubMedID 31327599

• Increased Vertebral Exposure in Anterior Lumbar Interbody Fusion Associated With Venous Injury and Deep Venous Thrombosis Ho, V. T., Colvard, B., Lee, J. T., Chandra, V. MOSBY-ELSEVIER. 2019: E248–E249

  View details for DOI 10.1016/j.jvs.2019.04.376

  View details for Web of Science ID 000469220300368

• Up to 18-Year Functional Outcomes Follow-up After 188 Rib Resections in Patients With Thoracic Outlet Syndrome Dua, A., Rothenberg, K. A., Gologorsky, R., Lavingia, K., Lee, J. T. MOSBY-ELSEVIER. 2019: E271–E272

  View details for DOI 10.1016/j.jvs.2019.04.415

  View details for Web of Science ID 000469220300407

• Diagnosis and management of external iliac endofibrosis: A case report JOURNAL OF VASCULAR NURSING Lindo, F. A., Lee, J. T., Morta, J., Ross, E., Shub, Y., Wilson, C. 2019; 37 (2): 86–90

  Abstract

  External iliac artery endofibrosis is an uncommon, nonatherosclerotic disease seen in endurance cyclists. It is poorly identified by providers. These otherwise healthy patients usually present with symptoms of arterial insufficiency, such as thigh or buttock pain, loss of power, or weakness occurring during strenuous exercises. These symptoms subside rapidly with rest. As these patients lack traditional risk factors of peripheral artery disease, their symptoms are often overlooked or are attributed to other etiologies, resulting in mismanagement and delayed treatment. In this case study, we report our experience with the successful management of a 48-year-old male who is a longstanding, avid cyclist. He self-referred to our institution after extensive research of providers familiar with his problem and at the recommendation of other cyclists with similar experiences. The patient underwent a successful left external iliac to common femoral artery endarterectomy and patch angioplasty. Three months after operation, he returned to cycling and, for the most part, has remained without symptoms.

  View details for DOI 10.1016/j.jvn.2018.11.008

  View details for Web of Science ID 000469492800003

  View details for PubMedID 31155167

• Zenith Fenestrated Outcomes for Patients Treated Inside Versus Outside of Instructions for Use Stern, J. R., Deslarzes-Dubuis, C., Tran, K., Lee, J. T. MOSBY-ELSEVIER. 2019: E119

  View details for DOI 10.1016/j.jvs.2019.04.142

  View details for Web of Science ID 000469220300139

• Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia George, E. L., Colvard, B., Ho, V. T., Rothenberg, K. A., Lee, J. T., Stern, J. R. MOSBY-ELSEVIER. 2019: E170–E171

  View details for DOI 10.1016/j.jvs.2019.04.236

  View details for Web of Science ID 000469220300232

• Cardiopulmonary-induced deformations of the thoracic aorta following thoracic endovascular aortic repair VASCULAR Suh, G., Ullery, B. W., Lee, J. T., Dake, M. D., Fleischmann, D., Cheng, C. 2019; 27 (2): 181–89

  View details for DOI 10.1177/1708538118811204

  View details for Web of Science ID 000462084800009

• N-2 supercritical jet to modify the characteristics of polymer material surfaces: Influence of the process parameters on the surface topography POLYMER ENGINEERING AND SCIENCE Khalsi, Y., Heim, F., Lee, J. T., Tazibt, A. 2019; 59 (3): 616–24

  View details for DOI 10.1002/pen.24977

  View details for Web of Science ID 000460185500021

• The role of industry in vascular surgery trainee education. Seminars in vascular surgery Dua, A., Rothenberg, K., Lee, J. T. 2019; 32 (1-2): 30–32

  Abstract

  Vascular surgery is a specialty discipline highlighted by a lifelong learning process from which new endovascular devices and techniques will continue to emerge. Industry partnerships can provide a safe learning environment for trainees, with a focus on maximizing learning opportunities during fellowship or residency. Unlike other surgical specialties, vascular surgery empowers its trainees to become competent in both open and image-guided endovascular interventions, requiring two unique skill sets to become a contemporary vascular surgeon. Due to the rapid growth of technology and innovations, industry partnerships enhance and maximize the learning experience of the trainee by often providing the products, education, research support, and financial assistance. This can come in the form of innovative and educational activities, including simulation, exposure to thought leaders, attendance at conferences and workshops, and one-on-one assistance with cases. In this article, we review the role that industry can serve in vascular education to support budding vascular surgeons through exposure and repetition as they lay down the fundamentals of their careers.

  View details for DOI 10.1053/j.semvascsurg.2019.01.008

  View details for PubMedID 31540654

• 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

• Complex endovascular aneurysm repair is associated with higher perioperative mortality but not late mortality compared with infrarenal endovascular aneurysm repair among octogenarians JOURNAL OF VASCULAR SURGERY Tran, K., Lee, A. M., McFarland, G. E., Sgroi, M. D., Lee, J. T. 2019; 69 (2): 327–33

  View details for DOI 10.1016/j.jvs.2018.04.064

  View details for Web of Science ID 000456316700005

• Total robotic iliac aneurysm repair with preservation of the internal iliac artery using sutureless vascular anastomosis. Journal of vascular surgery cases and innovative techniques Colvard, B. n., Georg, Y. n., Lejay, A. n., Ricco, J. B., Swanstrom, L. n., Lee, J. n., Bismuth, J. n., Chakfé, N. n., Thaveau, F. n. 2019; 5 (3): 218–24

  Abstract

  Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments.Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft.The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m2 (range, 23-26.4 kg/m2). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs.Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.

  View details for DOI 10.1016/j.jvscit.2019.01.001

  View details for PubMedID 31297470

  View details for PubMedCentralID PMC6598873

• 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

• Renal Artery Coverage During EVAR for Ruptured AAA. Annals of vascular surgery Tanious, A. n., Boitano, L. T., Wang, L. J., Shames, M. L., Lee, J. T., Eagleton, M. J., Clouse, W. D., Conrad, M. F. 2019

  Abstract

  Coverage of one or both renal arteries may be required to facilitate endovascular repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAA). We sought to understand the consequences of renal coverage during these emergent procedures.Utilizing the VQI dataset from 2013-2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included in-hospital mortality, composite permanent-dialysis/30-day-death, and 1-year survival.Overall there were 2278 patients presenting with ruptured aneurysms. The majority of patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of in-hospital mortality (OR=5.7, +/-4; p=.030) permanent-dialysis/30-day-death (OR=9.5, +/-7; p=.016), and permanent dialysis (OR=47.5, +/-47; p<.001). Two patients with bilateral renal coverage did not suffer permanent-dialysis/death. Single renal artery coverage significantly increased the odds of permanent-dialysis/30-day-death (OR=2.8, +/-1.6; p=.044) driven mainly by its effect on the outcome of permanent-dialysis (OR=12.3, +/-6; p <.001). Unadjusted Kaplan Meier one-year survival estimates were significantly lower with bilateral renal coverage (HR=3.4, p=.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR=3.5, p=0.002), however single renal coverage did not significantly affect survival in unadjusted or adjusted models.Bilateral renal coverage in rAAA significantly increases in-hospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its affect on permanent dialysis, it does not significantly affect in-hospital mortality or one-year survival and may be a viable option for select patients with rAAA.

  View details for DOI 10.1016/j.avsg.2019.05.005

  View details for PubMedID 31201979

• Early Real-World Experience with Endoanchors by Indication. Annals of vascular surgery Ho, V. T., George, E. L., Dua, A. n., Lavingia, K. S., Sgroi, M. D., Dake, M. D., Lee, J. T. 2019

  Abstract

  The Heli-Fx Endoanchor system is a transmural aortic fixation device with Federal Drug Administration (FDA) approval for treatment of endoleaks, endograft migration, or high-risk seal zones. Published data is primarily from industry-sponsored registries highlighting safety and efficacy. Our objective is to evaluate real-world outcomes of Endoanchor usage after FDA approval across a variety of stent-grafts and indications at a single institution.We retrospectively reviewed our prospectively maintained aneurysm database for patients undergoing endovascular aortic repair with Heli-Fx Endoanchors (EAs). Technical success was defined as successful EA deployment, while procedural success was defined as absence of endoleak on completion aortogram. Cohorts were divided by indication and outcomes assessed via review of clinical and radiographic data.From 2016-2018, 37 patients underwent EA fixation. We divided the cohort by indication: Group A (Prior EVAR with endoleak), B (intraoperative type 1A endoleak), C (high-risk seal zone), and D (TEVAR). In Group A (n=11), all endoleaks were type 1A and a mean of 10 EAs were deployed with 100% technical and 45.4% procedural success. Two perioperative re-interventions were performed (translumbar coil embolization; proximal graft extension with bilateral renal artery stents). At a mean 10.6 months follow-up, 45.4% of patients had persistent endoleaks, with 100% aortic related survival. In Group B (n=10), a mean of 8.7 EAs were used with 100% technical and procedural success. One immediate adverse event occurred (right iliac dissection from wire manipulation, treated with a covered stent). At 13.6 month mean follow-up, there was significant sac regression (mean 9.75 mm) with no type 1A endoleaks. In Group C (n=10), a mean of 9.5 EAs were deployed with 100% technical and procedural success. At 11.2 month mean follow-up, there were no residual endoleaks and significant sac regression (mean 3.4 mm). Overall survival was 100%. In Group-D (n=6), a mean of 8.3 EAs were used with 83.3% technical and 66.6% procedural success. One immediate adverse event occurred, in which an EA embolized to the left renal artery. At 9.4 month mean follow-up, overall survival was 83.3% with a mean 2.2 mm increase in sac diameter.Early experience suggests EAs effectively treat intraoperative type-1A endoleaks and high-risk seal zones, with significant sac regression and no proximal endoleaks on follow-up. In patients treated for prior EVAR with postoperative type-1A endoleaks, fewer than half resolved after EA attempted repair. Further experience and longer-term followup will be necessary to determine which patients most benefit from postoperative EA fixation.

  View details for DOI 10.1016/j.avsg.2019.05.006

  View details for PubMedID 31201976

• Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Percutaneous Vascular Closure Device. Circulation. Cardiovascular interventions Wood, D. A., Krajcer, Z. n., Sathananthan, J. n., Strickman, N. n., Metzger, C. n., Fearon, W. n., Aziz, M. n., Satler, L. F., Waksman, R. n., Eng, M. n., Kapadia, S. n., Greenbaum, A. n., Szerlip, M. n., Heimansohn, D. n., Sampson, A. n., Coady, P. n., Rodriguez, R. n., Krishnaswamy, A. n., Lee, J. T., Ben-Dor, I. n., Moainie, S. n., Kodali, S. n., Chhatriwalla, A. K., Yadav, P. n., O'Neill, B. n., Kozak, M. n., Bacharach, J. M., Feldman, T. n., Guerrero, M. n., Nanjundappa, A. n., Bersin, R. n., Zhang, M. n., Potluri, S. n., Barker, C. n., Bernardo, N. n., Lumsden, A. n., Barleben, A. n., Campbell, J. n., Cohen, D. J., Dake, M. n., Brown, D. n., Maor, N. n., Nardone, S. n., Lauck, S. n., O'Neill, W. W., Webb, J. G. 2019; 12 (7): e007258

  Abstract

  Open surgical closure and small-bore suture-based preclosure devices have limitations when used for transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or percutaneous thoracic endovascular aortic aneurysm repair. The MANTA vascular closure device is a novel collagen-based technology designed to close large bore arteriotomies created by devices with an outer diameter ranging from 12F to 25F. In this study, we determined the safety and effectiveness of the MANTA vascular closure device.A prospective, single arm, multicenter investigation in patients undergoing transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or thoracic endovascular aortic aneurysm repair at 20 sites in North America. The primary outcome was time to hemostasis. The primary safety outcomes were accessed site-related vascular injury or bleeding complications. A total of 341 patients, 78 roll-in, and 263 in the primary analysis cohort, were entered in the study between November 2016 and September 2017. For the primary analysis cohort, transcatheter aortic valve replacement was performed in 210 (79.8%), and percutaneous endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic aneurysm repair was performed in 53 (20.2%). The 14F MANTA was used in 42 cases (16%), and the 18F was used in 221 cases(84%). The mean effective sheath outer diameter was 22F (7.3 mm). The mean time to hemostasis was 65±157 seconds with a median time to hemostasis of 24 seconds. Technical success was achieved in 257 (97.7%) patients, and a single device was deployed in 262 (99.6%) of cases. Valve Academic Research Consortium-2 major vascular complications occurred in 11 (4.2%) cases: 4 received a covered stent (1.5%), 3 had access site bleeding (1.1%), 2 underwent surgical repair (0.8%), and 2 underwent balloon inflation (0.8%).In a selected population, this study demonstrated that the MANTA percutaneous vascular closure device can safely and effectively close large bore arteriotomies created by current generation transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, and thoracic endovascular aortic aneurysm repair devices.URL: https://www.clinicaltrials.gov . Unique identifier: NCT02908880.

  View details for DOI 10.1161/CIRCINTERVENTIONS.119.007258

  View details for PubMedID 31296082

• Cardiopulmonary-induced deformations of the thoracic aorta following thoracic endovascular aortic repair. Vascular Suh, G., Ullery, B. W., Lee, J. T., Dake, M. D., Fleischmann, D., Cheng, C. 2018: 1708538118811204

  Abstract

  OBJECTIVES: Thoracic endovascular aortic repair has become a preferred treatment strategy for thoracic aortic aneurysms and dissections. Yet, it is not well understood if the performance of endografts is affected by physiologic strain due to cyclic aortic motion during cardiac pulsation and respiration. We aim to quantify cardiac- and respiratory-induced changes of the postthoracic endovascular aortic repair thoracic aorta and endograft geometries.METHODS: Fifteen thoracic endovascular aortic repair patients (66±10 years) underwent cardiac-resolved computed tomography angiographies during inspiratory/expiratory breath holds. The computed tomography angiography images were utilized to build models of the aorta, and lumen centerlines and cross-sections were extracted. Arclength and curvature were computed from the lumen centerline. Effective diameter was computed from cross-sections of the thoracic aorta. Deformation was computed from the mid-diastole to end-systole (cardiac deformation) and expiration to inspiration (respiratory deformation).RESULTS: Cardiac pulsation induced significant changes in arclength, mean curvature, maximum curvature change, and effective diameter of the ascending aorta, as well as effective diameter of the stented aortic segment. Respiration, however, induced significant change in mean curvature and effective diameter of the ascending aorta only. Cardiac-induced arclength change of the ascending aorta was significantly greater than respiratory-induced arclength change.CONCLUSIONS: Deformations are present across the thoracic aorta due to cardiopulmonary influences after thoracic endovascular aortic repair. The geometric deformations are greatest in the ascending aorta and decline at the stented thoracic aorta. Additional investigation is warranted to correlate aortic deformation to endograft performance.

  View details for PubMedID 30426849

• NCCN Guidelines Insights: Cancer-Associated Venous Thromboembolic Disease, Version 2.2018. Journal of the National Comprehensive Cancer Network : JNCCN Streiff, M. B., Holmstrom, B., Angelini, D., Ashrani, A., Bockenstedt, P. L., Chesney, C., Fanikos, J., Fenninger, R. B., Fogerty, A. E., Gao, S., Goldhaber, S. Z., Gundabolu, K., Hendrie, P., Lee, A. I., Lee, J. T., Mann, J., McMahon, B., Millenson, M. M., Morton, C., Ortel, T. L., Ozair, S., Paschal, R., Shattil, S., Siddiqi, T., Smock, K. J., Soff, G., Wang, T., Williams, E., Zakarija, A., Hammond, L., Dwyer, M. A., Engh, A. M. 2018; 16 (11): 1289–1303

  Abstract

  Venous thromboembolism (VTE) is common in patients with cancer and increases morbidity and mortality. VTE prevention and treatment are more complex in patients with cancer. The NCCN Guidelines for Cancer-Associated Venous Thromboembolic Disease outline strategies for treatment and prevention of VTE in adult patients diagnosed with cancer or in whom cancer is clinically suspected. These NCCN Guidelines Insights explain recent changes in anticoagulants recommended for the treatment of cancer-associated VTE.

  View details for DOI 10.6004/jnccn.2018.0084

  View details for PubMedID 30442731

• Multicenter study of retrograde open mesenteric artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia JOURNAL OF VASCULAR SURGERY Oderich, G. S., Macedo, R., Stone, D. H., Woo, E. Y., Panneton, J. M., Resch, T., Dias, N. V., Sonesson, B., Schermerhorn, M. L., Lee, J. T., Kalra, M., DeMartino, R. R., Sandri, G. A., Tenorio, E., Low Frequency Vasc Dis Res Consort 2018; 68 (2): 470-+

  Abstract

  Retrograde open mesenteric stenting (ROMS) through laparotomy was introduced as an alternative to surgical bypass in patients with acute mesenteric ischemia (AMI). The purpose of this study was to evaluate the indications and outcomes of ROMS for treatment of AMI and chronic mesenteric ischemia.We reviewed the clinical data and outcomes of all consecutive patients treated by ROMS in seven academic centers from 2001 to 2013. ROMS was performed through laparotomy with retrograde access into the target mesenteric artery and stent placement using a retrograde or antegrade approach. End points were early (<30 days) and late mortality, morbidity, patency rates, and freedom from symptom recurrence and reintervention.There were 54 patients, 13 male and 41 female, with a mean age of 72 ± 11 years. Indications for ROMS were AMI in 44 patients (81%) and subacute-on-chronic mesenteric ischemia with flush mesenteric occlusion in 10 patients (19%). A total of 56 target mesenteric vessels were stented, including 52 superior mesenteric arteries and 4 celiac axis lesions, with a mean treatment length of 42 ± 26 mm. Retrograde mesenteric access was used in all patients, but 16 patients also required a simultaneous antegrade brachial approach. The retrograde puncture was closed primarily in 34 patients and with patch angioplasty in 17 patients; 1 patient had manual compression. Bowel resection was needed in 29 patients (66%) with AMI because of perforation or gangrene. Technical success was achieved in all (98%) except one patient for whom ROMS failed, who was treated by bypass. Early mortality was 45% (20/44) for AMI and 10% (1/10) for subacute-on-chronic mesenteric ischemia (P = .04). Early morbidity was 73% for AMI and 50% for subacute-on-chronic mesenteric ischemia (P = .27). Patient survival for the entire cohort was 43% ± 9% at 2 years. Primary patency and secondary patency at 2 years were 76% ± 8% and 90% ± 8%, respectively. Freedom from symptom recurrence and freedom from reinterventions were 72% ± 8% and 74% ± 8% at the same interval.ROMS offers an alternative to bypass or percutaneous stenting in patients with AMI who require abdominal exploration and in those who have flush mesenteric occlusions and have failed to respond to or are considered unsuitable for stenting by a percutaneous approach. Despite high technical success, mortality remains elevated in patients with AMI. Patency rates and freedom from symptom recurrence and reinterventions are comparable to the results achieved with stenting using percutaneous technique.

  View details for PubMedID 29548812

• Practice Patterns of Fenestrated Aortic Aneurysm Repair: Nationwide Comparison of Z-Fen Adoption at Academic and Community Centers Since Commercial Availability VASCULAR AND ENDOVASCULAR SURGERY Wiske, C., Lee, J. T., Rockman, C., Veith, F. J., Cayne, N., Adelman, M., Maldonado, T. 2018; 52 (6): 434–39

  Abstract

  Over the past decade, a number of endovascular approaches have evolved to treat aortic aneurysms with anatomy that is not amenable to traditional endovascular repair, although the optimal practice and referral patterns remain in question. The Zenith fenestrated (Z-Fen) endograft (Cook Medical) represents the first commercially available fenestrated graft product in the United States.We aim to quantify practice patterns in Z-Fen use during the first 5 years of commercial availability, and we identify predictors of high and low uptake.This is a retrospective review of complete order records for Z-Fen endografts since June 2012. We performed univariate and multivariate regressions of predictors that surgeons and centers would be in the top and bottom quartiles of annual Z-Fen use.Since June 15, 2012, 744 surgeons have been trained to use Z-Fen, and 4133 cases have been performed at 409 trained centers. The average annual number of cases per trained surgeon was 4.46 [95% confidence interval (CI), 3.58-5.70]; however, many surgeons performed few or no cases following training, and there was a skew toward users with low average annual volumes (25th percentile 1.23, 50th percentile 2.35, 75th percentile 4.93, and 99th percentile 33.29). Predictors of high annual use in the years following training included academic center (aOR 5.87, P = .001) and training within the first 2 years of availability (aOR 46.23, P < .001).While there is literature supporting the safety and efficacy of Z-Fen, adoption has been relatively slow in an era when the vast majority of vascular surgeons have advanced endovascular skills. Given the training and resources required to use fenestrated or branched aortic endovascular devices, referral patterns should be determined and training should be focused on centers with high expected volumes.

  View details for PubMedID 29843567

• Identification of optimal device combinations for the chimney endovascular aneurysm repair technique within the PERICLES registry JOURNAL OF VASCULAR SURGERY Scali, S. T., Beck, A. W., Torsello, G., Lachat, M., Kubilis, P., Veith, F. J., Lee, J. T., Donas, K. P., PERICLES Investigators 2018; 68 (1): 24–35

  Abstract

  The ideal stent combination for chimney endovascular aneurysm repair remains undetermined. Therefore, we sought to identify optimal aortic and chimney stent combinations that are associated with the best outcomes by analyzing the worldwide collected experience in the PERformance of chImney technique for the treatment of Complex aortic pathoLogiES (PERICLES) registry.The PERICLES registry was reviewed for patients with pararenal aortic disease electively treated from 2008 to 2014. Eleven different aortic devices were identified with three distinct subgroups: group A (n = 224), nitinol/polyester; group B (n = 105), stainless steel/polyester; and group C (n = 69), nitinol/expanded polytetrafluoroethylene. The various chimney stent subtypes included the balloon-expandable covered stent (BECS), self-expanding covered stent, and bare-metal stent. Deidentified aortic and chimney device combinations were compared for risk of chimney occlusion, type IA endoleak, and survival. Effects of high-volume centers (>100 cases), use of an internal lining chimney stent, number of chimney stents, and number of chimney stent subtypes deployed were also considered. We considered demographics, comorbidities, and aortic anatomic features as potential confounders in all models.The 1- and 3-year freedom from BECS chimney occlusion was not different between groups (group A, 96% ± 2% and 87% ± 5%; groups B and C, 93% ± 3% and 76% ± 10%; Cox model, P = .33). Similarly, when non-BECS chimney stents were used, no difference in occlusion risk was noted for the three aortic device groupings; however, group C patients receiving BECS did have a trend toward higher occlusion risk relative to group C patients not receiving a BECS chimney stent (hazard ratio [HR], 4.0; 95% confidence interval [CI], 0.85-18.84; P = .08). Patients receiving multiple chimney stents, irrespective of stent subtype, had a 1.8-fold increased risk of occlusion for each additional stent (HR, 1.8; 95% CI, 1.2-2.9; P = .01). Use of a bare-metal endolining stent doubled the occlusion hazard (HR, 2.1; 95% CI, 1.0-4.5; P = .05). Risk of type IA endoleak (intraoperatively and postoperatively) did not significantly differ for the aortic devices with BECS use; however, group C patients had higher risk relative to groups A/B without BECS (C vs B: odds ratio [OR], 3.2 [95% CI, 1-11; P = .05]; C vs A/B: OR, 2.4 [95% CI, 0.9-6.4; P = .08]). Patients treated at high-volume centers had significantly lower odds for development of type IA endoleak (OR, 0.2; 95% CI, 0.1-0.7; P = .01) irrespective of aortic or chimney device combination. Mortality risk was significantly higher in group C + BECS vs group A + BECS (HR, 5.3; 95% CI, 1.6-17.5; P = .006). The 1- and 3-year survival for groups A, B, and C (+BECS) was as follows: group A, 97% ± 1% and 92% ± 3%; group B, 93% ± 3% and 83% ± 7%; and group C, 84% ± 7% and 63% ± 14%. Use of more than one chimney subtype was associated with increased mortality (HR, 3.2; 95% CI, 1.4-7.5; P = .006).Within the PERICLES registry, use of nitinol/polyester stent graft devices with BECS during chimney endovascular aneurysm repair is associated with improved survival compared with other aortic endografts. However, this advantage was not observed for non-BECS repairs. Repairs incorporating multiple chimney subtypes were also associated with increased mortality risk. Importantly, increasing chimney stent number and bare-metal endolining stents increase chimney occlusion risk, whereas patients treated at low-volume centers have higher risk of type IA endoleak.

  View details for PubMedID 29395423

• Complex endovascular aneurysm repair is associated with higher perioperative mortality but not late mortality compared with infrarenal endovascular aneurysm repair among octogenarians. Journal of vascular surgery Tran, K., Lee, A. M., McFarland, G. E., Sgroi, M. D., Lee, J. T. 2018

  Abstract

  OBJECTIVE: As our collective experience with complex endovascular aneurysm repair (EVAR) has grown, an increasing number of older patients are being offered endovascular repair of juxtarenal aneurysms. Outcomes after complex EVAR in this older subpopulation are not well-described. We sought to specifically evaluate clinical outcomes after complex EVAR compared with infrarenal EVAR in a cohort of octogenarians.METHODS: A single-center retrospective review was conducted using a database of consecutive patients treated with elective EVAR for abdominal aortic aneurysms (AAAs) between 2009 and 2015. Only patients 80years of age or older were included. Patients in the complex EVAR group were treated with either snorkel/chimney or fenestrated techniques, whereas infrarenal EVAR consisted of aneurysm repair without renal or visceral involvement. Relevant demographic, anatomic, and device variables, and clinical outcomes were collected.RESULTS: There were 103 patients (68 infrarenal, 35 complex) treated within the study period with a mean follow-up of 21months. A total of 75 branch grafts were placed (59 renal, 11 celiac, 5 superior mesenteric artery) in the complex group, with a target vessel patency of 98.2% at latest follow-up. Patients undergoing complex EVAR were more likely to be male (82.8% vs 60.2%; P= .02) and have a higher prevalence of renal insufficiency (71.4% vs 44.2%; P= .008). The 30-day mortality was significantly greater in patients treated with complex EVAR (8.6% vs 0%; P= .03). There were no differences in major adverse events (P= .795) or late reintervention (P= .232) between groups. Interestingly, sac growth of more than 10mm was noted to be more frequent with infrarenal EVAR (17.6% vs 2.8%; P= .039). However, both type IA (5.7% infrarenal; 4.9% complex) and type II endoleaks (32.3% infrarenal; 25.7% complex) were found to be equally common in both groups. Complex EVAR was not associated with increased all-cause mortality at latest follow-up (P= .322). Multivariable Cox modeling demonstrated that AAAs greater than 75mm in diameter (hazard ratio; 4.9; 95% confidence interval, 4.6-48.2) and renal insufficiency (hazard ratio, 3.71; 95% confidence interval, 1.17-11.6) were the only independent risk factors of late death.CONCLUSIONS: Complex EVAR is associated with greater perioperative mortality compared with infrarenal EVAR among octogenarians. However, late outcomes, including the need for reintervention and all-cause mortality, are not significantly different. Larger aneurysms and chronic kidney disease portends greater risk of late death after EVAR, regardless of AAA complexity. These patient-related factors should be considered when offering endovascular treatment to older patients.

  View details for PubMedID 29970274

• Early Experience With the Octopus Endovascular Strategy in the Management of Thoracoabdominal Aneurysms Dua, A., Lavingia, K., Dake, M. D., Lee, J. T. MOSBY-ELSEVIER. 2018: E112

  View details for Web of Science ID 000433036700123

• Geometric Deformations of the Thoracic Aorta and Supra-Aortic Arch Branch Vessels Following Thoracic Endovascular Aortic Repair VASCULAR AND ENDOVASCULAR SURGERY Ullery, B. W., Suh, G., Hirotsu, K., Zhu, D., Lee, J. T., Dake, M. D., Fleischmann, D., Cheng, C. P. 2018; 52 (3): 173–80

  Abstract

  To utilize 3-D modeling techniques to better characterize geometric deformations of the supra-aortic arch branch vessels and descending thoracic aorta after thoracic endovascular aortic repair.Eighteen patients underwent endovascular repair of either type B aortic dissection (n = 10) or thoracic aortic aneurysm (n = 8). Computed tomography angiography was obtained pre- and postprocedure, and 3-D geometric models of the aorta and supra-aortic branch vessels were constructed. Branch angle of the supra-aortic branch vessels and curvature metrics of the ascending aorta, aortic arch, and stented thoracic aortic lumen were calculated both at pre- and postintervention.The left common carotid artery branch angle was lower than the left subclavian artery angles preintervention ( P < .005) and lower than both the left subclavian and brachiocephalic branch angles postintervention ( P < .05). From pre- to postoperative, no significant change in branch angle was found in any of the great vessels. Maximum curvature change of the stented lumen from pre- to postprocedure was greater than those of the ascending aorta and aortic arch ( P < .05).Thoracic endovascular aortic repair results in relative straightening of the stented aortic region and also accentuates the native curvature of the ascending aorta when the endograft has a more proximal landing zone. Supra-aortic branch vessel angulation remains relatively static when proximal landing zones are distal to the left common carotid artery.

  View details for PubMedID 29400263

• Acute Type B Dissection Causing Collapse of EVAR Endograft and Iliac Limb Occlusion Itoga, N. K., Wu, T., Dake, M. D., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2018: 206.e1–206.e4

  Abstract

  We describe a rare case of acute type B dissection (ATBDs) causing collapse of a previously placed infrarenal stent graft, resulting in acute limb ischemia due to left iliac limb thrombosis in a 59-year-old male. The patient presented with acute back and abdominal discomfort radiating to his back, bilateral buttock stabbing discomfort and left > right thigh and calf rest pain. CT angiography showed a spiral type B dissection with collapse of the proximal portion of the endovascular repair of aortic aneurysm (EVAR) device and left limb occlusion. Urgent treatment with thoracic endovascular aortic repair distal to the left subclavian covered the entry tear and redirected the majority of the flow to the true lumen leading to near immediate expansion of the proximal portion of the EVAR device. After surgical femoral control, balloon embolectomy of the occluded iliac limb was performed and the limb relined. His lower extremity ischemic symptoms resolved, and his abdominal and back pain dissipated. At latest 6-month follow-up, CT angiography shows an intact thoracic endovascular aortic repair stent graft and a widely patent EVAR stent graft, and the patient has no further abdominal, back, or leg symptoms. ATBD causing proximal abdominal EVAR collapse is an extremely rare presentation of false lumen pressurization and can be treated similarly to complicated type B dissection with the goal of restoring true lumen patency.

  View details for PubMedID 28739456

  View details for PubMedCentralID PMC5842241

• Changes in Geometry and Cardiac Deformation of the Thoracic Aorta after Thoracic Endovascular Aortic Repair Hirotsu, K., Suh, G., Lee, J. T., Dake, M. D., Fleischmann, D., Cheng, C. P. ELSEVIER SCIENCE INC. 2018: 83–89

  View details for DOI 10.1016/j.avsg.2017.07.033

  View details for Web of Science ID 000418233100011

• Changes in Geometry and Cardiac Deformation of the Thoracic Aorta after Thoracic Endovascular Aortic Repair. Annals of vascular surgery Hirotsu, K., Suh, G., Lee, J. T., Dake, M. D., Fleischmann, D., Cheng, C. P. 2017

  Abstract

  BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has dramatically expanded treatment options for patients with thoracic aortic pathology. The interaction between endografts and the dynamic anatomy of the thoracic aorta is not well characterized for repetitive physiologic stressors and subsequent issues related to long-term durability. Through three-dimensional (3D) modeling we sought to quantify cardiac-induced aortic deformation before and after TEVAR to assess the impact of endografts on dynamic aortic anatomy.METHODS: Eight patients with acute (n=4) or chronic (n=3) type B dissections, or chronic arch aneurysm (n=1), underwent TEVAR with a single (n=5) or multiple (n=3) Gore C-TAG(s). Cardiac-resolved thoracic CT images were acquired pre- and post-TEVAR. 3D models of thoracic aorta and branch vessels were constructed in systole and diastole. Axial length, mean, and peak curvature of the ascending aorta, arch, and stented lumens were computed from the aortic lumen centerline, delineated with branch vessel landmarks. Cardiac-induced deformation was computed from mid-diastole to end-systole.RESULTS: Pre-TEVAR, there were no significant cardiac-induced changes for aortic axial length or mean curvature. Post-TEVAR, the ascending aorta increased in axial length (2.7±3.1%, P<0.05) and decreased in mean curvature (0.38±0.05 0.36±0.05cm-1, P<0.05) from diastole to systole. From pre- to post-TEVAR, axial length change increased in the ascending aorta (P<0.02), mean curvature decreased in the arch and stented aorta (P<0.03), and peak curvature decreased in the stented aorta (P<0.05).CONCLUSIONS: TEVAR for a range of indications not only causes direct geometric changes to the stented aorta but also results in dynamic changes to the ascending and stented aorta. In our cohort, endograft placement straightens the stented aorta and mutes cardiac-induced bending due to longitudinal stiffness. This is compensated by greater length and curvature changes from diastole to systole in the ascending aorta, relative to pre-TEVAR.

  View details for PubMedID 28887263

• Complex EVAR Is Associated With Higher Perioperative Mortality but Not Late-Mortality Compared to Infrarenal EVAR Amongst Octogenarians Tran, K., Lee, A., McFarland, G., Sgroi, M., Itoga, N., Lee, J. MOSBY-ELSEVIER. 2017: E47

  View details for Web of Science ID 000412559500008

• 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

• Impact of Discordant Views in the Management of Descending Thoracic Aortic Aneurysm SEMINARS IN THORACIC AND CARDIOVASCULAR SURGERY Chiu, P., Sailer, A., Baiocchi, M., Goldstone, A. B., Schaffer, J. M., Trojan, J., Fleischmann, D., Mitchell, R., Miller, D., Dake, M. D., Woo, Y., Lee, J. T., Fischbein, M. P. 2017; 29 (3): 283–91

  Abstract

  Thoracic endovascular aortic repair has a lower perceived risk than open surgical repair and has become an increasingly popular alternative. Whether general consensus exists regarding candidacy for either operation among open and endovascular specialists is unknown. A retrospective review of isolated descending thoracic aortic aneurysm at our institution between January 2005 and October 2015 was performed, excluding trauma and dissection. Two cardiac surgeons, 2 cardiovascular surgeons, 1 vascular surgeon, and 1 interventional radiologist gave their preference for open vs endovascular repair. Interobserver agreement was assessed with the kappa coefficient. k-means clustering agnostically grouped various patterns of agreement. The mean rating was predicted using least absolute shrinkage and selection operator regression. Negative binomial regression predicted the discrepancy between our panel of raters and the historical operation. Generalized estimating equation modeling was then used to evaluate the association between the extent of discrepancy and the adverse perioperative outcome. There were 77 patients with preoperative imaging studies. Pairwise interobserver agreement was only fair (median weighted kappa 0.270 [interquartile range 0.211-0.404]). Increasing age and proximal neck length predicted an increasing preference for thoracic endovascular aortic repair in our panel; larger proximal neck diameter predicted a general preference for open surgical repair. Increasing proximal neck diameter predicted a larger discrepancy between our panel and the historical operation. Greater discrepancy was associated with adverse outcome. Substantial disagreement existed among our panel, and an exploratory analysis of the effect of increasing discrepancy demonstrated an association with adverse perioperative outcome. An investigation of the effect of a thoracic aortic team with open and endovascular specialists is warranted.

  View details for PubMedID 29195571

• 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

• 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

• Practice Patterns of Fenestrated Aortic Aneurysm Repair: Nationwide Comparison of Z-Fen Adoption at Academic and Community Centers Since Commercial Availability Wiske, C. P., Rockman, C., Lee, J. T., Maldonado, T. MOSBY-ELSEVIER. 2017: 81S–82S

  View details for DOI 10.1016/j.jvs.2017.03.153

  View details for Web of Science ID 000403108000142

• Prospective, multicenter study of endovascular repair of aortoiliac and iliac aneurysms using the Gore Iliac Branch Endoprosthesis. Journal of vascular surgery Schneider, D. B., Matsumura, J. S., Lee, J. T., Peterson, B. G., Chaer, R. A., Oderich, G. S. 2017

  Abstract

  The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, Ariz) is an iliac branch stent graft system designed to preserve internal iliac artery perfusion during endovascular repair of aortoiliac aneurysms (AIAs) and common iliac artery (CIA) aneurysms (CIAAs). We report the 6-month primary end point results of the IBE 12-04 United States pivotal trial for endovascular treatment of AIAs and CIAAs using the IBE device.The trial prospectively enrolled 63 patients with AIA or CIAA who underwent implantation of the IBE device at 28 centers in the United States from 2013 to 2015. All patients underwent placement of a single IBE device. Twenty-two patients (34.9%) with bilateral CIAs were enrolled after undergoing staged coil or plug embolization (21 of 22) or surgical revascularization (1 of 22) of the contralateral internal iliac artery. Follow-up at 30 days and 6 months included clinical assessment and computed tomography angiography evaluation as assessed by an independent core laboratory. The primary effectiveness end point was freedom from IBE limb occlusion and reintervention for type I or III endoleak and ≥60% stenosis at 6 months, and the secondary effectiveness end point was freedom from new onset of buttock claudication on the IBE side at 6 months.Mean CIA diameter on the IBE side was 41.0 ± 11.4 mm (range, 25.2-76.3 mm). There were no procedural deaths, and technical success, defined as successful deployment and patency of all IBE components and freedom from type I or III endoleak, was 95.2% (60 of 63). Data for 61 patients were available for primary and secondary effectiveness end point analysis. Internal iliac limb patency was 95.1% (58 of 61), and no new type I or III endoleaks or device migrations were observed at 6 months. The three patients with loss of internal iliac limb patency were asymptomatic, and freedom from new-onset buttock claudication on the IBE side was 100% at 6 months. New-onset buttock claudication occurred on the non-IBE treatment side in six of 21 patients (28.6%) who underwent staged internal iliac artery coil embolization.These results confirm that the IBE device is effective at treating CIAAs and AIAs, maintaining blood flow into the internal iliac artery, and avoiding complications associated with internal iliac artery sacrifice. Follow-up will be continued for 5 years to establish the long-term durability of iliac aneurysm repair with the IBE device.

  View details for DOI 10.1016/j.jvs.2017.02.041

  View details for PubMedID 28559174

• Percutaneous Septectomy in Chronic Dissection with Abdominal Aortic Aneurysm Creates Uniluminal Neck for EVAR. Cardiovascular and interventional radiology Gissler, M. C., Ogawa, Y., Lee, J. T., Chandra, V., Dake, M. D. 2017

  Abstract

  The intent of this report is to describe the technical details and rationale of endovascular septectomy using a wire saw maneuver in cases of chronic aortic dissection and associated infra-renal aortic aneurysm to allow standard endovascular abdominal aortic graft placement; preliminary clinical experience is also retrospectively reviewed.Between June 2013 and June 2016, four consecutive patients (mean age 55.3 years; range 52-58 years) with chronic type B aortic dissection and isolated infra-renal abdominal aortic aneurysm (AAA) underwent endovascular aneurysm repair (EVAR) following guidewire septectomy to create a suitable proximal aortic landing zone. Technical success was evaluated by angiography performed at the end of the procedure. Procedural safety was determined by assessing any major adverse events through 30 days of follow-up. Endoleaks and longer-term efficacy were evaluated.Four patients with chronic aortic dissections had associated AAA with a mean maximum diameter of 60 ± 13 mm (range 50-77 mm). All underwent guidewire saw septectomy to facilitate EVAR. Following successful septectomy, standard abdominal bifurcated endografts were implanted uneventfully. No major adverse events and no endoleaks were noted on CT angiographic examinations through 30 days following the procedure. Also, no rupture, re-intervention or endoleak has been noted during follow-up at a mean of 21.8 ± 15 months (range 4-39 months).Guidewire saw septectomy is a technique that has the potential to create an anatomically suitable proximal neck for successful EVAR management of AAA in select patients with associated chronic aortic dissection.

  View details for DOI 10.1007/s00270-017-1668-3

  View details for PubMedID 28493108

• Gender-Related Differences in Iliofemoral Arterial Anatomy among Abdominal Aortic Aneurysm Patients. Annals of vascular surgery Tran, K., Dorsey, C., Lee, J. T., Chandra, V. 2017

  Abstract

  Gender-related differences in iliofemoral anatomy are critically important for delivery of modern EVAR devices, however remains poorly characterized in the context of other patient-specific factors. The goal of the present study was to provide a detailed quantification of anatomic differences in iliofemoral anatomy between genders while controlling for height, weight, and vascular comorbidities.Fifty women with computed tomography angiograms for evaluation of abdominal aortic aneurysm between 2000 and 2012 were selected and matched to an equal nonpaired cohort of males with similar age, body mass indices (BMIs), and prevalence of vascular comorbidities (e.g., coronary artery disease, peripheral vascular disease). A 3-dimensional workstation was used to measure outer and inner diameters at anatomic reference locations at the common iliac (CIA), external iliac (EIA), and common femoral (CFA) arteries. Iliac aneurysms were excluded from analysis. Multivariate analysis-of-covariance models were employed for evaluating CIA, EIA, and CFA diameters as dependent variables.Luminal diameters were significantly smaller at the CIA (8.8 vs. 11.8 mm, P < 0.001), EIA (7.0 vs. 8.4 mm, P < 0.001), and CFA (6.7 vs. 9.5 mm, P < 0.001) arteries between men and women despite similar BMIs (27.7 vs. 27.5, P = 0.20). Similar statistically significant differences were found between men and women when comparing adventitial diameters (P < 0.001), however not when comparing degrees of stenosis (defined as outer diameter minus inner diameter [P = 0.96]). Female gender was negatively correlated with luminal diameter at the CIA (-2.34 [-3.72 to -0.96]; coef. [95% CI]), EIA (-0.95 [-1.8 to -0.04]), and CFA (-2.61 [-3.51 to -1.71]) arteries. Weight (per 10 kg) was positively correlated with luminal diameters measured at the CIA (0.41 [0.12-0.68]) and CFA (0.35 [0.16-0.53]). No independent relationships between height, vascular comorbidities, and arterial diameters were identified. 24% (n = 12) of females compared to only 14% (n = 7) of males in this study would have been ineligible for EVAR with current devices due to poor iliac access criteria.Women have significantly smaller iliofemoral arterial systems compared to men, even after controlling for height, weight, and other comorbidities that are known to affect vascular anatomy. This quantifiable difference in arterial anatomy is important to consider when deciding between various open versus endovascular treatment strategies for women.

  View details for DOI 10.1016/j.avsg.2017.01.025

  View details for PubMedID 28479440

• Dynamic Geometric Analysis of the Renal Arteries and Aorta following Complex Endovascular Aneurysm Repair. Annals of vascular surgery Ullery, B. W., Suh, G., Kim, J. J., Lee, J. T., Dalman, R. L., Cheng, C. P. 2017

  Abstract

  Aneurysm regression and target vessel patency during early and mid-term follow-up may be related to the effect of stent-graft configuration on the anatomy. We quantified geometry and remodeling of the renal arteries and aneurysm following fenestrated (F-) or snorkel/chimney (Sn-) endovascular aneurysm repair (EVAR).Twenty-nine patients (mean age, 76.8 ± 7.8 years) treated with F- or Sn-EVAR underwent computed tomography angiography at preop, postop, and follow-up. Three-dimensional geometric models of the aorta and renal arteries were constructed. Renal branch angle was defined relative to the plane orthogonal to the aorta. End-stent angle was defined as the angulation between the stent and native distal artery. Aortic volumes were computed for the whole aorta, lumen, and their difference (excluded lumen). Renal patency, reintervention, early mortality, postoperative renal impairment, and endoleak were reviewed.From preop to postop, F-renal branches angled upward, Sn-renal branches angled downward (P < 0.05), and Sn-renals exhibited increased end-stent angulation (12 ± 15°, P < 0.05). From postop to follow-up, branch angles did not change for either F- or Sn-renals, whereas F-renals exhibited increased end-stent angulation (5 ± 10°, P < 0.05). From preop to postop, whole aortic and excluded lumen volumes increased by 5 ± 14% and 74 ± 81%, whereas lumen volume decreased (39 ± 27%, P < 0.05). From postop to follow-up, whole aortic and excluded lumen volumes decreased similarly (P < 0.05), leaving the lumen volume unchanged. At median follow-up of 764 days (range, 7-1,653), primary renal stent patency was 94.1% and renal impairment occurred in 2 patients (6.7%).Although F- and Sn-EVAR resulted in significant, and opposite, changes to renal branch angle, only Sn-EVAR resulted in significant end-stent angulation increase. Longitudinal geometric analysis suggests that these anatomic alterations are primarily generated early as a consequence of the procedure itself and, although persistent, they show no evidence of continued significant change during the subsequent postoperative follow-up period.

  View details for DOI 10.1016/j.avsg.2016.12.005

  View details for PubMedID 28390918

• Change in Aortic Neck Diameter after Endovascular Aortic Aneurysm Repair. Annals of vascular surgery Kret, M. R., Tran, K., Lee, J. T. 2017

  Abstract

  Implications of aortic neck dilatation following endovascular aneurysm repair (EVAR) are unclear. Previous studies are limited to comparisons of individual, early generation devices. We compared aortic neck dilatation among contemporary stent grafts.We reviewed preoperative and postoperative computed tomographic angiograms for EVARs performed from 2008-2014. Images were analyzed using 3-dimensional centerline reconstructions. Aortic neck diameter was measured in orthogonal planes at and 10 mm below the lowest renal artery. Device type and main body graft diameter were obtained from operative reports.Eighty-six patients were analyzed with a median radiologic follow-up of 21.9 months (range: 4-64). Stent grants implanted included 26 Cook Zenith, 26 Gore Excluder, 22 Medtronic Endurant, 10 Endologix Powerlink, and 2 Trivascular Ovation devices. Mean device oversizing was 13.6 ± 11.5% and did not vary by device type (P = 0.54). Most patients (86.0%) experienced increases in aortic neck diameter during follow-up, with a mean increase of 1.3 ± 2.2 mm (5.9 ± 9.3%) and 3.3 ± 0.6 mm (8.9 ± 2.5%) at 30 day and latest follow-up scans, respectively. Repeated-measures analysis further demonstrated a significant increase in mean neck dilatation during follow-up (P < 0.001). Neck dilatation was not significantly different across different devices (P = 0.233). However, there was a moderate positive correlation between percent change in neck diameter and degree of oversizing, which was statistically significant (rs = 0.41, P < 0.001). Type Ia endoleak was observed in 2 patients and was associated with greater mean neck dilatation (8.8 ± 3.3 mm vs. 3.35 ± 2.71, P = 0.041). There was no relationship between changes in neck diameter and sac regression/expansion.Aortic neck diameter increases consistently over time following EVAR. The degree of neck dilatation correlates with degree of device oversize but not with device type.

  View details for DOI 10.1016/j.avsg.2016.11.013

  View details for PubMedID 28341512

• Impact of an Interactive Vascular Surgery Web-Based Educational Curriculum on Surgical Trainee Knowledge and Interest. Journal of surgical education Zayed, M. A., Lilo, E. A., Lee, J. T. 2017; 74 (2): 251-257

  Abstract

  The surgical council on resident education developed an online competency-based self-study curriculum for general surgery residency trainees. Vascular surgery trainees are yet to have a similarly validated and readily accessible self-study curriculum. We sought to determine the effect of an interactive online vascular surgery curriculum on trainee knowledge and interest in vascular surgery.Over 15 months, 53 trainees (36 medical students and 16 surgical residents) performing a vascular surgery rotation were enrolled in a prospective, randomized, 2-cohort study. Before starting a 4-week rotation, trainee baseline demographics were collected, and a pretest was administered to evaluate baseline vascular surgery knowledge. During the same study period, 31 trainees (GROUP 1) were randomized to an interactive online curriculum with weekly reading assignments, and 21 trainees (GROUP 2) did not have access to the online curriculum. At the conclusion, all trainees received a posttest and survey to evaluate any change in vascular surgery knowledge and interest.Although 26.8% of trainees predicted that online computer modules would be a beneficial learning tool, most of trainees indicated textbook reading and case discussions are preferred. Analysis of GROUPS 1 and 2 revealed no significant differences in the average trainee age, training level, sex, or number of surgical cases observed during the rotation. Improvement in vascular surgery knowledge in GROUP 1 was significantly higher compared to GROUP 2 (average increase in posttest scores of 16.1% vs 6.6%, p = 0.009). New interest in vascular surgery was increased by 22.2% in GROUP 1, but was decreased by 40% in GROUP 2 (p < 0.001).Basic vascular surgery principles can be efficiently introduced through an interactive online curriculum. This type of self-study can improve trainee knowledge, and foster interest in vascular surgery. As in other specialties, a standardized and validated online vascular surgery curriculum should be developed for emerging trainees.

  View details for DOI 10.1016/j.jsurg.2016.09.003

  View details for PubMedID 27727138

• Orientation of Renal Stent Grafts Within the Proximal Seal Zone Affects Risk of Early Type Ia Endoleaks Following Snorkel-Chimney Endovascular Aneurysm Repair Tran, K., Ullery, B. W., Itoga, N. K., Lee, J. T. MOSBY-ELSEVIER. 2017: E1

  View details for DOI 10.1016/j.jvs.2016.12.025

  View details for Web of Science ID 000397987900002

• Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair. Journal of vascular surgery Ullery, B. W., Tran, K., Itoga, N. K., Dalman, R. L., Lee, J. T. 2017

  Abstract

  Alternative endovascular strategies using parallel or snorkel/chimney (chimney endovascular aneurysm repair [ch-EVAR]) techniques have been developed to address the lack of widespread availability and manufacturing limitations with branched/fenestrated aortic devices for the treatment of complex abdominal aortic aneurysms. Despite high technical success and midterm patency of snorkel stent configurations, concerns remain regarding the perceived increased incidence of early gutter-related type Ia endoleaks. We aimed to evaluate the incidence and natural history of gutter-related type Ia endoleaks following ch-EVAR.Review of medical records and available imaging studies, including completion angiography and serial computed tomographic angiography, was performed for all patients undergoing ch-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Primary outcomes of the study were presence and persistence or resolution of early gutter-related type Ia endoleak. Secondary outcomes included aneurysm sac shrinkage and need for secondary intervention related to the presence of type Ia gutter endoleak.Sixty patients (mean age, 75.8 ± 7.6 years; male, 70.0%) underwent ch-EVAR with a total of 111 snorkel stents (97 renal [33 bilateral renal], 12 superior mesenteric artery, 2 celiac). A mean of 1.9 ± 0.6 snorkel stents were placed per patient. Early gutter-related type Ia endoleaks were noted on 30.0% (n = 18) of initial postoperative imaging studies. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 44.3%, 65.2%, and 88.4% of patients at 6, 12, and 18 months postprocedure, respectively. Long-term anticoagulation, degree of oversizing, stent type and diameter, and other clinical/anatomic variables were not significantly associated with presence of gutter endoleaks. Two patients (3.3%) required secondary intervention related to persistent gutter endoleak. At a mean radiologic follow-up of 20.9 months, no difference in mean aneurysm sac size change was observed between those with or without early type Ia gutter endoleak (-6.1 ± 10.0 mm vs -4.9 ± 11.5 mm; P = .23).Gutter-related type Ia endoleaks represent a relatively frequent early occurrence after ch-EVAR, but appears to resolve spontaneously in the majority of cases during early to midterm follow-up. Given that few ch-EVAR patients require reintervention related to gutter endoleaks and the presence of such endoleak did not correlate to increased risk for aneurysm sac growth, its natural history may be more benign than originally expected.

  View details for DOI 10.1016/j.jvs.2016.10.085

  View details for PubMedID 28189356

• Outcomes of Endovascular Repair of Aortoiliac Aneurysms and Analyses of Anatomic Suitability for Internal Iliac Artery Preserving Devices in Japanese Patients. Circulation journal Itoga, N. K., Fujimura, N., Hayashi, K., Obara, H., Shimizu, H., Lee, J. T. 2017

  Abstract

  Understanding that the common iliac arteries (CIA) are shorter in Asian patients, we investigated whether this anatomic difference affects the clinical outcomes of internal iliac artery (IIA) exclusion during endovascular aneurysm repair (EVAR) of aortoiliac aneurysm and thus limits the use of IIA-preserving devices in Japanese patients.Methods and Results:From 2008 to 2014, 69 Japanese patients underwent EVAR of aortoiliac aneurysms with 53 unilateral and 16 bilateral IIA exclusions. One patient had persistent buttock claudication during follow-up; however, colonic or spinal cord ischemia was not observed. Anatomic suitability was investigated for the iliac branch device (IBD) by Cook Medical and the iliac branch endoprosthesis (IBE) by WL Gore: 87 aortoiliac segments were analyzed, of which 17% met the criteria for the IBD, 25% met the criteria for the IBE and 40% met the criteria for either. Main exclusions for the IBD were IIA diameter >9 mm or <6 mm (47%) and CIA length <50 mm (39%). Main exclusions for the IBE were proximal CIA diameter <17 mm (44%) and aortoiliac length <165 mm (24%).EVAR with IIA exclusions in Japanese patients showed low incidence of persistent buttock claudication and no major pelvic complications. Aorto-iliac morphology demonstrated smaller proximal CIA diameters and shorter CIA lengths, limiting the use of IIA-preserving devices.

  View details for DOI 10.1253/circj.CJ-16-1109

  View details for PubMedID 28154297

• Real-World Performance of Paclitaxel Drug-Eluting Bare Metal Stenting (Zilver PTX) for the Treatment of Femoropopliteal Occlusive Disease ANNALS OF VASCULAR SURGERY Tran, K., Ullery, B. W., Kret, M. R., Lee, J. T. 2017; 38: 90-98

  Abstract

  The aim of this study was to evaluate the performance and predictors of stent failure of paclitaxel drug-eluting stents for the treatment of femoropopliteal disease.A retrospective review of clinical and angiographic data was performed for patients treated for femoropopliteal disease with the Zilver PTX (Cook Medical, Bloomington, IN) stent by a single operator between 2012 and 2015 at a tertiary referral center. Clinical grading was determined by both Rutherford classification and the Society for Vascular Surgery's Wound, Ischemia, and Foot Infection (WIFi) scoring system, and lesions were classified anatomically by the TransAtlantic Intersociety Consensus (TASC) II criteria. Treated lesions included those with prior in-stent restenosis and long-segment disease. Primary clinical end points were stent failure, need for reintervention, and major adverse limb events (MALE). Kaplan-Meier methods and Cox proportional hazard models were used to evaluate factors affecting outcomes.Zilver PTX stents were placed in 52 limbs among 46 patients (71.1% male, mean age 72.6 years) with a median follow-up of 11.1 (range 1-26) months. Limbs were treated for life-disabling claudication in 76.9% and critical limb ischemia in 23.1%. Disease severity was highly variable, with 21 (40.4%) limbs with TASC C or D lesions and 16 (30.7%) treated for restenosis after prior endovascular treatment. During follow-up, 6 (12.7%) limbs experienced loss of stent patency (5 occlusions, one >50% restenosis). Four limbs underwent target lesion revascularization, 2 required open bypass, 2 underwent thrombolysis, and no patients required major amputation. Primary patency was 88.9%, 81.6%, and 81.6% at 6, 12, and 18 months, respectively. Treated lesion length (hazard ratio [HR] 4.99, 95% confidence interval [CI] 1.14-21.75) was the only independent predictor of patency loss. Freedom from target lesion revascularization at 6, 12, and 18 months was 94.2%, 87.8%, and 87.8%, respectively. Freedom from MALE (composite of thrombolysis, major amputation, and bypass operation) was 97.5%, 90.9%, and 79.6% at 6, 12, and 18 months, respectively. Chronic renal insufficiency was the only factor that trended toward increased risk of MALE (HR 9.92, 95% CI 0.86-113.35) within a multivariate model.Our real-world experience supports the continued use of the Zilver PTX for the treatment of both de novo lesions and lesions with prior endovascular revascularization in the femoropopliteal segment. Routine follow-up between 6 and 12 months postoperatively is essential for detecting early restenosis and guiding reintervention. Careful attention when treating complex lesions and long-segment disease remains important for selecting the optimal revascularization strategy for individual patients and optimizing stent patency.

  View details for DOI 10.1016/j.avsg.2016.08.006

  View details for Web of Science ID 000396441100014

• Challenging AAA Neck Anatomy: Does the Fenestrated or Snorkel/Chimney Technique Improve Mortality and Freedom from Reintervention Relative to Open Repair? DIFFICULT DECISIONS IN VASCULAR SURGERY: AN EVIDENCE-BASED APPROACH Ullery, B. W., Lee, J. T., Skelly, C. L., Milner, R. 2017: 49–61

  View details for DOI 10.1007/978-3-319-33293-2_5

  View details for Web of Science ID 000428461500006

• 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

• Incidence and prognostic factors related to major adverse cerebrovascular events in patients with complex aortic diseases treated by the chimney technique. Journal of vascular surgery Bosiers, M. J., Tran, K. n., Lee, J. T., Donas, K. P., Veith, F. J., Torsello, G. n., Pecoraro, F. n., Stavroulakis, K. n. 2017

  Abstract

  Endovascular aneurysm repair (EVAR) with the chimney technique (ch-EVAR) has been used for the treatment of aortic aneurysms as an alternative approach to fenestrated endografting or open repair. Nonetheless, the need for an upper extremity arterial access may contribute to a higher risk for periprocedural cerebrovascular events. This study reports on the perioperative cerebral and major adverse cardiac and cerebrovascular events (MACCE) after ch-EVAR.The PERICLES registry (PERformance of the chImney technique for the treatment of Complex aortic pathoLogiES) is an international, retrospective multicenter study evaluating the performance of ch-EVAR for the treatment of complex aortic pathologies. For the purpose of the current analysis, 425 patients treated by ch-EVAR between 2008 and 2014 were included. The primary outcome of this analysis was the incidence of procedure related cerebrovascular events defined as transient ischemic attack or stroke. The secondary end point was in-hospital MACCE, including acute coronary syndrome, stroke, and death of any cause.The incidence of clinical relevant cerebrovascular events was 1.9% (8/425). A postoperative transient ischemic attack was observed in four patients (0.95%) and a stroke in additional four (0.95%). Three patients died during the hospital stay secondary to sequelae from postoperative stroke. A prior history of stroke/transient ischemic attack, atrial fibrillation, previous carotid revascularization, or known carotid artery disease did not significantly increase the risk for adverse neurologic events. The overall MACCE rate amounted to 8.5% (36/425). Logistic regression analysis revealed that the use of bilateral upper extremity access (odds ratio [OR], 2.79; 95% confidence interval [CI], 1.04-7.45]), aneurysm rupture (OR, 5.33; 95% CI, 1.74-16.33), and a prolonged operation time (>290 minutes; OR, 1.005; 95% CI, 1.001-1.008) were associated with a significantly increased risk for MACCE.This analysis demonstrates that ch-EVAR is associated with a relatively low rate of cerebrovascular events. However, a postoperative stroke is associated with increased mortality. Ruptured aneurysms, bilateral upper extremity access as in case of multiple chimney graft placement, and longer operative times were identified as independent risk factors for MACCE.

  View details for PubMedID 29103932

• Polar orientation of renal grafts within the proximal seal zone affects risk of early type Ia endoleaks after chimney endovascular aneurysm repair. Journal of vascular surgery Tran, K. n., Ullery, B. W., Itoga, N. n., Lee, J. T. 2017

  Abstract

  The objective of this study was to describe the polar orientation of renal chimney grafts within the proximal seal zone and to determine whether graft orientation is associated with early type Ia endoleak or renal graft compression after chimney endovascular aneurysm repair (ch-EVAR).Patients who underwent ch-EVAR with at least one renal chimney graft from 2009 to 2015 were included in this analysis. Centerline three-dimensional reconstructions were used to analyze postoperative computed tomography scans. The 12-o'clock polar position was set at the takeoff of the superior mesenteric artery. Relative polar positions of chimney grafts were recorded at the level of the renal artery ostium, at the mid-seal zone, and at the proximal edge of the graft fabric. Early type Ia endoleaks were defined as evidence of a perigraft flow channel within the proximal seal zone.There were 62 consecutive patients who underwent ch-EVAR (35 double renal, 27 single renal) for juxtarenal abdominal aortic aneurysms with a mean follow-up of 31.2 months; 18 (29%) early type Ia "gutter" endoleaks were identified. During follow-up, the majority of these (n = 13; 72%) resolved without intervention, whereas two patients required reintervention (3.3%). Estimated renal graft patency was 88.9% at 60 months. Left renal chimney grafts were most commonly at the 3-o'clock position (51.1%) at the ostium, traversing posteriorly to the 5- to 7-o'clock positions (55.5%) at the fabric edge. Right renal chimney grafts started most commonly at the 9-o'clock position (n = 17; 33.3%) and tended to traverse both anteriorly (11 to 1 o'clock; 39.2%) and posteriorly (5 to 7 o'clock; 29.4%) at the fabric edge. In the polar plane, the majority of renal chimney grafts (n = 83; 85.6%) traversed <90 degrees before reaching the proximal fabric edge. Grafts that traversed >90 degrees were independently associated with early type Ia endoleaks (odds ratio, 11.5; 95% confidence interval, 2.1-64.8) even after controlling for other device and anatomic variables. Polar orientation of the chimney grafts was not associated with graft kinking or compression (P = .38) or occlusion (P = .10). Takeoff angle of the renal arteries was the most significant predictor of chimney graft orientation. Caudally directed arteries (takeoff angle >30 degrees) were less likely to have implanted chimney grafts that traversed >90 degrees in polar angle (odds ratio, 0.09; 95% confidence interval, 0.01-0.55).Renal chimney grafts vary considerably in both starting position and their polar trajectory within the proximal seal zone. Grafts that traverse >90 degrees in polar angle within the seal zone may be at increased risk of early type Ia endoleaks and require more frequent imaging surveillance. Caudally directed renal arteries result in a more favorable polar geometry (eg, cranial-caudal orientation) with respect to endoleak risk and thus are more ideal candidates for parallel graft strategies.

  View details for PubMedID 29074111

• 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

• Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm. Journal of vascular surgery Zettervall, S. L., Soden, P. A., Buck, D. B., Cronenwett, J. L., Goodney, P. P., Eslami, M. H., Lee, J. T., Schermerhorn, M. L. 2016

  Abstract

  Limited data exist comparing perioperative morbidity and mortality after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR) among regions of the United States. This study evaluated the regional variation in mortality and perioperative outcomes after repair of AAAs.The Vascular Quality Initiative (VQI) was used to identify patients undergoing open AAA repair and EVAR between 2009 and 2014. Ruptured and intact aneurysms were evaluated separately, and the analysis of intact aneurysms was limited to infrarenal AAAs. All 16 regions of the VQI were deidentified, and those with <100 open repairs were combined to eliminate the effect of low-volume regions. Regional variation was evaluated using χ(2) and Fisher exact tests. Regional rates were compared against current quality benchmarks.Perioperative outcomes from 14 regions were compared. After open repair of intact aneurysms, no significant variation was seen in 30-day or in-hospital mortality; however, multiple regions exceeded the Society for Vascular Surgery benchmark for in-hospital mortality after open repair of intact aneurysms of <5% (range, 0%-7%; P = .55). After EVAR, all regions met the Society for Vascular Surgery benchmark of <3% (range, 0%-1%; P = .75). Significant variation in in-hospital mortality existed after open (14%-63%; P = .03) and endovascular (3%-32%; P = .03) repair of ruptured aneurysms across the VQI regional groups. After repair of intact aneurysms, wide variation was seen in prolonged length of stay (>7 days for open repair: 32%-53%, P = .54; >2 days for EVAR: 16-43%, P < .01), transfusion (open: 10%-35%, P < .01; EVAR: 7%-18%, P < .01), use of vasopressors (open: 19%-37%, P < .01; EVAR: 3%-7%, P < .01), and postoperative myocardial infarction (open: 0%-13%, P < .01; EVAR: 0%-3%, P < .01). After open repair, worsening renal function (6%-18%; P = .04) and respiratory complications (6%-20%; P = .20) were variable across regions. The frequency of endoleak at completion of EVAR also had considerable variation (15%-38%; P < .01).Despite limited variation, multiple regions do not meet current benchmarks for in-hospital mortality after open AAA repair for intact aneurysms. Significant regional variation exists in perioperative outcomes and length of stay, and mortality is widely variable after repair for rupture. These data identify important areas for quality improvement initiatives and clinical practice guidelines.

  View details for DOI 10.1016/j.jvs.2016.08.110

  View details for PubMedID 27887854

• Regional variation exists in patient selection and treatment of abdominal aortic aneurysms. Journal of vascular surgery Zettervall, S. L., Buck, D. B., Soden, P. A., Cronenwett, J. L., Goodney, P. P., Eslami, M. H., Lee, J. T., Schermerhorn, M. L. 2016; 64 (4): 921-927 e1

  Abstract

  Significant regional variation in surgical rates has been identified following multiple surgical procedures. However, limited data have examined the regional variability in patient selection and treatment of abdominal aortic aneurysms (AAAs). This study aimed to evaluate regional variation in patient selection, perioperative management, and operative approach for the repair of AAAs.All patients undergoing open repair or endovascular aneurysm repair (EVAR) of an AAA in the Vascular Quality Initiative from 2009 to 2014 were identified. All regional groups were deidentified, and those with fewer than 100 open repairs were combined into a single region.We identified 17,269 elective repairs (EVAR, 13,759; open, 3510) and 1462 ruptured AAAs (EVAR, 749; open, 713). There was significant regional variation in the use of EVAR for elective repair (range, 66%-88%; P < .01) and ruptured AAA repair (40%-80%; P < .01). The median diameter for elective repair was similar among regions (EVAR, 5.4 cm; open, 5.7 cm). There was wide variation in the treatment of small aneurysms in male patients (<5.5 cm) for EVAR (34%-49%; P < .01) and open repair (17%-38%; P < .01) and variation in the treatment of small aneurysms in female patients (<5 cm) for EVAR (14%-32%; P < .01) but not significant for open repair (6%-24%). For elective cases, preoperative aspirin (EVAR, 50%-75% [P < .01]; open, 49%-78% [P < .01]) and statin use (EVAR, 61%-75% [P < .01]; open, 56%-80% [P < .01]) varied widely. Among elective cardiac patients, preoperative management varied significantly, including beta-blocker use (EVAR, 66%-78% [P < .01]; open, 69%-88% [P = .01]) and the frequency of stress tests (EVAR, 33%-64% [P < .01]; open, 31%-73% [P < .01]). Among open repairs for aneurysms extending at or beyond the juxtarenal segment, there was wide variation in the use of retroperitoneal exposures (7%-70%; P < .01) and adjunctive renal protective measures (cold renal perfusion, 2%-43% [P < .01]; mannitol, 47%-92% [P < .01]).Significant regional variation exists in patient selection, perioperative management, and operative approach for the repair of AAA. Definitive evidence is lacking in many aspects of operative care, including the use of the retroperitoneal approach and renal protective strategies. However, this variation emphasizes the importance of research to determine best practice in the areas of greatest variation. Furthermore, where current clinical process measures exist and data are clear, such as the use of statin and antiplatelet agents, the high degree of variation should serve as an impetus for regional quality improvement projects.

  View details for DOI 10.1016/j.jvs.2016.02.036

  View details for PubMedID 27066949

• Real-World Performance of Paclitaxel Drug-Eluting Bare Metal Stenting (Zilver PTX) for the Treatment of Femoropopliteal Occlusive Disease. Annals of vascular surgery Tran, K., Ullery, B. W., Kret, M. R., Lee, J. T. 2016

  Abstract

  The aim of this study was to evaluate the performance and predictors of stent failure of paclitaxel drug-eluting stents for the treatment of femoropopliteal disease.A retrospective review of clinical and angiographic data was performed for patients treated for femoropopliteal disease with the Zilver PTX (Cook Medical, Bloomington, IN) stent by a single operator between 2012 and 2015 at a tertiary referral center. Clinical grading was determined by both Rutherford classification and the Society for Vascular Surgery's Wound, Ischemia, and Foot Infection (WIFi) scoring system, and lesions were classified anatomically by the TransAtlantic Intersociety Consensus (TASC) II criteria. Treated lesions included those with prior in-stent restenosis and long-segment disease. Primary clinical end points were stent failure, need for reintervention, and major adverse limb events (MALE). Kaplan-Meier methods and Cox proportional hazard models were used to evaluate factors affecting outcomes.Zilver PTX stents were placed in 52 limbs among 46 patients (71.1% male, mean age 72.6 years) with a median follow-up of 11.1 (range 1-26) months. Limbs were treated for life-disabling claudication in 76.9% and critical limb ischemia in 23.1%. Disease severity was highly variable, with 21 (40.4%) limbs with TASC C or D lesions and 16 (30.7%) treated for restenosis after prior endovascular treatment. During follow-up, 6 (12.7%) limbs experienced loss of stent patency (5 occlusions, one >50% restenosis). Four limbs underwent target lesion revascularization, 2 required open bypass, 2 underwent thrombolysis, and no patients required major amputation. Primary patency was 88.9%, 81.6%, and 81.6% at 6, 12, and 18 months, respectively. Treated lesion length (hazard ratio [HR] 4.99, 95% confidence interval [CI] 1.14-21.75) was the only independent predictor of patency loss. Freedom from target lesion revascularization at 6, 12, and 18 months was 94.2%, 87.8%, and 87.8%, respectively. Freedom from MALE (composite of thrombolysis, major amputation, and bypass operation) was 97.5%, 90.9%, and 79.6% at 6, 12, and 18 months, respectively. Chronic renal insufficiency was the only factor that trended toward increased risk of MALE (HR 9.92, 95% CI 0.86-113.35) within a multivariate model.Our real-world experience supports the continued use of the Zilver PTX for the treatment of both de novo lesions and lesions with prior endovascular revascularization in the femoropopliteal segment. Routine follow-up between 6 and 12 months postoperatively is essential for detecting early restenosis and guiding reintervention. Careful attention when treating complex lesions and long-segment disease remains important for selecting the optimal revascularization strategy for individual patients and optimizing stent patency.

  View details for DOI 10.1016/j.avsg.2016.08.006

  View details for PubMedID 27554688

• Renal function changes after fenestrated endovascular aneurysm repair JOURNAL OF VASCULAR SURGERY Kenneth Tran, K., Fajardo, A., Ullery, B. W., Goltz, C., Lee, J. T. 2016; 64 (2): 273-280

  Abstract

  Limited data exist regarding the effect of fenestrated endovascular aneurysm repair (fEVAR) on renal function. We performed a comprehensive analysis of acute and chronic renal function changes in patients after fEVAR.This study included patients undergoing fEVAR at two institutions between September 2012 and March 2015. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula with serum creatinine levels obtained during the study period. Acute and chronic renal dysfunction was assessed using the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) criteria and the chronic kidney disease (CKD) staging system, respectively.fEVAR was performed in 110 patients for juxtarenal or paravisceral aortic aneurysms, with a mean follow-up of 11.7 months. A total of 206 renal stents were placed, with a mean aneurysm size of 62.9 mm (range, 45-105 mm) and a mean neck length of 4.1 mm. Primary renal stent patency was 97.1% at the latest follow-up. Moderate kidney disease (CKD stage ≥ 3) was present in 51% of patients at baseline, with a mean preoperative glomerular filtration rate of 60.0 ± 19.6 mL/min/1.73 m(2). Acute kidney injury occurred in 25 patients (22.7%), although 15 of these (60%) were classified as having mild dysfunction. During follow-up, 59 patients (73.7%) were found to have no change or improved renal disease by CKD staging, and 19 (23.7%) had a CKD increase of one stage. Two patients were noted to have end-stage renal failure requiring hemodialysis. Clinically significant renal dysfunction was noted in 21 patients (26.2%) at the latest follow-up. Freedom from renal decline at 1 year was 76.1% (95% confidence interval, 63.2%-85.0%). Surrogate markers for higher operative complexity, including operating time (P = .001), fluoroscopy time (P < .001), contrast volume (P = .017), and blood loss (P = .002), served as dependent risk factors for acute kidney injury, although though no independent predictors were identified. Age (P = .008) was an independent risk factor for long-term decline, whereas paradoxically, baseline kidney disease (P = .032) and longer operative times (P = .014) were protective of future renal dysfunction.Acute and chronic renal dysfunction both occur in approximately one-quarter of patients after fEVAR; however, most of these cases are classified as mild according to consensus definitions of renal injury. The presence of mild or moderate baseline kidney disease should not preclude endovascular repair in the juxtarenal population. Routine biochemical analysis and branch vessel surveillance remain important aspects of clinical follow-up for patients undergoing fEVAR.

  View details for DOI 10.1016/j.jvs.2016.01.041

  View details for PubMedID 27237402

• 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

• Operative Results of Iliac Artery Endofibrosis in High-Performance Athletes Wu, T., Olcott, C., Lee, J. T. MOSBY-ELSEVIER. 2016: 551

  View details for DOI 10.1016/j.jvs.2016.05.037

  View details for Web of Science ID 000380753300072

• Sustained Late Branch Patency and Low Incidence of Persistent Type Ia Endoleaks Following Snorkel/chimney EVAR Shown in the Updated PERICLES Registry Lee, J. T., Pecoraro, F., Dalman, R. L., Tran, K., Torsello, G., Veith, F. J., Lachat, M., Donas, K. P. MOSBY-ELSEVIER. 2016: 145S

  View details for DOI 10.1016/j.jvs.2016.03.251

  View details for Web of Science ID 000376230600232

• Results from the PRESERVE II Zenith Iliac Branch Clinical Study Lee, W. A., Lee, J. T., Long, G., Sanborn, K. J. MOSBY-ELSEVIER. 2016: 227S–228S

  View details for DOI 10.1016/j.jvs.2016.03.380

  View details for Web of Science ID 000376230600361

• Pivotal Results for the Gore Excluder Iliac Branch Endoprosthesis for Treatment of Aortoiliac Aneurysms in the IBE 12-04 Prospective, Multicenter Study Schneider, D. B., Matsumura, J., Oderich, G. S., Lee, J. T., Peterson, B. G. MOSBY-ELSEVIER. 2016: 226S–227S

  View details for DOI 10.1016/j.jvs.2016.03.379

  View details for Web of Science ID 000376230600360

• Learning Curve of Robotic-Assisted Anastomosis: Shorter than the Laparoscopic Technique? An Educational Study ANNALS OF VASCULAR SURGERY Lucereau, B., Thaveau, F., Lejay, A., Roussin, M., Georg, Y., Heim, F., Lee, J. T., Chakfe, N. 2016; 33: 39-44

  Abstract

  Achieving aortic anastomosis in laparoscopic surgery remains a technical challenge. The Da Vinci robot could theoretically counteract this issue by minimizing the technical challenge. The aim of this study was to compare the learning curves of performing vascular anastomoses by trainees without any experience using purely laparoscopic versus robotic-assisted techniques.Surgery residents were randomly included in the laparoscopic group (group A, n = 3) and the robotic group (group B, n = 3). They performed 10 end-to-end anastomoses on 18-mm-diameter tubular expanded polytetrafluoroethylene grafts. The parameters recorded were duration to complete the anastomosis and an indirect sealing quality evaluation (ISQE) defined as the following ratio: number of stitches with a distance of less than 4 mm/total number of stitches.The mean duration to perform the anastomosis decreased from 2340 s (±64) for the first anastomosis to 651 s (±248) for the last in group A (P < 0.05) and from 1989 s (±556) to 801 s (±120) in group B (P < 0.05). The mean ISQE increased from 74% (±18) for the first anastomosis to 98% (±3) for the last in group A (P < 0.05) and decreased from 100% to 98% (±2) in group B (nonsignificant). The mean duration to perform the first anastomosis was lower in group B than in group A (P < 0.05). The mean duration to perform the last anastomosis was not significantly different between the groups. Sealing tended to be better in group B for the first anastomosis compared with group A.Minimally invasive laparoscopic technique training demonstrates a learning curve to perform vascular anastomoses. The robotic-assisted technique tended to improve suturing skills and should be considered as a valuable tool to reduce the technical learning curve.

  View details for DOI 10.1016/j.avsg.2015.12.001

  View details for PubMedID 26806248

• Tomographic Measurement of Gutters and Analysis of the Conformability of Stent Grafts in the Octopus Technique for Endovascular Thoracoabdominal Aneurysm Repair. Annals of vascular surgery Franklin, R. N., Silveira, P. G., Timi, J. R., Lee, J. T., Galego, G. d., Bortoluzzi, C. T. 2016; 33: 202-209

  Abstract

  The Octopus technique is an off-label and off-the-shelf strategy used as an option in the management of some specific and selected cases of thoracoabdominal aortic aneurysms (TAAA). We sought to compare 2 different methods of measurements on computed tomography (CT) slices and to evaluate the accommodation and conformability, before and after ballooning, of the components used in the Octopus technique.The CT gutter analysis between the 3 stent grafts within the short docking limb of the Excluder(®) was made using Viabahns(®) of 8, 7, and 6 mm in diameter. Each of the 10 possible combinations underwent a CT established protocol. The best axial image of the docking limb was submitted for an evaluation by 2 independent analysts, using 2 different methods. We also performed a postballooning evaluation, and the same CT protocol was used.There was no significant difference between the formats of measurement type "A" and type "B." Furthermore, there was no significant difference between the measurements made by the independent analysts. The tomography analyses demonstrated that the combination of stent grafts (Viabahn) of 8 and 7 mm diameter, inside the short docking limb of the bifurcated endoprosthesis, had the best possible relationship between the diameters used. These combinations showed better conformability and juxtaposition, with smaller areas of gutters and theoretically less possibility of endoleak. In addition, we found that postimplant balloon dilatation impaired the conformability and juxtaposition of the stent grafts (Viabahn) in the optimum combinations.In this analysis, we demonstrated a feasible, reliable, and reproducible form of CT measurement of the gutters in the Octopus technique for endovascular repair of TAAAs. Based on these measurements, there is a preferable combination of Viabahn sizes to be used in the Octopus technique and that postdilatation impairs the conformability and juxtaposition.

  View details for DOI 10.1016/j.avsg.2015.11.030

  View details for PubMedID 26965797

• Comparative geometric analysis of renal artery anatomy before and after fenestrated or snorkel/chimney endovascular aneurysm repair JOURNAL OF VASCULAR SURGERY Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Daman, R. L., Cheng, C. P. 2016; 63 (4): 922-929

  Abstract

  The durability of stent grafts may be related to how procedures and devices alter native anatomy. We aimed to quantify and compare renal artery geometry before and after fenestrated (F-) or snorkel/chimney (Sn-) endovascular aneurysm repair (EVAR).Forty patients (75 ± 6 years) underwent computed tomographic angiography before and after F-EVAR (n = 21) or Sn-EVAR (n = 19), with a total of 72 renal artery stents. Renal artery geometry was quantified using three-dimensional model-based centerline extraction. The stented length was computed from the vessel origin to the stent end. The branch angle was computed relative to the orthogonal configuration with respect to the aorta. The end-stent angle was computed relative to the distal native renal artery. Peak curvature was defined as the inverse of the radius of the circumscribed circle at the highest curvature within the proximal portion from the origin to the stent end and the distal portion from the stent end to the first renal artery bifurcation.Sn-renals had greater stented length compared to F-renals (P < .05). From the pre- to the postoperative period, the origins of the Sn-left renal artery and right renal artery (RRA) angled increasingly downward by 21 ± 19° and 13 ± 17°, respectively (P < .005). The F-left renal artery and RRA angled upward by 25 ± 15° and 14 ± 15°, respectively (P < .005). From the pre- to the postoperative period, the end-stent angle of the Sn-RRA increased by 17 ± 12° (P < .00001), with greater magnitude change compared to the F-RRA (P < .0005). Peak curvature increased in distal Sn-RRAs by .02 ± .03 mm(-1) (P < .05). Acute renal failure occurred in 12.5% of patients, although none required dialysis following either F- and Sn-EVAR. Renal stent patency was 97.2% at mean follow-up of 13.7 months. Three type IA endoleaks were identified, prompting one secondary procedure, with the remainder resolving at 6-month follow-up. One renal artery reintervention was performed due to a compressed left renal stent in an asymptomatic patient.Stented renal arteries were angled more inferiorly after Sn-EVAR and more superiorly after F-EVAR due to stent configuration. Sn-EVAR induced significantly greater angle change at the stent end and curvature change distal to the stent compared to F-EVAR, although no difference in patency was noted in this small series with relatively short follow-up. Sn-RRAs exhibited greater end-stent angle change from the pre- to the postoperative period as compared to the F-RRA. These differences may exert differential effects on long-term renal artery patency, integrity, and renal function following complex EVAR for juxta- or pararenal abdominal aortic aneurysms.

  View details for DOI 10.1016/j.jvs.2015.10.091

  View details for Web of Science ID 000372958200012

• Five Year Outcomes of Surgical Treatment for Popliteal Artery Entrapment Syndrome EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY Lejay, A., Delay, C., Georg, Y., Gaertner, S., Ohana, M., Thaveau, F., Lee, J. T., Geny, B., Chakfe, N. 2016; 51 (4): 557-564

  Abstract

  The aim of this study was to evaluate long-term outcomes following surgery for popliteal artery entrapment syndrome.A retrospective study of all patients that underwent surgery for popliteal artery entrapment syndrome between January 2003 and December 2009 was performed. Patient demographic data, clinical features, imaging modalities, and surgical management were recorded. The primary outcome was 5 year patency.Eighteen patients (25 limbs) underwent surgery. The mean age at the time of surgical procedure was 35 (median 35 years; range 15-49). Presentation was bilateral in seven patients (39%). Diagnosis was made using various imaging modalities, including position stress test, Duplex ultrasonography, computed tomography angiography, magnetic resonance imaging and conventional angiography. In four limbs the popliteal artery was compressed and undamaged (16%), and treatment consisted of musculo-tendinous division alone. In 16 limbs the popliteal artery was damaged with lesions limited to the popliteal artery (64%) where treatment consisted of venous interposition. In five limbs lesions extended beyond the popliteal artery (20%) and procedures included one below knee femoro-popliteal bypass, three femoro-posterior tibial bypasses, and one popliteo-posterior tibial bypass. Musculo-tendinous division was associated with vascular reconstruction in 19 limbs (90%). Mean follow up was 82 months (median 81 months, range 60-120). Five year patency was 84%.Long-term outcomes of surgical procedures performed for popliteal artery entrapment syndrome can be considered satisfactory.

  View details for DOI 10.1016/j.ejvs.2015.12.015

  View details for Web of Science ID 000374618400020

  View details for PubMedID 26905622

• Comparative geometric analysis of renal artery anatomy before and after fenestrated or snorkel/chimney endovascular aneurysm repair. Journal of vascular surgery Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. 2016; 63 (4): 922-929

  Abstract

  The durability of stent grafts may be related to how procedures and devices alter native anatomy. We aimed to quantify and compare renal artery geometry before and after fenestrated (F-) or snorkel/chimney (Sn-) endovascular aneurysm repair (EVAR).Forty patients (75 ± 6 years) underwent computed tomographic angiography before and after F-EVAR (n = 21) or Sn-EVAR (n = 19), with a total of 72 renal artery stents. Renal artery geometry was quantified using three-dimensional model-based centerline extraction. The stented length was computed from the vessel origin to the stent end. The branch angle was computed relative to the orthogonal configuration with respect to the aorta. The end-stent angle was computed relative to the distal native renal artery. Peak curvature was defined as the inverse of the radius of the circumscribed circle at the highest curvature within the proximal portion from the origin to the stent end and the distal portion from the stent end to the first renal artery bifurcation.Sn-renals had greater stented length compared to F-renals (P < .05). From the pre- to the postoperative period, the origins of the Sn-left renal artery and right renal artery (RRA) angled increasingly downward by 21 ± 19° and 13 ± 17°, respectively (P < .005). The F-left renal artery and RRA angled upward by 25 ± 15° and 14 ± 15°, respectively (P < .005). From the pre- to the postoperative period, the end-stent angle of the Sn-RRA increased by 17 ± 12° (P < .00001), with greater magnitude change compared to the F-RRA (P < .0005). Peak curvature increased in distal Sn-RRAs by .02 ± .03 mm(-1) (P < .05). Acute renal failure occurred in 12.5% of patients, although none required dialysis following either F- and Sn-EVAR. Renal stent patency was 97.2% at mean follow-up of 13.7 months. Three type IA endoleaks were identified, prompting one secondary procedure, with the remainder resolving at 6-month follow-up. One renal artery reintervention was performed due to a compressed left renal stent in an asymptomatic patient.Stented renal arteries were angled more inferiorly after Sn-EVAR and more superiorly after F-EVAR due to stent configuration. Sn-EVAR induced significantly greater angle change at the stent end and curvature change distal to the stent compared to F-EVAR, although no difference in patency was noted in this small series with relatively short follow-up. Sn-RRAs exhibited greater end-stent angle change from the pre- to the postoperative period as compared to the F-RRA. These differences may exert differential effects on long-term renal artery patency, integrity, and renal function following complex EVAR for juxta- or pararenal abdominal aortic aneurysms.

  View details for DOI 10.1016/j.jvs.2015.10.091

  View details for PubMedID 26755068

• Snorkel endovascular abdominal aortic aneurysm repair versus fenestrated endovascular aneurysm repair: is it a competition? SEMINARS IN VASCULAR SURGERY Tanious, A., Lee, J. T., Shames, M. 2016; 29 (1-2): 68-73

  Abstract

  The endovascular treatment of juxtarenal abdominal aortic aneurysm (AAA) can be performed by either a standard endovascular stent graft with additional snorkle grafts to aorta branches (snorkel endovascular aneurysm repair) or implantation of a fenestrated stent graft (fenestrated endovascular aneurysm repair). While many vascular surgeons consider snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair to be competing techniques or alternate strategies, published procedural outcomes suggest more complementary roles. In this clinical review, the advantages and disadvantages of these two approaches are debated, as much can be learned from both strategies. Because the indications and circumstances for juxtarenal AAA repair vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons have access to, and experience with, both treatment strategies. Based on published outcomes, patient outcomes, stent-graft patency, and re-intervention rates are generally similar and acceptable compared with open AAA repair. We conclude that there is a time and a place for both snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair for the endovascular management of juxtarenal and pararenal AAA anatomy.

  View details for DOI 10.1053/j.semvascsurg.2016.07.002

  View details for PubMedID 27823593

• Use of Aortic Endograft for Repair of Intraoperative Iliocaval Injury during Anterior Spine Exposure. Annals of vascular surgery Chou, E. L., Colvard, B. D., Lee, J. T. 2016; 31: 207 e5-8

  Abstract

  Vascular injury during anterior lumbar interbody fusion (ALIF) is a well-documented occurrence. Most vascular injuries continue to be managed with direct open repair. We report the outcome of a 61-year-old woman who experienced inferior vena cava and left common iliac vein injury during a difficult exposure for multilevel ALIF. The distal cava and common iliac vein were repaired with a Gore Excluder cuff and limb. The endovascular repair permitted control of the injury without more morbid maneuvers such as iliac artery transection. Thus endovascular repair of intraoperative caval injury is a valuable option in emergent situations with low morbidity and good durability.

  View details for DOI 10.1016/j.avsg.2015.08.008

  View details for PubMedID 26597236

• Snorkel/Chimney Stent Morphology Predicts Renal Dysfunction after Complex Endovascular Aneurysm Repair ANNALS OF VASCULAR SURGERY Tran, K., Ullery, B. W., Lee, J. T. 2016; 30: 1-11

  Abstract

  Despite the high technical success and midterm patency of snorkel stents, concerns remain about structural durability and its effect on long-term renal function. We sought to evaluate the luminal stability of renal snorkel stents to investigate morphologic predictive factors of renal dysfunction after snorkel/chimney endovascular aneurysm repair (sn-EVAR).Patients with high quality computer tomography angiography after sn-EVAR between 2009 and 2013 were included for analysis. Luminal diameters of renal snorkel stents were measured on a 3-dimensional workstation at the proximal, main-body junction, and distal locations. Creatinine values and estimated glomerular filtration rates (eGFR) were recorded throughout the preoperative, perioperative, and postoperative course. Acute kidney injury (AKI) and chronic renal decline were evaluated using the risk, injury, failure, loss of function, end stage renal disease (RIFLE) criteria and chronic kidney disease (CKD) staging system, respectively.52 patients underwent sn-EVAR (33 double renal, 19 single renal) with a 2-year primary patency of 95% at a mean follow-up of 21 months, of which 34 had suitable imaging protocols. In this subset, snorkel stents had mean deformations of -0.14 ± 0.52 (2.8%), -0.23 ± 0.52 (4.6%) and -0.04 ± 0.16 mm (1.8%) at the proximal, junction, and distal segments. Four cases of significant >50% stent collapse occurred during follow-up, all of which occurred at the junctional segment. In the total cohort, 17 (32.6%) and 16 (30.7%) patients developed AKI and chronic renal decline, respectively. Multivariate regression identified larger proximal luminal diameters at latest follow-up (odds ratio 0.67; confidence interval [CI] 0.006-0.740; P = 0.037) as the only protective morphologic risk factor for developing chronic renal decline. No independent predictor factors for AKI were found. Rates of renal decline were significantly worse with smaller measured proximal lumens with a 1-year freedom from renal decline of 50% vs. 77-83% for diameters measured less than 4 mm vs. greater than 4 mm (P = 0.010). Degree of oversizing also affected rates of decline with greater oversizing associated with improved freedom from renal decline at 1 year of 100% vs. 57% (P = 0.012). Using a multivariate Cox model, stent oversizing (hazard ratio [HR], 0.039; P = 0.018) and baseline CKD (HR 0.033, P = 0.004) were the only independent factors, both of which resulted in slower rates of renal decline during follow-up.Renal snorkel stent grafts maintain a high degree of patency and luminal stability at 2-year follow-up. However, stent collapse remains a rare but concerning risk, with the junctional segment most prone to significant stent deformation. Renal snorkel stents must be critically sized relative to native renal anatomy, and we recommend using at least stents sized ≥6 mm to minimize the risk of renal dysfunction. Frequent and regular radiographic and laboratory follow-up remains important as we further optimize the approach to complex EVAR.

  View details for DOI 10.1016/j.avsg.2015.04.093

  View details for Web of Science ID 000367408700001

• Snorkel/Chimney Stent Morphology Predicts Renal Dysfunction after Complex Endovascular Aneurysm Repair. Annals of vascular surgery Tran, K., Ullery, B. W., Lee, J. T. 2016; 30: 1-11.e1

  Abstract

  Despite the high technical success and midterm patency of snorkel stents, concerns remain about structural durability and its effect on long-term renal function. We sought to evaluate the luminal stability of renal snorkel stents to investigate morphologic predictive factors of renal dysfunction after snorkel/chimney endovascular aneurysm repair (sn-EVAR).Patients with high quality computer tomography angiography after sn-EVAR between 2009 and 2013 were included for analysis. Luminal diameters of renal snorkel stents were measured on a 3-dimensional workstation at the proximal, main-body junction, and distal locations. Creatinine values and estimated glomerular filtration rates (eGFR) were recorded throughout the preoperative, perioperative, and postoperative course. Acute kidney injury (AKI) and chronic renal decline were evaluated using the risk, injury, failure, loss of function, end stage renal disease (RIFLE) criteria and chronic kidney disease (CKD) staging system, respectively.52 patients underwent sn-EVAR (33 double renal, 19 single renal) with a 2-year primary patency of 95% at a mean follow-up of 21 months, of which 34 had suitable imaging protocols. In this subset, snorkel stents had mean deformations of -0.14 ± 0.52 (2.8%), -0.23 ± 0.52 (4.6%) and -0.04 ± 0.16 mm (1.8%) at the proximal, junction, and distal segments. Four cases of significant >50% stent collapse occurred during follow-up, all of which occurred at the junctional segment. In the total cohort, 17 (32.6%) and 16 (30.7%) patients developed AKI and chronic renal decline, respectively. Multivariate regression identified larger proximal luminal diameters at latest follow-up (odds ratio 0.67; confidence interval [CI] 0.006-0.740; P = 0.037) as the only protective morphologic risk factor for developing chronic renal decline. No independent predictor factors for AKI were found. Rates of renal decline were significantly worse with smaller measured proximal lumens with a 1-year freedom from renal decline of 50% vs. 77-83% for diameters measured less than 4 mm vs. greater than 4 mm (P = 0.010). Degree of oversizing also affected rates of decline with greater oversizing associated with improved freedom from renal decline at 1 year of 100% vs. 57% (P = 0.012). Using a multivariate Cox model, stent oversizing (hazard ratio [HR], 0.039; P = 0.018) and baseline CKD (HR 0.033, P = 0.004) were the only independent factors, both of which resulted in slower rates of renal decline during follow-up.Renal snorkel stent grafts maintain a high degree of patency and luminal stability at 2-year follow-up. However, stent collapse remains a rare but concerning risk, with the junctional segment most prone to significant stent deformation. Renal snorkel stents must be critically sized relative to native renal anatomy, and we recommend using at least stents sized ≥6 mm to minimize the risk of renal dysfunction. Frequent and regular radiographic and laboratory follow-up remains important as we further optimize the approach to complex EVAR.

  View details for DOI 10.1016/j.avsg.2015.04.093

  View details for PubMedID 26187702

• Plug the Hole-A Bailout Option for Acute Focal Aortic Rupture. Annals of vascular surgery Zayed, M. A., Marshall, C., Dake, M., Lee, J. T. 2016; 30: 309 e5-9

  Abstract

  Focal aortic rupture may result from expanding aneurysms, penetrating aortic wall ulcerations, or virulent infections. An urgent repair of paravisceral focal aortic rupture is associated with high morbidity. A staged repair approach may provide an alternative option.A 64-year-old woman presented with acute focal rupture of the posterior paravisceral aortic wall and was progressing to hemorrhagic shock and mesenteric ischemia. Given the patient's dire condition, an endovascular approach was used to plug her focal aortic wall defect using a ventricular septal defect occluder device. Subsequently, the patient underwent resuscitation, stabilization, and operative exploration. Postoperatively, she recovered well from this staged approach.This case provides an example of a staged endovascular plugging of an acute paravisceral focal aortic rupture. In select cases, this type of repair strategy is feasible, until off-the-shelf endovascular repair options become a reality.

  View details for DOI 10.1016/j.avsg.2015.07.033

  View details for PubMedID 26522581

• The model for Fundamentals of Endovascular Surgery (FEVS) successfully defines the competent endovascular surgeon JOURNAL OF VASCULAR SURGERY Duran, C., Estrada, S., O'Malley, M., Sheahan, M. G., Shames, M. L., Lee, J. T., Bismuth, J. 2015; 62 (6): 1660-1666

  Abstract

  Fundamental skills testing is now required for certification in general surgery. No model for assessing fundamental endovascular skills exists. Our objective was to develop a model that tests the fundamental endovascular skills and differentiates competent from noncompetent performance.The Fundamentals of Endovascular Surgery model was developed in silicon and virtual-reality versions. Twenty individuals (with a range of experience) performed four tasks on each model in three separate sessions. Tasks on the silicon model were performed under fluoroscopic guidance, and electromagnetic tracking captured motion metrics for catheter tip position. Image processing captured tool tip position and motion on the virtual model. Performance was evaluated using a global rating scale, blinded video assessment of error metrics, and catheter tip movement and position. Motion analysis was based on derivations of speed and position that define proficiency of movement (spectral arc length, duration of submovement, and number of submovements).Performance was significantly different between competent and noncompetent interventionalists for the three performance measures of motion metrics, error metrics, and global rating scale. The mean error metric score was 6.83 for noncompetent individuals and 2.51 for the competent group (P < .0001). Median global rating scores were 2.25 for the noncompetent group and 4.75 for the competent users (P < .0001).The Fundamentals of Endovascular Surgery model successfully differentiates competent and noncompetent performance of fundamental endovascular skills based on a series of objective performance measures. This model could serve as a platform for skills testing for all trainees.

  View details for DOI 10.1016/j.jvs.2015.09.026

  View details for PubMedID 26598123

• 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

• Part Two: Against the Motion. Fenestrated EVAR Procedures are not Better than Snorkels, Chimneys, or Periscopes in the Treatment of Most Thoracoabdominal and Juxtarenal Aneurysms EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY Lee, J. T. 2015; 50 (5): 557-561

  View details for DOI 10.1016/j.ejvs.2015.07.025

  View details for PubMedID 26602953

• Debate: Whether branched/fenestrated endovascular aneurysm repair procedures are better than snorkels, chimneys, or periscopes in the treatment of most thoracoabdominal and juxtarenal aneurysms JOURNAL OF VASCULAR SURGERY Hertault, A., Haulon, S., Lee, J. T. 2015; 62 (5): 1357-1365

  Abstract

  Vascular surgeons are an innovative group, and during the last decade, we have seen unparalleled advances in the endovascular treatment of extensive aortic pathologies. Collaborative efforts between surgeons and industry have introduced fenestrated and branched devices that are becoming more widely used, with wider regulatory approval, availability, and less need for customization. Prior to this, parallel stent approaches had been developed to fill the void where this technology was not available or for urgent cases. A separate and distinct body of evidence and expertise subsequently developed for both strategies. This debate explores where these approaches now sit in the armamentarium of vascular surgeons.

  View details for DOI 10.1016/j.jvs.2015.07.001

  View details for PubMedID 26506275

• Giant Abdominal Aortic Aneurysms: A Case Series and Review of the Literature VASCULAR AND ENDOVASCULAR SURGERY Ullery, B. W., Itoga, N. K., Lee, J. T. 2015; 49 (8): 242-246

  Abstract

  Giant abdominal aortic aneurysms (AAAs), defined as those measuring greater than 13.0 cm in transverse diameter, represent a rare clinical entity and present unique anatomic challenges.A retrospective review of a prospectively maintained aneurysm database from 2000 to 2013 was performed at a single academic referral center. Preoperative comorbid status, aneurysm characteristics, procedural details, and perioperative course were recorded for all patients.Four patients (male, n = 3) with a mean age of 75.2 years (range, 71-80 years) underwent open repair of giant AAAs. The mean AAA size was 14.4 cm (range, 13.2-15.5 cm). All giant AAAs were associated with neck length <10 mm and/or severe neck angulation. At a mean follow-up of 22 months, there has been 1 late death due to nonaneurysm-related causes.Due to anatomic limitation with currently available aortic endografts, giant AAAs have been traditionally repaired using a standard open surgical approach. The feasibility of endovascular aortic aneurysm repair (EVAR) with or without the use of adjunct techniques, including snorkel/chimney or fenestrated EVAR, has yet to be elucidated.

  View details for DOI 10.1177/1538574415617554

  View details for PubMedID 26647427

• Geometric analysis of thoracic aorta and arch branches before and after TEVAR Suh, G., Hirotsu, K., Zhu, Y. D., Lee, J., Dake, M., Fleischmann, D., Cheng, C. ELSEVIER SCIENCE INC. 2015: B129

  View details for DOI 10.1016/j.jacc.2015.08.340

  View details for Web of Science ID 000363329000283

• Snorkel/chimney and fenestrated endografts for complex abdominal aortic aneurysms. journal of cardiovascular surgery Ullery, B. W., Lee, J. T., Dalman, R. L. 2015; 56 (5): 707-717

  Abstract

  Complex endovascular aneurysm repair (EVAR) involves extension of the proximal aortic seal zone with preservation of branch vessel patency, thereby expanding the applicability of endografting from the infrarenal to the suprarenal aorta. Snorkel/chimney (Sn-EVAR) and fenestrated EVAR (f-EVAR) serve as the two most commonly utilized advanced endovascular techniques to combat hostile proximal neck anatomy. The purpose of this article is to describe the principles and evolution of these advanced endovascular strategies, technical considerations, and results of sn- and f-EVAR in the management of challenging neck anatomy in abdominal aortic aneurysm disease.

  View details for PubMedID 25800354

• 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

• Transcatheter fiber heart valve: Effect of crimping on material performances JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B-APPLIED BIOMATERIALS Khoffi, F., Heim, F., Chakfe, N., Lee, J. T. 2015; 103 (7): 1488-1497

  Abstract

  Transcatheter aortic valve implantation (TAVI) has become a popular alternative technique to surgical valve replacement. However, the biological valve tissue used in these devices appears to be fragile material in the long term particularly due being folded for low diameter catheter insertion purposes and when released in a calcified environment with irregular geometry. Textile polyester material is characterized by outstanding folding and strength properties combined with proven biocompatibility. It could therefore be considered as a replacement for biological valve leaflets in the TAVI procedure. The folding process associated with crimping, however, may degrade the filaments involved in the fibrous assembly and limit the durability of the device. The purpose of the present work is to study the effect of different crimping conditions on the mechanical performances of textile valve prototypes made from various fabric constructions. Results show that crimping generates some creases in the fabrics, which surface topography varies with fabric construction and crimping configuration. The mechanical properties of the crimped materials are globally slightly reduced. To determine how critical the modifications due to crimping are for prosthesis durability, more detailed long term in vitro and in vivo trials with crimped textile prototypes are needed in addition to this preliminary work.

  View details for DOI 10.1002/jbm.b.33330

  View details for PubMedID 25448469

• 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

• A Comparison of Training Experience, Training Satisfaction, and Job Search Experiences between Integrated Vascular Surgery Residency and Traditional Vascular Surgery Fellowship Graduates ANNALS OF VASCULAR SURGERY Colvard, B., Shames, M., Schanzer, A., Rectenwald, J., Chaer, R., Lee, J. T. 2015; 29 (7): 1333-1338

  Abstract

  The first 2 integrated vascular residents in the United States graduated in 2012, and in 2013, 11 more entered the job market. The purpose of this study was to compare the job search experiences of the first cohort of integrated 0 + 5 graduates to their counterparts completing traditional 5 + 2 fellowship programs.An anonymous, Web-based, 15-question survey was sent to all 11 graduating integrated residents in 2013 and to the 25 corresponding 5 + 2 graduating fellows within the same institution. Questions focused on the following domains: training experience, job search timelines and outcomes, and overall satisfaction with each training paradigm.Survey response was nearly 81% for the 0 + 5 graduates and 64% for the 5 + 2 graduates. Overall, there was no significant difference between residents and fellows in the operative experience obtained as measured by the number of open and endovascular cases logged. Dedicated research time during the entire training period was similar between residents and fellows. Nearly all graduates were extremely satisfied with their training and had positive experiences during their job searches with respect to starting salaries, numbers of offers, and desired practice type. More 0 + 5 residents chose academic and mixed practices over private practices compared with 5 + 2 fellowship graduates.Although longer term data are needed to understand the impact of the addition of 0 + 5 graduating residents to the vascular surgery work force, preliminary survey results suggest that both training paradigms (0 + 5 and 5 + 2) provide positive training experiences that result in excellent job search experiences. Based on the current and future need for vascular surgeons in the work force, the continued growth and expansion of integrated 0 + 5 vascular surgery residency positions as an alternative to traditional fellowship training is thus far justified.

  View details for DOI 10.1016/j.avsg.2015.04.078

  View details for PubMedID 26133994

• Collected World Experience About the Performance of the Snorkel/Chimney Endovascular Technique in the Treatment of Complex Aortic Pathologies The PERICLES Registry ANNALS OF SURGERY Donas, K. P., Lee, J. T., Lachat, M., Torsello, G., Veith, F. J. 2015; 262 (3): 546-553

  Abstract

  We sought to analyze the collected worldwide experience with use of snorkel/chimney endovascular aneurysm repair (EVAR) for complex abdominal aneurysm treatment.EVAR has largely replaced open surgery worldwide for anatomically suitable aortic aneurysms. Lack of availability of fenestrated and branched devices has encouraged an alternative strategy utilizing parallel or snorkel/chimney grafts (ch-EVAR).Clinical and radiographic information was retrospectively reviewed and analyzed on 517 patients treated by ch-EVAR from 2008 from 2014 by prearranged defined and documented protocols.A total of 119 patients in US centers and 398 in European centers were treated during the study period. US centers preferentially used Zenith stent-grafts (54.2%) and European centers Endurant stent-grafts (62.2%) for the main body component. Overall 898 chimney grafts (49.2% balloon expandable, 39.6% self-expanding covered stents, and 11.2% balloon expandable bare metal stents) were placed in 692 renal arteries, 156 superior mesenteric arteries (SMA), and 50 celiac arteries. At a mean follow-up of 17.1 months (range: 1-70 months), primary patency was 94%, with secondary patency of 95.3%. Overall survival of patients in this high-risk cohort for open repair at latest follow-up was 79%.This global experience represents the largest series in the ch-EVAR literature and demonstrates comparable outcomes to those in published reports of branched/fenestrated devices, suggesting the appropriateness of broader applicability and the need for continued careful surveillance. These results support ch-EVAR as a valid off-the-shelf and immediately available alternative in the treatment of complex abdominal EVAR and provide impetus for the standardization of these techniques in the future.

  View details for DOI 10.1097/SLA.0000000000001405

  View details for PubMedID 26258324

• Important Clarifications About Treating Indeterminate Vascular Injuries to the Neck JAMA SURGERY Lee, J. T. 2015; 150 (9): 847–48

  View details for PubMedID 26200203

• Cancer-Associated Venous Thromboembolic Disease, Version 1.2015 Featured Updates to the NCCN Guidelines JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Streiff, M. B., Holmstrom, B., Ashrani, A., Bockenstedt, P. L., Chesney, C., Eby, C., Fanikos, J., Fenninger, R. B., Fogerty, A. E., Gao, S., Goldhaber, S. Z., Hendrie, P., Kuderer, N., Lee, A., Lee, J. T., Lovrincevic, M., Millenson, M. M., Neff, A. T., Ortel, T. L., Paschal, R., Shattil, S., Siddiqi, T., Smock, K. J., Soff, G., Wang, T., Yee, G. C., Zakarija, A., McMillian, N., Engh, A. M. 2015; 13 (9): 1079-1096

  Abstract

  The NCCN Guidelines for Cancer-Associated Venous Thromboembolic Disease outline strategies for treatment and prevention of venous thromboembolism (VTE) in adult patients with a diagnosis of cancer or for whom cancer is clinically suspected. VTE is a common complication in patients with cancer, which places them at greater risk for morbidity and mortality. Therefore, risk-appropriate prophylaxis is an essential component for the optimal care of inpatients and outpatients with cancer. Critical to meeting this goal is ensuring that patients get the most effective medication in the correct dose. Body weight has a significant impact on blood volume and drug clearance. Because obesity is a common health problem in industrialized societies, cancer care providers are increasingly likely to treat obese patients in their practice. Obesity is a risk factor common to VTE and many cancers, and may also impact the anticoagulant dose needed for safe and effective prophylaxis. These NCCN Guidelines Insights summarize the data supporting new dosing recommendations for VTE prophylaxis in obese patients with cancer.

  View details for Web of Science ID 000361419800007

• Impact of Renal Artery Angulation on Procedure Efficiency During Fenestrated and Snorkel/Chimney Endovascular Aneurysm Repair. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists Ullery, B. W., Chandra, V., Dalman, R. L., Lee, J. T. 2015; 22 (4): 594-602

  Abstract

  To determine the impact of renal artery angulation on time to successful renal artery cannulation and procedure efficiency during fenestrated and snorkel/chimney endovascular aneurysm repair (EVAR).The imaging and procedure logs of 77 patients (mean age 74.2 years; 63 men) who underwent complex EVAR (24 fenestrated, 53 snorkel/chimney) from 2009 to 2013 were reviewed. Renal artery angulation was measured on preoperative computed tomographic angiography scans. Time to renal artery cannulation was retrieved from the EVAR procedure logs and compared to preoperative renal artery angulation and other metrics of procedure efficiency (eg, procedure time, fluoroscopy time, blood loss, etc). In all, 111 renal arteries were available for renal artery angulation measurement (39 fenestrated, 72 snorkel/chimney); 22 renal cannulations were inappropriate for the comparative analyses due to concomitant visceral artery stenting (n=15), combined procedures (n=6), or unsuccessful cannulation (n=1).For patients undergoing fenestrated EVAR, mean renal artery angulation was -28°±21° (range +37° to -60°), not significantly different (p=0.66) from patients receiving snorkel/chimney grafts (mean -30°±19°, range +22° to -65°). Comparative analysis using median renal artery angulation (-30° for both groups) demonstrated that renal artery cannulation during fenestrated EVAR was performed significantly faster in arteries with less downward (≥ -30°) angulation (16.0 vs 32.8 minutes, p=0.04), whereas cannulation in snorkel/chimneys was faster in arteries with greater downward (< -30°) angulation (10.9 vs 17.3 minutes, p=0.05). Fenestrated EVAR cases involving less downward (≥ -30°) renal artery angulation were also associated with shorter overall procedure time (187.7 vs 246.2 minutes, p=0.01) and decreased fluoroscopy time (70.3 vs 98.2 minutes, p=0.04). Immediate renal function decline, procedural complications, and postoperative issues were not associated with renal artery angulation.Procedural efficiency may be optimized by considering renal artery angulation as one of several objective variables used in the selection of an appropriate endovascular strategy. The fenestrated approach is more efficient with less downward angulation to the renal arteries, while the snorkel/chimney strategy is facilitated by more downward renal artery angulation.

  View details for DOI 10.1177/1526602815590119

  View details for PubMedID 26045462

• Endovascular Management of Intraoperative Iliocaval Injuries With Commercially Available Endografts Chandra, V., Dorsey, C., Colvard, B., Lee, J. T. MOSBY-ELSEVIER. 2015: 530

  View details for DOI 10.1016/j.jvs.2015.06.020

  View details for Web of Science ID 000358431900059

• Impact of Renal Artery Angulation on Procedure Efficiency During Fenestrated and Snorkel/Chimney Endovascular Aneurysm Repair JOURNAL OF ENDOVASCULAR THERAPY Ullery, B. W., Chandra, V., Dalman, R. L., Lee, J. T. 2015; 22 (4): 594-602

  Abstract

  To determine the impact of renal artery angulation on time to successful renal artery cannulation and procedure efficiency during fenestrated and snorkel/chimney endovascular aneurysm repair (EVAR).The imaging and procedure logs of 77 patients (mean age 74.2 years; 63 men) who underwent complex EVAR (24 fenestrated, 53 snorkel/chimney) from 2009 to 2013 were reviewed. Renal artery angulation was measured on preoperative computed tomographic angiography scans. Time to renal artery cannulation was retrieved from the EVAR procedure logs and compared to preoperative renal artery angulation and other metrics of procedure efficiency (eg, procedure time, fluoroscopy time, blood loss, etc). In all, 111 renal arteries were available for renal artery angulation measurement (39 fenestrated, 72 snorkel/chimney); 22 renal cannulations were inappropriate for the comparative analyses due to concomitant visceral artery stenting (n=15), combined procedures (n=6), or unsuccessful cannulation (n=1).For patients undergoing fenestrated EVAR, mean renal artery angulation was -28°±21° (range +37° to -60°), not significantly different (p=0.66) from patients receiving snorkel/chimney grafts (mean -30°±19°, range +22° to -65°). Comparative analysis using median renal artery angulation (-30° for both groups) demonstrated that renal artery cannulation during fenestrated EVAR was performed significantly faster in arteries with less downward (≥ -30°) angulation (16.0 vs 32.8 minutes, p=0.04), whereas cannulation in snorkel/chimneys was faster in arteries with greater downward (< -30°) angulation (10.9 vs 17.3 minutes, p=0.05). Fenestrated EVAR cases involving less downward (≥ -30°) renal artery angulation were also associated with shorter overall procedure time (187.7 vs 246.2 minutes, p=0.01) and decreased fluoroscopy time (70.3 vs 98.2 minutes, p=0.04). Immediate renal function decline, procedural complications, and postoperative issues were not associated with renal artery angulation.Procedural efficiency may be optimized by considering renal artery angulation as one of several objective variables used in the selection of an appropriate endovascular strategy. The fenestrated approach is more efficient with less downward angulation to the renal arteries, while the snorkel/chimney strategy is facilitated by more downward renal artery angulation.

  View details for DOI 10.1177/1526602815590119

  View details for Web of Science ID 000358119200019

• Safety and efficacy of antiplatelet/anticoagulation regimens after Viabahn stent graft treatment for femoropopliteal occlusive disease JOURNAL OF VASCULAR SURGERY Ullery, B. W., Tran, K., Itoga, N., Casey, K., Dalman, R. L., Lee, J. T. 2015; 61 (6): 1479-1488

  Abstract

  We aimed to determine the safety and efficacy of antiplatelet/anticoagulation regimens after placement of Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) for the treatment of femoropopliteal occlusive disease.Clinical, angiographic, and procedural data for patients undergoing endovascular treatment of femoropopliteal occlusive disease using Viabahn covered stent grafts at a single institution between 2006 and 2013 were retrospectively reviewed. Graft patency and freedom from thrombolysis, major adverse limb event, and reintervention were determined by Kaplan-Meier analysis. The influence of relevant variables on clinical outcome was determined through univariate and multivariate Cox proportional hazards analyses.Viabahn stent grafts were placed in a total of 91 limbs in 61 patients (66% men; mean age, 69 ± 12 years) during the study period. Indication for intervention was either claudication (n = 59) or critical limb ischemia (n = 32), with the majority (70%) classified as TransAtlantic Inter-Society Consensus II C (n = 33) or D (n = 31) lesions. Mean follow-up was 38.3 months (range, 1-91 months). Postprocedural pharmacologic regimens included aspirin, clopidogrel, and warfarin (47%); indefinite aspirin and clopidogrel (46%); or aspirin and temporary clopidogrel (7%). Primary and secondary patency rates were 60%, 44%, and 36% and 95%, 82%, and 74% at 1 year, 3 years, and 5 years, respectively. Kaplan-Meier analysis demonstrated more aggressive antiplatelet/anticoagulation regimens to be associated with improved primary patency and freedom from reintervention. Cox proportional hazards analysis demonstrated TransAtlantic Inter-Society Consensus II D lesions, tobacco use, coronary artery disease, and smaller stent diameter to be independent risk factors for stent graft failure. Bleeding events were limited to those in the aspirin, clopidogrel, and warfarin group (11.6% [n = 5]; P = .052), although the majority of these events were not life-threatening, and only two cases required blood transfusion.Increasingly aggressive antithrombotic regimens after Viabahn stent graft placement trended toward improved overall clinical outcomes, although the marginal patency benefit observed with the addition of warfarin to dual antiplatelet therapy was tempered by an observed increased risk of bleeding complications. Longer term follow-up and multicenter studies are needed to further define optimal type and duration of antithrombotic therapy after endovascular peripheral interventions.

  View details for DOI 10.1016/j.jvs.2014.12.062

  View details for Web of Science ID 000355018500013

  View details for PubMedID 25704407

• Renal Function Changes Following Fenestrated EVAR Ullery, B., Tran, K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2015: 56S

  View details for DOI 10.1016/j.jvs.2015.04.429

  View details for Web of Science ID 000361884200102

• Comparative Geometric Analysis of Renal Artery Anatomy Before and After Fenestrated or Snorkel/Chimney EVAR Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. MOSBY-ELSEVIER. 2015: 117S–118S

  View details for DOI 10.1016/j.jvs.2015.04.226

  View details for Web of Science ID 000361884200221

• Safety and efficacy of antiplatelet/anticoagulation regimens after Viabahn stent graft treatment for femoropopliteal occlusive disease. Journal of vascular surgery Ullery, B. W., Tran, K., Itoga, N., Casey, K., Dalman, R. L., Lee, J. T. 2015; 61 (6): 1479-1488

  Abstract

  We aimed to determine the safety and efficacy of antiplatelet/anticoagulation regimens after placement of Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) for the treatment of femoropopliteal occlusive disease.Clinical, angiographic, and procedural data for patients undergoing endovascular treatment of femoropopliteal occlusive disease using Viabahn covered stent grafts at a single institution between 2006 and 2013 were retrospectively reviewed. Graft patency and freedom from thrombolysis, major adverse limb event, and reintervention were determined by Kaplan-Meier analysis. The influence of relevant variables on clinical outcome was determined through univariate and multivariate Cox proportional hazards analyses.Viabahn stent grafts were placed in a total of 91 limbs in 61 patients (66% men; mean age, 69 ± 12 years) during the study period. Indication for intervention was either claudication (n = 59) or critical limb ischemia (n = 32), with the majority (70%) classified as TransAtlantic Inter-Society Consensus II C (n = 33) or D (n = 31) lesions. Mean follow-up was 38.3 months (range, 1-91 months). Postprocedural pharmacologic regimens included aspirin, clopidogrel, and warfarin (47%); indefinite aspirin and clopidogrel (46%); or aspirin and temporary clopidogrel (7%). Primary and secondary patency rates were 60%, 44%, and 36% and 95%, 82%, and 74% at 1 year, 3 years, and 5 years, respectively. Kaplan-Meier analysis demonstrated more aggressive antiplatelet/anticoagulation regimens to be associated with improved primary patency and freedom from reintervention. Cox proportional hazards analysis demonstrated TransAtlantic Inter-Society Consensus II D lesions, tobacco use, coronary artery disease, and smaller stent diameter to be independent risk factors for stent graft failure. Bleeding events were limited to those in the aspirin, clopidogrel, and warfarin group (11.6% [n = 5]; P = .052), although the majority of these events were not life-threatening, and only two cases required blood transfusion.Increasingly aggressive antithrombotic regimens after Viabahn stent graft placement trended toward improved overall clinical outcomes, although the marginal patency benefit observed with the addition of warfarin to dual antiplatelet therapy was tempered by an observed increased risk of bleeding complications. Longer term follow-up and multicenter studies are needed to further define optimal type and duration of antithrombotic therapy after endovascular peripheral interventions.

  View details for DOI 10.1016/j.jvs.2014.12.062

  View details for PubMedID 25704407

• Geometry and respiratory-induced deformation of abdominal branch vessels and stents after complex endovascular aneurysm repair JOURNAL OF VASCULAR SURGERY Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. 2015; 61 (4): 875-884

  Abstract

  This study quantified the geometry and respiration-induced deformation of abdominal branch vessels and stents after fenestrated (F-) and snorkel (Sn-) endovascular aneurysm repair (EVAR).Twenty patients (80% male; mean age, 75.2 ± 7.4 years; mean aneurysm diameter, 6.2 ± 1.8 cm) underwent computed tomography angiography during inspiratory and expiratory breath hold protocols after F-EVAR (n = 11) or Sn-EVAR (n = 9). Centerlines for the aorta and visceral vessels were extracted from three-dimensional models. Branch angles were computed relative to the orthogonal plane at the branch ostia, and end-stent angles of the left renal artery (LRA) and right renal artery (RRA) were computed relative to the distal stent orientation. The radius of peak curvature was defined by the circumscribed circle at the highest curvature.Sn-renal branches were more downward-angled than F-renal branches (P < .04). At the distal ends of the RRA stents, Sn-RRAs were angled greater than F-RRAs (P < .03) and had a smaller radius of peak curvature (P < .03). With expiration, the end-stent angle of Sn-LRAs increased by 4° ± 4° (P < .02) and exhibited a significant reduction of radius of curvature (P < .04). The unstented celiac arteries were more downward-angled (P < .02, inspiration), with a smaller radius of curvature (P < .00001), than the unstented superior mesenteric arteries. With expiration, the celiac arteries angled upwards by 9° ± 9° (P < .0005), which was greater than the superior mesenteric arteries (P < .03). At a median postoperative follow-up of 12.6 months (range, 1.0-37.1 months), branch vessel patency was 100%, serum creatinine levels remained stable, and one reintervention was required for a type III endoleak at the main body-LRA stent interface.Sn-renals were angled more inferiorly at the branch and more angulated at the stent end than F-renals due to stent placement strategies. Sn-LRAs exhibited a significant change in end-stent angle and curvature during respiration, a finding that may compromise long-term durability for parallel stent graft configurations. Further investigation is warranted to better optimize anatomic, patient, and branch vessel stent selection between fenestrated and snorkel strategies and their relationship to long-term patency.

  View details for DOI 10.1016/j.jvs.2014.11.075

  View details for PubMedID 25601499

• Stent-Assisted Coil Embolization for a Traumatic Pseudoaneurysm of the Visceral Aortic Segment JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Shu, C., Wang, T., Li, Q., Li, M., Lee, J. T. 2015; 26 (3): 451–53

  View details for DOI 10.1016/j.jvir.2014.11.024

  View details for Web of Science ID 000350834000025

  View details for PubMedID 25735531

• Cheese wire fenestration of a chronic juxtarenal dissection flap to facilitate proximal neck fixation during EVAR. Annals of vascular surgery Ullery, B. W., Chandra, V., Dake, M., Lee, J. T. 2015; 29 (1): 124 e1-5

  Abstract

  To describe successful endovascular repair of a complex chronic aortoiliac dissection facilitated by a unique endovascular fenestration technique at the proximal neck.A 57-year-old man presented with disabling lower extremity claudication and a remote history of medically treated type B aortic dissection. Computed tomographic angiography demonstrated a complex dissection with 7.1-cm false lumen aneurysmal dilatation and significant true lumen compression within bilateral iliac aneurysms and no suitable proximal infrarenal neck free of dissection.Using intravascular ultrasound, guidewires were introduced into true and false lumens. A 9F sheath was placed on the right side, and a 20-ga Chiba needle was positioned at the level of the celiac artery and oriented toward the dissection flap. The needle was advanced to puncture the flap, and a 0.014-in wire was then snared from the true to the false lumen. Shearing of the dissection flap in the juxtarenal segment was performed using a "cheese wire" technique, whereby both ends of the guidewire were pulled caudally in a sawing motion down through the infrarenal neck and into the aneurysm sac. Angiography confirmed absence of residual dissection and perfusion of the visceral vessels via the true lumen. Given the newly created infrarenal neck, standard endovascular aortic repair (EVAR) was performed and antegrade and retrograde false lumen flow was obliterated from the visceral vessels. Postoperative imaging confirmed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indices.Endovascular management of false lumen aneurysms in the setting of chronic dissection is limited by the ability of stent grafts to obtain adequate proximal or distal fixation. Endovascular fenestration of these chronic flaps facilitates generation of suitable landing zones, thereby serving as a useful adjunct to standard EVAR.

  View details for DOI 10.1016/j.avsg.2014.07.025

  View details for PubMedID 25192823

• Anatomic Suitability of Aortoiliac Aneurysms for Next Generation Branched Systems ANNALS OF VASCULAR SURGERY Pearce, B. J., Varu, V. N., Glocker, R., Novak, Z., Jordan, W. D., Lee, J. T. 2015; 29 (1): 69-75

  Abstract

  Preservation of internal iliac flow is an important consideration to prevent ischemic complications during endovascular aneurysm repair. We sought to determine the suitability of aortoiliac aneurysms for off-the-shelf iliac branched systems currently in clinical trial.Patients undergoing abdominal aortic aneurysm repair from 2004 to 2013 at 2 institutions were reviewed. Centerline diameters and lengths of aortoiliac morphology were measured using three-dimensional workstations and compared with inclusion/exclusion criteria for both Cook and Gore iliac branch devices.Of the nearly 2,400 aneurysm repairs performed during the study period, 99 patients had common iliac aneurysms suitable for imaging review. Eighteen of the 99 (18.2%) patients and 25/99 (25.3%) patients fit the inclusion criteria and would have been able to be treated using the Cook and Gore iliac branch devices, respectively. The most common reason for exclusion from Cook was internal iliac diameter of <6 or >9 mm (68/99, 68.7%). The most common reason for exclusion from Gore was proximal common iliac diameter of <17 mm (39/99, 39.4%) and inadequate internal iliac artery diameter of <6.5 or >13.5 mm (37/99, 37.3%). Comparing the included patients across both devices, a total of 35/99 (35.4%) of patients would be eligible for the treatment of aortoiliac aneurysms based on anatomic criteria.Only 35% of the aneurysm repairs involving common iliac arteries would have been candidates for the 2 iliac branch devices currently in trial based on anatomic criteria. The major common reason for exclusion is the internal iliac landing zone for both devices. Design modifications for future generation iliac branch technology should focus on diameter accommodations for the hypogastric branch stent and proximal and distal sizes of the iliac branch components. Familiarity with alternate branch preserving techniques is still needed in the majority of cases.

  View details for DOI 10.1016/j.avsg.2014.08.003

  View details for PubMedID 25194549

• Thoracic outlet syndrome in high-performance athletes 28th Annual Meeting of the Western-Vascular-Society Chandra, V., Little, C., Lee, J. T. MOSBY-ELSEVIER. 2014: 1012–17

  Abstract

  Repetitive upper extremity use in high-performance athletes is associated with the development of neurogenic and vascular thoracic outlet syndrome (TOS). Surgical therapy in appropriately selected patients can provide relief of symptoms and protection from future disability. We sought to determine the incidence and timing of competitive athletes to return to their prior high-performance level after TOS treatment and surgery.We reviewed all competitive high school, collegiate, and professional athletes treated for venous or neurogenic TOS (nTOS) from 2000 to 2012. Patient demographics, workup, and treatment approaches were recorded and analyzed. Patients with nTOS were assessed with quality of life surveys using the previously validated 11-item version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scale, scored from 0 to 100 (100 = worse). Return to full athletic activity was defined as returning to prior competitive high school, collegiate, or professional sports.During the study period, 41 competitive athletes (44% female) with a mean age of 19 years, were treated, comprising 13 baseball/softball players, 11 swimmers, 5 water polo players, 4 rowers, 2 volleyball players, 2 synchronized swimmers, 1 wrestler, 1 diver, 1 weightlifter, and 1 football player. Twenty-seven athletes (66%) were treated for nTOS, and 14 (34%) had Paget-Schroetter syndrome (PSS). All PSS patients underwent typical treatment of consisting of thrombolysis/anticoagulation, followed by first rib resection. Most nTOS patients were treated according to our previously reported highly selective algorithm, beginning with TOS-specific physical therapy (PT) after the clinical diagnosis was made. Because of mild to modest symptom improvement after PT, 67% of the nTOS athletes evaluated ultimately underwent supraclavicular first rib resection and brachial plexus neurolysis. Return to full competitive athletics was achieved in 85% of all patients, including 93% of the PSS patients and 81% of the nTOS athletes, at an average of 4.6 months after the intervention. In the nTOS cohort successfully returning to prior sports ability, seven (32%) were treated only with PT. Of those athletes who underwent surgery for nTOS, 83% returned to full competitive levels. QuickDASH disability scores improved from a mean of 40.4 preoperatively to 11.7 postoperatively, indicating significant improvement in symptoms after treatment. Recurrence of symptoms was noted in two nTOS (7%) and two PSS (14%) athletes.Standardized treatment algorithms for venous and nTOS and aggressive TOS-specific PT are key components to optimizing clinical outcomes in this special cohort of TOS patients. Most athletes treated for venous and nTOS can successfully return to competitive sports at their prior high-performance level.

  View details for DOI 10.1016/j.jvs.2014.04.013

  View details for Web of Science ID 000343316600031

• Thoracic outlet syndrome in high-performance athletes. Journal of vascular surgery Chandra, V., Little, C., Lee, J. T. 2014; 60 (4): 1012-7; discussion 1017-8

  Abstract

  Repetitive upper extremity use in high-performance athletes is associated with the development of neurogenic and vascular thoracic outlet syndrome (TOS). Surgical therapy in appropriately selected patients can provide relief of symptoms and protection from future disability. We sought to determine the incidence and timing of competitive athletes to return to their prior high-performance level after TOS treatment and surgery.We reviewed all competitive high school, collegiate, and professional athletes treated for venous or neurogenic TOS (nTOS) from 2000 to 2012. Patient demographics, workup, and treatment approaches were recorded and analyzed. Patients with nTOS were assessed with quality of life surveys using the previously validated 11-item version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scale, scored from 0 to 100 (100 = worse). Return to full athletic activity was defined as returning to prior competitive high school, collegiate, or professional sports.During the study period, 41 competitive athletes (44% female) with a mean age of 19 years, were treated, comprising 13 baseball/softball players, 11 swimmers, 5 water polo players, 4 rowers, 2 volleyball players, 2 synchronized swimmers, 1 wrestler, 1 diver, 1 weightlifter, and 1 football player. Twenty-seven athletes (66%) were treated for nTOS, and 14 (34%) had Paget-Schroetter syndrome (PSS). All PSS patients underwent typical treatment of consisting of thrombolysis/anticoagulation, followed by first rib resection. Most nTOS patients were treated according to our previously reported highly selective algorithm, beginning with TOS-specific physical therapy (PT) after the clinical diagnosis was made. Because of mild to modest symptom improvement after PT, 67% of the nTOS athletes evaluated ultimately underwent supraclavicular first rib resection and brachial plexus neurolysis. Return to full competitive athletics was achieved in 85% of all patients, including 93% of the PSS patients and 81% of the nTOS athletes, at an average of 4.6 months after the intervention. In the nTOS cohort successfully returning to prior sports ability, seven (32%) were treated only with PT. Of those athletes who underwent surgery for nTOS, 83% returned to full competitive levels. QuickDASH disability scores improved from a mean of 40.4 preoperatively to 11.7 postoperatively, indicating significant improvement in symptoms after treatment. Recurrence of symptoms was noted in two nTOS (7%) and two PSS (14%) athletes.Standardized treatment algorithms for venous and nTOS and aggressive TOS-specific PT are key components to optimizing clinical outcomes in this special cohort of TOS patients. Most athletes treated for venous and nTOS can successfully return to competitive sports at their prior high-performance level.

  View details for DOI 10.1016/j.jvs.2014.04.013

  View details for PubMedID 24835692

• Shuttering of the superior mesenteric artery during fenestrated endovascular aneurysm repair. Journal of vascular surgery Ullery, B. W., Lee, G. K., Lee, J. T. 2014; 60 (4): 900-7

  Abstract

  Shuttering occurs when a scallop or fenestration does not align perfectly with the target vessel ostium and is potentially minimized by stenting. The current United States Food and Drug Administration-approved fenestrated endovascular aneurysm repair (f-EVAR) device is most commonly configured with an unstented superior mesenteric artery (SMA) scallop, thereby subjecting the SMA to risk of partial coverage. We aimed to describe the incidence, severity, and clinical effect of SMA shuttering during f-EVAR.Patients undergoing f-EVAR using the commercially available Zenith (Cook Medical, Bloomington, Ind) fenestrated stent graft system containing an SMA scallop at our institution between September 2012 and January 2014 were included for analysis. Corrected multiplanar reformatted images on postoperative computed tomographic angiography were reviewed to measure SMA shuttering, defined as the percentage of scallop misalignment relative to the SMA ostial diameter.Of the 28 f-EVAR cases performed at our institution during the study period, 18 patients (78% male) had an SMA scallop and were included in this analysis. The median age was 78 years (interquartile range [IQR], 72-81 years), and the median abdominal aortic aneurysm size was 61 mm (IQR, 56-64 mm). Fifty-one vessels were targeted (18 SMA scallops, 32 renal fenestrations, 1 renal snorkel), with covered stents placed in all fenestrations. Target vessel catheterization and successful branch stent deployment was achieved in 100% of patients. SMA shuttering measured on postoperative computed tomographic angiography of any amount occurred in 50% of patients (range of SMA shuttering, 12%-40%). The severity of SMA shuttering varied: one patient had 11% to 20%, four had 21% to 30%, and four had 31 to 40%. When compared with patients without shuttering, patients with any SMA shuttering were noted to have a shorter infra-SMA neck length (17 vs. 25 mm; P = .007), higher volume of intraprocedural contrast administration (100 vs. 66 mL; P = .001), and had a trend toward longer procedural durations (240 vs. 188 minutes; P = .09). No association was found between SMA shuttering and the preoperative measured clock position of the visceral vessels, percentage of device oversizing, number of target vessels per patient, aortic diameter at the SMA or seal zone, aneurysm neck morphology, infrarenal neck length, scallop width, or SMA ostial diameter. No acute or chronic events of mesenteric ischemia were noted during a median clinical follow-up period of 11 months (IQR, 5-14 months).Even with the custom design of currently available fenestrated technology, shuttering of the SMA occurred in one-half of the patients in our cohort, although no clinical events were noted. Further details of the incidence, magnitude, and tolerance of SMA shuttering during f-EVAR are warranted to fully understand the clinical implication of this radiographic finding. Future design considerations for advanced EVAR should take into account SMA shuttering to further refine operative planning.

  View details for DOI 10.1016/j.jvs.2014.04.055

  View details for PubMedID 24865786

• Predicted shortfall in open aneurysm experience for vascular surgery trainees. Journal of vascular surgery Dua, A., Upchurch, G. R., Lee, J. T., Eidt, J., Desai, S. S. 2014; 60 (4): 945-9

  Abstract

  Since the introduction of endovascular aneurysm repair (EVAR), the volume of open aneurysm repair (OAR) has steadily declined since 2000. The introduction of next-generation devices and branched and fenestrated endograft technology continues to increase the anatomic applicability of EVAR, further decreasing the need for OAR. This study models the decline in OAR and uses historical trends to forecast future decline in volume and its potential effect on vascular surgery training.An S-curve modified logistic function was used to model the effect of introducing a new technology (EVAR) on the standard management of abdominal aortic aneurysm (AAA) with OAR starting in the year 2000, when an International Classification of Diseases, Ninth Revision, code was first introduced for EVAR. Patients who underwent EVAR and OAR for AAA were determined using the Nationwide Inpatient Sample from 1998 to 2011. Weighted samples and data from the United States Census Bureau were used to extrapolate these numbers to estimate population statistics. The number of cases completed at teaching hospitals was calculated using the Nationwide Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees.The highest number of OAR cases in this study was 42,872 in 2000 compared with just 10,039 in 2011. This was mirrored by a rise in EVAR from 2358 cases in 2000 (5.2%) to 35,028 in 2011 (76.5% by volume). Of the OAR volume in 2011, 6055 cases (60.3%) were completed at teaching institutions. An S-curve model with a correlation coefficient of R2 = 0.982 predicted 3809 open AAA cases at teaching hospitals by 2015, 2162 by 2020, and 1231 by 2025. When compared with the 2011 Accreditation Council for Graduate Medical Education National Resident Report, vascular surgery residents had 44.4% utilization with regard to OAR (2690 cases covered of 6055 total). When combined with the increase in vascular surgery trainees and lower number of open repairs, vascular fellows will complete about 10 OAR cases in 2015 and five OAR cases in 2020.The decreasing number of OAR cases will limit exposure for vascular trainees, who may be ill equipped to treat patients who require open repair beyond 2015. Additional methods for providing OAR training should be explored.

  View details for DOI 10.1016/j.jvs.2014.04.057

  View details for PubMedID 24877855

• Comparison of fenestrated endografts and the snorkel/chimney technique. Journal of vascular surgery Lee, J. T., Lee, G. K., Chandra, V., Dalman, R. L. 2014; 60 (4): 849-56; discussion 856-7

  Abstract

  Recent approval by the Food and Drug Administration of custom fenestrated endografts has increased endovascular options for patients with short-neck or juxtarenal abdominal aortic aneurysms (AAAs). We sought to compare the early learning curve at a single institution of fenestrated repair vs the snorkel technique.From 2009 to 2013, we performed 57 consecutive snorkel procedures for juxtarenal AAAs in an Institutional Review Board-approved prospective cohort, and since the summer of 2012, we gained access to the Food and Drug Administration-approved custom fenestrated device. Patient demographics, imaging, and operative techniques were compared between the first 15 cases for each of the snorkel (sn-EVAR) and fenestrated (f-EVAR) endovascular aneurysm repair (EVAR) techniques.Patient demographics and AAA morphology on preoperative imaging were similar between the groups. Operative time tended to be similar in the 3- to 4-hour range, with more fluoroscopy time and less contrast material used in f-EVAR than in sn-EVAR (P < .05) because of differing strategies of renal premarking. Larger delivery systems for f-EVAR required a higher rate of iliac conduits (40% vs 0%). Perioperative complications, short-term renal patency rates, and evidence of acute kidney injury were similar.The early experience of f-EVAR was similar to that of sn-EVAR in terms of patient demographics, case selection, and procedural characteristics. A significant portion of the learning curve for both procedures, particularly for f-EVAR, lies in the preoperative planning of fenestrations and the cannulation of branch vessels. Similar short-term postoperative outcomes between these two particular techniques indicate that both will have utility in the treatment of high-risk patients with complex anatomy.

  View details for DOI 10.1016/j.jvs.2014.03.255

  View details for PubMedID 24785682

• Reentry device aided endovascular aneurysm repair in patients with abdominal aortic aneurysm and unilateral iliac artery occlusion. Annals of vascular surgery Varu, V. N., Lee, G. K., Chang, S., Lee, J. T. 2014; 28 (7): 1800.e1-7

  Abstract

  We report 2 cases of patients undergoing endovascular aneurysm repair (EVAR) using reentry devices to recanalize unilateral iliac artery occlusions and complete a bifurcated endovascular repair.Patient 1 is a 70-year-old male with an enlarging 6.5-cm abdominal aortic aneurysm (AAA) and disabling left leg claudication with L external iliac occlusion with patent common and internal iliac arteries. Patient 2 is a 67-year-old male with an asymptomatic 4.0-cm AAA and L iliac chronic total occlusion (CTO) and disabling claudication. Both patients were poor operative candidates for open repair.Both patients underwent elective percutaneous EVAR along with left iliac artery revascularization. Initial angiography in both cases showed a blind ending of the left common iliac artery. Retrograde subintimal dissection through the occluded iliac segment was attempted but in both cases the wire was unable to traverse back into the true aortic lumen. Using either the Outback LTD or Pioneer reentry catheter, direct visualization of the true aortic lumen was obtained to re-enter the true lumen. The subintimal iliac tract was then predilated to facilitate routine EVAR in both cases. Both patients were discharged the following day and 1-year and 6-month follow-up imaging revealed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indexes. The previously patent internal iliac artery was preserved.While not always technically possible, reentry device aided EVAR is safe, feasible, and durable in the mid-term and avoids the morbidity and mortality related to aortouniiliac/femoral-femoral bypass and open repair. This technique should be considered in patients with iliac artery CTO and concurrent AAA to allow total endovascular repair.

  View details for DOI 10.1016/j.avsg.2014.05.008

  View details for PubMedID 24911810

• Comparison of fenestrated endografts and the snorkel/chimney technique 28th Annual Meeting of the Western-Vascular-Society Lee, J. T., Lee, G. K., Chandra, V., Dalman, R. L. MOSBY-ELSEVIER. 2014: 849–56

  Abstract

  Recent approval by the Food and Drug Administration of custom fenestrated endografts has increased endovascular options for patients with short-neck or juxtarenal abdominal aortic aneurysms (AAAs). We sought to compare the early learning curve at a single institution of fenestrated repair vs the snorkel technique.From 2009 to 2013, we performed 57 consecutive snorkel procedures for juxtarenal AAAs in an Institutional Review Board-approved prospective cohort, and since the summer of 2012, we gained access to the Food and Drug Administration-approved custom fenestrated device. Patient demographics, imaging, and operative techniques were compared between the first 15 cases for each of the snorkel (sn-EVAR) and fenestrated (f-EVAR) endovascular aneurysm repair (EVAR) techniques.Patient demographics and AAA morphology on preoperative imaging were similar between the groups. Operative time tended to be similar in the 3- to 4-hour range, with more fluoroscopy time and less contrast material used in f-EVAR than in sn-EVAR (P < .05) because of differing strategies of renal premarking. Larger delivery systems for f-EVAR required a higher rate of iliac conduits (40% vs 0%). Perioperative complications, short-term renal patency rates, and evidence of acute kidney injury were similar.The early experience of f-EVAR was similar to that of sn-EVAR in terms of patient demographics, case selection, and procedural characteristics. A significant portion of the learning curve for both procedures, particularly for f-EVAR, lies in the preoperative planning of fenestrations and the cannulation of branch vessels. Similar short-term postoperative outcomes between these two particular techniques indicate that both will have utility in the treatment of high-risk patients with complex anatomy.

  View details for DOI 10.1016/j.jvs.2014.03.255

  View details for Web of Science ID 000343316600003

• Reentry Device Aided Endovascular Aneurysm Repair in Patients with Abdominal Aortic Aneurysm and Unilateral Iliac Artery Occlusion 23rd Annual Winter Meeting of the Peripheral-Vascular-Surgery-Society Varu, V. N., Lee, G. K., Chang, S., Lee, J. T. ELSEVIER SCIENCE INC. 2014

  Abstract

  We report 2 cases of patients undergoing endovascular aneurysm repair (EVAR) using reentry devices to recanalize unilateral iliac artery occlusions and complete a bifurcated endovascular repair.Patient 1 is a 70-year-old male with an enlarging 6.5-cm abdominal aortic aneurysm (AAA) and disabling left leg claudication with L external iliac occlusion with patent common and internal iliac arteries. Patient 2 is a 67-year-old male with an asymptomatic 4.0-cm AAA and L iliac chronic total occlusion (CTO) and disabling claudication. Both patients were poor operative candidates for open repair.Both patients underwent elective percutaneous EVAR along with left iliac artery revascularization. Initial angiography in both cases showed a blind ending of the left common iliac artery. Retrograde subintimal dissection through the occluded iliac segment was attempted but in both cases the wire was unable to traverse back into the true aortic lumen. Using either the Outback LTD or Pioneer reentry catheter, direct visualization of the true aortic lumen was obtained to re-enter the true lumen. The subintimal iliac tract was then predilated to facilitate routine EVAR in both cases. Both patients were discharged the following day and 1-year and 6-month follow-up imaging revealed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indexes. The previously patent internal iliac artery was preserved.While not always technically possible, reentry device aided EVAR is safe, feasible, and durable in the mid-term and avoids the morbidity and mortality related to aortouniiliac/femoral-femoral bypass and open repair. This technique should be considered in patients with iliac artery CTO and concurrent AAA to allow total endovascular repair.

  View details for DOI 10.1016/j.avsg.2014.05.008

  View details for Web of Science ID 000342162000069

• Predicted shortfall in open aneurysm experience for vascular surgery trainees JOURNAL OF VASCULAR SURGERY Dua, A., Upchurch, G. R., Lee, J. T., Eidt, J., Desai, S. S. 2014; 60 (4): 945-949

  Abstract

  Since the introduction of endovascular aneurysm repair (EVAR), the volume of open aneurysm repair (OAR) has steadily declined since 2000. The introduction of next-generation devices and branched and fenestrated endograft technology continues to increase the anatomic applicability of EVAR, further decreasing the need for OAR. This study models the decline in OAR and uses historical trends to forecast future decline in volume and its potential effect on vascular surgery training.An S-curve modified logistic function was used to model the effect of introducing a new technology (EVAR) on the standard management of abdominal aortic aneurysm (AAA) with OAR starting in the year 2000, when an International Classification of Diseases, Ninth Revision, code was first introduced for EVAR. Patients who underwent EVAR and OAR for AAA were determined using the Nationwide Inpatient Sample from 1998 to 2011. Weighted samples and data from the United States Census Bureau were used to extrapolate these numbers to estimate population statistics. The number of cases completed at teaching hospitals was calculated using the Nationwide Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees.The highest number of OAR cases in this study was 42,872 in 2000 compared with just 10,039 in 2011. This was mirrored by a rise in EVAR from 2358 cases in 2000 (5.2%) to 35,028 in 2011 (76.5% by volume). Of the OAR volume in 2011, 6055 cases (60.3%) were completed at teaching institutions. An S-curve model with a correlation coefficient of R2 = 0.982 predicted 3809 open AAA cases at teaching hospitals by 2015, 2162 by 2020, and 1231 by 2025. When compared with the 2011 Accreditation Council for Graduate Medical Education National Resident Report, vascular surgery residents had 44.4% utilization with regard to OAR (2690 cases covered of 6055 total). When combined with the increase in vascular surgery trainees and lower number of open repairs, vascular fellows will complete about 10 OAR cases in 2015 and five OAR cases in 2020.The decreasing number of OAR cases will limit exposure for vascular trainees, who may be ill equipped to treat patients who require open repair beyond 2015. Additional methods for providing OAR training should be explored.

  View details for DOI 10.1016/j.jvs.2014.04.057

  View details for Web of Science ID 000343316600021

• Shuttering of the superior mesenteric artery during fenestrated endovascular aneurysm repair 42nd Annual Symposium of the Society-for-Clinical-Vascular-Surgery Ullery, B. W., Lee, G. K., Lee, J. T. MOSBY-ELSEVIER. 2014: 900–907

  Abstract

  Shuttering occurs when a scallop or fenestration does not align perfectly with the target vessel ostium and is potentially minimized by stenting. The current United States Food and Drug Administration-approved fenestrated endovascular aneurysm repair (f-EVAR) device is most commonly configured with an unstented superior mesenteric artery (SMA) scallop, thereby subjecting the SMA to risk of partial coverage. We aimed to describe the incidence, severity, and clinical effect of SMA shuttering during f-EVAR.Patients undergoing f-EVAR using the commercially available Zenith (Cook Medical, Bloomington, Ind) fenestrated stent graft system containing an SMA scallop at our institution between September 2012 and January 2014 were included for analysis. Corrected multiplanar reformatted images on postoperative computed tomographic angiography were reviewed to measure SMA shuttering, defined as the percentage of scallop misalignment relative to the SMA ostial diameter.Of the 28 f-EVAR cases performed at our institution during the study period, 18 patients (78% male) had an SMA scallop and were included in this analysis. The median age was 78 years (interquartile range [IQR], 72-81 years), and the median abdominal aortic aneurysm size was 61 mm (IQR, 56-64 mm). Fifty-one vessels were targeted (18 SMA scallops, 32 renal fenestrations, 1 renal snorkel), with covered stents placed in all fenestrations. Target vessel catheterization and successful branch stent deployment was achieved in 100% of patients. SMA shuttering measured on postoperative computed tomographic angiography of any amount occurred in 50% of patients (range of SMA shuttering, 12%-40%). The severity of SMA shuttering varied: one patient had 11% to 20%, four had 21% to 30%, and four had 31 to 40%. When compared with patients without shuttering, patients with any SMA shuttering were noted to have a shorter infra-SMA neck length (17 vs. 25 mm; P = .007), higher volume of intraprocedural contrast administration (100 vs. 66 mL; P = .001), and had a trend toward longer procedural durations (240 vs. 188 minutes; P = .09). No association was found between SMA shuttering and the preoperative measured clock position of the visceral vessels, percentage of device oversizing, number of target vessels per patient, aortic diameter at the SMA or seal zone, aneurysm neck morphology, infrarenal neck length, scallop width, or SMA ostial diameter. No acute or chronic events of mesenteric ischemia were noted during a median clinical follow-up period of 11 months (IQR, 5-14 months).Even with the custom design of currently available fenestrated technology, shuttering of the SMA occurred in one-half of the patients in our cohort, although no clinical events were noted. Further details of the incidence, magnitude, and tolerance of SMA shuttering during f-EVAR are warranted to fully understand the clinical implication of this radiographic finding. Future design considerations for advanced EVAR should take into account SMA shuttering to further refine operative planning.

  View details for DOI 10.1016/j.jvs.2014.04.055

  View details for Web of Science ID 000343316600014

• Renal function changes after snorkel/chimney repair of juxtarenal aneurysms. Journal of vascular surgery Lee, J. T., Varu, V. N., Tran, K., Dalman, R. L. 2014; 60 (3): 563-570

  Abstract

  The snorkel approach for endovascular aneurysm repair (EVAR) has been found to be a safe and viable alternative to open repair for juxtarenal abdominal aortic aneurysms with good short-term outcomes. Concerns about long-term durability and renal branch patency with this technique have been raised with the increasing availability of fenestrated devices. We sought to evaluate renal function changes in patients undergoing "snorkel" EVAR (sn-EVAR).Patients who underwent sn-EVAR from 2009 to 2012 were included in this analysis. Creatinine values were obtained throughout the patient's preoperative, perioperative, and postoperative course. Glomerular filtration rate (GFR) was estimated by the simplified Modification of Diet in Renal Disease formula. Acute renal dysfunction was analyzed according to the RIFLE (Risk, Injury, Failure, Loss, End stage) criteria, whereas chronic renal dysfunction was stratified by the chronic kidney disease staging system.Forty-three consecutive patients underwent sn-EVAR (31 double renal, 12 single renal) for juxtarenal aortic aneurysms. Mean follow-up time was 21 months. Mean aneurysm size was 6.6 cm (range, 5.1-10.5 cm) with anatomy not suitable for treatment with standard EVAR (mean neck length, 1.6 mm); 74 renal snorkel stents were placed in these patients with a 2-year primary patency of 95%. On average, the cohort at baseline was stratified as having moderate renal dysfunction. Mean baseline, maximum postoperative, and latest follow-up creatinine concentrations were 1.20, 1.49, and 1.43, respectively (P = .004). Mean baseline, maximum postoperative, and latest follow-up GFRs were 57.4, 47.8, and 49.2, respectively (P = .014). With use of RIFLE criteria, 14 patients (32.6%) experienced some form of acute kidney injury, although 10 of these patients (23.3%) were classified as mild (25%-50% decline in GFR). On analysis without the RIFLE criteria, 21.4% of patients had postoperative creatinine concentration >1.5 mg/dL, 28.6% had postoperative creatinine concentration increase >30%, and 28.6% had postoperative GFR decline >30%. For the entire study cohort at latest follow-up, 51% experienced no decline of chronic renal dysfunction and 8.1% had improvement in renal function. Renal function declined by one stage in 35.2% of the cohort and by two stages in 5.4%. On analysis without chronic kidney disease staging, 24.3% of patients had latest follow-up creatinine concentration >1.5 mg/dL, 29.7% had latest follow-up creatinine concentration increase >30%, and 24.3% had latest follow-up GFR decline >30%. Mean survival time from significant renal decline was 23.4 months.sn-EVAR continues to demonstrate a high rate of technical success and results in only mild rates of acute and midterm renal function decline according to a number of established definitions for renal dysfunction. Continued monitoring of renal function, renal stent behavior, and abdominal aortic aneurysm sac changes remains critically important in the long-term management of patients undergoing sn-EVAR, particularly given the high comorbidities associated with juxtarenal aortic aneurysms.

  View details for DOI 10.1016/j.jvs.2014.03.239

  View details for PubMedID 24785683

• Substantial Variation Exists Between SVS VQI Regions in Patient Selection and Treatment of Abdominal Aortic Aneurysms Buck, D. B., Darling, J., Cronenwett, J. L., Goodney, P. P., Moll, F. L., Lee, J. T., Schermerhorn, M. L. MOSBY-ELSEVIER. 2014: 830

  View details for DOI 10.1016/j.jvs.2014.06.072

  View details for Web of Science ID 000341629700098

• Considerations for patients undergoing endovascular abdominal aortic aneurysm repair. Anesthesiology clinics Ullery, B. W., Lee, J. T. 2014; 32 (3): 723-734

  Abstract

  Endovascular aneurysm repair has taken over open surgery as the primary strategy for treatment of patients with abdominal and thoracic aneurysms. The minimally invasive nature of these techniques requires alterations in preoperative workup, intraoperative management, and familiarity with unique complications that can occur. Familiarity from the anesthetic standpoint of endovascular techniques, including treatment of patients with fenestrated, chimney, snorkel, and periscope grafts, is necessary for the contemporary cardiac anesthesiologist.

  View details for DOI 10.1016/j.anclin.2014.05.003

  View details for PubMedID 25113729

• More Aggressive Anticoagulation/Antiplatelet Regimen Improves Patency Following Viabahn Stent Grafting of the SFA Ullery, B. W., Itoga, N., Tran, K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2014: 549

  View details for DOI 10.1016/j.jvs.2014.05.086

  View details for Web of Science ID 000341627600067

• Geometry and Respiratory-Induced Deformation of Abdominal Branch Vessels Following Complex EVAR Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. MOSBY-ELSEVIER. 2014: 539–40

  View details for DOI 10.1016/j.jvs.2014.05.061

  View details for Web of Science ID 000341627600044

• Endovascular Stent-Graft Repair of Proximal Renal Artery Aneurysms Chandra, V., Ullery, B. W., Lee, J. T. MOSBY-ELSEVIER. 2014: 546–47

  View details for DOI 10.1016/j.jvs.2014.05.080

  View details for Web of Science ID 000341627600061

• Postapproval outcomes of juxtarenal aortic aneurysms treated with the Zenith fenestrated endovascular graft JOURNAL OF VASCULAR SURGERY Vemuri, C., Oderich, G. S., Lee, J. T., Farber, M. A., Fajardo, A., Woo, E. Y., Cayne, N., Sanchez, L. A. 2014; 60 (2): 295-300

  Abstract

  The objective of this study was to evaluate postapproval outcomes of patients with juxtarenal aortic aneurysms treated with the Zenith fenestrated endovascular graft (Cook Inc, Bloomington, Ind).We reviewed clinical data of consecutive patients treated with the Zenith fenestrated endovascular graft in the United States at seven institutions with early commercial access from July 2012 to December 2012. Clinical outcomes and compliance to anatomic guidelines were compared with results of the U.S. fenestrated trial (USFT).Fifty-seven patients were treated. There were significantly more (P < .05) patients with coronary artery disease, myocardial infarction, and preoperative renal insufficiency than in the USFT. Thirty-six patients (63.2%) did not meet the USFT anatomic criteria of a >4-mm infrarenal neck, and there were significantly more mesenteric stents (13 vs 0; P < .05) used in this group than in the USFT, reflecting the higher anatomic complexity of these patients. The total operative time was 250.2 ± 14.8 minutes, the fluoroscopy time was 68.9 ± 4.47 minutes, and the average volume of contrast material was 108.6 ± 5.6 mL. Technical success was 100% in regard to aneurysm exclusion, although the left renal fenestration was not able to be aligned in two patients, and one patient had a kinked renal stent that was successfully restented. During this time period, there were a total of 10 endoleaks, of which two were type III and eight were type II.Despite higher rates of comorbidities and more challenging anatomy, early 30-day outcomes of juxtarenal aortic aneurysms treated postapproval with the Zenith fenestrated endovascular graft compare well with USFT data. Future studies are needed to assess durability of this treatment modality as the technology diffuses and data mature.

  View details for DOI 10.1016/j.jvs.2014.01.071

  View details for PubMedID 24680241

• The "Terrace Technique"-Totally Endovascular Repair of a Type IV Thoracoabdominal Aortic Aneurysm. Annals of vascular surgery Dorsey, C., Chandra, V., Lee, J. T. 2014; 28 (6): 1563 e11-6

  Abstract

  As an alternative to branched or fenestrated aortic stent grafts, the "snorkel" or "chimney graft" strategy is a feasible endovascular option, particularly for juxtarenal aneurysms. When more than 2 visceral vessels require revascularization, however, the summative displacement of the main body endograft theoretically increases gutter formation with subsequent endoleak. The "terrace" strategy, or "sandwich", stacks the snorkel grafts into separate layers, and we describe a case using 4 snorkel grafts during endovascular aneurysm repair of a type IV thoracoabdominal aortic aneurysm (TAAA).A 76-year-old man with prohibitive operative risk has been followed for years with an asymptomatic TAAA that grew to 6.2 cm. Endovascular strategy consisted of celiac and superior mesenteric artery snorkel stents deployed and molded adjacent to a 36-mm proximal thoracic cuff (Cook TX2).Through the proximal thoracic endograft, both renals were then accessed, and in this second layer, or "terrace configuration," bilateral renal snorkels were deployed and molded adjacent to a 36-mm bifurcated abdominal stent-graft system (Cook Zenith). "Quadruple kissing" balloon angioplasty was then performed to mold the lower part of the devices. Operative time was 4 hr, the patient was extubated immediately and recovered quickly on the floor, being discharged in 3 days. Postoperative imaging at 6 months, 1 year, and 2 years have revealed patent aortic components without evidence of stent-graft migration or significant endoleak. The terrace snorkel stents were all patent to the celiac, superior mesenteric, and right renal arteries, while the left renal artery stent shows some stent compression.In select high-risk patients opting for an all-endovascular approach of type IV TAAAs, up to 4 snorkel grafts can be deployed in a "terrace" or "sandwich" configuration to successfully revascularize all visceral branches and provide aneurysm exclusion. Long-term follow-up is necessary to understand the overall success of this strategy.

  View details for DOI 10.1016/j.avsg.2014.03.010

  View details for PubMedID 24704581

• Elective EVAR in Nonagenarians Is Safe in Carefully Selected Patients. Annals of vascular surgery Lee, G. K., Ullery, B. W., Lee, J. T. 2014; 28 (6): 1402-1408

  Abstract

  Nonagenarians are typically considered poor operative candidates for major aortic intervention because of shorter life expectancy, multiple comorbidities, and increased perioperative morbidity and mortality. Endovascular abdominal aortic aneurysm repair (EVAR) has clearly been associated with a lower perioperative morbidity and mortality in most anatomically suitable patients. There have been many reports of the technical success of EVAR in octogenarians, but few documenting EVAR in nonagenarians. In this study, we sought to review our experience with elective EVAR in nonagenarians to determine outcomes, complications, and long-term survival after repair.We retrospectively reviewed our prospectively maintained aneurysm database from 2000 to 2010 at an academic referral center. Fifteen patients ≥90 years old underwent elective EVAR. No symptomatic or ruptured abdominal aortic aneurysm patients >90 years old were treated. Comorbidities, preoperative and postoperative functional status, aneurysm size, and technical success rate were all recorded in accordance with Society for Vascular Surgery reporting guidelines. Follow-up was performed within 30 days, 6 months, and annually thereafter unless more frequent follow-up was indicated.Of the 749 EVAR procedures performed in the decade-long experience, 15 nonagenarians underwent repair (14 male, 93%; mean age, 90.3 ± 0.6 years). Mean aneurysm diameter was 6.4 ± 1.45 cm with a median diameter of 5.8 cm (range 4.5-8.8 cm). All patients were offered repair because of having good to excellent preoperative functional status with an average number of comorbidities per patient of 2.7. Immediate technical success rate was 100%. Median intensive care unit stay was 1 day (range 1-17 days). Mean length of stay was 4.6 ± 5.3 days with a median of 3.5 days. Thirty-day mortality was 0%. Mean follow-up was 35 months. Mean survival was 56 months. Overall survival estimated annually extending out to 5 years was 91.7%, 83.3%, 71.4%, 57.1%, and 38.1%, respectively. Thirty-day rate of any complication was 40%, with a 20% readmission rate, with many of the issues being related to wound complications. On follow-up imaging there were noted to be 4 (27%) type I, 9 (60%) type II, and no type III or type IV endoleaks identified. Overall reintervention rate was 27%. No ruptures were noted in the postoperative period or long-term follow-up, and there were no conversions to open surgery.We found a median survival of 56.2 months in this carefully selected cohort of EVAR in nonagenarians. As techniques and technology improve and evolve, and particularly as devices become lower profile, there is the potential to apply EVAR to the increasingly older population. If perioperative morbidity can be minimized and the patient has good functional status, EVAR can be a safe procedure and provide rupture-free survival.

  View details for DOI 10.1016/j.avsg.2014.03.026

  View details for PubMedID 24704051

• North American Vascular Surgery Exchange Training Program: A Collaborative Approach to Enhance the Breadth of Vascular Training Zayed, M., Faulds, J., Lee, J. T., Harlock, J. MOSBY-ELSEVIER. 2014: 101S

  View details for DOI 10.1016/j.jvs.2014.03.220

  View details for Web of Science ID 000337258400211

• Impact of Renal Artery Angulation on Procedural Complexity During Fenestrated and Snorkel EVAR Ullery, B. W., Chandra, V., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2014: 10S–11S

  View details for DOI 10.1016/j.jvs.2014.03.030

  View details for Web of Science ID 000337258400020

• Debulking of the Anterolateral Quadrant of the Medial Gastrocnemius for Functional Popliteal Entrapment Syndrome in High-Performance Athletes Zayed, M., Fredericson, M., Fleischmann, D., Lee, J. T. MOSBY-ELSEVIER. 2014: 71S

  View details for DOI 10.1016/j.jvs.2014.03.158

  View details for Web of Science ID 000337258400148

• Popliteal artery entrapment syndrome JOURNAL OF CARDIOVASCULAR SURGERY Lejay, A., Ohana, M., Lee, J. T., Georg, Y., Delay, C., Lucereau, B., Thaveau, F., Gaertner, S., Chakfe, N. 2014; 55 (2): 225-237

  Abstract

  Intermittent claudication is frequently encountered in vascular surgical practice in atherosclerotic patients. However, it may also be observed in a younger subset of patients without any cardiovascular risk factors and can represent a challenging diagnosis. Popliteal artery entrapment syndrome is rare but can cause intermittent claudication in young people. There is a lack of consensus about optimal strategies or diagnosis and management, particularly for variants such as functional popliteal entrapment. Since the first description in 1959, knowledge of the pathology and the underlying anatomic abnormalities was advanced through sporadic publications of case reports and small case series, but popliteal artery entrapment syndrome still remains a rare anatomic abnormality. It can be difficult to differentiate from other causes of lower limb pain in young patients, and diagnosis can be challenging. We propose to review clinical symptomatology, classification, radiological diagnosis and treatment of popliteal entrapment syndrome.

  View details for Web of Science ID 000336514400025

  View details for PubMedID 24796917

• Validated Assessment Tool Paves the Way for Standardized Evaluation of Trainees on Anastomotic Models 23rd Annual Winter Meeting of the Peripheral-Vascular-Surgery-Society Duran, C. A., Shames, M., Bismuth, J., Lee, J. T. ELSEVIER SCIENCE INC. 2014: 115–21

  Abstract

  Simulation modules allow for the safe practice of certain techniques and are becoming increasingly important in the shift toward education for integrated vascular residents. There is an unquestionable need to standardize the evaluation of trainees on these simulation models to assure their impact and effectiveness. We sought to validate such an assessment tool for a basic open vascular technique.Vascular fellows, integrated vascular residents, and general surgery residents attending Society for Clinical Vascular Surgery, Introduction to Academic Vascular Surgery, and Methodist Boot Camp in 2012 were asked to participate in an assessment model using multiple anastomotic models and given 20 minutes to complete an end-to-side anastomosis. Trained vascular faculty evaluated subjects using an assessment tool that included a 25-point checklist and a graded overall global rating scale (GRS) on a 5-point Likert scale with 8 parameters. Self-assessment using the GRS was performed by 20 trainees. Reliability and construct validity were evaluated.Ninety-two trainees were assessed. There was excellent agreement between assessors on 21 of the 25 items, with 2 items found not to be relevant for the bench-top model. Graders agreed that the checklist was prohibitively cumbersome to use. Scores on the global assessments correlated with experience and were higher for the senior trainees, with median global summary scores increasing by postgraduate year. Reliability was confirmed through interrater correlation and internal consistency. Internal consistency was 0.92 for the GRS. There was poor correlation between grades given by the expert observers and the self-assessment from the trainee, but good correlation between scores assigned by faculty. Assessment of appropriate hemostasis was poor, which likely reflects the difficulty of evaluating this parameter in the current inanimate model.Performance on an open simulation model evaluated by a standardized global rating scale correlated to trainee experience level. This initial work confirms the ease and applicability of the grading tool among multiple expert observers and different platforms, and supports additional; research into applications translating this performance into the operating room.

  View details for DOI 10.1016/j.avsg.2013.07.005

  View details for Web of Science ID 000328646400016

  View details for PubMedID 24189012

• Improved Efficiency and Safety for EVAR with Utilization of a Hybrid Room EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY Varu, V. N., Greenberg, J. I., Lee, J. T. 2013; 46 (6): 675-679

  Abstract

  Access to a hybrid endovascular suite is touted as a necessity for advanced endovascular aneurysm repair (EVAR) to improve imaging accuracy and safety. Yet there remain little data documenting this intuitive advantage of a hybrid setup versus a traditional operating room (OR) utilizing a portable fluoroscopic unit (C-arm) for imaging. We hypothesized that standard elective EVAR performed in a hybrid suite would improve procedural efficiency and accuracy, as well minimize patient exposure to both contrast and radiation.We retrospectively reviewed a single attending surgeon's EVAR practice, which encompassed the transition to a hybrid endovascular suite (opened July 2010). Only consecutive abdominal aneurysms were included in the analysis to attempt to create a homogenous cohort. All emergent, aorto-uni-iliac (AUI), snorkel, fenestrated, or hybrid procedures were excluded. Standard variables evaluated and compared between the two study subgroups included fluoroscopy time, operative time, contrast use, stent-graft component utilization, complication rates, and short-term endoleaks.From January 2008 to August 2012, we performed 213 EVAR procedures for abdominal aortic aneurysms. After excluding emergent, AUI, snorkel, or hybrid procedures, we analyzed 109 routine EVARs. Fifty-eight consecutive cases were done in the OR with a C-arm until July 2010, and the last 51 cases were done in the hybrid room. Both groups were well matched in terms of demographics, aneurysm morphology, and procedural characteristics. No difference was found in terms of complication rates or operative mortality, although there was a trend towards decreased fluoroscopy time, type I/III endoleaks, and a number of additional endograft components utilized. Compared with patients repaired in the OR/C-arm, EVAR done in the hybrid room resulted in less total OR time and contrast usage (p < .05).Routine EVAR performed in a hybrid fixed-imaging suite affords greater efficiency and less harmful exposure of contrast and possible radiation to the patient. Accurate imaging quality and deployment is associated with less need for additional endograft components, which should lead to improved cost efficiency. Confirmation of these findings might be necessary in a randomized control trial to fully justify the capital expenditure necessary for hybrid endovascular suites.

  View details for DOI 10.1016/j.ejvs.2013.09.023

  View details for PubMedID 24161724

• Venous Thromboembolic Disease Clinical Practice Guidelines in Oncology JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Streiff, M. B., Bockenstedt, P. L., Cataland, S. R., Chesney, C., Eby, C., Fanikos, J., Fogerty, A. E., Gao, S., Goldhaber, S. Z., Hassoun, H., Hendrie, P., Holmstrom, B., Kuderer, N., Lee, J. T., Millenson, M. M., Neff, A. T., Ortel, T. L., Siddiqi, T., Smith, J. L., Yee, G. C., Zakarija, A., McMillian, N., Naganuma, M. 2013; 11 (11): 1402-1429

  Abstract

  Venous thromboembolism (VTE) remains a common and life-threatening complication among patients with cancer. Thromboprophylaxis can be used to prevent the occurrence of VTE in patients with cancer who are considered at high risk for developing this complication. Therefore, it is critical to recognize the various risk factors for VTE in patients with cancer. Risk assessment tools are available to help identify patients for whom discussions regarding the potential benefits and risks of thromboprophylaxis would be appropriate. The NCCN Clinical Practice Guidelines in Oncology for VTE provide recommendations on risk evaluation, diagnosis, prevention, and treatment of VTE in patients with cancer.

  View details for Web of Science ID 000327066800009

• Post-Approval Outcomes of Juxtarenal Aortic Aneurysms Treated with the Zenith Fenestrated Endovascular Graft Vemuri, C., Woo, E., Fajardo, A., Cayne, N., Farbar, M., Lee, J., Oderich, G., Sanchez, L. A. MOSBY-ELSEVIER. 2013: 1434

  View details for DOI 10.1016/j.jvs.2013.08.066

  View details for Web of Science ID 000326593900062

• Midterm Changes in Renal Function Following Snorkel Repair of Juxtarenal Aneurysms Varu, V. N., Tran, K., Chandra, V., Lee, G. K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2013: 555

  View details for DOI 10.1016/j.jvs.2013.05.052

  View details for Web of Science ID 000322759500052

• Early Experience with Fenestrated Endografts Compared to the Snorkel Technique: Lessons learned Lee, G., Varu, V., Chandra, V., Lee, J., Dalman, R. MOSBY-ELSEVIER. 2013: 555

  View details for DOI 10.1016/j.jvs.2013.05.051

  View details for Web of Science ID 000322759500051

• Iliac Artery Inflow for High-Risk Cerebral Revascularization Greenberg, J. I., Lee, J. T., Zarins, C. K. MOSBY-ELSEVIER. 2013: 564

  View details for DOI 10.1016/j.jvs.2013.05.077

  View details for Web of Science ID 000322759500078

• Thoracic Outlet Syndrome in High-Performance Athletes Chandra, V., Colvard, B., Little, C., Olcott, C., Lee, J. T. MOSBY-ELSEVIER. 2013: 567–68

  View details for DOI 10.1016/j.jvs.2013.05.086

  View details for Web of Science ID 000322759500086

• The "Periscope" Technique Successfully Lengthens the Distal Landing Zone During TEVAR Varu, V., Chandra, V., Dake, M. D., Lee, J. T. MOSBY-ELSEVIER. 2013: 556

  View details for DOI 10.1016/j.jvs.2013.05.055

  View details for Web of Science ID 000322759500055

• 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

• 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

• Creating a Vascular Skills Examination: Three New Validated Assessment Models Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) Sheahan, M. G., Sheahan, C., Gerdes, J., Bismuth, J., Lee, J., Shames, M., Wilkinson, J., Eidt, J. MOSBY-ELSEVIER. 2013: 14S–15S

  View details for Web of Science ID 000318685300023

• Differences in readmissions after open repair versus endovascular aneurysm repair 26th Annual Meeting of the Western-Vascular-Society Casey, K., Hernandez-Boussard, T., Mell, M. W., Lee, J. T. MOSBY-ELSEVIER. 2013: 89–95

  Abstract

  Reintervention rates after repair of abdominal aortic aneurysm (AAA) are higher for endovascular repair (EVAR) than for open repair, mostly due to treatment for endoleaks, whereas open surgical operations for bowel obstruction and abdominal hernias are higher after open repair. However, readmission rates after EVAR or open repair for nonoperative conditions and complications that do not require an intervention are not well documented. We sought to determine reasons for all-cause readmissions within the first year after open repair and EVAR.Patients who underwent elective AAA repair in California during a 6-year period were identified from the Health Care and Utilization Project State Inpatient Database. All patients who had a readmission in California ≤1 year of their index procedure were included for evaluation. Readmission rates and primary and secondary diagnoses associated with each readmission were analyzed and recorded.From 2003 to 2008, there were 15,736 operations for elective AAA repair, comprising 9356 EVARs (60%) and 6380 open repairs (40%). At 1 year postoperatively, the readmission rate was 52.1% after open repair and 55.4% after EVAR (P=.0003). The three most common principle diagnoses associated with readmission after any type of AAA repair were failure to thrive, cardiac issues, and infection. When stratified by repair type, patients who underwent open repair were more likely to be readmitted with primary diagnoses associated with failure to thrive, cardiac complications, and infection compared with EVAR (all P<.001). Those who underwent EVAR were more likely, however, to be readmitted with primary diagnoses of device-related complications (P=.05), cardiac complications, and infection.Total readmission rates within 1 year after elective AAA repair are greater after EVAR than after open repair. Reasons for readmission vary between the two cohorts but are related to the magnitude of open surgery after open repair, device issues after EVAR, and the usual cardiac and infectious complications after either intervention. Systems-based analysis of these causes of readmission can potentially improve patient expectations and care after elective aneurysm repair.

  View details for DOI 10.1016/j.jvs.2012.07.005

  View details for Web of Science ID 000312833800016

  View details for PubMedID 23164606

• A comparison of 0+5 versus 5+2 applicants to vascular surgery training programs 26th Annual Meeting of the Western-Vascular-Society Zayed, M. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2012: 1448–52

  Abstract

  The new integrated 0 + 5 vascular surgery (VS) training paradigm introduced in 2007 required program directors and faculty to reconsider recruiting methods and exposure of medical students to VS. As a means to identify variables important for recruitment of 0 + 5 VS applicants, we sought to analyze national 0 + 5 VS residency application trends and to compare medical school demographics of applicants to both our 0 + 5 residency and 5 + 2 fellowship programs.Electronic Residency Application Service and National Resident Matching Program online public databases were queried to evaluate nationwide trends in the number of applicants to integrated VS residency programs between 2007 and 2010. Demographic data from Electronic Residency Application Service applications submitted to our institution's 0 + 5 and 5 + 2 VS training programs during the same time period were reviewed.From 2008 to 2011, there were 190 applicants to our 0 + 5 VS residency program and 161 applicants to our 5 + 2 fellowship program, with 127 (66.8%) and 122 (75.8%) being United States medical graduates, respectively. Annual application volume to our programs over these years remained stable for both training pathways (range, 39-49 for 0 + 5 integrated; range, 39-43 for 5 + 2 traditional). Nationally, applications to 0 + 5 programs increased sixfold over the same time period (52 in 2007 to 340 applicants in 2010; P < .001), far exceeding the available training positions. Compared with applicants to the 5 + 2 VS fellowships, medical students applying to the 0 + 5 programs are more likely to be female, be slightly older, have additional postgraduate degrees and publications, have higher United States Medical Licensure Examination test scores, and are more likely to be in the top quartile of their medical school class.Nationwide interest in the 0 + 5 vascular surgery residency training paradigm continues to significantly increase. Significant differences exist between the cohorts of 0 + 5 residency and 5 + 2 fellowship program applicants at the completion of medical school, suggesting that 0 + 5 VS residency programs are attracting a different medical student population to the VS specialty. VS program directors should continue to foster interest in this new applicant pool through early exposure, mentorship, and extracurricular research activities.

  View details for DOI 10.1016/j.jvs.2012.05.083

  View details for PubMedID 22857814

• Results of a double-barrel technique with commercially available devices for hypogastric preservation during aortoilac endovascular abdominal aortic aneurysm repair 26th Annual Meeting of the Western-Vascular-Society DeRubertis, B. G., Quinones-Baldrich, W. J., Greenberg, J. I., Jimenez, J. C., Lee, J. T. MOSBY-ELSEVIER. 2012: 1252–59

  Abstract

  To assess technical feasibility and short-term outcome of a novel hypogastric preservation technique in patients with aortoiliac aneurysms using commercially available endografts without device modification.Multi-institution review of prospectively acquired database of patients undergoing double-barrel endograft repair of aortoiliac aneurysms.Twenty-two patients underwent endovascular aneurysm repair for aortoiliac aneurysms from 2010 to 2011, with 23 double-barrel hypogastric preservation procedures successfully completed in 21 patients. The technique involved bifurcated main body placement followed by simultaneous deployment of parallel endograft limbs into the external iliac (ipsilateral approach) and hypogastric (contralateral femoral or brachial approach) arteries. Bilateral hypogastric branches were performed in two patients, and unilateral branches with and without contralateral coil embolization were performed in nine and ten patients, respectively. Procedural success rate was 96%, technical success rate (successful implantation with immediate aneurysm exclusion and no observed endoleak) was 88%, and access was fully-percutaneous in 86%. Two type III endoleaks between branch components were noted on completion angiograms, but both resolved spontaneously on follow-up imaging. One type Ib endoleak was noted on postoperative imaging (contralateral to hypogastric branch, repaired with limb extension), as were three type II endoleaks (14%) without sac expansion. Early (<2 weeks) limb occlusion (one external iliac, two hypogastric) occurred in two patients, though no subsequent occlusions have occurred (mean follow-up, 7.2 months; range, 1-20 months). Primary patency for external iliac and hypogastric limbs at 6 months was 95% and 88%, respectively. There were no deaths; complications included groin hematoma in 10% and acute renal insufficiency in 5%. Buttock claudication (n = 4) only occurred in patients who had ipsilateral coil embolization of hypogastric arteries (n = 9) for bilateral iliac aneurysms in which only unilateral hypogastric preservation was performed, resulting in rate of 44% in these patients.The double-barrel technique for hypogastric preservation is technically feasible across multiple interventionalists using commercially available endografts without device modification. These procedures are associated with minimal morbidity, acceptable short-term limb-patency rates, and reduced buttock claudication compared with those involving contralateral hypogastric embolization.

  View details for DOI 10.1016/j.jvs.2012.04.070

  View details for Web of Science ID 000310428200008

  View details for PubMedID 22743017

• Could the Endo-first Strategy Really Be Better? INVITED CRITIQUE ARCHIVES OF SURGERY Lee, J. T. 2012; 147 (9): 846-846

  View details for Web of Science ID 000308883700018

• Could the endo-first strategy really be better? Archives of surgery Lee, J. T. 2012; 147 (9): 846-?

  View details for DOI 10.1001/archsurg.2012.2021

  View details for PubMedID 22987178

• Transesophageal Echocardiography Guidance for Stent-Graft Repair of a Thoracic Aneurysm is Facilitated by the Ability of Partial Stent Deployment ANNALS OF VASCULAR SURGERY Crimi, E., Lee, J. T., Dake, M. D., van der Starre, P. J. 2012; 26 (6)

  Abstract

  Transesophageal echocardiography (TEE) is routinely used in our Institution for monitoring correct positioning of thoracic aortic stent grafts. We present a case of successful endovascular repair of three discrete thoracic aortic aneurysms with Zenith TX2 endovascular stent grafts in an 82-year-old female patient. Our focus is on the increased value of TEE guidance because of the ability of partial stent deployment and manipulation during insertion.

  View details for DOI 10.1016/j.avsg.2012.01.013

  View details for PubMedID 22794345

• Ethnic differences in arm vein diameter and arteriovenous fistula creation rates in men undergoing hemodialysis access 26th Annual Meeting of the Western-Vascular-Society Ishaque, B., Zayed, M. A., Miller, J., Nguyen, D., Kaji, A. H., Lee, J. T., O'Connell, J., de Virgilio, C. MOSBY-ELSEVIER. 2012: 424–32

  Abstract

  The National Kidney Foundation recommends that arteriovenous fistulas (AVFs) be placed in at least 65% of hemodialysis patients. Some studies suggest that African American patients are less likely to receive a first-time AVF than patients of other ethnicities, although the reason for this disparity is unclear. The purpose of our study is to determine (1) whether there are ethnic differences in AVF creation, (2) whether this may be related to differences in vein diameters, and (3) whether AVF patency rates are similar between African American and non-African American male patients.Consecutive male patients undergoing first-time hemodialysis access from 2006 to 2010 at two institutions were retrospectively reviewed. Data collected included age, ethnicity, weight, height, body mass index, diabetes, hypertension, congestive heart failure, smoking history, intravenous drug abuse, need for temporary access placement, and preoperative venous ultrasound measurements. Categoric variables were compared using χ(2) analysis, and the Wilcoxon rank-sum test was used to compare continuous variables.Of 249 male patients identified, 95 were African American. Median age in African American and non-African American patients was 63 years. Hypertension and hyperlipidemia were statistically significantly greater in African American patients. The need for temporary access before hemoaccess was similar between the cohorts. African American patients demonstrated significantly smaller median basilic and cephalic vein diameters at most measured sites. Overall, 221 of 249 (88.8%) underwent AVF first. An AV graft was created in 17.9% of African American patients vs in only 7.1% of non-African Americans (odds ratio, 2.8; 95% confidence interval, 1.3-6.4; P = .009). The difference between median vein diameters used for autologous fistula creation in African American and non-African American patients was not significant. There was no significant difference in the primary patency (80.8% vs 76.2%; P = .4), primary functional patency (73.1% vs 69.2%; P = .5), or secondary functional patency rates (91.0% vs 96.5%; P = .1). Average primary fistula survival time was 257 days in African American and 256 in non-African American patients (P = .2).African American patients are less likely than non-African American patients to undergo AVF during first-time hemodialysis access surgery. This ethnic discrepancy appears to be due to smaller arm vein diameters in African American patients. In African American patients with appropriate vein diameters who do undergo AVF, primary and functional patencies are equivalent to non-African American patients.

  View details for DOI 10.1016/j.jvs.2012.01.029

  View details for Web of Science ID 000307160400020

  View details for PubMedID 22551911

• 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

• Fenestrate What You Can't Snorkel? ANNALS OF VASCULAR SURGERY Zayed, M. A., Chowdhury, M., Casey, K., Dalman, R. L., Lee, J. T. 2012; 26 (5)

  Abstract

  Although challenging proximal necks have limited the utility of standard endovascular aneurysm repair (EVAR) devices, sophisticated endovascular techniques have evolved in recent years for the repair of juxtarenal abdominal aortic aneurysms (AAAs). Among these techniques, snorkel or chimney EVAR (sn-EVAR) and fenestrated EVAR (f-EVAR) have emerged as options for repairing anatomic high-risk AAAs. Unfortunately, in the United States, except in the context of a clinical trial or physician-sponsored device exemption, limited long-term data exist on the treatment of juxta- and suprarenal AAAs with either sn-EVAR or f-EVAR. Owing to these limitations, comparison of these two techniques is challenging, and we sought to describe a case when one was favored over the other.A 72-year-old man presented with an enlarging, asymptomatic, juxtarenal fusiform AAA (5.9 cm), a moderately enlarged right common iliac artery (2.8 cm), a history of oxygen-dependent chronic obstructive pulmonary disease, and a previous right nephrectomy. An initial sn-EVAR was attempted but was unsuccessful owing to the inability to deliver the "snorkel" covered stent via a brachial approach because of renal ostial stenosis and cephalad angulation of the patient's left renal artery. A subsequent f-EVAR approach was successfully used to repair the juxtarenal AAA while preserving adequate renal artery blood flow. Two-year postoperative follow-up demonstrated a stable endovascular repair without endoleaks, a shrinking aneurysm sac, and stable renal function.The sn-EVAR configuration in this case report was precluded by cephalad renal angulation, and the AAA was instead repaired using an f-EVAR approach, with good 2-year follow-up outcomes. The sn-EVAR strategy requires downward pointing renal arteries in addition to adequate brachial/axillary artery access dimensions to facilitate successful repair. With improving techniques and technology for either approach, anatomic specifications and indications for these advanced EVAR strategies will need to be delineated.

  View details for DOI 10.1016/j.avsg.2011.08.027

  View details for PubMedID 22664290

• Hybrid Treatment of Celiac Artery Compression (Median Arcuate Ligament) Syndrome DIGESTIVE DISEASES AND SCIENCES Palmer, O. P., Tedesco, M., Casey, K., Lee, J. T., Poultsides, G. A. 2012; 57 (7): 1782-1785

  View details for DOI 10.1007/s10620-011-2019-x

  View details for PubMedID 22212729

• See One, Sim One, Do One, Teach One: Results of a Prospective Randomized Trial of Endovascular Skills Training for Surgical Residents 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 Lee, J. T., Peruzzaro, A., Krummel, T., Dalman, R. L. MOSBY-ELSEVIER. 2012: 27–27

  View details for Web of Science ID 000304398900047

• Spinal Cord Injury after Hybrid Endovascular Repair of Thoracoabdominal Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry 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 Oderich, G. S., Timaran, C., Farber, M., Quinones-Baldrich, W., Escobar, G., Gloviczki, P., Greenberg, R. K., Black, J., Ellozy, S., Woo, E., Singh, M., Fillinger, M., Lee, J., Dosluoglu, H. H. MOSBY-ELSEVIER. 2012: 93–94

  View details for Web of Science ID 000304398900178

• Outcomes of Ischemic Colitis after Hybrid Endovascular Repair of Complex Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry 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 Timaran, C. H., Oderich, G. S., Farber, M. A., Quinones-Baldrich, W., Gloviczki, P., Escobar, G., Greenberg, R. K., Black, J., Ellozy, S., Woo, E., Singh, M., Fillinger, M., Lee, J., Dosluoglu, H. H. MOSBY-ELSEVIER. 2012: 9–9

  View details for Web of Science ID 000304398900013

• 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

• VALIDATION OF A POWER LAW MODEL IN UPPER EXTREMITY VESSELS: POTENTIAL APPLICATION IN ULTRASOUND BLEED DETECTION ULTRASOUND IN MEDICINE AND BIOLOGY Wang, A. S., Liang, D. H., Bech, F., Lee, J. T., Zarins, C. K., Zhou, W., Taylor, C. A. 2012; 38 (4): 692-701

  Abstract

  Vascular ultrasound can provide quick and reliable diagnosis of arterial bleeding but it requires trained and experienced personnel. Development of automated sonographic bleed detection methods would potentially be valuable for trauma management in the field. We propose a detection method that (1) measures blood flow in a trauma victim, (2) determines the victim's expected normal limb arterial flow using a power law biofluid model where flow is proportional to the vessel diameter taken to a power of k and (3) quantifies the difference between measured and expected flow with a novel metric, flow split deviation (FSD). FSD was devised to give a quantitative value for the likelihood of arterial bleeding and validated in human upper extremities. We used ultrasound to demonstrate that the power law with k = 2.75 appropriately described the normal brachial artery bifurcation geometry and adequately determined the expected normal flows. Our metric was then applied to three-dimensional (3-D) computational models of forearm bleeding and on dialysis patients undergoing surgical construction of wrist arteriovenous fistulas. Computational models showed that larger sized arterial defects produced larger flow deviations. FSD values were statistically higher (paired t-test) for arms with fistulas than those without, with average FSDs of 0.41 ± 0.12 and 0.047 ± 0.021 (mean ± SD), respectively. The average of the differences was 0.36 ± 0.12 (mean ± SD).

  View details for DOI 10.1016/j.ultrasmedbio.2011.12.016

  View details for PubMedID 22341050

• Early experience with the snorkel technique for juxtarenal aneurysms 26th Annual Meeting of the Western-Vascular-Society Lee, J. T., Greenberg, J. I., Dalman, R. L. MOSBY-ELSEVIER. 2012: 935–46

  Abstract

  The lack of readily available branched and fenestrated endovascular aneurysm repair (EVAR) options has created an opportunity for creative deployment of endograft components to treat juxtarenal aneurysms. We present our early experience with "snorkel" or "chimney" techniques in the endovascular management of complex aortic aneurysms.We retrospectively reviewed planned snorkel procedures for juxtarenal aneurysms performed from September 2009 to August 2011. Our standardized technique included axillary or brachial cutdown for delivery of covered snorkel stents and mostly percutaneous femoral access for the main body endograft.Fifty-six snorkel grafts were successfully placed in 28 consecutive patients (mean age, 75 years) with juxtarenal aneurysms. Mean aneurysm size was 64.8 mm (range, 53-87 mm). The snorkel configuration extended the proximal seal zone from an unsuitable infrarenal neck for standard EVAR (median diameter, 33.5 mm; length, 0.0 mm) to a median neck diameter of 24.5 mm and length of 18.0 mm. Five patients had unilateral renal snorkels, 17 had bilateral renal snorkels, and six had celiac/superior mesenteric artery/renal combinations. Technical success of snorkel placements was 98.2%, with loss of wire access leading to one renal stent deployment failure. Thirty-day mortality was 7.1%: one patient was readmitted 1 week postoperatively with pneumonia and died of sepsis; one patient died at 1 week of a right hemispheric stroke. Other major complications included perinephric hematomas, 7.1%; permanent hemodialysis, 3.6%; iliac artery injury requiring endoconduit placement, 3.6%; and brachial plexus nerve injury, 3.6%. Cardiac complications included self-limited arrhythmias (14.3%) and one non-Q-wave myocardial infarction (3.6%), with all recovering without coronary intervention. Mean follow-up was 10.7 months (range, 3-25 months). One patient died of nonaneurysmal-related causes at 3 months (89.3% survival). Postoperative imaging revealed one renal snorkel graft occlusion occurring at 3 months (98.2% overall primary patency). Seven (25%) early endoleaks were noted on the first follow-up computed tomography angiography: two type I, three type II, and two type III (25%), leading to one secondary intervention (3.6%) with bridging cuff placement (type III). The small type Ia endoleaks and other type III endoleak resolved at the 6-month scan. Mean sac regression at the latest follow-up was 7.3 mm. No aneurysm has enlarged on postoperative imaging.Early success with the snorkel technique for juxtarenal aneurysms has made it our procedure of choice for complex short-neck to no-neck EVAR. Although long-term follow-up is needed, the flexibility of the snorkel technique and lack of requirement for custom-built devices may make this approach more attractive than branched or fenestrated stent grafts.

  View details for DOI 10.1016/j.jvs.2011.11.041

  View details for PubMedID 22244859

• Delayed Hypogastric Artery Pseudoaneurysm Following Blunt Trauma Without Evidence of Pelvic Fracture ANNALS OF VASCULAR SURGERY Al-Khatib, W. K., Lee, G. K., Casey, K., Lee, J. T. 2012; 26 (3)

  Abstract

  Arterial pelvic bleeding caused by bony fragments is a common finding in patients with pelvic fractures after blunt trauma (Durkin et al., Am J Surg 2006;192:211-23). However, arterial injury in the absence of bony fracture is extremely rare, and in the event that it does occur, is immediately discovered on cross-sectional imaging. We present an unusual case of a 15-year-old boy who was involved in a bicycle accident, and who, a week after his injury, developed a delayed hypogastric branch artery pseudoaneurysm causing sciatic nerve compression with a right foot drop. Initial magnetic resonance imaging scan and pelvic X-ray at the time of the injury showed no evidence of pelvic fracture or vascular damage. The pseudoaneurysm was successfully treated with selective coil embolization and hematoma evacuation. This study represents only the second reported case of delayed pelvic pseudoaneurysm in the absence of pelvic fracture.

  View details for DOI 10.1016/j.avsg.2011.11.007

  View details for PubMedID 22326296

• Invited commentary. Journal of vascular surgery Lee, J. T. 2012; 55 (3): 720-?

  View details for DOI 10.1016/j.jvs.2011.09.076

  View details for PubMedID 22370024

• Endovascular Repair of Bilateral Iliac Artery Aneurysms in a Patient With Loeys-Dietz Syndrome 21st Annual Winter Meeting of the Peripheral-Vascular-Surgery-Society Casey, K., Zayed, M., Greenberg, J. I., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012

  Abstract

  Loeys-Dietz syndrome (LDS) is a rare congenital connective tissue disorder (CTD) caused by mutations in the gene encoding for transforming growth factor-β receptors I and II. This recently described syndrome is characterized by aortic aneurysms and dissections, arterial tortuosity, and spontaneous organ perforation. The technical feasibility of endovascular interventions, particularly endovascular aneurysm repair (EVAR), in CTDs is relatively unknown.A 38-year-old man presented with asymptomatic bilateral common iliac artery aneurysms measuring 5.3 cm on the right and 4.3 cm on the left. The patient had an extensive surgical and medical history, including a recently repaired Stanford type-A aortic dissection, total colectomy with end ileostomy for a colonic perforation, splenectomy for rupture, and cirrhosis secondary to chronic hepatitis C. The patient's CTD, multiple abdominal surgeries performed in the past, and ileostomy made him a poor candidate for open repair. We elected to offer him a complex endovascular repair and hoped to preserve his pelvic circulation by using "double-barrel" configuration of stent-grafts in the right iliac artery system. Successful deployment of the devices and repair of femoral access allowed routine discharge on postoperative day 2. At 6-month follow-up, the patient's pelvic circulation has been maintained, the aneurysms are excluded without endoleak, and sac regression has been shown.LDS is a rare connective tissue disorder characterized by vascular aneurysms and arterial tortuosity. When vascular reconstruction is necessary, open techniques are often preferred given the lack of data on endovascular procedures. In the present case, we report the first successful abdominal EVAR in a high-risk patient with LDS, providing excellent short-term results.

  View details for DOI 10.1016/j.avsg.2011.06.005

  View details for PubMedID 21835579

• 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

• Early results of a highly selective algorithm for surgery on patients with neurogenic thoracic outlet syndrome 25th Annual Meeting of the Western-Vascular-Society Chandra, V., Olcott, C., Lee, J. T. MOSBY-ELSEVIER. 2011: 1698–1705

  Abstract

  Neurogenic thoracic outlet syndrome (nTOS) encompasses a wide spectrum of disabling symptoms that are often vague and difficult to diagnose and treat. We developed and prospectively analyzed a treatment algorithm for nTOS utilizing objective disability criteria, thoracic outlet syndrome (TOS)-specific physical therapy, radiographic evaluation of the thoracic outlet, and selective surgical decompression.Patients treated for nTOS from 2000-2009 were reviewed (n = 93). In period 1, most patients were offered surgery with documentation of appropriate symptoms. A prospective observational study began in 2007 (period 2) and was aimed at determining which patients benefited most from surgical intervention. Evaluation began with a validated mini-QuickDASH (QD) quality-of-life scale (0-100, 100 = worse) and duplex imaging of the thoracic outlet. Patients then participated in TOS-specific physical therapy (PT) for 2 to 4 months and were offered surgery based on response to PT and improvement in symptoms.Thirty-four patients underwent first rib resection in period 1 (68% female, mean age 39, 18% athletes, 15% workers comp). In operated patients undergoing duplex imaging, 47% showed compression of their thoracic outlet arterial flow on provocative positioning. Based on subjective improvement of symptoms, 56% of patients at 1 year had a positive outcome. In period 2 during the prospective cohort, 59 consecutive patients were evaluated for nTOS (64% female, mean age 36, 32% athletes, 12% workers comp) with a mean pre-PT QD disability score of 55.1. All patients were prescribed PT, and 24 (41%) were eventually offered surgical decompression based on compliance with PT, interval improvement on QD score, and duplex compression of the thoracic outlet. Twenty-one patients underwent surgery (SURG group) consisting of first rib resection, middle and anterior scalenectomy, and brachial plexus neurolysis. There were significant differences between the SURG and non-SURG cohorts with respect to age, participation in competitive athletics, history of trauma, and symptom improvement with PT. At 1-year follow-up, 90% of patients expressed symptomatic improvement with the mean post-op QD disability score decreasing to 24.9 (P = .005) and 1-year QD scores improving down to 20.5 (P = .014).This highly-selective algorithm for nTOS surgery leads to improvement in overall success rates documented subjectively and objectively. Compliance with TOS-specific PT, improvement in QD scores after PT, young age, and competitive athletics are associated with improved surgical outcomes. Long-term follow-up will be necessary to document sustained symptom relief and to determine who the optimal surgical candidates are.

  View details for DOI 10.1016/j.jvs.2011.05.105

  View details for PubMedID 21803527

• Development and Implementation of an Introductory Endovascular Training Course for Medical Students ANNALS OF VASCULAR SURGERY Aparajita, R., Zayed, M. A., Casey, K., Dayal, R., Lee, J. T. 2011; 25 (8): 1104-1112

  Abstract

  Endovascular simulation has been promoted as an educational tool for trainees to practice procedures in a safe environment and improve basic technical skills. We sought to determine whether an established endovascular training course for medical students could increase technical proficiency, enhance interest in vascular surgery, and be implemented at another academic institution.At Center A, medical students participated in an eight-week elective course with a structured curriculum comprised of weekly mentored simulator sessions and didactic teachings. A similar course was developed at Center B to train a similar cohort of students using the same high-fidelity simulator. Demographics and survey data, including interest in vascular surgery, were obtained, and pre- and postcourse graded simulator sessions on renal stent or iliac/superficial femoral artery stent modules were conducted. Performance was assessed by expert observers using a standardized global endovascular rating scale and objective procedural metrics collected from the simulator.Seventy-seven medical students (41 at Center A and 36 at Center B; 56 men and 21 women) completed the course from 2007 to 2009. Parameters measured on the standardized global endovascular rating scale, including angiography skills, wire handling, and interventional criteria as well as simulator-generated metrics, significantly improved from pre- to postcourse values for both groups of medical students at the two institutions (p < 0.05). More than 94% of the students agreed or strongly agreed that the simulation course increased their interest in vascular surgery.A simulation-based endovascular course provides an educational tool that improves basic technical performance and increases interest in vascular surgery among medical students. This simple educational module appears to be transferable and adaptable at another institution with minimal modification to produce similar results.

  View details for DOI 10.1016/j.avsg.2011.07.002

  View details for Web of Science ID 000296553100014

  View details for PubMedID 21945331

• Long-term impact of a preclinical endovascular skills course on medical student career choices 25th Annual Meeting of the Western-Vascular-Society Lee, J. T., Son, J. H., Chandra, V., Lilo, E., Dalman, R. L. MOSBY-ELSEVIER. 2011: 1193–1200

  Abstract

  Surging interest in the 0 + 5 integrated vascular surgery (VS) residency and successful recruitment of the top students in medical school requires early exposure to the field. We sought to determine the impact of a high-fidelity simulation-based preclinical endovascular skills course on medical student performance and ultimate career specialty choices.Fifty-two preclinical medical students enrolled in an 8-week VS elective course from 2007 to 2009. Students completed a baseline and postcourse survey and performed a renal angioplasty/stent procedure on an endovascular simulator (pretest). A curriculum consisting of didactic teaching covering peripheral vascular disease and weekly mentored simulator sessions concluded with a final graded procedure (posttest). Long-term follow-up surveys 1 to 3 years after course completion were administered to determine ultimate career paths of participants as well as motivating factors for career choice.Objective and subjective performance measured on the simulator and through structured global assessment scales improved in all students from pre- to posttest, particularly with regard to technical skill and overall procedural competency (P < .001). Prior to enrolling in the course, 9% of the students expressed high interest in VS, and after completing the course, this response nearly tripled in terms of seriously considering VS as a career option (P = .03). Overall interest postcourse in VS and procedural-based surgical specialties was nearly 90%. In long-term follow-up, 25% were still strongly considering integrated VS residencies, with other top career choices including surgical subspecialties (64%), radiology (10%), and cardiology (6%). Most respondents indicated major reasons for continued interest in VS were the ability to practice endovascular procedures on the simulator (92%) and mentorship from VS faculty (70%).Basic endovascular skills can be efficiently introduced through a simulation-based curriculum and lead to improved novice performance. Early exposure of preclinical medical students provides an effective teaching and recruitment tool for procedural-based fields, particularly surgical subspecialties. Mentored exposure to endovascular procedures on the simulator positively impacts long-term medical student attitudes toward vascular surgery and ultimate career choices.

  View details for DOI 10.1016/j.jvs.2011.04.052

  View details for PubMedID 21723068

• Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome DIGESTIVE DISEASES AND SCIENCES Magee, G., Slater, B. J., Lee, J. T., Poultsides, G. A. 2011; 56 (9): 2528-2531

  View details for DOI 10.1007/s10620-011-1757-0

  View details for PubMedID 21643740

• Two Decades of Progress in Vascular Medicine AMERICAN JOURNAL OF MEDICINE Leeper, N. J., Lee, J. T., Cooke, J. P. 2011; 124 (9): 791-792

  View details for DOI 10.1016/j.amjmed.2011.03.017

  View details for PubMedID 21683936

• Who is Applying to Vascular Surgery? A Comparison of Demographics of 0+5 versus 5+2 Applicants Zayed, M. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2011: 587

  View details for DOI 10.1016/j.jvs.2011.05.060

  View details for Web of Science ID 000293814400065

• Validation of Simulation as a Tool for Assessing Endovascular Procedural Competency Dawson, D. L., Mitchell, E. L., Lee, J. T., Mills, J. L., Laird, J. R., Hedayati, N., Lee, E. S., Pevec, W. C. MOSBY-ELSEVIER. 2011: 587–87

  View details for Web of Science ID 000293814400064

• Results of a Double-Barrel Technique with Commercially Available Devices for Hypogastric Preservation during Aortoiliac EVAR DeRubertis, B. G., Quinones-Baldrich, W. J., Greenberg, J., Jimenez, J. C., Lee, J. T. MOSBY-ELSEVIER. 2011: 588–89

  View details for Web of Science ID 000293814400069

• Long-Term Results after Accessory Renal Artery Coverage during Endovascular Aortic Aneurysm Repair Greenberg, J. I., Dorsey, C., Dalman, R. L., Lee, J. T., Mell, M. W. MOSBY-ELSEVIER. 2011: 588–88

  View details for Web of Science ID 000293814400067

• Early Experience with the Snorkel Technique for Juxtarenal Aneurysms: The Preferred Off-the-Shelf Solution for Challenging EVAR Anatomy? Lee, J. T., Greenberg, J. I., Dalman, R. L. MOSBY-ELSEVIER. 2011: 589–89

  View details for Web of Science ID 000293814400070

• Readmissions after Abdominal Aortic Aneurysm Repair: Differences between Open Repair and Endovascular Aneurysm Repair Casey, K. M., Hernandez-Boussard, T., Al-Khatib, W. K., Mell, M. W., Lee, J. T. MOSBY-ELSEVIER. 2011: 590–90

  View details for Web of Science ID 000293814400073

• Venous Thromboembolic Disease JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Streiff, M. B., Bockenstedt, P. L., Cataland, S. R., Chesney, C., Eby, C., Fanikos, J., Fogarty, P. F., Gao, S., Garcia-Aguilar, J., Goldhaber, S. Z., Hassoun, H., Hendrie, P., Holmstrom, B., Jones, K. A., Kuderer, N., Lee, J. T., Millenson, M. M., Neff, A. T., Ortel, T. L., Smith, J. L., Yee, G. C., Zakarija, A. 2011; 9 (7): 714-777

  View details for Web of Science ID 000292264200005

  View details for PubMedID 21715723

• Surgery for Thoracic Outlet Syndrome: A Nationwide Perspective Vascular Annual Meeting of the Society-for-Vascular-Surgery Lee, J. T., Dua, M. M., Chandra, V., Hernandez-Boussard, T. M., Illig, K. A. MOSBY-ELSEVIER. 2011: 100S–101S

  View details for Web of Science ID 000291410700194

• Interactive Online Training Improves Trainee Test Performance in Vascular Surgery Vascular Annual Meeting of the Society-for-Vascular-Surgery Zayed, M. A., Casey, K., Lilo, E., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2011: 99S–100S

  View details for Web of Science ID 000291410700192

• A comparison between one- and two-stage brachiobasilic arteriovenous fistulas 25th Annual Meeting of the Western-Vascular-Surgical-Society Reynolds, T. S., Zayed, M., Kim, K. M., Lee, J. T., Ishaque, B., Dukkipati, R. B., Kaji, A. H., de Virgilio, C. MOSBY-ELSEVIER. 2011: 1632–38

  Abstract

  Brachiobasilic arteriovenous fistulas (BBAVF) can be performed in one or two stages. We compared primary failure rates, as well as primary and secondary patency rates of one- and two-stage BBAVF at two institutions.Patients undergoing one- and two-stage BBAVF at two institutions were compared retrospectively with respect to age, sex, body mass index, use of preoperative venous duplex ultrasound, diabetes, hypertension, and cause of end-stage renal disease. Categorical variables were compared using chi-square and Fisher's exact test, whereas the Wilcoxon rank-sum test was used to compare continuous variables. Patency rates were assessed using the Kaplan-Meier survival analysis and the Cox proportional hazards model with propensity analysis to determine hazard ratios.Ninety patients (60 one-stage and 30 two-stage) were identified. Mean follow-up was 14.2 months and the mean time interval between the first and second stage was 11.2 weeks. Although no significant difference in early failure existed (one-stage, 22.9% vs two-stage, 9.1%; P = .20), the two-stage BBAVF showed significantly improved primary functional patency at 1 year at 88% vs 61% (P = .047) (hazard ratio, 0.2 (95% confidence interval [CI], .04-.80; P = .03). Patency for one-stage BBAVF markedly decreased to 34% at 2 years compared with 88% for the two-stage procedure (P = .047). Median primary functional patency for one-stage BBAVF was 31 weeks (interquartile range [IQR], 11-54) vs 79 weeks (IQR, 29-131 weeks) for the two-stage procedure, respectively (P = .0015). Two-year secondary functional patency for one- and two-stage procedures were 41% and 94%, respectively (P = .015).Primary and secondary patency at 1 and 2 years as well as functional patency is improved with the two-stage BBAVF when compared with the one-stage procedure. Lower primary failure rates prior to dialysis with the two-stage procedure approached, but did not reach statistical significance. While reasons for these finding are unclear, certain technical aspects of the procedure may play a role.

  View details for DOI 10.1016/j.jvs.2011.01.064

  View details for Web of Science ID 000291410600026

  View details for PubMedID 21531530

• Early Results of a Highly Selective Algorithm for Surgery on Patients with Neurogenic Thoracic Outlet Syndrome: A Prospective Analysis 25th Annual Meeting of the Western-Vascular-Society Chandra, V., Olcott, C., Lee, J. T. MOSBY-ELSEVIER. 2010: 525–25

  View details for Web of Science ID 000280455900056

• Long-Term Impact of a Preclinical Endovascular Skills Course on Medical Student Career Choices 25th Annual Meeting of the Western-Vascular-Society Son, J. H., Zayed, M. A., Tedesco, M. M., Chandra, V., Lilo, E. A., Lee, J. T. MOSBY-ELSEVIER. 2010: 526–26

  View details for Web of Science ID 000280455900058

• Re: Thoracic Outlet Syndrome Recalling "Murphy's Law" Reply PM&R Lee, J. T. 2010; 2 (6): 581-582

  View details for DOI 10.1016/j.pmrj.2010.03.017

  View details for Web of Science ID 000208412300018

• A survey of demographics, motivations, and backgrounds among applicants to the integrated 0+5 vascular surgery residency JOURNAL OF VASCULAR SURGERY Lee, J. T., Teshome, M., De Virgilio, C., Ishaque, B., Qiu, M., Dalman, R. L. 2010; 51 (2): 496-503

  Abstract

  The 0 + 5 integrated vascular surgery (VS) residency has altered the training paradigm for future vascular specialists. Rising interest in these novel programs highlights our need to better understand the applicant pool. We compared demographics and surveyed recent applicants to our integrated program to gain more insight into their background and motivation for accelerated vascular training.Demographics and objective parameters were determined from all 65 applicants to the integrated VS program at Stanford University Medical Center and compared to 58 applicants interviewed by the general surgery (GS) program at Harbor-UCLA Medical Center by querying the Electronic Residency Application System for the programs in 2009. There was no overlap of applicants between programs. An anonymous, voluntary Web-based survey was sent to these cohorts with a response rate of 82% for VS applicants and 60% for GS applicants. Subjects were queried regarding their background, personal experience, prior exposure to VS, and motivations for residency specialty selection.Applicants to integrated VS programs tended to be older, were less likely to be from a US medical school, had a higher number of publications, and a higher percentage of cardiovascular-related publications than the GS applicants. When stratified by the 27 VS applicants (41%) that were offered an interview, this highly selected and desirable group for training was nearly 40% female, more likely to have an additional degree (PhD, master's), just as likely to be in the top quartile of their medical school class (60%), and score equally well on standardized board examinations (90th percentile) than the top GS applicants offered interviews. Survey data revealed that the majority of career choices (65%) were made during the third and fourth years of medical school. Factors most strongly influencing the decision to choose VS as a career were endovascular technologies/devices, challenging open vascular operations, clinical rotations on vascular surgery, the aging patient population, and perceived need for vascular surgeons and vascular surgeon mentorship. The most common reasons cited for particularly pursuing an integrated 0 + 5 VS training program were (1) more focused training/integration of cardiovascular medicine, (2) interest in catheter-based endovascular therapies, and (3) shorter time in training. Of the GS applicants, 58% indicated they would be interested in applying to an integrated residency in their subspecialty of interest, and 45% listed vascular surgery as a potential fellowship option after general surgery.Applicants to 0 + 5 integrated vascular residencies were more likely to have rotated on a vascular surgery service, observed vascular cases, identified a vascular surgery mentor, and been actively involved in cardiovascular research. The quality of the top VS applicant based on class rank and test scores is comparable to the top GS applicants, yet the VS applicant has a higher percentage of advanced degrees, more publications, and more involvement in cardiovascular research. Institutional strategies to increase medical student exposure to vascular surgery clinically and via research programs will optimize our ability to attract and train the best candidates in these new training programs.

  View details for DOI 10.1016/j.jvs.2009.08.076

  View details for PubMedID 20022205

• Thoracic outlet syndrome. PM & R : the journal of injury, function, and rehabilitation Lee, J., Laker, S., Fredericson, M. 2010; 2 (1): 64-70

  View details for DOI 10.1016/j.pmrj.2009.12.001

  View details for PubMedID 20129515

• Thoracic Outlet Syndrome PM&R Lee, J., Laker, S., Fredericson, M. 2010; 2 (1): 64-67

  View details for DOI 10.1016/j.pmrj.2009.12.001

  View details for Web of Science ID 000208359100013

• The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery. Journal of surgical education Lee, J. T., Qiu, M., Teshome, M., Raghavan, S. S., Tedesco, M. M., Dalman, R. L. 2009; 66 (6): 367-373

  Abstract

  New training paradigms in vascular surgery allow for early specialization out of medical school. Surgical simulation has emerged as an educational tool for trainees to practice procedures in a controlled environment allowing interested medical students to perform procedures without compromising patient safety. The purpose of this study is to assess the ability of a simulation-based curriculum to improve the technical performance and interest level of medical students in vascular surgery.Prospective observational cohort study of medical student performance.Academic medical center.Forty-one medical students (23 first year, 15 second year, 3 other) enrolled in a vascular surgery elective course. Students completed a survey of their interests and performed a renal stent procedure on an endovascular simulator (pretest). The curriculum consisted of didactic teaching and weekly mentored simulator sessions and concluded with a final renal stent procedure on the simulator (posttest). Objective procedural measures were determined during the pre- and posttest by the simulator, and subjective performance was graded by expert observers utilizing a structured global assessment scale. After the course, the students were surveyed as to their opinions about vascular surgery as a career option. Finally, 1 year after the course, all students were again surveyed to determine continued interest in vascular surgery.The objective and subjective criteria measured on the simulator and structured global assessment scale significantly improved from pre- to posttest in terms of performer technical skill, patient safety measures, and structured global assessments. Before beginning the course, 8.5% of the students expressed high interest in vascular surgery, and after completing the course 70% were seriously considering vascular surgery as a career option (p = 0.0001). More than 95% of the students responded that endovascular simulation increased their knowledge and interest in vascular surgery. In the 1-year follow-up survey (n = 23 medical students), 35% had already entered their clinical years. Seventy percent of the students were still considering vascular surgery, while several other career options were still popular including the surgical subspecialties (70%), interventional cardiology (57%), and interventional radiology (48%). Most respondents indicated the major reasons for continued interest in vascular surgery were the ability to practice endovascular procedures on the simulator (100%) and mentorship from vascular surgery faculty (78%).The use of high fidelity endovascular simulation within an introductory vascular surgery course improves medical student performance with respect to technical skill, patient safety parameters, and global performance assessment. Mentored exposure to endovascular procedures on the simulator positively impacts long term medical student attitudes towards vascular surgery. Simulator-based courses may have the potential to be an important component in the assessment and recruitment of medical students for future surgical training programs.

  View details for DOI 10.1016/j.jsurg.2009.06.002

  View details for PubMedID 20142137

• Preoperative Thrombus Volume Predicts Sac Regression After Endovascular Aneurysm Repair JOURNAL OF ENDOVASCULAR THERAPY Yeung, J. J., Hernandez-Boussard, T. M., Song, T. K., Dalman, R. L., Lee, J. T. 2009; 16 (3): 380-388

  Abstract

  To examine whether preoperative aneurysm thrombus volume correlated with abdominal aortic aneurysm (AAA) sac regression following endovascular aneurysm repair (EVAR).Clinical records and computed tomographic angiograms (CTAs) from patients undergoing EVAR from 2003 to 2008 were reviewed. Inclusion criteria for this study were available preoperative CTA images, >or=12-month follow-up with surveillance imaging, lack of re-intervention at 12 months, and treatment with commercially available devices. Patients with ruptured AAAs, those requiring an aortomonoiliac stent-graft, and clinical trial cases were excluded. Based on these criteria, satisfactory images and clinical follow-up were available in 100 patients (90 men; mean age 76.8 years, range 55-95). Preoperative CTAs were categorized as demonstrating "minimal," "moderate," or "severe" aneurysm thrombus load by 2 independent examiners blinded to clinical outcome. Percentage of the aortic cross-sectional area occluded by clot (% clot area) was calculated as [(total area) - (luminal area)]/(total area). Multivariate logistic regression analysis was performed to determine predictors of sac shrinkage at long-term follow-up.AAA thrombus was classified as minimal in 24%, moderate in 23%, and severe in 53%. Thrombus area averaged 11%+/-13%, 41%+/-14%, and 72+/-12% in each group, respectively. By multivariate analysis, minimal thrombus (OR = 1.47) and greater AAA diameter (OR = 1.3) were independent predictors of sac regression at 1, 6, and 12 months (all p<0.05). Presence of neck plaque and endoleak were also independent predictors of sac expansion (p<0.05). Patients with severe preoperative thrombus were less likely to demonstrate sac regression even in the absence of endoleak. Thrombus judgment (subjective) and percent clot area (objective) were strongly correlated (R = 0.82, p<0.05). Interobserver agreement on thrombus judgment was 86%.Thrombus burden on preoperative CTA is a strong independent predictor of sac regression following EVAR. If validated by prospective studies, relative thrombus burden should be incorporated into postoperative surveillance algorithms to define procedural success and optimize the timing and cost-effectiveness of cross-sectional imaging.

  View details for PubMedID 19642793

• Not All "Microemboli" are Created Equal: Hypotension During Carotid Stenting May be a Cause for Some Lesions. American-Association-International-Stroke Conference 2009 Kleinman, J. T., Tedesco, M. M., Gottesman, R. F., Lane, B., Zhou, W., Dalman, R. L., Lee, J. T. LIPPINCOTT WILLIAMS & WILKINS. 2009: E175–E175

  View details for Web of Science ID 000264709500373

• Reduction of postprocedure microemboli following retrospective quality assessment and practice improvement measures for carotid angioplasty and stenting JOURNAL OF VASCULAR SURGERY Tedesco, M. M., Dalman, R. L., Zhou, W., Coogan, S. M., Lane, B., Lee, J. T. 2009; 49 (3): 607-612

  Abstract

  We have previously demonstrated a 70% incidence of microemboli on diffusion weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS). The purpose of this study is to compare the incidence of microemboli in two distinct time periods when procedural modifications were implemented into a CAS program.Following a retrospective quality review of our CAS cohort (n = 27) from November 2004 through April 2006 (period 1), we enrolled patients (n = 20) from May 2006 through February 2008 (period 2) undergoing CAS into a prospective cohort that included obtaining pre- and postprocedure DW-MRI exams. Procedural modifications during period 2 included the preferential use of closed-cell systems (60% vs 0% in period 1), early heparinization at the initiation of arterial access, and elimination of an arch angiogram. The hospital records of these 47 patients were reviewed; symptoms, comorbidities, lesion characteristics, periprocedural information, and postoperative outcomes were collected. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs.Twenty (74%) CAS patients from period 1 and seven (35%) patients from period 2 demonstrated acute microemboli on postprocedural DW-MRI (P = .02). The mean number of microemboli in period 1 was 4.1 +/- 5.3 vs 1.5 +/- 2.7 during period 2 (P = .04). Two of the 27 patients (7.4%) during period 1 experienced temporary neurologic changes that resolved within 36 hours. None of the patients during period 2 exhibited any neurologic changes. Patient demographics, comorbidities, and presenting symptoms were similar between the two groups except for smoking prevalence, female presence, and obesity (BMI > 30). Period 2 patients when compared with period 1 had more technically challenging anatomy with more calcified lesions (68% vs 27%), longer lesions (15.9 mm vs 8.2 mm), and higher incidence of ulceration (55% vs 27%) (all P < .04).Despite successful performance of 47 consecutive CAS procedures without permanent neurologic sequelae, significant reductions in periprocedural embolic events as identified via DW-MRI lesions may be achieved through implementation of quality improvement measures identified through continuous outcome analysis. The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined.

  View details for DOI 10.1016/j.jvs.2008.10.031

  View details for PubMedID 19135833

• 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

• Relationship Between Hypotension and Distribution of Microemboli on DW-MRI Following Carotid Angioplasty and Stenting 81st Annual Scientific Session of the American-Heart-Association Lee, J. T., Kleinman, J. T., Teshome, M., Raghavan, S., Tedesco, M. M., Lane, B., Zhou, W., Dalman, R. L. LIPPINCOTT WILLIAMS & WILKINS. 2008: S1077–S1077

  View details for Web of Science ID 000262104504278

• Treating superficial venous thrombophlebitis. Journal of the National Comprehensive Cancer Network Lee, J. T., Kalani, M. A. 2008; 6 (8): 760-765

  Abstract

  Superficial venous thrombophlebitis (SVT) is characterized as a localized inflammatory condition of the venous vessels underlying the skin. It arises from thrombosis of a superficial vein, and clinical presentation usually involves pain, erythema, and tenderness at the sites of inflammation. Although the condition is usually self-limited and not serious or fatal, symptomatic superficial thrombophlebitis can be debilitating, limit movement and certain capabilities, or progress to involve the deep venous system and cause pulmonary embolism. SVT is typically associated with venous valvular insufficiency, pregnancy, infection, and prothrombotic conditions, including malignancy. Currently, medical therapies comprising bedrest, elastic stockings, compression bandages, nonsteroidal anti-inflammatory drugs, and low molecular weight heparins are used to reduce the extension of inflammation and recurrence of thrombotic events in patients experiencing SVT. In patients refractory to conservative measures, surgical interventions such as phlebectomy, sclerotherapy, saphenous junction ligation, or saphenous vein stripping are potential treatments.

  View details for PubMedID 18926088

• Simulation based training improves medical student performance on an endovascular simulator 94th Annual Clinical Congress of the American-College-of-Surgeons/63rd Annual Sessions of the Owen H Wangensteen Forum on Fundamental Surgical Problems Tedesco, M. M., Peterson, D. A., Song, T. K., Parent, R., Qiu, M., Lee, J. T. ELSEVIER SCIENCE INC. 2008: S87–S87

  View details for Web of Science ID 000259288500187

• Venous thromboembolic disease. NCCN. Clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network Wagman, L. D., Baird, M. F., Bennett, C. L., Bockenstedt, P. L., Cataland, S. R., Fanikos, J., Fogarty, P. F., Goldhaber, S. Z., Grover, T. S., Haire, W., Hassoun, H., Hutchinson, S., Jahanzeb, M., Lee, J., Linenberger, M. L., Millenson, M. M., Ortel, T. L., Salem, R., Smith, J. L., Streiff, M. B., Vedantham, S. 2008; 6 (8): 716-753

  View details for PubMedID 18926086

• 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

• Developing an Arterial Bleed Detection Algorithm for Diagnostic Ultrasound IEEE Ultrasonics Symposium Wang, A. S., Bech, F., Lee, J., Taylor, C. A., Liang, D. H. IEEE. 2008: 1627–1630

  View details for Web of Science ID 000268845800397

• Risk factors for developing postprocedural microemboli following carotid interventions JOURNAL OF ENDOVASCULAR THERAPY Tedesco, M. M., Coogan, S. M., Dalman, R. L., Haukoos, J. S., Lane, B., Loh, C., Penkar, T. S., Lee, J. T. 2007; 14 (4): 561-567

  Abstract

  To determine risk factors predictive of microemboli found on diffusion-weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS) with distal protection and carotid endarterectomy (CEA).A retrospective review was conducted of all carotid interventions at a single institution between 2004 and 2006. In that time frame, 64 carotid interventions (34 CAS, 30 CEA) were performed in 63 male patients (mean age 69.5 years, range 52 to 91) with DW-MRI scans available for review. Patient characteristics, including age, gender, smoking history, diabetes mellitus, hypertension, hyperlipidemia, obesity (body mass index >30), coronary artery disease (CAD), chronic obstructive pulmonary disease, peripheral vascular disease, and atrial fibrillation, were documented. For the CAS patients, anatomical and procedural characteristics, including fluoroscopy time, contrast volume, performance of an arch angiogram, and lesion anatomy, were recorded. Bivariate analyses were performed to determine which parameters were associated with the occurrence of acute postprocedural microemboli found on DW-MRI by 2 blinded neuroradiologists.Twenty-four (71%) of the 34 CAS patients and 1 (3%) of the 30 CEA patients demonstrated new cerebral microemboli postoperatively. In the bivariate analyses of all patient, anatomical, and procedural characteristics, only a history of CAD was associated with an increased risk of microemboli; 20 (80%) of the 25 patients who had postprocedure microemboli had CAD compared to 18 (46%) of 39 patients without microemboli (p=0.007). Twenty (53%) of the 38 (59%) patients with CAD developed microemboli compared to 5 (19%) of the 26 patients without CAD (p=0.007). All other patient, procedural, and anatomical characteristics were not found to be independent risk factors predictive of postprocedure microemboli.CAS with distal protection carries a significantly greater risk for developing new microemboli compared to CEA. Of all the risk factors analyzed, only a history of CAD emerged as an independent risk factor for the development of microemboli following carotid intervention. This finding may influence the decision to perform CAS in patients deemed high risk solely due to the presence of CAD.

  View details for PubMedID 17696633

• Postprocedural microembolic events following carotid surgery and carotid angioplasty and stenting 21st Annual Meeting of the Western-Vascular-Society Tedesco, M. M., Lee, J. T., Dalman, R. L., Lane, B., Loh, C., Haukoos, J. S., Rapp, J. H., Coogan, S. M. MOSBY-ELSEVIER. 2007: 244–50

  Abstract

  The relative safety of percutaneous carotid interventions remains controversial. Few studies have used diffusion-weighted magnetic resonance imaging (DW-MRI) to evaluate the safety of these interventions. We compared the incidence and distribution of cerebral microembolic events after carotid angioplasty and stenting (CAS) with distal protection to standard open carotid endarterectomy (CEA) using DW-MRI.From November 2004 through August 2006, 69 carotid interventions (27 CAS, and 42 CEA) were performed in 68 males at a single institution. Pre- and postprocedure DW-MRI exams were obtained on each patient undergoing CAS and the 20 most recent CEA operations. These 46 patients (47 procedures as one patient underwent bilateral CEAs in a staged fashion) constitute our study sample, and the hospital records of these patients (27 CAS and 20 CEA) were retrospectively reviewed. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs and assessed independently by two neuroradiologists without knowledge of the subjects' specific procedure.Nineteen CAS patients (70%, 95% confidence interval [CI]: 42%-81%) demonstrated evidence of postoperative, acute, cerebral microemboli by DW-MRI vs none of the CEA patients (0%, 95% CI: 0%-17%) (P < .0001). Of the 19 CAS patients with postoperative emboli, nine (47%) were ipsilateral to the index carotid lesion, three (16%) contralateral, and seven (36%) bilateral. The median number of ipsilateral microemboli identified in the CAS group was 1 (interquartile ranges [IQR]: 0-2, range 0-21). The median number of contralateral microemboli identified in the CAS group was 0 (IQR: 0-1, range 0-5). Three (11%) CAS patients experienced temporary neurologic sequelae lasting less than 36 hours. These patients suffered 12 (six ipsilateral and six contralateral), 20 (19 ipsilateral and one contralateral), and zero microemboli, respectively. By univariate analysis, performing an arch angiogram prior to CAS was associated with a higher risk of microemboli (median microemboli 5 vs none, P =.04)Although our early experience suggests that CAS may be performed safely (no permanent neurologic deficits following 27 consecutive procedures), cerebral microembolic events occurred in over two-thirds of the procedures despite the uniform use of distal protection. Open carotid surgery in this series seems to offer a lower risk of periprocedural microembolic events detected by DW-MRI.

  View details for DOI 10.1016/j.j.jvs.2007.04.049

  View details for PubMedID 17600657

• Iliac fixation inhibits migration of both suprarenal and infrarenal aortic endografts 60th Annual Meeting of the Society-for-Vascular-Surgery Benharash, P., Lee, J. T., Abilez, O. J., Crabtree, T., Bloch, D. A., Zarins, C. K. MOSBY-ELSEVIER. 2007: 250–57

  Abstract

  To evaluate the role of iliac fixation in preventing migration of suprarenal and infrarenal aortic endografts.Quantitative image analysis was performed in 92 patients with infrarenal aortic aneurysms (76 men and 16 women) treated with suprarenal (n = 36) or infrarenal (n = 56) aortic endografts from 2000 to 2004. The longitudinal centerline distance from the superior mesenteric artery to the top of the stent graft was measured on preoperative, postimplantation, and 1-year three-dimensional computed tomographic scans, with movement more than 5 mm considered to be significant. Aortic diameters were measured perpendicular to the centerline axis. Proximal and distal fixation lengths were defined as the lengths of stent-graft apposition to the aortic neck and the common iliac arteries, respectively.There were no significant differences in age, comorbidities, or preoperative aneurysm size (suprarenal, 6.0 cm; infrarenal, 5.7 cm) between the suprarenal and infrarenal groups. However, the suprarenal group had less favorable aortic necks with a shorter length (13 vs 25 mm; P < .0001), a larger diameter (27 vs 24 mm; P < .0001), and greater angulation (19 degrees vs 11 degrees ; P = .007) compared with the infrarenal group. The proximal aortic fixation length was greater in the suprarenal than in the infrarenal group (22 vs 16 mm; P < .0001), with the top of the device closer to the superior mesenteric artery (8 vs 21 mm; P < .0001) as a result of the 15-mm uncovered suprarenal stent. There was no difference in iliac fixation length between the suprarenal and infrarenal groups (26 vs 25 mm; P = .8). Longitudinal centerline stent graft movement at 1 year was similar in the suprarenal and infrarenal groups (4.3 +/- 4.4 mm vs 4.8 +/- 4.3 mm; P = .6). Patients with longitudinal centerline movement of more than 5 mm at 1 year or clinical evidence of migration at any time during the follow-up period comprised the respective migrator groups. Suprarenal migrators had a shorter iliac fixation length (17 vs 29 mm; P = .006) and a similar aortic fixation length (23 vs 22 mm; P > .999) compared with suprarenal nonmigrators. Infrarenal migrators had a shorter iliac fixation length (18 vs 30 mm; P < .0001) and a similar aortic fixation length (14 vs 17 mm; P = .1) compared with infrarenal nonmigrators. Nonmigrators had closer device proximity to the hypogastric arteries in both the suprarenal (7 vs 17 mm; P = .009) and infrarenal (8 vs 24 mm; P < .0001) groups. No migration occurred in either group in patients with good iliac fixation. Multivariate logistic regression analysis revealed that iliac fixation, as evidenced by iliac fixation length (P = .004) and the device to hypogastric artery distance (P = .002), was a significant independent predictor of migration, whereas suprarenal or infrarenal treatment was not a significant predictor of migration. During a clinical follow-up period of 45 +/- 22 months (range, 12-70 months), there have been no aneurysm ruptures, abdominal aortic aneurysm-related deaths, or surgical conversions in either group.Distal iliac fixation is important in preventing migration of both suprarenal and infrarenal aortic endografts that have longitudinal columnar support. Secure iliac fixation minimizes the risk of migration despite suboptimal proximal aortic neck anatomy. Extension of both iliac limbs to cover the entire common iliac artery to the iliac bifurcation seems to prevent endograft migration.

  View details for DOI 10.1016/j.jvs.2006.09.061

  View details for PubMedID 17263997

• Applications of Intravascular Ultrasound in the Treatment of Peripheral Occlusive Disease SEMINARS IN VASCULAR SURGERY Lee, J. T., Fang, T. D., White, R. A. 2006; 19 (3): 139-144

  Abstract

  Intravascular ultrasound (IVUS) has emerged as a useful and often necessary adjunct in a rising number of catheter-based peripheral interventions. IVUS catheters enable luminal and transmural cross-sectional imaging of peripheral vessels with high dimensional accuracy and provide detailed information about lesion morphology. IVUS is able to guide the optimal choice of appropriate angioplasty technique, guide the delivery of endovascular devices, and assess the immediate outcome of an intervention. In this review we discuss the role of IVUS for peripheral occlusive diseases, specifically the application of IVUS technology during percutaneous transluminal angioplasty (PTA), intravascular stent placement, crossing total occlusions, and venous obstructive disease.

  View details for DOI 10.1053/j.semvascsurg.2006.06.004

  View details for PubMedID 16996415

• 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

• Endovascular stent-graft repair of thoracic aortic aneurysms and dissections VASCULAR SURGERY: BASIC SCIENCE AND CLINICAL CORRELATIONS, 2ND EDITION Lee, J. T., White, R. A., White, R. A., Hollier, L. H. 2005: 554–66

  View details for DOI 10.1002/9780470987094.ch48

  View details for Web of Science ID 000298080000049

• Colonic histoplasmosis presenting as colon cancer in the nonimmunocompromised patient: Report of a case and review of the literature Annual Meeting of the Southern California Chapter of the American-College-of-Surgeons Lee, J. T., Dixon, M. R., Murrell, Z., Konyalian, V., Agbunag, R., Rostami, S., French, S., Kumar, R. R. SOUTHEASTERN SURGICAL CONGRESS. 2004: 959–63

  Abstract

  Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn's disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic anti-fungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.

  View details for Web of Science ID 000225229400005

  View details for PubMedID 15586505

• Current status of thoracic aortic endograft repair SURGICAL CLINICS OF NORTH AMERICA Lee, J. T., White, R. A. 2004; 84 (5): 1295-?

  Abstract

  The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections,penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality.Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy.

  View details for DOI 10.1016/j.suc.2004.04.012

  View details for PubMedID 15364556

• Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections 56th Annual Meeting of the Society-for-Vascular-Surgery Hansen, C. J., Bui, H., Donayre, C. E., Aziz, I., Kim, B., Kopchok, G., Walot, I., Lee, J., Lippmann, M., White, R. A. MOSBY-ELSEVIER. 2004: 228–34

  Abstract

  The advent of endovascular prostheses to treat descending thoracic aortic lesions offers an alternative approach in patients who are poor candidates for surgery. The development of this approach includes complications that are common to the endovascular treatment of abdominal aortic aneurysms and some that are unique to thoracic endografting.We conducted a retrospective review of 60 emergent and high-risk patients with thoracic aortic aneurysms (TAAs) and dissections treated with endovascular prostheses over 4 years under existing investigational protocols or on an emergent compassionate use basis.Fifty-nine of the 60 patients received treatment, with one access failure. Thirty-five patients received treatment of TAAs. Four of these procedures were performed emergently because of active hemorrhage. Twenty-four patients with aortic dissections (16 acute, 8 chronic) also received treatment. Eight of the patients with acute dissection had active hemorrhage at the time of treatment. Three devices were used: AneuRx (Medtronic; n = 31), Talent (Medtronic; n = 27), and Excluder (Gore; n = 1). Nineteen secondary endovascular procedures were performed in 14 patients. Most were secondary to endoleak (14 of 19), most commonly caused by modular separation of overlapping devices (n = 8). Other endoleaks included 4 proximal or distal type I leaks and 2 undefined endoleaks. The remaining secondary procedures were performed to treat recurrent dissection (n = 1), pseudoaneurysm enlargement (n = 3), and endovascular abdominal aortic aneurysm repair (n = 1). One patient underwent surgical repair of a retrograde ascending aortic dissection after endograft placement. Procedure-related mortality was 17% in the TAA group and 13% in the dissection group, including 2 acute retrograde dissections that resulted in death from cardiac tamponade. Overall mortality was 28% at 2-year follow-up.Although significant morbidity and mortality remain, endovascular repair of descending TAAs and dissections in patients at high-risk patients can be accomplished with acceptable outcomes compared with traditional open repair. The major cause for repeat intervention in these patients was endoleak, most commonly caused by device separation. Improved understanding of these complications may result in a decrease in secondary procedures, morbidity, and mortality in these patients. The need for secondary interventions in a significant number of patients underscores the necessity for continued surveillance.

  View details for DOI 10.1016/j.jvs.2004.03.051

  View details for Web of Science ID 000227388100006

  View details for PubMedID 15297815

• Basics of intravascular ultrasound: an essential tool for the endovascular surgeon. Seminars in vascular surgery Lee, J. T., White, R. A. 2004; 17 (2): 110-118

  Abstract

  The concept of catheter-based ultrasound imaging was first introduced in the early 1970s. Since its inception, intravascular ultrasound (IVUS) technology has become more user-friendly because of improvements in both the catheters and computer-driven imaging platforms. IVUS catheters enable luminal and transmural cross-sectional imaging of coronary and peripheral blood vessels with high-dimensional accuracy and detailed information about lesion morphology. With the advent of endovascular techniques in both the coronary and peripheral vasculature, IVUS has emerged as a useful and necessary adjunct. In addition to providing diagnostic information, IVUS enables optimal choice of appropriate angioplasty technique, endovascular device guidance, and controlled assessment of the efficacy of interventions. In this review we discuss the design and function of available IVUS catheters, imaging techniques and interpretation, and the present and future clinical utility in peripheral endovascular interventions.

  View details for PubMedID 15185176

• Volume regression of abdominal aortic aneurysms and its relation to successful endoluminal exclusion 50th Annual Meeting of the American-Association-for-Vascular-Surgery/Society-for-Vascular-Surgery Lee, J. T., Aziz, I. N., Lee, J. T., Haukoos, J. S., Donayre, C. E., Walot, I., Kopchok, G. E., Lippmann, M., White, R. A. MOSBY-ELSEVIER. 2003: 1254–63

  Abstract

  Evaluating the success of endoluminal repair of abdominal aortic aneurysms (AAAs) is frequently based on diameter measurements and determining the presence of endoleaks. The use of three-dimensional volumetric data and observation of morphologic changes in the aneurysm and device have been proposed to be more appropriate for postdeployment surveillance. The purpose of this study was to analyze the long-term volumetric and morphologic data of 161 patients who underwent endovascular AAA exclusion and to assess the utility of volume measurements for determining successful AAA repair.Patients with spiral computed tomography scans obtained preoperatively, within the first postoperative month, at 6 months, and annually thereafter, were included in this analysis. Computerized interactive three-dimensional reconstruction of each AAA scan was performed. Total aneurysm sac volume was measured at each time interval (mean preoperative volume 169.0 +/- 78.5 mL), and the significance of volume changes was determined by mixed linear modeling, a form of repeated measures analysis, to account for longitudinal data clustered at the individual level. Sixty-two patients (38%) developed endoleaks at some time during follow-up-15 type I leaks, 45 type II leaks, and 2 type III leaks. The patients with type I and type III leaks were treated with cuffs, and the type II leaks were treated either with observation, side-branch embolization, or required open conversion.Aneurysm sac volume increased slightly at 1-month follow-up (+3.3%), and then decreased steadily to -12.9% at 5 years (P <.0001). This effect remained unchanged after controlling for the three device types used in our study population. Patients who did not exhibit an endoleak (n = 99) showed a significant decrease in aneurysm volume across the entire follow-up duration when compared with those who did exhibit an endoleak (n = 62) (P <.0001). The presence of a 10% or greater decrease in volume at 6 months demonstrated a sensitivity of 64%, a specificity of 95%, a positive predictive value of 95%, a negative predictive value of 62%, and an accuracy of 75% for predicting primary clinical success defined by successful deployment of the device; freedom from aneurysm- or procedure-related death; freedom from endoleak, rupture, migration, or device malfunction; or conversion to open repair.Volumetric analysis may be used to predict successful endoluminal exclusion of AAAs. Volume regression appears to be device-independent and should be expected in most clinically successful cases. The presence of volume increases in the first 6 months is suspicious for an endoleak that is pressurizing the aneurysm sac and heralds the need for closer evaluation and possible intervention. A volume decrease of 10% or greater at 6 months and continuing regression over time is associated with successful endovascular repair.

  View details for DOI 10.1016/S0741-5214(03)00924-8

  View details for Web of Science ID 000186955400027

  View details for PubMedID 14681624

• Validation of an updated approach to preoperative cardiac risk assessment in vascular surgery Annual Meeting of the Southern California Chapter of the American-College-of-Surgeons Bui, H., Lee, J. T., Greenway, S., Donayre, C., De Virgilio, C. SOUTHEASTERN SURGICAL CONGRESS. 2003: 923–26

  Abstract

  To validate a more selective approach to cardiac assessment which consisted of limiting stress testing and coronary revascularization to highly selected patients and limiting coronary revascularization to patients with severe cardiac symptoms, we compared two time periods (1994-1995 and 2000-2001) with respect to cardiac work-up and cardiac morbidity and mortality. Our method involved a retrospective review of patients undergoing vascular procedures from 2000 to 2001 at a single institution. In group 1 (2000-2001), 139 operations were performed on 120 patients. In group 2 (1994-1995), 145 procedures were performed on 109 patients. Preoperative stress testing was reduced from 42 patients (29%) in group 2 to 20 patients (14%) in group 1 (P < 0.01), and preoperative coronary artery bypass grafting was reduced from six (4.1%) to two (1.4%) (P < 0.28), respectively. Coronary angiography was unchanged: 8 (5.8%) patients in group 1 versus 11 (7.9%) patients in group 2 (P = NS). Two (1.4%) patients underwent percutaneous transluminal coronary angioplasty in group 1 and group 2. Cardiac event rates were similar: seven (5%) patients in both groups. Cardiac death was not significantly different: two (1.4%) in group 1 versus one (0.7%) in group 2. Cardiac morbidity and mortality after major vascular surgery remain the same despite using a more selective cardiac stress protocol.

  View details for Web of Science ID 000186440000001

  View details for PubMedID 14627248

• An alternative anesthetic technique for the morbidly obese patient undergoing endovascular repair of an abdominal aortic aneurysm ANESTHESIA AND ANALGESIA Lippmann, M., Rubin, S., Ginsburg, R., White, R. A., Lee, J., Lee, J., Aziz, I. 2003; 97 (4): 981-983

  Abstract

  Abdominal aortic aneurysms have been treated by open operative repair for many years. A frequent rate of morbidity is associated with the natural history of abdominal aortic aneurysms in combination with open surgical repair. Recently a new technique that is less surgically invasive has been developed as an alternative to open repair. The present case report outlines a less invasive anesthetic technique for the morbidly obese patient.This case report discusses a minimally invasive anesthetic approach towards the morbidly obese patient undergoing endovascular abdominal aortic aneurysm repair. It demonstrates a safe and cost-effective means of managing a patient with numerous comorbidities. We also discuss an anesthetic/surgical approach on how to provide maximum analgesia with minimal anesthesia.

  View details for DOI 10.1213/01.ANE.0000081791.02404.F7

  View details for Web of Science ID 000185492300011

  View details for PubMedID 14500144

• Cardiac risk stratification in patients undergoing endoluminal graft repair of abdominal aortic aneurysm: A single-institution experience with 365 patients 17th Annual Meeting of the Western-Vascular-Society Aziz, I. N., Lee, J. T., Kopchok, G. E., Donayre, C. E., White, R. A., de Virgilio, C. MOSBY-ELSEVIER. 2003: 56–60

  Abstract

  Patients undergoing abdominal aortic aneurysm repair have a high incidence of coexisting cardiac disease. The traditional cardiac risk stratification for open abdominal aortic aneurysm surgery may not apply to patients undergoing endoluminal graft exclusion. The purpose of this study was to examine predictive risk factors for perioperative cardiac events.As part of multiple prospective endograft trials approved by the US Food and Drug Administration, data for 365 patients who underwent endoluminal graft repair from 1996 to 2001 were collected. Variables included for analysis were age and sex; history of smoking; presence of hypertension, diabetes mellitus, or renal insufficiency; Eagle clinical cardiac risk factors; American Society of Anesthesiologists index; type of anesthesia administered; estimated blood loss; preoperative hemoglobin level; preoperative use of beta-blocker therapy; duration of surgery; need for iliac artery conduit; and concomitant other vascular procedures. Univariate and multivariate logistic regression analysis were used to determine which variables were predictive of an adverse perioperative cardiac event, eg, Q wave and non-Q wave myocardial infarction (MI), congestive heart failure (CHF), severe arrhythmia, and unstable angina.The study cohort included 322 men and 43 women (mean age, 74.2 years). Fifty-two (14.2%) postoperative cardiac events occurred: severe dysrhythmia in 15 patients (4.1%), MI in 14 patients (3.8%), non-Q wave MI in 8 patients (2.2%), CHF in 8 patients (2.2%), and unstable angina in 7 patients (1.9%). Univariate analysis demonstrated that age 70 years or older (P =.034), history of MI (P =.018), angina (P =.004), history of CHF (P <.001), two or more Eagle risk factors (P <.001), and lack of use of preoperative beta-blocker therapy (P =.005) were predictors of perioperative cardiac events. Multivariate analysis identified only age 70 years or older (P =.026), history of MI (P =.024) or CHF (P =.001), and lack of use of preoperative beta-blocker therapy (P =.007) as independent risk factors for an adverse cardiac event.Age 70 years or older, history of MI or CHF, and lack of use of preoperative beta-blocker therapy are independent risk factors for perioperative cardiac events in patients undergoing endoluminal graft repair.

  View details for DOI 10.1016/S0741-5214(03)00475-0

  View details for Web of Science ID 000183985900009

  View details for PubMedID 12844089

• Accuracy of three-dimensional simulation in the sizing of aortic endoluminal devices 20th Annual Meeting of the Southern-California-Vascular-Surgical-Society Aziz, I., Lee, J., Lee, J. T., Donayre, C. E., Walot, I., Kopchok, G., Mirahashemi, S., Esmailzadeh, H., White, R. A. ELSEVIER SCIENCE INC. 2003: 129–36

  Abstract

  The purpose of this study is to examine the accuracy of a 3D simulation generated by inclusion of various intensity-selected portions of spiral CT data into a proprietary software program (Preview, Medical Media Systems, MMS) in preoperative and postoperative assessment of the anatomical features of abdominal aortic aneurysm (AAA). The accuracy of this software was measured against two other modalities-intravascular ultrasound (IVUS) and axial CT scan-using the IVUS as the reference. Eighty-five patients were included; 43 underwent AAA endovascular exclusion with Talent devices, and 42 with Aneurx devices. Measurement of proximal neck diameter was performed using IVUS, Preview software, and axial CT scan with manual calipers. Measurement of the AAA maximum diameter was performed using Preview software and axial CT scan; 253 measurements in the 85 patients were included. These measurements were compared by means of both linear regression and Bland-Altman agreement analysis. Our results showed that the 95% confidence interval between the Preview software and mean IVUS measurement of proximal AAA neck (3.1 and 2.5) is narrow enough for the software to be used in sizing AAA. This would be especially important for having the properly sized devices available preoperatively. The Preview software tended to be more accurate than CT scans although it was not statistically significant.

  View details for DOI 10.1007/s10016-001-0398-8

  View details for Web of Science ID 000182424700003

  View details for PubMedID 12616351

• Stent-graft migration following endovascular repair of aneurysms with large proximal necks: Anatomical risk factors and long-term sequelae JOURNAL OF ENDOVASCULAR THERAPY Lee, J. T., Lee, J., Aziz, I., Donayre, C. E., Walot, I., Kopchok, G. E., Heilbron, M., Lippmann, M., White, R. A. 2002; 9 (5): 652-664

  Abstract

  To evaluate the outcome of aortic endografts deployed in large infrarenal necks and to identify any association of preoperative aneurysm characteristics and postoperative morphological changes with the incidence of neck dilatation and device migration in this patient subset.The records of 47 patients (41 men; mean age 74, range 55-84) with large aortic neck diameters treated with Talent stent-grafts from 1998 to 2001 were reviewed. Patients with anatomical criteria that precluded aneurysm exclusion with currently available devices were preferentially selected. Mean baseline aneurysm morphology included 27.6-mm (range 18-33.4) suprarenal and 28.1-mm (range 24-34) infrarenal neck diameters; the infrarenal neck length was 26 +/- 16 mm with angulation of 37 degrees +/- 18 degrees. Computed tomographic (CT) angiograms up to 3 years were analyzed using specialized interactive software; migration was defined as >1-cm change in the distance from the lower renal artery to the top of the device. Pre- and postoperative morphological characteristics of the aneurysm were compared between patients with and without migration.Of the 45 patients successfully treated, 40 had complete CT data for analysis. During a mean 17-month follow-up, 7 (17.5%) of the 40 devices exhibited distal migration. Six patients required secondary procedures; 5 were in the migration cohort. No preoperative anatomical characteristic or degree of neck dilatation over time was predictive of stent-graft migration. Aneurysm sac regression was significant at 1 (-0.09 +/- 4.90 mm) and 2 (-1.48 +/- 2.56 mm) years in endografts without migration (p<0.001). Distal endograft migration >1 cm predicted the need for secondary interventions (p<0.001), with 83% sensitivity and 94% specificity.Endovascular repair is successful in patients with large infrarenal necks and complex neck morphology. Changes in aneurysm remodeling over time were similar to reported observations in patients with more favorable neck criteria. Although no anatomical factor associated with migration could be identified from this analysis, distal displacement >1 cm correlated with the need for a secondary intervention.

  View details for Web of Science ID 000179638100018

  View details for PubMedID 12431151

• Regression of a descending thoracoabdominal aortic dissection following staged deployment of thoracic and abdominal aortic endografts JOURNAL OF ENDOVASCULAR THERAPY White, R. A., Donayre, C., Walot, I., Lee, J., Kopchok, G. E. 2002; 9: 92-97

  View details for Web of Science ID 000177054300015

• Regression of a descending thoracoabdominal aortic dissection following staged deployment of thoracic and abdominal aortic endografts. Journal of endovascular therapy White, R. A., Donayre, C., Walot, I., Lee, J., Kopchok, G. E. 2002; 9: II92-7

  Abstract

  To describe the successful endovascular repair and regression of an extensive descending thoracoabdominal aortic dissection associated with thoracic and abdominal aortic aneurysms.An 83-year-old man presented with acute chest pain and shortness of breath. A descending thoracoabdominal aortic dissection that extended from near the left subclavian artery (LSA) to the right common iliac artery was found on computed tomography. Separate aneurysms in the thoracic and abdominal aorta were also identified. Staged endovascular procedures were undertaken to (1) close the single entry site and exclude the aneurysm in the thoracic aorta with an AneuRx thoracic stent-graft, (2) exclude the abdominal aneurysm and distal re-entry site with a bifurcated AneuRx endograft, and (3) treat a newly dilated thoracic segment between the LSA and first thoracic stent-graft. At 1 year, the false lumen had completely disappeared, the thoracic aneurysm had collapsed onto the endograft, and the abdominal aneurysm had shrunk by 30%.The potential to treat extensive aortic dissections with the hope that they might regress is promising, but repair of highly complex lesions involving one or more aneurysms in addition to the dissection requires meticulous imaging studies both preoperatively and intraprocedurally.

  View details for PubMedID 12166848

• Endovascular Aortic Repair After Proximal Stent Graft Migration of a Modified Frozen Elephant Trunk. Innovations (Philadelphia, Pa.) Dalal, A. R., Pedroza, A. J., Iwakoshi, S. n., Lee, J. T., Fleischmann, D. n., Watkins, A. C. ; 15 (2): 169–72

  Abstract

  We describe the endovascular repair for a proximal endograft migration following a modified frozen elephant trunk (mFET) repair for a retrograde type A dissection (retro-A AD). A 40-year-old man presented with a type B aortic dissection that progressed to a retro-A AD. He was emergently taken to the operating room for an mFET repair. Computed tomography (CT) angiogram on the day of discharge revealed that the proximal end of the endograft migrated through the primary intimal tear resulting in obstruction of true lumen flow. The patient returned to the catheterization lab for endovascular repair utilizing a through-and-through wire to extend the endograft proximally and a left carotid-subclavian artery bypass. This complication highlights the importance of postoperative CT surveillance and the endovascular technique utilized to restore aortic true lumen flow.

  View details for DOI 10.1177/1556984520902839

  View details for PubMedID 32352908