Dr. Kasirajan is a board-certified, fellowship-trained vascular surgeon. Also known as Dr. Kasi, he is a clinical professor of vascular surgery at Stanford University School of Medicine.
Dr. Kasirajan preserves limbs, facilitates access to dialysis, and helps his patients manage conditions such as aneurysms, varicose veins, thoracic outlet syndrome, and deep vein thrombosis. Many of his limb preservation patients smoke, have diabetes, or are experiencing renal failure. Dr. Kasirajan’s experience also centers around the treatment of aneurysms and prevention of strokes.
In all cases, his goal is to provide either noninvasive or minimally invasive management whenever possible. He performs open surgery only when it is the best option. Dr. Kasirajan treats many patients with stents and stent grafts, which can shorten hospital stays and recovery times.
Dr. Kasirajan (Kasi) receives referrals of patients from primary care physicians, nephrologists, podiatrists, cardiologists, woundcare specialists, diabetologists, neurologists, and other specialists. He welcomes referrals as early as possible, ideally before patients become symptomatic. A strong proponent of doing early screening for peripheral artery disease, Dr. Kasirajan advocates for the use of the ankle-brachial index (ABI) in routine physical examinations. When providers detect an imbalance between leg and arm blood pressure, Dr. Kasirajan can help create customized strategies to address the cause before the problem worsens.
In addition to offering excellent vascular care to the community, Dr. Kasirajan joined Stanford to continue pursuing his research interests. He has conducted research into advances in minimally invasive procedures for stroke prevention and for aneurysm management. His research has also focused on how to improve surgery outcomes to help patients suffering from peripheral vascular disease. Dr. Kasirajan has been the investigator in over 40 multicenter studies involving new stent graphs, thrombectomy catheters, and other advances in endovascular technology.
Dr. Kasirajan has made more than 100 presentations worldwide on minimally invasive vascular surgery techniques and preventive care in the vascular patient. He has spoken at multiple conferences including the Society for Vascular Surgery, Peripheral Vascular Society, and the South Asian American Vascular Society. He has earned numerous honors for his academic achievements, including the prestigious Alpha Omega Alpha award for medical student and resident education.
As the author of more than 120 journal articles, Dr. Kasirajan’s work has appeared in the Journal of Vascular Surgery, Endovascular Today, Pharmacogenomics Journal, Catheter Cardiovascular Intervention, and many other publications. He also has authored 20 book chapters in textbooks including Medical Management of the Surgical Patient 5th Edition, Advances in Phlebology and Venus Surgery Volume 1, Current Therapy in Vascular Surgery, Mastery of Surgery, and many more.
Dr. Kasirajan has served on the editorial boards of the Journal of Endovascular Therapy, Annals of Vascular Surgery, International Journal of Angiology, and other publications.
- Vascular Surgery
- Abdominal Aortic Aneurysms
- Thoracic Aortic Aneurysms
- Thoracic Outlet Syndrome
- Peripheral Arterial Disease
- Deep vein thrombosis
- Carotid Artery Stenosis
- Limb Salvage
- Dialysis access creation
Clinical Professor, Surgery - Vascular Surgery
Clinical Professor of Surgery, Stanford (2020 - Present)
Honors & Awards
Alpha Omega Alpha, AOA
Boards, Advisory Committees, Professional Organizations
Member, Society for vascular Surgery (2003 - Present)
Fellowship: Cleveland Clinic Foundation Hospital (2000) OH
Board Certification: American Board of Surgery, Vascular Surgery (2001)
Board Certification: American Board of Surgery, General Surgery (1999)
Residency: Western Reserve Care System (1998) OH
Residency: Lincoln Medical and Mental Health Center General Surgery Residency (1994) NY
Medical Education: Madras Medical College (1991) India
Use of a novel embolic filter in carotid artery stenting: 30-Day results from the EMBOLDEN Clinical Study.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
2018; 92 (6): 1128–35
The EMBOLDEN study was conducted to test the safety and efficacy of a novel emboli protection filter design for use in carotid artery stenting (CAS) in patients with severe carotid stenosis who were at high risk of operative complications from carotid endarterectomy (CEA).General considerations for filter design usually involve trade-offs between trackability/profile and wall apposition/capture efficiency. The GORE® Embolic Filter (GEF) is intended to address these design goals via a hybrid construction.Patients at high risk for CEA (N = 250) were treated with CAS using the GEF study device paired with an FDA-approved carotid stent. The primary outcome was death, stroke, and myocardial infarction (MI) at 30 days, compared to a pre-determined performance goal. Neurologic outcomes were judged by an independent assessor and angiographic results evaluated by an independent central core lab.The GEF study device was successfully deployed in 96.4% of procedures. The primary endpoint of 30-day death, stroke, and MI occurred in 4.0% of subjects and was significantly lower than the pre-defined performance goal (P < 0.001). The 30-day rate for death and major stroke was 1.2% and for death and any stroke was 3.6%. The rate of major adverse events was 5.4% among octogenarians and 3.2% among non-octogenarians.In patients at high risk for CEA undergoing CAS, the GEF not only showed high rates of successful deployment but also met the primary endpoint of low death, stroke, and MI rates, thus demonstrating safety and effectiveness.
View details for DOI 10.1002/ccd.27474
View details for PubMedID 29314704
Cost-effectiveness of one-time genetic testing to minimize lifetime adverse drug reactions.
The pharmacogenomics journal
2016; 16 (2): 129–36
We evaluated the cost-effectiveness of one-time pharmacogenomic testing for preventing adverse drug reactions (ADRs) over a patient's lifetime. We developed a Markov-based Monte Carlo microsimulation model to represent the ADR events in the lifetime of each patient. The base-case considered a 40-year-old patient. We measured health outcomes in life years (LYs) and quality-adjusted LYs (QALYs) and estimated costs using 2013 US$. In the base-case, one-time genetic testing had an incremental cost-effectiveness ratio (ICER) of $43,165 (95% confidence interval (CI) is ($42,769,$43,561)) per additional LY and $53,680 per additional QALY (95% CI is ($53,182,$54,179)), hence under the base-case one-time genetic testing is cost-effective. The ICER values were most sensitive to the average probability of death due to ADR, reduction in ADR rate due to genetic testing, mean ADR rate and cost of genetic testing.
View details for DOI 10.1038/tpj.2015.39
View details for PubMedID 25987241
Costs of repair of abdominal aortic aneurysm with different devices in a multicenter randomized trial
JOURNAL OF VASCULAR SURGERY
2015; 61 (1): 59–U388
Prior analysis in the Open vs Endovascular Repair Veterans Affairs (VA) Cooperative Study (CSP #498) demonstrated that survival, quality of life, and total health care costs are not significantly different between the open and endovascular methods of repair of abdominal aortic aneurysm. The device is a major cost of this method of repair, and the objective of this study was to evaluate the costs of the device, abdominal aortic aneurysm repair, and total health care costs when different endograft systems are selected for the endovascular repair (EVR). Within each selected system, EVR costs are compared with open repair costs.The study randomized 881 patients to open (n = 437) or EVR (n = 444). Device selection was recorded before randomization; therefore, open repair controls were matched to each device cohort. Data were excluded for two low-volume devices, implanted in only 13 individuals, leaving 423 control and 431 endovascular patients: 166 Zenith (Cook Medical, Bloomington, Ind), 177 Excluder (W. L. Gore & Associates, Flagstaff, Ariz), and 88 AneuRx (Medtronic, Minneapolis, Minn). Mean device, hospitalization, and total health care costs from randomization to 2 years were compared. Health care utilization data were obtained from patients and national VA and Medicare data sources. VA costs were determined using methods previously developed by the VA Health Economics Resource Center. Non-VA costs were obtained from Medicare claims data and billing data from the patient's health care providers.Implant costs were 38% of initial hospitalization costs. Mean device (range, $13,600-$14,400), initial hospitalization (range, $34,800-$38,900), and total health care costs at 2 years in the endovascular (range, $72,400-$78,200) and open repair groups (range, $75,600-$82,100) were not significantly different among device systems. Differences between endovascular and corresponding open repair cohorts showed lower mean costs for EVR (range, $3200-$8300), but these were not statistically different.The implant costs of endovascular aneurysm repair are substantial. When evaluating total health care system expenditures, there is large individual variability in costs, and there is no significant difference at 2 years among systems or when an individual system is compared with open repair.
View details for DOI 10.1016/j.jvs.2014.08.003
View details for Web of Science ID 000346637600009
View details for PubMedID 25238728
Computed tomography angiography-based evaluation of great saphenous vein conduit for lower extremity bypass
MOSBY-ELSEVIER. 2013: 50–55
Lower extremity computed tomography angiography (CTA) is frequently used for anatomic assessment of lower extremity peripheral arterial disease. When lower extremity bypass is planned, duplex ultrasound (DUS) is routinely obtained to evaluate the great saphenous vein (GSV) for use as conduit. Although GSV can be visualized on CTA images, diameter assessment is not routinely included in formal study interpretation. We hypothesized that CTA images could be used to measure GSV diameters and that CTA-based diameters would correlate with measurements obtained using DUS.Consecutive patients undergoing lower extremity arterial bypass who were evaluated preoperatively with both CTA and DUS vein mapping were identified at a single hospital. Minimum above- and below-knee GSV diameters were measured from electronically archived CTA images by two independent observers. CTAs were performed using standard arterial phase protocol without additional venous phase imaging. Between-observer reproducibility of CTA-based diameter measurements was evaluated using intraclass correlation coefficients. Correlation between CTA and DUS-based GSV diameters was evaluated with Spearman correlation coefficients. CTA diameter cut-points for identification of adequate GSV bypass conduit, defined as DUS-based minimum GSV diameter≥3 mm, were determined using receiver-operating characteristic curves.Sixty-three lower extremities were evaluated in 36 patients. In the absence of previous surgical removal, GSV was visible on all CTAs reviewed. No instances of GSV thrombosis were identified on DUS. Minimum DUS-based above-knee GSV diameter was 2.9±0.1 mm (range, 1.4-4.6 mm), and mean below-knee diameter was 2.6±0.1 mm (range, 1.3-4.0 mm). When GSV was visible and exceeded the minimum diameter threshold for CTA measurement, correlation between CTA- and DUS-based diameters was both positive and highly significant (ρ=0.595; P<.0001). CTA-based diameters also had excellent reliability between observers (r [95% CI]: 0.88 [0.85-0.91]). For identification of adequate bypass conduit using CTA, above-knee GSV diameter≥3.9 mm was 67% sensitive and 73% specific; below-knee GSV diameter≥3.0 mm was 75% sensitive and 84% specific.CTA-based GSV diameter measurements have good reproducibility and highly significant correlation with DUS-based diameters. CTA-based GSV diameter is a specific but relatively insensitive indicator of adequate bypass conduit. When CTA-based diameters indicate inadequate GSV bypass conduit, confirmatory DUS vein mapping is warranted. Confirmatory DUS vein mapping may be unnecessary when adequate vein diameter is identified on CTA.
View details for DOI 10.1016/j.jvs.2012.06.077
View details for Web of Science ID 000312833800009
View details for PubMedID 22963811
Late Gore Excluder endoprosthesis fabric tear leading to abdominal aortic aneurysm rupture 5 years after initial implant
JOURNAL OF VASCULAR SURGERY
2013; 57 (1): 221–24
Endoprosthesis fabric tear leading to abdominal aortic aneurysm rupture is a rare event. In this report, we describe a patient who presented with an abdominal aortic aneurysm rupture after a tear in the fabric of the Gore Excluder endoprosthesis (W. L. Gore and Associationes, Flagstaff, Ariz) 5 years after implantation. The reason for the fabric tear was unknown. The complication was successfully treated by relining the endograft with an aortic cuff and two iliac limbs. The patient experienced an uneventful recovery after the intervention.
View details for DOI 10.1016/j.jvs.2012.06.102
View details for Web of Science ID 000312833800035
View details for PubMedID 23141682
Long-Term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysm
NEW ENGLAND JOURNAL OF MEDICINE
2012; 367 (21): 1988-1997
Whether elective endovascular repair of abdominal aortic aneurysm reduces long-term morbidity and mortality, as compared with traditional open repair, remains uncertain.We randomly assigned 881 patients with asymptomatic abdominal aortic aneurysms who were candidates for both procedures to either endovascular repair (444) or open repair (437) and followed them for up to 9 years (mean, 5.2). Patients were selected from 42 Veterans Affairs medical centers and were 49 years of age or older at the time of registration.More than 95% of the patients underwent the assigned repair. For the primary outcome of all-cause mortality, 146 deaths occurred in each group (hazard ratio with endovascular repair versus open repair, 0.97; 95% confidence interval [CI], 0.77 to 1.22; P=0.81). The previously reported reduction in perioperative mortality with endovascular repair was sustained at 2 years (hazard ratio, 0.63; 95% CI, 0.40 to 0.98; P=0.04) and at 3 years (hazard ratio, 0.72; 95% CI, 0.51 to 1.00; P=0.05) but not thereafter. There were 10 aneurysm-related deaths in the endovascular-repair group (2.3%) versus 16 in the open-repair group (3.7%) (P=0.22). Six aneurysm ruptures were confirmed in the endovascular-repair group versus none in the open-repair group (P=0.03). A significant interaction was observed between age and type of treatment (P=0.006); survival was increased among patients under 70 years of age in the endovascular-repair group but tended to be better among those 70 years of age or older in the open-repair group.Endovascular repair and open repair resulted in similar long-term survival. The perioperative survival advantage with endovascular repair was sustained for several years, but rupture after repair remained a concern. Endovascular repair led to increased long-term survival among younger patients but not among older patients, for whom a greater benefit from the endovascular approach had been expected. (Funded by the Department of Veterans Affairs Office of Research and Development; OVER ClinicalTrials.gov number, NCT00094575.).
View details for DOI 10.1056/NEJMoa1207481
View details for Web of Science ID 000311340200006
View details for PubMedID 23171095
Contralateral occlusion is not a clinically important reason for choosing carotid artery stenting for patients with significant carotid artery stenosis
36th Annual Meeting of the Southern-Association-for-Vascular-Surgery
MOSBY-ELSEVIER. 2012: 1291–94
Contralateral carotid artery occlusion by itself carries an increased risk of stroke. Carotid endarterectomy (CEA) in the presence of contralateral carotid artery occlusion has high reported rates of perioperative morbidity and mortality. Our objective was to determine if there is a clinical benefit to patients who receive carotid artery stenting (CAS) compared to CEA in the presence of contralateral carotid artery occlusion.We conducted a retrospective medical chart review over a 4.5-year institutional experience of persons with contralateral carotid artery occlusion and ipsilateral carotid artery stenosis who underwent CAS or CEA. The main outcome measures were 30-day cardiac, stroke, and mortality rate, and midterm mortality.Of a total of 713 patients treated for carotid artery stenosis during this time period, 57 had contralateral occlusion (~8%). Thirty-nine of these patients were treated with CAS, and 18 with CEA. The most common indications for CAS were prior neck surgery (18), contralateral internal carotid occlusion (nine), and prior neck radiation (seven). The average age was 70 ± 8.5 for CEA and 66.7 ± 9.3 for CAS (P = .20). Both groups were predominantly men (CEA 12 of 18; CAS 28 of 39; P = .76), with similar prevalence of symptomatic lesions (CEA 8 of 18, CAS 20 of 39; P = .77). Two patients died within 30 days in the CAS group (5%). No deaths occurred within 30 days in the CEA group (P = .50); the mortality rate for CAS and CEA combined was 3.5%. No perioperative strokes or myocardial infarction occurred in either group. Two transient ischemic attacks occurred after CAS. At mean follow-up of 29.4 ± 16 months (CEA) and 28 ± 14.4 months (CAS; range, 1.5-48.5 months), seven deaths occurred in the CAS group and one in the CEA group (17.9% vs 5.5%; P = .40). There were two reinterventions in the CAS group for in-stent restenosis and there were no reoperations in the CEA group.Although CEA and CAS can both be performed with good perioperative results and acceptable midterm mortality, the observed outcomes do not support use of contralateral carotid artery occlusion as a selection criterion for CAS over CEA in the absence of other indications.
View details for DOI 10.1016/j.jvs.2012.04.033
View details for Web of Science ID 000310428200015
View details for PubMedID 22840742
- PROPATEN graft: an unlikely heparin-induced thrombocytopenia culprit VASCULAR 2012; 20 (5): 299
Outcomes After Heparin-Induced Thrombocytopenia in Patients With Propaten Vascular Grafts
ANNALS OF VASCULAR SURGERY
2012; 26 (6): 802–8
Heparin-induced thrombocytopenia (HIT) can result in a life- or limb-threatening condition that can be reversed with early detection and prompt discontinuation of systemic heparin. The advent of heparin-bonded grafts may introduce a new level of complexity in some patients with a suspected diagnosis of HIT. This review evaluates the outcomes of patients who received the Gore Propaten vascular graft with a subsequent suspicion of HIT.This is a retrospective analysis of cases with suspected type II HIT after implant of the Propaten vascular graft that were reported to W.L. Gore & Associates. Data reviewed included clinical studies, including physician-sponsored studies, both inside and outside the United States; published literature; and Gore's product surveillance records.Overall, as of June 2011, there have been 27 cases (27 patients and 30 vascular grafts) of suspected HIT after graft implant. Of these 27 patients, 18 were tested for HIT antibodies (enzyme-linked immunosorbent assay, heparin-induced platelet activation test, serotonin release assay, drug-induced platelet activation test, platelet aggregation test, an HIT panel, or an unknown HIT test), with a positive test result in 17 of the 18 cases. In 5 of the 18 cases, patients were tested with two distinct HIT assays, resulting in one positive and one negative test. Among patients with available data, the mean preoperative heparin dose was 4850 ± 1634 U, and four patients had a postoperative heparin drip. The mean preoperative platelet count was 227,000 ± 71,616. Mean platelet count at time of diagnosis of HIT was 53,429 ± 36,832. For the majority of those patients known to have had heparin discontinued once HIT was suspected, Argatroban was the anticoagulant of choice. Sixteen patients had grafts that remained implanted and in circulation, eight patients had grafts that were explanted, two patients had grafts that were ligated in situ, and the outcome was unknown for one patient. Among the 16 patients with grafts remaining in circulation, four grafts required thrombectomy for occlusion. Two patients died, one other patient had a remote thrombotic event, and the remaining patients had no reported adverse events. Among the 10 patients with graft removal or ligation, six had a graft occlusion, four required an amputation, and two died. Among the cases in which the recovery of platelet count was reported after systemic heparin was discontinued, the majority were cases in which the grafts were left in circulation.Analysis of the cases of suspected HIT in patients with implanted Propaten vascular grafts reveals that the HIT observed appears to be related to the systemic administration of heparin. After discontinuation of systemic heparin, platelet counts normalized in the presence of patent Propaten vascular grafts. Hence, based on current data, our recommendation would be to tailor treatment to individual patients. Functioning grafts in patients with or without thrombotic events and return of platelet count to normal values may not require grafts to be explanted in the presence of HIT.
View details for DOI 10.1016/j.avsg.2011.12.011
View details for Web of Science ID 000306436700007
View details for PubMedID 22717356
Incidental Findings in Patients Evaluated for Thoracic Aortic Pathology Using Computed Tomography Angiography
ANNALS OF VASCULAR SURGERY
2012; 26 (3): 306–11
Computed tomography angiography (CTA) is routinely used to diagnose thoracic aortic pathology and for surveillance after thoracic endovascular aortic repair. The purpose of our study was to assess the prevalence of unsuspected disease identified on CTA examination for thoracic aortic pathology and to determine potential clinical significance of these findings.A retrospective review of 242 patients (136 men and 106 women; mean age, 65.7 ± 13.9 years) referred for clinical evaluation of thoracic aortic pathology during a 12-year period was performed. CTA was acquired after obtaining full written informed consent and injecting nonionic contrast Omnipaque 350 intravenously. Subsequently, axial images were obtained from the thoracic inlet through the pubic symphysis. The prevalence of incidental findings was recorded. A finding was judged potentially significant if a therapeutic intervention or radiologic follow-up was deemed advisable on the basis of the CTA findings.Prevalence of incidental findings were noncalcified pulmonary lesions (subcentimeter nodule [28, 11.57%], nodule >1 cm [16, 6.61%], and pulmonary mass >3 cm [4, 1.65%]), calcified pulmonary nodules (35, 14.46%), simple liver cysts (32, 13.22%), contrast-enhancing liver lesion (7, 2.89%), renal mass (7, 2.89%), and pancreatic mass (5, 2.06%). Subsequent diagnostic tests were recommended for 63 findings in 55 (22.72%) patients, which revealed 11 (4.5%) patients had metastatic disease-six primary lung cancer, one metastatic lesion (mets) to the lung, one renal cell carcinoma with mets in the lung, one primary pancreatic adenocarcinoma with mets in the liver, one unknown primary with mets in the liver, and one other poorly differential metastatic carcinoma with lesions in the pancreas, adrenal glands, kidneys, and small bowel with unknown primary.CTA evaluation in patient with aortic pathology may reveal a high rate of malignant lesions. Attention to the incidental finding of suspicious lesion on computed tomographic scans in the chest and abdomen and appropriate follow-up by the requesting surgeon is important in patients undergoing surveillance for aortic pathologies.
View details for DOI 10.1016/j.avsg.2011.08.017
View details for Web of Science ID 000301847700002
View details for PubMedID 22321476
New C-TAG device and overcome of compression events
JOURNAL OF CARDIOVASCULAR SURGERY
2012; 53 (2): 169–72
This article describes the modifications made to the TAG thoracic device (WL Gore, Flagstaff, AZ, USA) to better accommodate to anatomies seen in young trauma patients and patients with dissections. The device was initially approved and tested for degenerative thoracic aneurysms. The newer conformable-TAG (cTAG) is better able to accommodate to tight aortic arches and smaller aortic diameter with circumferential aortic wall opposition.
View details for Web of Science ID 000305040300005
View details for PubMedID 22456638
Incidence and outcomes after infolding or collapse of thoracic stent grafts
Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) / Plenary Session of William Von Liebig Forum / 36th Annual Spring Meeting of the Peripheral-Vascular-Surgery-Society
MOSBY-ELSEVIER. 2012: 652–58
Device-related complications in the thoracic aorta are partly due to the unavoidable proximal angulation and increased flow-related forces. The present study evaluated the incidence, predictors, and outcome of the complication of infolding with the GORE TAG thoracic endoprosthesis (TAG device) to better understand the factors that might help predict these events.We reviewed all complaints reported to W. L. Gore and Associates (Flagstaff, Ariz) related to device infolding after the use of the GORE TAG device on or before December 2008. Events related to device infolding were evaluated. Reporting physicians and local company representatives were contacted, when necessary, to assemble all available imaging, data, and outcomes related to these case reports. When available, computed tomography images were reviewed to confirm aortic landing zone diameters, which were subsequently compared with the implanted device size.From 1998 through December 2008, device infolding was reported in 139 patients (mean age, 40 ± 17 years; 73.4% men) from 33,289 device implants (reported incidence, 0.4%). Events were noted in implants for trauma (60%), dissection (19%), aneurysm (10%), and other (9%) and unknown (2%) etiologies. In 77 patients with available imaging, the average minimum aortic diameter was 21.4 ± 4.4 mm. The mean device diameter was 28.5 ± 3.5 mm, with an average oversizing of nearly 33%. Of reported patients, 51% were asymptomatic, with the diagnosis being made on routine chest imaging. Time to diagnosis was 76 ± 222 days (median, 9.5 days). Only 16 patients received no intervention after the diagnosis of device infolding, all of whom were asymptomatic. The other 123 patients underwent 135 interventions. Of these, 30 patients (24%) underwent open surgical conversion and complete or partial endograft removal. The other interventions included a variety of endovascular techniques, such as large balloon-expandable stent(s) in 40%, relining with additional endograft(s) in 31%, and repeat ballooning in seven patients. Ten patients died after device infolding, all after one or more attempts to repair the infolded device: five died of symptoms related to the infolding and five secondary to the intervention undertaken to correct the device infolding.TAG device infolding appears to be an infrequent event, primarily occurring in young trauma patients secondary to excessive oversizing and severe proximal aortic angulation. However, there clearly exists a need for devices that treat such patients. As a result, future device designs should consider the compression failure mode when being designed in order to help prevent such events.
View details for DOI 10.1016/j.jvs.2011.09.079
View details for Web of Science ID 000300941100003
View details for PubMedID 22169662
Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes
MOSBY-ELSEVIER. 2012: 268–73
The impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events.CEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ(2) or Fisher's exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors.A total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21).Resident surgeon participation during CEA is not associated with risk of adverse perioperative events.
View details for DOI 10.1016/j.jvs.2011.08.039
View details for Web of Science ID 000298772900041
View details for PubMedID 22051871
Pivotal results for the Medtronic Valiant Thoracic Stent Graft System in the VALOR II trial.
Journal of vascular surgery
2012; 56 (5): 1222–31.e1
We report 30-day and 12-month results of endovascular treatment with the Valiant Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, Calif) in patients with descending thoracic aortic aneurysms of degenerative etiology. The Valiant stent graft is an evolution of the Talent thoracic stent graft (Medtronic Vascular).The VALOR II (Evaluation of the Clinical Performance of the Valiant Thoracic Stent Graft System in the Treatment of Descending Thoracic Aneurysms of Degenerative Etiology in Subjects Who Are Candidates for Endovascular Repair) was a prospective, nonrandomized, pivotal trial conducted at 24 U.S. sites with enrollment between December 2006 and September 2009. Standard follow-up examinations, including physical examination, computed tomography, and chest radiography, were at 1, 6, and 12 months, and annually through 5 years. VALOR II outcomes were compared with those from the pivotal VALOR (Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms) trial of the Talent stent graft, which enrolled 195 patients with similar enrollment criteria.VALOR II enrolled 160 patients. Compared with VALOR patients, VALOR II patients had similar age and sex distribution but higher rates of cardiovascular risk factors and significantly more severe modified Society for Vascular Surgery/American Association for Vascular Surgery risk scores. Stent graft delivery and deployment were successful in 154 patients (96.3%). Outcomes at 30 days in VALOR II were perioperative mortality, 3.1%; major adverse events, 38.1%; paraplegia, 0.6%; paraparesis, 1.9%; and stroke, 2.5%. At 12 months, after the minimum sample size was reached, 151 patients were evaluated: aneurysm-related mortality was 4.0%, stent graft migration was 2.9%, and endoleak was 13.0%. Through 12 months, there were no ruptures, conversions to open surgery, secondary procedures due to endoleak >30 days, or loss of stent graft patency. The Valiant stent graft was statistically noninferior to the Talent stent graft in 12-month all-cause mortality (12.6% vs 16.1%) and exceeded the primary effectiveness goal of 12-month successful aneurysm treatment, defined as absence of aneurysm growth >5 mm and of secondary procedures for type I/III endoleak (97.4% vs 80.0%).The VALOR II 12-month results demonstrate that the Medtronic Valiant thoracic stent graft is a safe and effective treatment for patients with descending thoracic aortic aneurysms of degenerative etiology.
View details for DOI 10.1016/j.jvs.2012.04.062
View details for PubMedID 22832267
Technical tips for successful outcomes using adjunctive procedures during endovascular aortic aneurysm repair.
Seminars in vascular surgery
2012; 25 (3): 161–66
The inability to obtain proximal or distal seal continues to remain one of the main challenges of endovascular aneurysm repair. This is particularly relevant when endografts are used in patients with unsuitable proximal or distal landing zones. A variety of techniques can be used to achieve a seal in these difficult situations. Two specific techniques that can help intraoperatively to resolve the lack of adequate graft to aortic wall opposition are discussed in this article. These include the use of Palmaz stents for proximal seal and hypogastric snorkel for distal seal with internal iliac flow preservation.
View details for DOI 10.1053/j.semvascsurg.2012.07.002
View details for PubMedID 23062496
Preoperative Inpatient Hospitalization and Risk of Perioperative Infection Following Elective Vascular Procedures
ELSEVIER SCIENCE INC. 2012: 46–54
Health care-associated infections are not uncommon after elective vascular surgery and can negatively impact mortality rates and hospital resource utilization. Identification of modifiable risk factors for perioperative infection is critical for efforts aimed toward reducing their incidence. We evaluated the associations between preoperative inpatient hospitalization and perioperative surgical site infection (SSI), pneumonia, and urinary tract infection (UTI) following elective vascular surgery procedures.Vascular procedures were identified from the 2005 to 2008 American College of Surgeons National Safety Quality Improvement Participant User Data File by using primary Current Procedural Terminology (CPT) codes. Perioperative infections were evaluated as outcomes based on three categories: SSI, pneumonia, and UTI. Patients admitted ≥1 day before operation were considered inpatients before surgery. Associations between preoperative inpatient hospitalization and perioperative SSI, pneumonia, and UTI were evaluated using the Cochran-Armitage trend test and multivariable logistic regression.In total 40,669 elective vascular procedures were identified, of which 7,514 (18.5%) were preoperative inpatients. Patients with preoperative inpatient hospitalization had a greater frequency of age >80 years and dependent functional status and also had higher rates of several comorbid conditions, including congestive heart failure, severe chronic obstructive pulmonary disease, >10% weight loss over the past 6 months, history of bleeding disorder, and current smoker within 1 year, than patients admitted on the same day of their procedure. The overall rates of SSI, pneumonia, and UTI were 3.2%, 1.9%, and 1.4%, respectively. Patients with preoperative inpatient hospitalization had higher 30-day incidence of SSI (4.5 vs. 2.9%), pneumonia (3.1 vs. 1.6%), and UTI (2.3 vs. 1.2%). In multivariable models including preoperative risk factors, preoperative inpatient hospitalization was associated with increased 30-day risk of SSI (odds ratio [OR], 1.21; 95% confidence interval [CI]: 1.06-1.39; p = 0.0066), pneumonia (OR, 1.64; 95% CI: 1.39-1.94; p < 0.0001), and UTI (OR, 1.46; 95% CI: 1.20-1.77; p < 0.0001).Preoperative inpatient hospitalization is associated with higher rates of perioperative SSI, pneumonia, and UTI in patients undergoing elective vascular surgery procedures. Avoidance of unnecessary preoperative hospitalization has potential to reduce rates of perioperative infection, but additional research is needed to develop evidence-based management strategies when hospitalization before elective procedures is necessary.
View details for DOI 10.1016/j.avsg.2011.08.008
View details for Web of Science ID 000298325900007
View details for PubMedID 22079458
Carotid revascularization outcomes comparing distal filters, flow reversal, and endarterectomy
MOSBY-ELSEVIER. 2011: 1000–1005
Contradictory outcomes exist for different methods of carotid artery revascularization. Here we provide the comparative rates of adverse events in patients after carotid endarterectomy (CEA), carotid artery stenting (CAS) with a distal embolic protection device (EPD), and CAS with a proximal flow reversal system (FRS) from a single institution by various specialists treating carotid artery disease.Procedural billing codes and the electronic medical records of patients undergoing revascularization for carotid artery stenosis from February 2007 through March 2010 were used for data collection. Primary outcome was the incidence of cerebrovascular accident (CVA), myocardial infarction (MI), or death after CEA and CAS. Each practitioner determined the choice of therapy, with five of the 14 specialists providing both CAS and CEA. Baseline characteristics were examined for effect on outcome. Planned comparisons between and within groups were analyzed using χ(2), t tests, and analysis of variance, as appropriate.A total of 495 procedures were documented, comprising 226 CEA, 216 CAS with EPD, and 53 CAS with FRS. Preoperative comparisons of patient comorbidities were similar among the cohorts. The carotid artery stenosis was symptomatic in 42% of these patients. Prior CEA was an indication for CAS rather than another CEA (P < .001). Significantly fewer patients undergoing CEA were receiving preoperative antiplatelet therapy (P < .001). The groups did not differ significantly in the overall composite end point of death, CVA, and MI (4%, 5.1%, 0%; P = .1) or any individual major adverse event. Overall, patients undergoing CAS with EPD had a statistically significant greater incidence of minor CVAs than CEA patients (P = .031), which was driven by the increased CVA risk for asymptomatic patients. Secondary end points occurred rarely (<2%). There have been no reoperations or interventions in these patients to date within this institution.We have established a similar and low incidence of MI, CVA, and death among patients undergoing CEA and CAS, of whom approximately 40% were symptomatic. FRS provided superior results in this series; however, its use was limited to 20% of the CAS procedures. Still, zero adverse events in this cohort make FRS an exciting technology that warrants a large-scale prospective comparative study.
View details for DOI 10.1016/j.jvs.2011.03.279
View details for Web of Science ID 000295562800011
View details for PubMedID 21871772
Simultaneous Arterial and Venous Ultrasound-Assisted Thrombolysis for Phlegmasia Cerulea Dolens
ANNALS OF VASCULAR SURGERY
2011; 25 (5): 696.e7–10
Phlegmasia cerulea dolens is a rare condition in which an extensive deep venous thrombus can partially or completely occlude venous outflow from the affected extremity. Clinical presentation is typically characterized by extremity edema, cyanosis, and pain. This condition is associated with a high rate of extremity amputation and mortality. Although numerous therapies have been described, there is no generalized treatment consensus and less invasive forms of therapy continue to evolve. We report a case of phlegmasia cerulea dolens in a patient who presented with concomitant arterial and venous thrombosis of the affected extremity. The patient's condition was successfully treated using combined ultrasound-assisted intra-arterial and intravenous catheter-directed thrombolysis.
View details for DOI 10.1016/j.avsg.2011.02.005
View details for Web of Science ID 000292303400020
View details for PubMedID 21514098
Thoracic endovascular repair as a safe management strategy for aortobronchial fistulas
MOSBY-ELSEVIER. 2011: 1202–9
This study assessed the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the management of aortobronchial fistulas.A retrospective review was performed at Emory University Hospital to identify all patients who presented with an aortobronchial fistula. The diagnosis was based on clinical, radiologic, and bronchoscopic findings. Patients who underwent TEVAR as definitive management of these fistulas were identified. Demographics, history of thoracic aorta pathology or intervention, type and number of endografts used, need for reoperation, and clinical and radiologic follow-up data were collected for each individual.Between 2000 and 2009, 11 patients received TEVAR as definitive management of aortobronchial fistulas. Technical success was achieved in 10 patients (91%). Six patients (55%) had previously undergone thoracic aortic surgery. A proximal type 1 endoleak developed in one patient after graft deployment and required reintervention for additional graft placement. No intraoperative or 30-day deaths occurred. Postoperative clinical and radiographic assessment was a mean of 8.8 months (range, 1-40 months). For all 10 patients in whom technical success was achieved at the initial operation, no endoleaks were noted at the follow-up CT scan. In addition, no patient required a further intervention.This study represents the largest reported series on the use of TEVAR in the management of aortobronchial fistulas. Supported by postoperative surveillance imaging and clinical evaluation, TEVAR has proven to be a safe and effective management strategy for an otherwise lethal condition. Long-term follow-up data are needed to ascertain the durability of this approach.
View details for DOI 10.1016/j.jvs.2010.10.103
View details for Web of Science ID 000290362100007
View details for PubMedID 21367565
Endovascular Management of a Ruptured Thoracoabdominal Aneurysm-Damage Control With Superior Mesenteric Artery Snorkel and Thoracic Stent-Graft Exclusion
ANNALS OF VASCULAR SURGERY
2011; 25 (4): 555.e5–9
We report a case of a large ruptured thoracoabdominal aortic aneurysm, which was stabilized with endovascular aortic exclusion and snorkel bypass of the superior mesenteric artery (SMA). An 80-year-old African American woman with multiple medical comorbidities and previous open infrarenal abdominal aortic aneurysm repair presented with a ruptured 10.7 × 7.3 cm thoracoabdominal aortic aneurysm involving the origins of the renal and mesenteric vessels. The patient underwent emergent endovascular aortic repair with placement of a covered stent into the SMA coursing parallel to the aortic endograft. This technique was initially successful in clinically stabilizing the patient; however; 3 weeks after the initial procedure, she presented with recurrent rupture necessitating proximal extension of her snorkeled SMA bypass and aortic endograft into the mid-descending thoracic aorta. The patient stabilized and was successfully discharged home.
View details for DOI 10.1016/j.avsg.2010.12.028
View details for Web of Science ID 000290298400021
View details for PubMedID 21549926
Neuroprotection during carotid artery stenting using the GORE flow reversal system: 30-day outcomes in the EMPiRE Clinical Study.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
2011; 77 (3): 420–29
Each of the embolic protection devices used in carotid artery stenting (CAS) has advantages and disadvantages. The prospective, multicenter, single-arm EMPiRE Clinical Study investigated a proximally placed device (GORE Flow Reversal System) that provides distal neuroprotection during CAS by reversing blood flow in the internal carotid artery, thereby directing emboli away from the brain.The study evaluated 30-day outcomes in 245 pivotal high-surgical-risk patients (mean age, 70 years; 32% symptomatic; 16% ≥80-years old) with carotid stenosis who underwent CAS using the flow reversal system. The primary endpoint was a major adverse event (MAE; stroke, death, myocardial infarction, or transient ischemic attack) within 30 days of CAS. The MAE rate was compared with an objective performance criterion (OPC) derived from CAS studies that included embolic protection.The MAE rate was 4.5% (11 patients; P=0.002 compared with the OPC). The stroke and death rate was 2.9%. No patient had a major ischemic stroke. Six patients (2.4%) had intolerance to flow reversal. The death and stroke rates in the symptomatic, asymptomatic, and octogenarian subgroups were 2.6, 3, and 2.6%, respectively, meeting American Heart Association guidelines for carotid endarterectomy.The stroke and death rate in this study was among the lowest in CAS trials. The results indicate that the flow reversal system is safe and effective when used for neuroprotection during CAS and that it provides benefits in a broad patient population.
View details for DOI 10.1002/ccd.22789
View details for PubMedID 20853365
Branched grafts for thoracoabdominal aneurysms: off-label use of FDA-approved devices.
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
2011; 18 (4): 471–76
To report off-label use of approved off-the-shelf endografts with no modification to the devices for the management of thoracoabdominal aneurysms (TAAA).The parallel endograft octopus technique is demonstrated in a 68-year-old woman with a past history of open TAAA repair with a patch reimplant of the visceral vessels who now presented with back pain. Non-contrast computed tomography revealed a 6.8-cm aneurysm of the visceral segment involving the celiac trunk, superior mesenteric artery (SMA), and right renal artery. As she was at high risk for redo surgery due to significant pulmonary dysfunction, she was an ideal candidate for a branched graft, but she could not travel to an investigational site for a custom graft. At surgery, 4 sheaths were introduced, 2 retrograde (18-F DrySeal) and 2 (8-F) antegrade, via the femoral arteries. The 18-F sheaths on both sides were connected to the 8-F sheaths for continued limb perfusion. Via an axillary conduit, a 12-F, 80-cm sheath was introduced into the proximal thoracic aorta over a stiff wire. Subsequently, two 28-mm Excluder endografts were introduced via the bilateral 18-F femoral sheaths and positioned side by side in the descending thoracic aorta such that the lower end of the Excluder limbs were positioned ≥2 cm above the target visceral vessels. Viabahn stent-grafts were then deployed in the celiac axis, SMA, and right renal artery from the axillary conduit. Subsequently, a 23-mm Excluder was deployed within the distal end of the upsized limb and extended to both common iliac arteries. Imaging at 6 months demonstrated no endoleaks, with good flow to all visceral vessels.The parallel endograft octopus technique described here, which has been applied successfully in 9 cases thus far, is a relatively simple method using currently available devices with no requirement for device modification or customization. Although this technique shows promise, long-term data will be required to prove efficacy. This technique demonstrates a concept for future development of branched graft technology.
View details for DOI 10.1583/11-3506R.1
View details for PubMedID 21861732
The incidence of microemboli to the brain is less with endarterectomy than with percutaneous revascularization with distal filters or flow reversal.
Journal of vascular surgery
2011; 53 (2): 316–22
Current data suggest microembolization to the brain may result in long-term cognitive dysfunction despite the absence of immediate clinically obvious cerebrovascular events. We reviewed a series of patients treated electively with carotid endarterectomy (CEA), carotid artery stenting (CAS) with distal filters, and carotid stenting with flow reversal (FRS) monitored continuously with transcranial Doppler scan (TCD) during the procedure to detect microembolization rates.TCD insonation of the M1 segment of the middle cerebral artery was conducted during 42 procedures (15 CEA, 20 CAS, and 7 FRS) in 41 patients seen at an academic center. One patient had staged bilateral CEA. Ipsilateral microembolic signals (MESs) were divided into three phases: preprotection phase (until internal carotid artery [ICA] cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection phase (until clamp/shunt was removed, filter removed, or antegrade flow re-established), and postprotection phase (after clamp/shunt was removed, filter removed, or antegrade flow re-established). Descriptive statistics are reported as mean ± SE for continuous variables and N (%) for categorical variables. Differences in ipsilateral emboli counts based on cerebral protection strategy were assessed using nonparametric methods.TCD insonation and procedural success were obtained in 33 procedures (79%; 14 CEA, 14 CAS, and 5 FRS). Highest ipsilateral MESs were observed for CAS (319.3 ± 110.3), followed by FRS (184.2 ± 110.5), and CEA (15.3 ± 22.0). Pairwise comparisons revealed significantly higher ipsilateral MESs with both FRS and CAS when compared to CEA (P = .007 for FRS and P < .001 for CAS vs CEA, respectively), whereas the difference in MESs between FRS and CAS was not significant (P = .053). Periods of maximum embolization were postprotection phase for CEA, protection phase for CAS, and preprotection phase for FRS. Preprotection MESs were frequently observed during both CAS and FRS (20.4% and 63.3% of total MESs across all phases, respectively), and the primary difference between these two methods seemed to be related to lower MESs during the protection phase with FRS.CEA is associated with lower rates of microembolization compared with carotid stenting. Flow reversal may represent a procedural modification with potential to reduce microembolization during carotid stenting; further investigation is warranted to determine the relationship between cerebral protection strategies and outcomes associated with carotid stenting.
View details for DOI 10.1016/j.jvs.2010.08.063
View details for PubMedID 21129899
Noninterruption of warfarin therapy is safe and does not compromise outcome in patients undergoing endovenous laser therapy (EVLT).
Vascular and endovascular surgery
2011; 45 (6): 524–26
To assess the need for cessation of oral anticoagulation with warfarin for patients undergoing endovenous laser therapy (EVLT).Between September 2004 and July 2010, 518 patients underwent 770 EVLT procedures on the lower extremity, at our institution. Of these patients, 5 underwent a total of 12 separate lower extremity EVLT procedures for the treatment of symptomatic reflux without interruption of warfarin therapy.No bleeding complications were observed during the procedure or in early follow-up. None of the patients developed a deep venous thrombosis. Complete ablation of the target vessel was observed in all patients on follow-up Duplex ultrasounds at 1 and 8 weeks postintervention.Endovenous laser therapy can be safely performed and does not compromise target vessel ablation in patients receiving oral anticoagulation warfarin therapy. Warfarin therapy should not be routinely interrupted in patients undergoing this procedure.
View details for DOI 10.1177/1538574411414302
View details for PubMedID 21715419
Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death.
Journal of vascular surgery
2011; 54 (4): 979–84
Left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) is often necessary due to anatomic factors and is performed in to up to 40% of procedures. Despite the frequency of LSA coverage during TEVAR, reported associations with risk of periprocedural stroke or death are inconsistent in reported literature. We examined the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data file to determine associations between LSA coverage during TEVAR and risk of perioperative stroke or death.Current procedural terminology (CPT) codes were used to identify patients undergoing TEVAR, LSA coverage, and subclavian revascularization. Patients undergoing coronary bypass, ascending aortic repair, abdominal aortic aneurysm repair, or nonvascular intra-abdominal procedures during the same operation were excluded. Perioperative stroke and mortality associations with LSA coverage were examined using logistic regression models for each outcome. Significance was assessed at α = 0.05, with univariable P < .05 required for multivariable model entry.Eight hundred forty-five TEVAR procedures were identified, of which 52 patients were excluded due to additional major procedures performed with TEVAR. Seven hundred thirty-three of the remaining 793 procedures included CPT codes indicating primary placement of an initial thoracic endograft and form the basis of this analysis. LSA coverage occurred in 279 procedures (38%). Thirty-day stroke and mortality rates were 5.7% and 7.0%, respectively. LSA coverage was associated with increased 30-day risk of stroke in multivariable modeling (odds ratio [OR], 2.17 95% confidence interval [CI], 1.13-4.14; P = .019). Other significant multivariable risk factors for stroke included proximal aortic cuff placement during TEVAR (OR, 2.58; 95% CI, 1.30-5.16; P = .007) and emergency procedure status (OR, 3.60; 95% CI, 1.87-6.94; P < .001). No significant association between LSA coverage and perioperative mortality was identified (univariable OR, 1.70; 95% CI, 0.98-2.93; P = .0578).LSA coverage during thoracic endovascular repair is associated with increased risk of perioperative stroke following TEVAR. Further evidence is needed to determine whether procedural modifications, including LSA revascularization, reduce the incidence of stroke associated with TEVAR.
View details for DOI 10.1016/j.jvs.2011.03.270
View details for PubMedID 21658894
Sex-based outcomes after endovascular repair of thoracic aortic aneurysms.
Journal of vascular surgery
2011; 54 (3): 669–75; discussion 675–76
Unlike with abdominal aortic aneurysms (AAA), women appear to have an almost comparable incidence as men for thoracic aortic aneurysms (TAA). However, the extent to which a patient's sex influences endograft treatment of TAA has not been reported. The current study analyzes the influence of sex on the endovascular management of TAAs.A total of 421 patients (265 men and 156 women) were identified as part of the TAG (W. L. Gore and Associates, Flagstaff, Ariz) thoracic stent graft trials. Preoperative risk factors, intraoperative events, and 365-day follow-up data were analyzed.Among 18 different preoperative risk factors evaluated, women were less likely to have prior vascular procedures (38.9% vs 55.3%; P = .004). A trend was noted toward lower rates of coronary artery disease (41.3% vs 51.2%; P = .09) and smoking (77.8% vs 85.6%; P = .08). Women were also more likely to be nonwhite (81.4% vs 87.9%; P = .007). Women had a smaller mean external iliac vessel diameter (7.1 vs 9.0 mm; P < .001), resulting in 24.4% vs 6.0% conduit use (P < .001) for device delivery. Local access site complications were significantly higher in women (14.1% vs 4.5%; P < .001). No difference was noted between sexes in the technical success rate (device delivery and successful aneurysm exclusion) or the major adverse event rate at 30 days (26.3% vs 20.4%; P = .18). The overall length of stay was 5.5 ± 6.2 days for female patients vs 4.8 ± 13.0 days (P < .001). No sex-related difference was noted in endoleak rate, aneurysm rupture, prosthetic migration, or aneurysm diameter change at 365 days.No significant differences in major outcomes were noted between men and women treated with endovascular repair of TAA at 1 month and 1 year. Women have more vascular complications, which are associated with smaller access vessels. A lower threshold for using conduits in women may be a more prudent approach.
View details for DOI 10.1016/j.jvs.2011.03.010
View details for PubMedID 21664092
Thoracic endovascular aneurysm repair for thoracic aneurysms: what we know, what to expect.
Annals of vascular surgery
2011; 25 (6): 856–65
Descending thoracic aneurysms are less common and less likely to rupture than abdominal aortic aneurysms. However, when left untreated they are lethal, and repairs are recommended only if the size of the aneurysm is 6 cm, or smaller if symptomatic. Open thoracic aneurysm repair was the standard therapy the last time this topic was reviewed in Annals of Vascular Surgery. Currently, thoracic aneurysms are usually treated with endovascular means when anatomically appropriate. This review demonstrates the benefits of endografting (namely decreased perioperative mortality and morbidity) and also the shortcomings (no late mortality benefit) as currently published in the literature, as well as summarizing available endografts and specific considerations for high-risk patient populations.
View details for DOI 10.1016/j.avsg.2011.03.003
View details for PubMedID 21620674
Midterm results of adjunctive neck therapies performed during elective infrarenal aortic aneurysm repair
MOSBY-ELSEVIER. 2010: 1435–41
This study evaluated the durability of adjunctive endovascular neck procedures, including aortic cuffs, Palmaz stents (Cordis, Miami Lakes, Fla), and high-pressure balloon angioplasty, at managing intraoperative proximal neck complications during endovascular aortic aneurysm repair (EVAR).This was a single-center retrospective review of EVARs. The primary outcome variable studied was survival free of a graft-related event (GRE). GRE was defined by the occurrence of one of the following: type I endoleak, sac enlargement, aneurysm rupture, death, or procedure related to the aortic neck. These outcome variables were assessed relative to the preoperative anatomic neck variables (neck length, diameter, degree of angulation, degree of circumferential thrombus, and presence of conicity), procedural variables (manufacturing type of graft, use of a Palmaz stent), and patient characteristics (age and presence of medical comorbidities). Outcomes were assessed by t tests, Pearson χ(2), and Kaplan-Meier analysis, when appropriate.A total of 174 EVARs performed between January 2005 and December 2007 were evaluated. Fifty-six adjunctive procedures were performed, with a 97% primary-assisted exclusion rate. Patients who received an adjunctive therapy had similar freedom from a GRE compared with EVARs that did not require adjunctive therapy (35.5 ± 2.6 vs 34.8 ± 1.5 months, P = .31, log-rank test). Subset analysis identified a significant association between Palmaz stent placement at the time of EVAR and decreased freedom from GREs (hazard ratio, 2.87; 95% confidence interval, 1.21-6.77; P = .02).Midterm results suggest that adjunctive therapies to manage intraoperative proximal neck complications do not compromise durability. The subset of patients requiring aortic neck Palmaz stent placement at the time of EVAR are among those at highest risk for subsequent GRE.
View details for DOI 10.1016/j.jvs.2010.06.163
View details for Web of Science ID 000285430500001
View details for PubMedID 21146743
Protected Carotid Stenting in High-Risk Patients: Results of the SpideRX Arm of the Carotid Revascularization with ev3 Arterial Technology Evolution Trial
JOURNAL OF INTERVENTIONAL CARDIOLOGY
2010; 23 (5): 491–98
A prospective nonrandomized multicenter registry of 160 patients with severe carotid stenosis and high-risk features for carotid endarterectomy was conducted during the 3-month period from March to May 2005.Carotid artery stenting (CAS) was performed with the SpideRX™ Embolic Protection System (ev3, Inc., Plymouth, MN, USA) as part of an investigational device exemption from the Food and Drug Administration.The primary end-point of major adverse cardiac and cerebrovascular events at 30 days after CAS was observed in nine patients (5.6%), including death in four patients (2.5%), nonfatal stroke in five patients (3.1%), and nonfatal myocardial infarction in one patient (0.6%). A secondary end-point of technical success (defined as successful deployment of all devices, filter retrieval, and final diameter stenosis <50%) was achieved in 156 of 160 patients (97.5%). The only independent predictor of death or stroke at 30 days was baseline stenosis severity (P < 0.05).CAS with distal embolic protection using the SpideRX™ Embolic Protection System is a reasonable alternative for revascularization of some high-risk patients with severe carotid stenosis.
View details for DOI 10.1111/j.1540-8183.2010.00578.x
View details for Web of Science ID 000282513700011
View details for PubMedID 20624206
Risk factors for late mortality after endovascular repair of the thoracic aorta
JOURNAL OF VASCULAR SURGERY
2010; 52 (3): 549–55
This study was conducted to identify risk factors for late mortality after thoracic endovascular aortic repair (TEVAR).A retrospective analysis of consecutive TEVAR was conducted. Medical record review, telephone contact, or query of the Social Security Death Index was used to determine 30-day and late survival. Late mortality was assessed with respect to patient characteristics at the time of the initial treatment, preoperative laboratory values, pathology, clinical presentation, and treatment adjuncts. Significant univariate predictors of death were entered into a multivariate Cox proportional hazards model.From 1998 to 2009, 252 patients (149 men; mean age, 68 years) underwent TEVAR for degenerative thoracic aortic aneurysm (TAA, n = 143), type B dissection (n = 62), mycotic aneurysm (n = 13), traumatic disruption (n = 12), penetrating ulcer or intramural hematoma (n = 10), anastomotic pseudoaneurysm (n = 4), or other pathology (n = 8). The 30-day mortality was 9.5%, with stroke or spinal cord injury in 5.6%. Mean follow-up was 22 +/- 22 months. Kaplan-Meier mean survival was 53 months. Predictors of late mortality by univariate analysis included age (P < .01), cardiac arrhythmia (P = .03), chronic obstructive pulmonary disease (P = .05), aneurysm diameter (P < .01), rupture (P < .01), debranching (P = .02), leukocytosis (white blood cell count > 10.0 x 10(3)/microL; P < .01), albumin, (P < .01), and creatinine > 1.7 mg/dL (P = .01). Multivariate predictors of mortality included rupture (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.02-9.44; P = .03), debranching (HR, 2.20; 95% CI, 1.09-4.24; P = .03), preoperative leukocytosis (HR, 1.23; 95% CI, 1.09-1.39; P = .001), and aneurysm diameter (HR, 1.02; 95% CI, 1.01-1.03; P = .04). Subgroup analysis of patients undergoing TEVAR for asymptomatic, nonruptured TAA demonstrated that debranching (HR, 2.47; 95% CI, 1.13-5.39; P = .02), White blood cell count (HR, 1.19; 95% CI, 1.01-1.40; P < .04), and aneurysm diameter (HR, 1.03; 95% CI, 1.01-1.05, P < .01) remain independently predictive of late mortality.Preoperative leukocytosis, aneurysm diameter, and concurrent debranching independently predict late mortality irrespective of clinical presentation and may assist in risk stratification.
View details for DOI 10.1016/j.jvs.2010.04.059
View details for Web of Science ID 000281570100003
View details for PubMedID 20598483
Nitinol Stent Implantation Versus Balloon Angioplasty for Lesions in the Superficial Femoral Artery and Proximal Popliteal Artery Twelve-Month Results From the RESILIENT Randomized Trial
2010; 3 (3): 267–76
Controversy still exists regarding the best endovascular treatment strategy for patients with symptomatic disease of the superficial femoral artery. There are conflicting data regarding the benefits of superficial femoral artery stenting and the role of primary stenting compared with balloon angioplasty with provisional stent implantation.A total of 206 patients from 24 centers in the United States and Europe with obstructive lesions of the superficial femoral artery and proximal popliteal artery and intermittent claudication were randomized to implantation of nitinol stents or percutaneous transluminal angioplasty. The mean total lesion length was 71 mm for the stent group and 64 mm for the angioplasty group. Acute lesion success (<30%residual stenosis) was superior for the stent group compared with the angioplasty group (95.8% versus 83.9%; P<0.01). Twenty-nine (40.3%) patients in the angioplasty group underwent bailout stenting because of a suboptimal angiographic result or flow-limiting dissection. Bailout stenting was treated as a target lesion revascularization and loss of primary patency in the final analysis. At 12 months, freedom from target lesion revascularization was 87.3% for the stent group compared with 45.1% for the angioplasty group (P<0.0001). Duplex ultrasound-derived primary patency at 12 months was better for the stent group (81.3% versus 36.7%; P<0.0001). Through 12 months, fractures occurred in 3.1% of stents implanted. No stent fractures resulted in loss of patency or target lesion revascularization.In this multicenter trial, primary implantation of a self-expanding nitinol stent for moderate-length lesions in the superficial femoral artery and proximal popliteal artery was associated with better acute angiographic results and improved patency compared with balloon angioplasty alone.URL: http://www.clinicaltrials.gov. Unique identifier: NCT00673985.
View details for DOI 10.1161/CIRCINTERVENTIONS.109.903468
View details for Web of Science ID 000279714200011
View details for PubMedID 20484101
Collected World and Single Center Experience With Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms
ANNALS OF SURGERY
2009; 250 (5): 818–24
Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial.To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers.Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR).Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients.These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed.
View details for DOI 10.1097/SLA.0b013e3181bdd7f5
View details for Web of Science ID 000208667400021
View details for PubMedID 19809296
Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm A Randomized Trial
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2009; 302 (14): 1535–42
Limited data are available to assess whether endovascular repair of abdominal aortic aneurysm (AAA) improves short-term outcomes compared with traditional open repair.To compare postoperative outcomes up to 2 years after endovascular or open repair of AAA in a planned interim report of a 9-year trial.A randomized, multicenter clinical trial of 881 veterans (aged > or = 49 years) from 42 Veterans Affairs Medical Centers with eligible AAA who were candidates for both elective endovascular repair and open repair of AAA. The trial is ongoing and this report describes the period between October 15, 2002, and October 15, 2008.Elective endovascular (n = 444) or open (n = 437) repair of AAA.Procedure failure, secondary therapeutic procedures, length of stay, quality of life, erectile dysfunction, major morbidity, and mortality.Mean follow-up was 1.8 years. Perioperative mortality (30 days or inpatient) was lower for endovascular repair (0.5% vs 3.0%; P = .004), but there was no significant difference in mortality at 2 years (7.0% vs 9.8%, P = .13). Patients in the endovascular repair group had reduced median procedure time (2.9 vs 3.7 hours), blood loss (200 vs 1000 mL), transfusion requirement (0 vs 1.0 units), duration of mechanical ventilation (3.6 vs 5.0 hours), hospital stay (3 vs 7 days), and intensive care unit stay (1 vs 4 days), but required substantial exposure to fluoroscopy and contrast. There were no differences between the 2 groups in major morbidity, procedure failure, secondary therapeutic procedures, aneurysm-related hospitalizations, health-related quality of life, or erectile function.In this report of short-term outcomes after elective AAA repair, perioperative mortality was low for both procedures and lower for endovascular than open repair. The early advantage of endovascular repair was not offset by increased morbidity or mortality in the first 2 years after repair. Longer-term outcome data are needed to fully assess the relative merits of the 2 procedures.clinicaltrials.gov Identifier: NCT00094575.
View details for DOI 10.1001/jama.2009.1426
View details for Web of Science ID 000270721800021
View details for PubMedID 19826022
- Endovascular Aneurysm Treatment in Patients With Vasculo-Behcet Disease JOURNAL OF ENDOVASCULAR THERAPY 2009; 16 (5): 637
Bone marrow mobilization with granulocyte macrophage colony-stimulating factor improves endothelial dysfunction and exercise capacity in patients with peripheral arterial disease
AMERICAN HEART JOURNAL
2009; 158 (1): 53–U5
We hypothesized that granulocyte macrophage colony-stimulating factor (GM-CSF) administration will be safe and will improve endothelial dysfunction and exercise capacity by mobilizing progenitor cells in patients with peripheral arterial disease (PAD).Forty-five patients with PAD received thrice-weekly injections for 2 weeks of 3, 6, or 10 microg/kg per day of GM-CSF or placebo in successive cohorts of 15 subjects randomized 2:1 to drug or placebo. CD34+ mononuclear cell subsets and colony formation assay, endothelial function, ankle-brachial index, and walking capacity were measured.Granulocyte macrophage colony-stimulating factor administration was safe. After pooling data from GM-CSF cohorts, at 2 weeks, there was a significant increase in total leukocytes (43%, P < .0001), CD34+ cells (46%, P = .035), and colony-forming units (31%, P = .026, week 1). At 12 weeks, endothelial function improved with GM-CSF (flow-mediated vasodilation increased by 59%, P < .01) as did pain-free treadmill walking time (38 seconds, P = .008) and total treadmill walking time (55 seconds, P = .016). Corresponding changes were not observed in the placebo group.Granulocyte macrophage colony-stimulating factor therapy in patients with PAD was associated with mobilization of progenitor cells, improvement of endothelial dysfunction, and exercise capacity. The efficacy of strategies designed to mobilize bone marrow progenitors warrants further study in patients with PAD.
View details for DOI 10.1016/j.ahj.2009.04.014
View details for Web of Science ID 000267630600008
View details for PubMedID 19540392
The phase I multicenter trial (STAPLE-1) of the Aptus endovascular repair system: results at 6 months and 1 year.
Journal of vascular surgery
2009; 49 (4): 851–57; discussion 857–58
This phase I IDE study (STAPLE-1) evaluated the primary endpoints of safety (major device-related adverse events at 30 days) and feasibility (successful deployment of all endograft components) of the Aptus Endovascular abdominal aortic aneurysm (AAA) Repair System (Aptus Endosystems, Inc, Sunnyvale, Calif) to treat AAAs.A prospective, single arm Federal Drug Administration (FDA) Phase I IDE study was performed. The Aptus endograft is a three-piece modular device with a flexible unsupported main body and two fully supported limbs in a 5.3 mm outer diameter (OD) (16F) delivery system for all iliac limbs and two of three main body sizes. The largest main body (29 mm diameter) is in a 6 mm (18 F OD) delivery system. EndoStaples measuring 4 mm (length) by 3 mm (diameter) designed to provide transmural graft fixation to the adventitia are applied independent of the endograft delivery system. Inclusion criteria included a proximal aortic neck length of 12 mm and iliac landing zone of 10 mm. Secondary endpoints included freedom from endoleaks, rupture, migration, and device integrity.Twenty-one (21) patients were enrolled at five centers. All patients received the Aptus Endograft and EndoStaples. Ninety-six EndoStaples (range, 2-10; median, 4) were implanted. All patients (n = 21) completed 1-month and 6-month follow-up evaluation and 14 completed 1-year follow-up. Two proximal cuffs and one limb extension were used as adjunctive endograft components at implantation. Three secondary interventions were performed in 2 patients for limb thrombosis. There were no EndoStaple-related adverse events, device integrity failures, migrations, or conversions.These results of the STAPLE-1 trial document the acute safety and feasibility of the Aptus Endograft and EndoStaples. Early follow-up demonstrates excellent 6-month and 1-year results. A pivotal phase II trial is underway at 25 US centers.
View details for DOI 10.1016/j.jvs.2008.10.064
View details for PubMedID 19341879
Endovascular repair for diverse pathologies of the thoracic aorta: an initial decade of experience.
Journal of the American College of Surgeons
2009; 208 (5): 802–16; discussion 816–8
Endovascular grafts have rapidly evolved as a minimally invasive treatment for a variety of acute and chronic disorders of the thoracic aorta. Application of this technology at a single center is reported.Between 1998 and 2007, 197 patients underwent thoracic endovascular aortic repair. Primary indications included degenerative aneurysms (n = 121), type B aortic dissection (n = 44), mycotic aneurysms (n = 9), traumatic disruptions (n = 9), intramural hematoma (n = 5), pseudoaneurysm (n = 4), and miscellaneous pathology (n = 5). An analysis of patient demographics, periprocedural records, complications, reinterventions, and survival was conducted.Thirty-day mortality was 6%, which was lowest among patients undergoing treatment for a degenerative thoracic aortic aneurysm (2.4%, 3 of 121). Major adverse events included stroke in 3%, spinal cord ischemia in 2%, peripheral vascular repair in 4.5%, renal failure in 4.5%, and open conversion in one patient (0.5%). Both preoperative serum creatinine (odds ratio 1.44, 95% CI 1.02 to 2.04, p = 0.039) and number of endograft components (odds ratio 1.43, 95% CI 1.01 to 2.01, p = 0.043) were predictors of major adverse events. Kaplan-Meier analysis revealed a reduction in late survival among patients with preoperative creatinine >or=1.8 mg/dL (p < 0.001). One- and 5-year intervention-free survivals were 77%+/-3% and 41%+/-6%, respectively.Thoracic endovascular aortic repair represents an effective treatment for a variety of pathologic states. But the risk-benefit analysis for thoracic endovascular aortic repair should carefully consider the extent of disease, pathologic condition, and renal function.
View details for DOI 10.1016/j.jamcollsurg.2008.12.021
View details for PubMedID 19476841
Hybrid Thoracic Stent Graft Repair of a Complex Type B Aortic Dissection in a Patient Who Presented Three Weeks After Repair of a Type A Aortic Dissection
INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY
2008; 3 (3): 158–60
Long-term management after repair of a type A aortic dissection includes aggressive medical therapy and routine surveillance with serial imaging to ensure thrombosis of the false lumen. Retained patency of the false lumen can lead to either the development of a false lumen aneurysm with a subsequent rupture or extension of dissection. Typically such events occur late, usually months after repair, and are treated with either a conventional one-stage open thoracoabdominal repair or a two-stage "elephant trunk" procedure. However, most patients who undergo such procedures experience major complications and the procedure-related mortality rate is high. We present a unique case of a 61-year-old woman who presented with a ruptured type B aortic dissection 3 weeks after repair of a type A aortic dissection. She underwent an emergent thoracotomy and primary repair of the ruptured aorta followed by concomitant arch debranching and thoracic stent graft placement. Simultaneous surgical debranching with a median sternotomy and endovascular repair with stent grafts is an attractive hybrid approach in patients who present with an acute rupture of a false lumen aneurysm soon after initial repair of an aortic dissection, a situation in which a conventional repair is not feasible. This report emphasizes that hybrid thoracic stent graft repair should be considered for such high-risk patients in the near future as it offers them relatively lower morbidity and mortality compared with what is seen with conventional repairs.
View details for DOI 10.1097/IMI.0b013e3181916602
View details for Web of Science ID 000217552000010
View details for PubMedID 22436859
A single-institution experience with the AneuRx stent graft for endovascular repair of abdominal aortic aneurysm
ANNALS OF VASCULAR SURGERY
2008; 22 (2): 221–26
We report our experience of endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) using the modular AneuRx Stent Graft System. We retrospectively reviewed the outcomes of 113 patients who underwent EVAR with the AneuRx system performed at our institution between October 1999 and August 2003. The mean age of this group was 72.5 years, with 71% (n = 80) over the age of 70 years and 95% (n = 107) males. Aneurysm diameter ranged 4.0-9.0 cm, with 33% (n = 37) >6.0 cm. The average duration of late follow-up was 32.6 +/- 24.8 months (median = 37). Successful deployment of the modular AneuRx system was noted in all patients. There were no immediate operative conversions, deaths within 24 hr of operation, or type I or III endoleaks observed at the completion of the procedure. Thirty-day mortality was 3.5% (n = 4). Acute deployment-related complications occurred in 10% (n = 13) of patients and included misdeployment, operative bleeding, arterial perforation/dissection, and access site complications. Acute systemic complications were present in nine patients, predominantly renal and cardiac complications. An endoleak noted at any time occurred in 25% of patients, with 40% of those requiring a secondary intervention. Two patients suffered late aneurysm rupture due to a type I endoleak and graft infection. Kaplan-Meier analysis revealed 5-year freedom from secondary intervention of 72.4%; freedom from aneurysm-related death of 93.9%; and probability of survival based on all-cause mortality of 60.1%. Endovascular treatment with the modular AneuRx Stent Graft System is safe and effective, producing acceptable rates of disease-free survival and mid-term clinical outcome.
View details for DOI 10.1016/j.avsg.2008.01.001
View details for Web of Science ID 000254655200013
View details for PubMedID 18346576
Ileofemoral malperfusion complicating type a dissection: Revascularization prevents renal failure
ANNALS OF THORACIC SURGERY
2007; 84 (6): 2099-2101
We report four cases of lower extremity malperfusion complicating acute type A dissection. Two patients were treated with acute type A dissection repair, followed by axillobifemoral bypass grafting when malperfusion persisted after aortic replacement and required dialysis. Two patients were managed with lower extremity revascularization procedures before acute type A dissection repair and had preserved renal function. Lower extremity revascularization before cardiopulmonary bypass minimizes ischemia and allows for controlled limb reperfusion under hypothermic conditions compared with delayed normothermic reperfusion when performed after acute type A dissection repair. This strategy may increase limb function salvage and decrease the incidence of dialysis after acute type A dissection repair in patients presenting with lower extremity malperfusion.
View details for DOI 10.1016/j.athoracsur.2007.07.011
View details for Web of Science ID 000251176300048
View details for PubMedID 18036949
Visceral debranching to facilitate repair of complex thoracic and thoracoabdominal aneurysms
2007; 3 (3): 271–81
The availability of thoracic and abdominal endografts has decreased the morbidity and mortality associated with the repair of aneurysms of the aorta. The current limitations of endografts for aneurysms involve adequate proximal and distal landing zones. Branches that are not critical, such as the internal iliac or left subclavian artery, may often be covered and included in the landing zone for most patients, with a few exceptions. However, aneurysms involving critical branch vessels to the brain and intra-abdominal viscera cannot be covered and open repair of aneurysms in these locations carry the highest morbidity and mortality. This review describes the various techniques to relocate these critical branch vessels to expand the use of stent grafts for the treatment of these complex aneurysms.
View details for DOI 10.2217/147966184.108.40.2061
View details for Web of Science ID 000218104200012
View details for PubMedID 19804219
Difficult anatomy: what characteristics are critical to good outcomes of either CEA or CAS?
Seminars in vascular surgery
2007; 20 (4): 216–25
Whether performing carotid endarterectomy or carotid stenting, patients are selected on the basis of their anatomical suitability for these procedures. The procedure is then tailored to the specific anatomy with which the patient presented. As a result, outcomes of both carotid endarterectomy and stenting are significantly influenced by anatomical considerations and good outcomes are determined, at least in part, by selecting, understanding, and managing a wide variety of anatomical presentations.
View details for DOI 10.1053/j.semvascsurg.2007.10.005
View details for PubMedID 18082838
Future of endograft surveillance
SEMINARS IN VASCULAR SURGERY
2006; 19 (2): 75–82
Frequent and sustained surveillance continues to be mandated for all patients who undergo endovascular repair of the aneurysmal aorta in order to minimize the small but attendant risk of aneurysm rupture. The primary motivation for surveillance includes evaluation of residual aneurysm sac size and presence of endoleak, as well as potential adverse device specific events, such as endograft migration, module disconnection, or component fatigue and failure. The current standard of care and future surveillance modalities after endovascular repair of both abdominal aortic and thoracic aortic aneurysms will be reviewed.
View details for DOI 10.1053/j.semvascsurg.2006.03.002
View details for Web of Science ID 000242240200003
View details for PubMedID 16782511
- Recommended clinical competencies for initiating a program in endovascular repair of the thoracic aorta JOURNAL OF VASCULAR SURGERY 2006; 43: 100A–105A
Aortic debranching to facilitate endograft repair of complex thoracoabdominal aneurysms
ALLIANCE COMMUNICATIONS GROUP DIVISION ALLEN PRESS. 2006: I13
View details for Web of Science ID 000235657900021
Unusual case of right-sided May-Thurner syndrome and review of its management
2006; 14 (1): 47–50
May-Thurner syndrome is a phenomenon commonly described as an acquired stenosis of the left common iliac vein as a result of right common iliac artery compression. We report an unusual case of right-sided May-Thurner syndrome in a patient found to have a left-sided inferior vena cava. We also review the management of this patient using angioplasty, intraoperative thrombolysis, and endoluminal stent placement.
View details for DOI 10.2310/6670.2006.00012
View details for Web of Science ID 000251658800009
View details for PubMedID 16849024
Combination therapies for deep venous thrombosis.
Seminars in vascular surgery
2006; 19 (2): 116–21
Nearly 1 million patients are treated for deep venous thrombosis annually in the United States, typically with anticoagulant therapy alone. While anticoagulation reduces risk for pulmonary embolism, up to two-thirds of patients experience some degree of postthrombotic syndrome. This review details the recent introduction of a variety of novel mechanical thrombectomy devices that, in combination with local delivery of thrombolytic agents, offers a new approach for rapid and effective removal of venous thrombus, while minimizing attendant risks of bleeding complications.
View details for DOI 10.1053/j.semvascsurg.2006.03.009
View details for PubMedID 16782518
- Late complications of thoracic endografts. Journal of vascular surgery 2006; 43 Suppl A: 94A–99A
Thoracic endografts: procedural steps, technical pitfalls and how to avoid them.
Seminars in vascular surgery
2006; 19 (1): 3–10
Recent US Food and Drug Administration (FDA) approval of a thoracic endograft has created explosive interest among physicians to learn to use this minimally invasive technology. The level of interest is similar to the period more than a decade ago, following FDA approval of infrarenal abdominal endografts, which initiated the "endo" revolution among vascular specialists. Many physicians view the descending thoracic aorta as a simple, straight tube and, thus, technically less challenging than endografts for infrarenal abdominal aortic aneurysm. However, the thoracic aorta presents certain unique features that make this a challenging procedure. Technical challenges posed by the thoracic aorta have resulted in a significant time-lag (since release of abdominal aortic aneurysm endografts), testing the ability of engineers and physicians to devise and complete trials successful enough for FDA approval of thoracic endografts. This article addresses the various procedural steps and tips on avoiding pitfalls.
View details for DOI 10.1053/j.semvascsurg.2005.11.001
View details for PubMedID 16533686
Secondary conversion of the Gore Excluder to operative abdominal aortic aneurysm repair
MOSBY-ELSEVIER. 2005: 631–38
Reports continue to document the occurrence of major adverse events after endovascular aortic aneurysm repair. Although many of these problems can be successfully managed through endovascular salvage, operative conversion with explantation of the endoprosthesis remains necessary in some patients. We report herein a review of all patients initially enrolled in multicenter US clinical trials of the Excluder endograft who underwent secondary conversion to open surgical repair.Clinical data and relevant medical records of patients enrolled in phase I and II multicenter US clinical trials of the Excluder endograft were retrospectively reviewed for adverse events and further narrowed to those patients who underwent secondary operative conversion. Hospital records, operative and anesthesia reports, and all imaging studies were analyzed at initial implantation and at the time of subsequent open surgical repair.Late open conversion was performed in 16 (2.7%) of the 594 patients enrolled in the Excluder clinical trials. Presumed endotension accounted for 8 of 16 of secondary conversions. In two of these patients, however, an endoleak was identified at the time of open surgical repair. Of the remaining eight patients, two underwent conversion for device infection, five for persistent endoleak, and one for aneurysm rupture. The overall 30-day mortality was 6.25% (1/16), with one death occurring in a patient with a ruptured aneurysm. Of patients who underwent conversion because of endotension, the maximal abdominal aortic aneurysm diameter (mean +/- SD) at the time of initial implantation and subsequent graft removal was 61 +/- 11 mm and 70 +/- 10 mm, respectively. The mean time to open conversion for treatment of endotension was 37 +/- 12 months (range, 20-50 months; median, 42 months). Freedom from conversion was 98.6% and 96.7% at 24 and 48 months, respectively.Endotension in the absence of a demonstrable endoleak has been a major indication for late surgical conversion in patients treated with the Excluder endograft. Given the potential presence of an undetected endoleak and the possible effects of progressive sac enlargement on long-term device stability, continued close surveillance of patients with assumed endotension is required. Should changes in device design eliminate endotension, a further reduction in the already low incidence of late open conversion of the Excluder endograft can be anticipated.
View details for DOI 10.1016/j.jvs.2005.05.056
View details for Web of Science ID 000232609300008
View details for PubMedID 16242545
- Re: "Extension of dissection in Stent-Graft treatment of type B aortic dissection: Lessons learned from endovascular experience" JOURNAL OF ENDOVASCULAR THERAPY 2005; 12 (5): 620–21
Endovascular management of ruptured, mycotic abdominal aortic aneurysm
SOUTHEASTERN SURGICAL CONGRESS. 2005: 515–17
Patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. Magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.
View details for Web of Science ID 000230013700014
View details for PubMedID 16044934
Safety and efficacy of carotid arteriography in vascular surgery practice
MOSBY-ELSEVIER. 2005: 238–45
Carotid arteriography (CA) is an important method of assessing carotid artery occlusive disease and is the best method of planning for carotid angioplasty and stent placement (CAS). This study compared the results of CA performed by vascular surgeons in a contemporary series against widely recognized interdisciplinary quality standards for this procedure. Although many vascular surgeons perform CA, there is a paucity of data about its safety, efficacy, and compliance with quality standards in vascular practice. The importance of quality CA will likely increase as CAS emerges to assume a broader clinical role.Carotid arteriograms performed by seven vascular surgeons at three institutions from September 2000 to May 2004 were reviewed. These results were compared with quality standards for the performance of CA.Five hundred three carotid arteriograms were performed over 45 months. Indications for the procedure were extracranial cerebrovascular disease (86%), trauma (5%), and other conditions (9%). Indications for the procedure were appropriate in 100% of patients (as determined by guidelines document) and exceeded the recommended standard of appropriate indications in 99%. All procedures successfully provided the information required, exceeding the threshold of 98% for procedural success. Reversible neurologic deficits occurred in 0.6% (two transient ischemic attacks and one stroke) compared with the threshold of 2.5%. A permanent neurologic deficit occurred in 0.2% (1 patient) compared with the published guideline of 1% after carotid arteriography. Major non-neurologic complications occurred in 1.2% (6 patients), less than the standard of 2.0%.The safety and efficacy of a contemporary series of CA performed in vascular surgery practice compared favorably with recognized interdisciplinary quality standards for this procedure. Ensuring safe and effective CA is likely to support the successful growth of CAS as a treatment option.
View details for DOI 10.1016/j.jvs.2004.11.024
View details for Web of Science ID 000227566800010
View details for PubMedID 15768005
Determinants of in-hospital mortality and length of stay for acute intestinal gangrene
AMERICAN JOURNAL OF SURGERY
2004; 187 (4): 482–85
Intestinal gangrene carries high operative mortality and morbidity rates. This study was undertaken to identify predictors of in-hospital death and length of stay.Retrospective review of hospital data over a 6-year period identified 107 patients diagnosed with acute bowel gangrene.Among the baseline factors that had a significant univariable association with mortality (51%) were age (P = 0.04), symptom duration (P = 0.01), preoperative and postoperative pH and lactic acid (P < or = 0.02), history of hypertension (P = 0.001), and renal failure (P = 0.008). Symptom duration and history of hypertension were independent risk factors for mortality. Longer length of stay was univariably associated with symptom duration (P = 0.006), systemic acidosis (P < or =0.005), vascular etiology (P = 0.04), amount of resected bowel (P = 0.001), and need for second-look procedures (P <0.001).The presence of multiple risk factors predictive of a high mortality rate may aid more realistic decision making for physicians, patients, and family members.
View details for DOI 10.1016/j.amjsurg.2003.12.049
View details for Web of Science ID 000220493400005
View details for PubMedID 15041495
- Off-pump management of aortic arch aneurysm by using an endovascular thoracic stent graft JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2003; 126 (4): 1181–83
Covered stents for true subclavian aneurysms in patients with degenerative connective tissue disorders
JOURNAL OF ENDOVASCULAR THERAPY
2003; 10 (3): 647–52
To report the endovascular repair of rare true aneurysms of the subclavian artery in patients with degenerative connective tissue disorders.Two patients, one with Marfan syndrome and the other with idiopathic cystic medial necrosis, presented with 3 subclavian artery aneurysms. A Wallgraft and 2 Viabahn covered stents were used to successfully exclude these aneurysms. After 3 months, the Wallgraft thrombosed, but the contralateral Viabahn remained patent at the most recent examination 13 months after treatment. The other patient with the unilateral aneurysm had a patent Viabahn stent-graft at 10 months.Patients with degenerative connective tissue disorders may benefit from less invasive treatment with stent-grafts. The more flexible Viabahn stent-graft may be better able to adapt to arterial tortuosity. However, the long-term results of this new technique have not yet been established.
View details for DOI 10.1583/1545-1550(2003)010<0647:CSFTSA>2.0.CO;2
View details for Web of Science ID 000185306200035
View details for PubMedID 12932181
Is carotid angioplasty and stenting more cost effective than carotid endarterectomy?
MOSBY, INC. 2003: 331–38
Carotid angioplasty and stenting (CAS) has been advocated as a minimally invasive and inexpensive alternative to carotid endarterectomy (CEA). However, a precise comparative analysis of the immediate and long-term costs associated with these two procedures has not been performed. To accomplish this, a Markov decision analysis model was created to evaluate the relative cost effectiveness of these two interventions.Procedural morbidity/mortality rate for CEA and costs (not charges) were derived from a retrospective review of consecutive patients treated at New York Presbyterian Hospital/Cornell (n = 447). Data for CAS were obtained from the literature. We incorporated into this model both the immediate procedural costs and the long-term cost of morbidities, such as stroke (major stroke in the first year = $52,019; in subsequent years = $27,336/y; minor stroke = $9419). We determined long-term survival rate in quality-adjusted life years and lifetime costs for a hypothetic cohort of 70-year-old patients undergoing either CEA or CAS. Our measure of outcome was the cost-effectiveness ratio.The immediate procedural costs of CEA and CAS were $7871 and $10,133 respectively. We assumed major plus minor stroke rates for CEA and CAS of 0.9% and 5%, respectively. We assumed a 30-day mortality rate of 0% for CEA and 1.2% for CAS. In our base case analysis, CEA was cost saving (lifetime savings = $7017/patient; increase in quality-adjusted life years saved = 0.16). Sensitivity analysis revealed major stroke and death rates as the major contributors to this differential in cost effectiveness. Procedural costs were less important, and minor stroke rates were least important. CAS became cost effective only if its major stroke and mortality rates were made equivalent to those of CEA.CEA is cost saving compared with CAS. This is related to the higher rate of stroke with CAS and the high cost of stents and protection devices. To be economically competitive, the mortality and major stroke rates of CAS must be at least equivalent if not less than those of CEA.
View details for DOI 10.1067/mva.2003.124
View details for Web of Science ID 000180893000022
View details for PubMedID 12563203
Filter devices for cerebral protection during carotid angioplasty and stenting.
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
2003; 10 (6): 1039–45
The risk of embolization during carotid artery stenting (CAS) has been the foremost reason for the cautious acceptance of this percutaneous alternative to carotid endarterectomy. To address this issue, numerous embolic protection devices are being evaluated as an adjunct to CAS for neuroprotection. Among the 3 main categories of these devices, distal filters, which trap embolic debris while maintaining distal cerebral perfusion, have attracted the most corporate interest. This review focuses on the emerging field of embolic protection filters for use in CAS.
View details for DOI 10.1177/152660280301000603
View details for PubMedID 14723572
The Trellis Thrombectomy System in the treatment of acute limb ischemia.
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
2003; 10 (2): 317–21
To report the use of a new percutaneous mechanical thrombectomy device in the treatment of acute limb-threatening ischemia.The Trellis Thrombectomy System is a 7-F drug dispersion catheter that features a treatment segment isolated by proximal and distal occlusion balloons, which help prevent distal embolization and systemic release of the infused thrombolytic agent. After inflating the distal balloon, the thrombolytic agent is infused and held at the target site by inflation of the proximal balloon. An oscillating dispersion wire optimizes dispersal of the thrombolytic agent as the thrombus is mechanically fragmented. The liquefied thrombus is then aspirated. Four consecutive patients with acute lower extremity ischemia secondary to bypass graft thrombosis were treated with the Trellis thrombectomy catheter. Overall, 95% of thrombus was successfully removed from the treatment zone, with no device-related complications. Only one patient required adjunctive thrombolytic therapy after thrombectomy with the Trellis device.The Trellis thrombectomy device is a safe and effective technique to isolate the infused thrombolytic agent in association with mechanical fragmentation for rapid blood flow restoration.
View details for DOI 10.1177/152660280301000223
View details for PubMedID 12877616
Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management.
Annals of vascular surgery
2003; 17 (6): 589–95
The magnitude of injury necessary to cause a traumatic aortic tear often results in high mortality. Open surgery in these patients is often not well tolerated. The purpose of this study was to compare the outcomes of three different treatment options in patients with traumatic aortic injuries. This was a retrospective review of a prospectively maintained computer database. Over a period of 33 months, 27 patients were diagnosed with thoracic aortic tears on the basis of a computed tomogram or a diagnostic angiogram. All patients were initially seen by trauma surgery staff and managed nonoperatively ( n = 12) if the predicted mortality due to associated injuries approached 100%. Thoracic surgery staff were consulted on all other patients, and open surgical repair was performed in 10 patients. Thoracic stent grafts were used in five patients because of inability to ventilate following an attempted thoracotomy ( n = 2) or associated organ injury that prohibited anticoagulation (head +/- liver injury, n = 3). Overall, patients in the endovascular group had a higher injury severity score than that of the open surgical group (42 +/- 9 vs. 32 +/- 11). However, mortality was lowest in the endovascular group (20%), higher in the open surgical group (50%), and highest in the nonoperative group (92%). No paraplegia was noted, and all surviving patients have been free of complications during the follow-up period. Due to the small number of patients in each treatment, no strong recommendations can be made. However, the results of thoracic stent grafts for patients with traumatic thoracic pseudoaneurysms may prove to be a safer and less invasive treatment option.
View details for DOI 10.1007/s10016-003-0066-2
View details for PubMedID 14569431
Technique and results of transfemoral superselective coil embolization of type II lumbar endoleak.
Journal of vascular surgery
2003; 38 (1): 61–66
This study was undertaken to describe the technique of transfemoral superselective coil embolization of type II endoleak and its influence on abdominal aortic aneurysm diameter.Over 23 months, 104 aortic stent grafts were deployed to exclude abdominal aortic aneurysms, at an academic medical center. Increase in aneurysm diameter and perigraft findings on contrast material-enhanced computed tomography scans prompted arteriography. Procedures were performed solely by vascular surgeons in a surgical angiography suite. In 7 patients aneurysm access was via the iliolumbar branches of the internal iliac artery, and in 1 patient aneurysm access was via the inferior mesenteric artery through the arc of Riolan from the superior mesenteric artery. Coaxial catheters were placed to gain access to the aneurysm (8F to 5F to 3F, or 5F to 3F). A 3F Tracker18 was the most distal catheter through which an assortment of 0.018 microcoils were deployed within the aneurysm, and the origin of the feeding vessels when possible.Aneurysm diameter increased 0.48 +/- 0.2 cm over 10.8 +/- 5 months before superselective coil embolization. In 6 of 8 patients superselective coil embolization embolization resulted in a mean decrease in aneurysm diameter of 1.3 +/- 1.2 cm over 9 +/- 3.2 months. Failure was presumed due to inability to reach the aneurysm sac in 1 patient and was associated with oral anticoagulation in 1 other patient.Proper identification of the source of type II endoleak and its complete occlusion, combined with aneurysm sac coiling, may result in prompt decrease in aneurysm size.
View details for DOI 10.1016/s0741-5214(02)75467-0
View details for PubMedID 12844090
- Regarding "Endograft limb occlusion and stenosis after ANCURE endovascular abdominal aneurysm repair" JOURNAL OF VASCULAR SURGERY 2002; 36 (4): 869–70
- Salvage of failed stent-graft: expanded indication for percutaneous thrombin injection AMERICAN JOURNAL OF SURGERY 2002; 183 (5): 600
- Endovascular management of acute traumatic thoracic aneurysm JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE 2002; 52 (2): 387–90
Current options in the diagnosis and management of acute limb ischemia.
Progress in cardiovascular nursing
2002; 17 (1): 26–34
Acute limb ischemia occurs due to a sudden decrease in the blood flow to a limb, resulting in a potential threat to the viability of the extremity. Unfortunately, the threat is not only to the limb, but these patients are also at high risk for death. Limb hypoperfusion results in systemic acid-base and electrolyte abnormalities that impair cardiopulmonary and renal function. Successful reperfusion may result in the release of highly toxic free radicals, further compromising these critically ill patients. Therapeutic choices are often few and patient expectations are not always realistic. The management of acute limb ischemia requires a thorough understanding of the anatomy of the arterial occlusion and the open surgical and percutaneous options for restoring limb perfusion. Priorities for the diagnosis and effective management of these critically ill patients are provided.
View details for DOI 10.1111/j.0889-7204.2002.00617.x
View details for PubMedID 11872978
- Regarding "Preprocedural risk stratification: identifying an appropriate population for carotid stenting". Journal of vascular surgery 2002; 35 (2): 407–8
Behcet's disease: Endovascular management of a ruptured peripheral arterial aneurysm
JOURNAL OF VASCULAR SURGERY
2001; 34 (6): 1127–29
Traditionally, bypass grafts are at a high risk for thrombosis or anastomotic degeneration in patients with Behçet's disease. We report the successful deployment of a vein-covered stent across the neck of a ruptured peripheral arterial aneurysm, via a remote site access, with intermediate-term follow-up. Covered stents may represent an attractive alternative to open surgical bypass for the management of aneurysms in patients with Behçet's disease.
View details for DOI 10.1067/mva.2001.118585
View details for Web of Science ID 000173002700035
View details for PubMedID 11743572
Rheolytic thrombectomy in the management of acute and subacute limb-threatening ischemia
JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY
2001; 12 (4): 413–21
To evaluate the use of a percutaneous mechanical thrombectomy (PMT) catheter (AngioJet) as an initial treatment for acute (<2 weeks) and subacute (2 weeks to 4 months) arterial occlusion of the limbs.A total of 86 (acute, n = 65; subacute, n = 21) patients were available for retrospective analysis, averaging 65 +/- 14 years of age. Outcomes assessed include initial angiographic success (failure = less than 50% luminal restoration [LR]; partial success = 50%-95% LR; success = more than 95% LR), pre- and postprocedural ankle-brachial index (ABI), device-related and systemic complications, 1-month amputation, mortality, and short-term patency.Angiographic success was evaluated in 83 of 86 patients (guide wire unable to traverse lesion in three patients). The procedure failed in 13 of 83 (15.6%) patients, partial success was seen in 19 of 83 patients (22.9%), and successful recanalization was noted in 51 of 83 patients (61.4%). Adjunctive thrombolysis was used in 50 of 86 patients (58%). However, thrombolysis resulted in angiographic improvement at the site of PMT in only seven of 50 of these patients (14%). Adjunctive thrombolysis was uniformly unsuccessful in patients in whom initial PMT failed. The median increase in ABI was 0.64 (95% CI: 0.43-0.81). Success was more likely in the setting of in situ thrombosis, with 61 of 68 (90%) procedures successful, compared to embolic occlusions, with nine of 15 (60%) procedures successful (P =.011). Angiographic outcome was not dependent on the duration of occlusion (acute, 51 of 62; subacute, 19 of 21; P =.35) or the conduit type (graft, 28 of 31; native vessel, 42 of 52; P =.35). An underlying stenosis was identified in 53 of the 70 patients (75.7%) with a successful PMT, and 51 of these 53 unmasked lesions were successfully treated. Follow-up data were available in 56 patients for patency assessment at a median of 3.9 months (range, 0.1-28.5 months). Patency at 6 months was 79% (95% CI: 65-92). Systemic complications occurred in 16.3% of patients, local complications were noted in 18.6%, and 1-month amputation and mortality rates were 11.6% and 9.3%, respectively.PMT offers the potential to rapidly reestablish flow to an ischemic extremity and may be the only available treatment option in patients at high risk for open surgery or with contraindications to pharmacologic thrombolysis.
View details for DOI 10.1016/S1051-0443(07)61878-8
View details for Web of Science ID 000167928600002
View details for PubMedID 11287526
Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis
JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY
2001; 12 (2): 179–85
This study was undertaken to evaluate the efficacy of a percutaneous mechanical thrombectomy (PMT) device for rapid thrombus removal following deep venous thrombosis (DVT).Over a 37-month period, 17 patients (14 women; mean age, 41 y +/- 20) with extensive DVT were treated with initial attempts at PMT with use of the AngioJet rheolytic thrombectomy device. Sites of venous thrombosis included lower extremities in 14 patients and upper extremity and brachiocephalic veins in three. The etiology for venous thrombosis was malignancy in seven, idiopathic etiology in three, May-Thurner syndrome and immobilization in three each, and oral contraceptive use and hypercoagulable disorder in one each. The primary endpoint was venographic evidence of thrombus extraction. Perioperative complications, mortality, and recurrence-free survival were also evaluated.After PMT, four of 17 patients (24%) had venographic evidence of >90% thrombus removal, six of 17 (35%) had 50%-90% thrombus removal, and seven of 17 (41%) had <50% thrombus extraction. Adjunctive thrombolytic therapy was used in nine of 13 patients with <90% thrombus extraction by PMT; six patients (35%) had contraindications to pharmacologic thrombolytic therapy. An underlying lesion responsible for the occlusion was uncovered in 10 patients (59%). Significant improvement in clinical symptoms was seen in 14 of 17 patients (82%). No complications were noted directly relating to the use of the AngioJet thrombectomy catheter. None of the patients were lost to follow-up during a mean of 8.9 months +/- 5.3 (range, 2-21 months). At 4 and 11 months, recurrence-free survival rates were 81.6% and 51.8%, respectively.PMT with adjunctive thrombolytic therapy is a minimally invasive, low-risk therapeutic option in patients with extensive DVT, associated with clinical benefits including thrombus removal, patency, and relief of symptoms.
View details for DOI 10.1016/S1051-0443(07)61823-5
View details for Web of Science ID 000166999000006
View details for PubMedID 11265881
Chronic mesenteric ischemia: Open surgery versus percutaneous angioplasty and stenting
MOSBY-ELSEVIER. 2001: 63–70
The aim of the study was to evaluate the safety and efficacy of percutaneous angioplasty and stenting (PAS) in comparison with traditional open surgical (OS) revascularization for the treatment of chronic mesenteric ischemia.Over a 3.5-year period, 28 patients (32 vessels) underwent PAS (balloon angioplasty alone, 5 [18%] of 28; angioplasty and stenting, 23 [82%] of 28) for symptoms of chronic mesenteric ischemia. These patients were compared with a previously published series of 85 patients (130 vessels) treated with OS (bypass grafting, 60 [71%] of 85; transaortic endarterectomy, 19 [22%] of 85; or patch angioplasty, 6 [7%] of 85).The PAS and OS groups were similar with respect to baseline comorbidities, duration of symptoms (median: 6.7 vs 10.5 months, P =.52), and the number of vessels involved, but the patients differed in their age at presentation (median: 72 vs 65 years, P =.005). Fewer vessels were revascularized per patient in the PAS group (1.1 +/- 0.4) compared with the OS group (1.5 +/- 0.6, P =.001). Overall, 85.7% (24/28) had one vessel and 14.3% (4/28) had two vessels revascularized in the PAS group versus 48.2% (41/85) with one-vessel and 47.1% (40/85) with two-vessel revascularization in the OS group. No difference was noted in the early in-hospital complications (median: 17.9% [PAS] vs 32.9% [OS], P =.12) or mortality rate (10.7% [PAS] vs 8.2% [OS], P =.71). A reduced length of hospital stay in the PAS patients did not attain statistical significance (median: 5 days [PAS] vs 13 days [OS], P =.08). Although the 3-year cumulative recurrent stenosis (P =.62) and mortality rate (P =.99) did not differ, the PAS treatment group had a higher incidence of recurrent symptoms (P =.001).Although the results of PAS and OS were similar with respect to morbidity, death, and recurrent stenosis, PAS was associated with a significantly higher incidence of recurrent symptoms. These findings suggest that OS should be preferentially offered to patients deemed fit for open revascularization.
View details for DOI 10.1067/mva.2001.111808
View details for Web of Science ID 000166576900016
View details for PubMedID 11137925
Mechanical thrombectomy as a first-line treatment for arterial occlusion.
Seminars in vascular surgery
2001; 14 (2): 123–31
The use of percutaneous mechanical thrombectomy devices to restore flow to an acutely ischemic limb is gaining popularity. Potential benefits include the minimally invasive nature of the procedure, rapid blood flow restoration, and a decrease in the dose and duration of adjunctive pharmacologic thrombolytic agents when required. A detailed description of the currently available mechanical thrombectomy devices, preclinical device evaluation, and published clinical trials for the management of acute limb-threatening ischemia are provided.
View details for DOI 10.1053/svas.2001.23169
View details for PubMedID 11400088
Endovascular management of visceral artery aneurysm.
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
2001; 8 (2): 150–55
To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques.Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 +/- 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels.Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 +/- 29.6 months.Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.
View details for DOI 10.1177/152660280100800209
View details for PubMedID 11357975
The use of mechanical thrombectomy devices in the management of acute peripheral arterial occlusive disease.
Journal of vascular and interventional radiology : JVIR
2001; 12 (4): 405–11
A number of percutaneous mechanical thrombectomy devices are currently being used or undergoing clinical evaluation for the treatment of acute and chronic limb-threatening ischemia. Preliminary studies on the safety, efficacy, and device limitations have spurred an interest in percutaneous techniques for thrombus debulking as stand-alone therapy or an adjunct to pharmacologic thrombolysis. The devices have various mechanisms or combinations of mechanisms to optimize thrombus removal. Efficacy of thrombus removal is balanced by the propensity for vessel wall damage and distal embolization, especially for wall-contact devices (Arrow-Trerotola device and Cragg and Castañeda brushes). Initial experience in hemodialysis graft occlusion has subsequently moved on to peripheral arterial occlusions. Although the U.S. Food and Drug Administration has approved eight mechanical thrombectomy devices (MTDs) for use in thrombosed hemodialysis grafts, only the AngioJet LF140 is currently approved for use in peripheral arterial occlusive disease. Nevertheless, numerous clinical articles and abstracts have reported the "off-label" use of MTDs in the management of limb-threatening ischemia. A description of the eight MTDs and a review of the current literature on use of MTDs for acute peripheral arterial occlusive disease are provided.
View details for DOI 10.1016/s1051-0443(07)61877-6
View details for PubMedID 11287525
Management of Acute Lower Extremity Ischemia: Treatment Strategies and Outcome.
Current interventional cardiology reports
2000; 2 (2): 119–29
Acute limb ischemia is a result of decreased arterial perfusion resulting in inadequate tissue perfusion. The severity of symptoms and urgency for treatment depends on the status of the collateral circulation. Therapy should be directed toward both systemic and local factors. Treatment is by open surgery, thrombolysis, or percutaneous thrombectomy. Unfortunately, none of the treatment modalities have proven to be the golden standard for limb salvage and patient survival. Review of current literature and a multimodality approach for the management of acute limb ischemia is presented in this article.
View details for PubMedID 11096659
- Is the use of suboptimal saphenous veins justifiable for limb salvage? VASCULAR SURGERY 1999; 33 (2): 157–62
Necrotizing esophagitis presenting as a black esophagus
SURGICAL ENDOSCOPY-ULTRASOUND AND INTERVENTIONAL TECHNIQUES
1998; 12 (12): 1430–33
A case of necrotizing esophagitis discovered during upper endoscopy is described. An 88-year-old woman was admitted to our hospital with complaints of multiple episodes of coffee ground emesis and dysphagia over 3 months. Ischemia is proposed as the etiology of necrotizing esophagitis on the basis of the patient's significant cardiac history, her age, and low-flow state.
View details for DOI 10.1007/s004649900875
View details for Web of Science ID 000077205300016
View details for PubMedID 9822473
- Synchronous management of incidental neck masses and carotid artery disease VASCULAR SURGERY 1998; 32 (6): 531–34
- Calciphylaxis: Calcific angiopathy resulting in acral gangrene - Case reports VASCULAR SURGERY 1998; 32 (5): 447–53
Stump appendicitis: A case report
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES-PART A
1997; 7 (6): 389–91
Residual appendicitis is a rare event that occurs when there is incomplete resection of the organ. A recent report suggested that this may be a complication of laparoscopic surgery. Following a case of stump appendicitis in a young patient, we thoroughly reviewed the literature and found that most reported cases have occurred in open appendectomy. Awareness of the existence of this uncommon condition will help in the early diagnosis and prompt treatment of this pathology.
View details for DOI 10.1089/lap.1997.7.389
View details for Web of Science ID 000071430800010
View details for PubMedID 9449091
- Electron microscopic luminal surface characteristics of carotid plaques WESTMINSTER PUBL INC. 1997: 769–74
Acute mesenteric vein thrombosis and pancreatitis
INTERNATIONAL JOURNAL OF PANCREATOLOGY
1997; 21 (3): 249–51
This article presents a case of acute mesenteric vein thrombosis with small bowel infarction associated with pancreatitis. Although a rare occurrence, the authors suggest this diagnosis should be considered as a possible complication of pancreatic inflammation.
View details for DOI 10.1007/BF02821611
View details for Web of Science ID A1997XW75500007
View details for PubMedID 9322124
PORTAL PYELOPHLEBITIS IDENTIFIED BY CT SCAN IN A PATIENT WITH ISCHEMIC BOWEL
1995; 61 (12): 1039–40
A 65-year-old male was found to have hepatic portal venous gas (HPVG) by computed tomogram secondary to ischemic bowel. Despite aggressive surgical and antibiotic treatment, the patient died within 12 hours. Portal pyelophlebitis, when identified by air in the portal venous system, is a grave indicator of ischemic bowel with a very high mortality rate, except in patients with inflammatory bowel disease.
View details for Web of Science ID A1995TG26700006
View details for PubMedID 7486440