Clinical Professor of Surgery
Chief, Division of Vascular Surgery at Santa Clara Valley Medical Center (SCVMC)
Dr. Garcia-Toca earned his medical degree at the Universidad Anahuac in Mexico 1999. He has a master’s degree in Health Policy from Stanford University.
He received his general surgery training at the Massachusetts General Hospital and Brown University in 2008. He then completed a Vascular Surgery fellowship at Northwestern University in 2010. Dr. Garcia-Toca is board certified in both surgery and vascular surgery.
Dr. Garcia-Toca joined Stanford Vascular Surgery in 2015. He is currently Clinical Professor of Surgery in the Division of Vascular Surgery. Dr. Garcia-Toca had previously served as an Assistant Professor of Surgery at Brown University. Dr. Garcia Toca is the division chief of vascular surgery at Santa Clara Valley Medical Center in San Jose.
His research interests include new therapeutic strategies and outcomes for the management of vascular trauma, cerebrovascular diseases, dialysis access, aortic dissection, and aneurysms.
Specialties: Open and endovascular management of vascular trauma, aortic dissection, complex thoracic and abdominal aortic aneurysm disease, critical limb ischemia, extracranial cerebrovascular disease and dialysis access.
M.S, Stanford University, Health Policy (2021)
Board Certification, American Board of Surgery, Vascular Surgery (2011)
Fellowhip, Northwestern University, Feinberg School of Medicine (2010)
Board Certification, American Board of Surgery, General Surgery (2009)
Residency, Rhode Island Hospital, Brown University., General Surgery (2008)
Residency, Massachusetts General Hospital (2006)
Internship, Cleveland Clinic Foundation (2004)
Residency, Instituto Nacional de Ciencias Médicas Salvador Zubiran, Mexico (2003)
Medical Education, Universidad Anahuac, Mexico (1999)
Current Research and Scholarly Interests
Open and endovascular management of vascular trauma, aortic dissection, complex thoracic and abdominal aortic aneurysm disease, critical limb ischemia, extracranial cerebrovascular disease and dialysis access.
Cost-Effectiveness Analysis of ABI Screening in Patients with Coronary Artery Disease to Optimize Medical Management.
Journal of vascular surgery
INTRODUCTION: Screening for peripheral artery disease (PAD) with the ankle-brachial index (ABI) test is currently not recommended in the general population; however, previous studies advocate screening in high-risk populations. Although providers may be hesitant to prescribe low-dose rivaroxaban to patients with coronary artery disease (CAD) alone, given the reduction in cardiovascular events and death associated with rivaroxaban, screening for PAD with the ABI test and accordingly prescribing rivaroxaban may provide additional benefits. We sought to describe the cost-effectiveness of screening for PAD in patients with CAD to optimize this high-risk populations' medical management.METHODS: We used a Markov model to evaluate the ABI test in patients with CAD. We assumed that all patients screened would be candidates for low dose rivaroxaban. We assessed the cost of ABI screening at $100 per patient and added additional charges for physician visits ($100) and rivaroxaban cost ($470 per month). We used a 30-day cycle and performed analysis over 35 years. We evaluated quality-adjusted life years (QALYs) from previous studies and determined the incremental cost-effectiveness ratio (ICER) according to our model. We performed a deterministic and probabilistic sensitivity analyses of variables with uncertainty and reported them in a Tornado diagram showing the variables with the greatest effect on the ICER.RESULTS: Our model estimates decision costs to screen or not screen at $94,953 and $82,553, respectively. The QALYs gained from screening was 0.060, generating an ICER of $207,491 / QALY. Factors most influential on the ICER were the reduction in all-cause mortality associated with rivaroxaban and the prohibitively high cost of rivaroxaban. If rivaroxaban cost less than $95 per month, this would make screening cost-effective based on a willingness to pay threshold of $50,000 / QALY.CONCLUSIONS: According to our model, screening patients with CAD for PAD to start low dose rivaroxaban is not currently cost-effective due to insufficient reduction in all-cause mortality and high medication costs. Nevertheless, vascular surgeons have a unique opportunity to prescribe or advocate for low dose rivaroxaban in patients with PAD to improve cardiovascular outcomes.
View details for DOI 10.1016/j.jvs.2021.05.049
View details for PubMedID 34175383
Analysis of Medicare Payments and Patient Outcomes with Pre-Operative Imaging for Carotid Endarterectomy.
Annals of vascular surgery
OBJECTIVE: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in pre-operative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease.METHODS: We used a 20% Medicare sample from 2006-2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated pre-operative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use.RESULTS: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8±7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4±1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5±2.1 ultrasounds, 0.95±0.86 neck CTs and 0.47±0.7 MRIs per patient. The average payment for ultrasound was $140±40, $282±94 for CT and $410±146 for MRI. The average inpatient reimbursements were $7,413±4,215 for patients without CSI compared with $7,792±3,921 for patients with CSI, P<.001. The average LOS during CEA admission was 2.5±3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by post-operative day two compared with ultrasound alone (88.9% vs. 91.5%, respectively, P<.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups.CONCLUSIONS: Our analysis found pre-operative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.
View details for DOI 10.1016/j.avsg.2021.06.001
View details for PubMedID 34153493
Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury.
Journal of vascular surgery
OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is an effective treatment for blunt thoracic aortic injury (BTAI), but the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications.METHODS: The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 to identify patients who underwent TEVAR for BTAI with or without administration of intraoperative heparin. Univariate analyses were performed with Student's t-test, Fisher exact, and chi-squared tests where appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality.RESULTS: 655 patients were included, of whom the majority presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) ≥ 15 (70.2% vs. 90.5%, p<0.0001), or major head or neck injury (39.6% vs. 62.9%, p<0.0001). Patients receiving heparin had lower incidence of inpatient death (5.1% vs. 12.9%, p<0.01). Across all injury grades, heparin use was not associated with intraoperative transfusion, postoperative transfusion, or hematoma. In patients with grade III BTAI, non-use of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%, P < 0.05). On multivariable logistic regression for inpatient mortality, intraoperative heparin use (OR = 0.31, 95% Confidence Interval [CI] 0.11 - 0.86, P < 0.05) and female gender (OR = 0.11, 95% CI 0.11 - 0.86, P < 0.05) were associated with better survival, even when controlling for head and neck trauma and injury grade. In contrast, increased age (OR = 1.06, 95% CI 1.03 - 1.1, P <0.001), postoperative transfusion (OR = 1.06, 95% CI 1.02 - 1.11, P < 0.01), Higher ISS (OR = 1.04, 95% CI 1.01 - 1.07, P < 0.05), postoperative dysrhythmia (OR = 4.48, 95% CI 1.10 - 18.18, P < 0.05), and postoperative stroke or transient ischemic attack (OR = 5.54, 95% CI 1.11 - 27.67, P < 0.05) were associated with increased odds of inpatient mortality.CONCLUSIONS: Intraoperative heparin use is associated with reduced inpatient mortality in patients undergoing during TEVAR for BTAI, including those with major head or neck trauma and high injury severity scores. Heparin did not increase risk of hemorrhagic complications across all injury grades, and in patients with grade III BTAI heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI, and should be administered when no specific contraindication exists.
View details for DOI 10.1016/j.jvs.2020.12.068
View details for PubMedID 33348003
Analysis of Medicare Payments for Preoperative Imaging Before Carotid Endarterectomy
MOSBY-ELSEVIER. 2020: E17–E18
View details for Web of Science ID 000544100700022
Cost-effectiveness Analysis of Ankle-Brachial Index Screening in Patients With Coronary Artery Disease to Optimize Medical Management
MOSBY-ELSEVIER. 2020: E250
View details for Web of Science ID 000544100700381
The Effect of Interfacility Transfer in Patients With Blunt Thoracic Aortic Injury
MOSBY-ELSEVIER. 2020: E167
View details for Web of Science ID 000544100700255
Intraoperative Heparin Use Is Associated With Reduced Inpatient Mortality After Thoracic Endovascular Aortic Repair for Blunt Aortic Injury
MOSBY-ELSEVIER. 2020: E99
View details for Web of Science ID 000544100700156
- Delayed Carotid Endarterectomy After Admission in Symptomatic Carotid Artery Disease Is Associated With Lower Postoperative Stroke Rates in the Medicare Population MOSBY-ELSEVIER. 2019: E86–E87
- Cost-Effectiveness Analysis of Fenestrated Endovascular Aneurysm Repair Compared With Open Surgical Repair for Patients With Juxtarenal Abdominal Aortic Aneurysms MOSBY-ELSEVIER. 2019: E244–E245
- Oakes Salvage Procedure Is a Better, More Durable Option Compared With Forearm Loop Expanded Polytetrafluoroethylene Graft to Preserve Forearm Dialysis Access in Patients With Failing Brescia-Cimino Fistula MOSBY-ELSEVIER. 2019: E242–E243
Secondary interventions in patients with implantable cardiac devices and ipsilateral arteriovenous access.
Journal of vascular surgery
OBJECTIVE: The number of patients with end-stage renal disease who require implantable cardiac devices is increasing. Rates of secondary interventions or fistula failure are not well studied in patients who have arteriovenous fistula (AVF) access placed on the ipsilateral side as a pacemaker. This study aimed to compare central vein-related interventions and failure rates of arteriovenous access in patients with pacemakers placed on the ipsilateral vs contralateral side.METHODS: A retrospective review of a prospectively collected database at a single high-volume dialysis institution was performed; all patients 18years or older who had both arteriovenous access and a pacemaker were included. Data points included the number of interventions such as thrombectomy, percutaneous transluminal angioplasty, and stent placement, as well as time to first intervention and failure of the fistula or graft. Patients with an implantable cardiac device who had contralateral AVF access were compared with AVF ipsilateral access using a t-test and Kaplan-Meier curves for primary patency. Outcomes evaluated included number of interventions and time to intervention from access creation.RESULTS: A total of 32 patients were identified; 20 had arteriovenous access on the contralateral side from the pacemaker and 12 had access on the ipsilateral side. In the contralateral group, there were a mean of 3.6 percutaneous transluminal angioplasties per patient (range, 1-12). In the ipsilateral group, there were an average of 2.8 percutaneous transluminal angioplasties per patient (range, 1-6). There was no difference in intervention rates between these cohorts; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5 vs 19.5months; P< .05). Patency rates did not differ (P= .068).CONCLUSIONS: There was no difference in intervention rates between ipsilateral and contralateral patients; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5months vs 19.5months). This study was limited by its lack of power. Patency rates did not differ (P= .068). Ipsilateral access placement should be considered rather than abandoning access in that extremity.
View details for PubMedID 30850286
- Arteriovenous Fistula and Graft Construction in Patients with Implantable Cardiac Devices: Does Side Matter? ELSEVIER SCIENCE INC. 2019: 66–71
Long-term durability of Oakes salvage procedure to preserve Brescia-Cimino arteriovenous fistula.
Journal of vascular surgery
In 2002, Oakes et al described a novel procedure designed to salvage the distal cephalic venous outflow of a Brescia-Cimino fistula by placing a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. In this fashion, the more proximal veins were saved for future procedures. Their approach was reported and found to be successful in the short term, but the long-term durability of the Oakes procedure has not been described. This study aimed to determine the long-term primary, primary-assisted, and secondary patency rates of the brachial to distal cephalic vein Oakes procedure.This is a retrospective review of a prospective database in a large, single institution. All patients who underwent the Oakes procedure from 1998 to 2012 were followed up to 2018. We reviewed the time to intervention, type of intervention, patency rates, and mortality of this patient population.Over the 5-year study period, 14 patients were identified who underwent the Oakes procedure, of whom seven (50%) were female. The average age was 55.7 years (range, 38-73 years). All patients had a previously placed Brescia-Cimino that was not suitable for dialysis but was patent. The average number of days to placement of an Oakes brachial to distal cephalic graft was 396 (range, 119-1167) days. A total of 71% (10) of patients underwent an intervention to maintain the graft, of whom 50% (5) underwent an angioplasty and 50% (5) had a thrombectomy/revision procedure. The average number of days to first intervention was 367.3 (range, 21-1048) days from Oakes placement. Of this cohort, 30% (3) of patients had a second intervention, of whom 1 (33%) underwent an angioplasty and 2 (66%) had revisions. One patient had a third and a fourth intervention at 39 days and 74 days, respectively, that were both angioplasties. The overall number of days the Oakes procedure remained usable from placement was 843.6 (range, 21-3790) days or 2.3 years.This study concluded that the Oakes procedure may extend the use of the distal dialysis access site by 2.3 years without increasing infection and is hence a durable solution that should be considered in patients requiring dialysis access.
View details for DOI 10.1016/j.jvs.2018.12.034
View details for PubMedID 30837176
"Investigation of an Immunogenetic profile in patients with Abdominal Aortic Aneurysms and possible applications in screening and surveillance".
Annals of vascular surgery
and objectives: The pathogenesis of atherosclerotic Abdominal Aortic Aneurysms (AAA) remains not fully understood. Histological analyses confirm chronic adventitial and medial inflammatory cell infiltration and its pathophysiology involves the upregulation of proteolytic pathways; added to this, genetic factors have been suggested to favor the susceptibility for AAA. The aim of the present study was to analyze the association between genetic polymorphism of the Class II Human Leukocyte Antigens (HLA-DRB1) with the susceptibility to develop AAA in Mexican patients and to initiate a pilot study of single-nucleotide polymorphisms (SNP) rs1024611 in the Monocyte chemoattractant protein-1 gene (MCP-1/CCL2) to investigate a possible role in the AAA pathogenesis.In a cohort of patients with AAA, HLA molecular typing was completed for DRB1 loci with LABType SSO-OneLambda kit in 39 patients (69% males with a mean age of 72 years) and compared with 99 without the disease (60% males, mean age 65 years) (Control group). Genotyping of rs1024611 in the MCP-1 gene was performed using TaqMan Pre-Designed single nucleotide polymorphism (SNP) genotyping assays in 27 AAA patients (63% males, mean age of 71). Gene (gf) and Genotype frequencies (Gf) were determined, categorical data were analyzed by nonparametric statistic test at significance level (p<0.05), and Odds Ratios (OR) were calculated using the STATA v14 Software and and StatCalc software Epi Info™ 188.8.131.52 .Seventy-eight HLA-DRB1 alleles of AAA patients and 198 from the control group were studied. We observed that the gf of HLA-DRB1*01 was 0.128 in the AAA group compared to 0.05 in the Control group [p=0.03, OR 2.6, 95% confidence interval (CI) 1.04-6.5], the gf of HLA-DRB1*16 were 0.115 in the AAA and 0.025 in CG (p=0.002, OR 5, 95% CI 1.6-16.9). The Gf for SNP rs1024611 were 0.51 in the GA genotype, 0.30 in AA, and 0.19 of GG. Four patients with the proinflammatory homozygous genotype GG (80%) were females and younger than patients with other genotypes, and only one had history of dyslipidemia.The dissection and interpretation of an immunogenetic profile in AAA patients is an active and complex field of research that might assist in a more precise identification of those patients at genetic risk. Our study demonstrated increased frequencies of HLA-DRB1*01 and HLA-DRB1*16 alleles in Mexican patients with AAA compared to an ethnically matched control group.
View details for DOI 10.1016/j.avsg.2019.05.004
View details for PubMedID 31201975
Arteriovenous Fistula and Graft Construction in Patients with Implantable Cardiac Devices: Does Side Matter?
Annals of vascular surgery
BACKGROUND: Limited reports have documented the effect cardiac implantable electronic devices (CIEDs) have on arteriovenous (AV) access patency. Current recommendations suggest placing the access on the contralateral side of the CIEDs, as there is concern for increased central venous stenosis and access failure. The goal of this study is to review our single-center AV access patency rates for dialysis patients with an ipsilateral or contralateral side CIED.METHODS: A retrospective review was performed from 2008 to 2016 at a single institution identifying all patients who have received a CIED and the diagnosis of end-stage renal disease (ESRD). Medical records were queried to identify each patient's dialysis access and whether it was ipsilateral or contralateral to the CIED. Primary outcomes of study were primary and secondary patency rates.RESULTS: A total of 44 patients were identified to have ESRD and CIED. Of these patients, 28 patients with fistulas or grafts (13 ipsilateral and 15 contralateral) had follow-up with regards to their AV access. There were 3 primary failures in both groups. For patients who had the CIED placed after already starting the dialysis, patency was based on when the cardiac device was implanted. Primary patency for ipsilateral and contralateral access was 20.2 and 22.2months, respectively. With secondary interventions, ipsilateral and contralateral mean patency was 39 and 48.8months, respectively. Six-month and 1-year primary patency for arteriovenous fistula or arteriovenous graft on patients with ipsilateral access was 69.2% and 53.8%, respectively. Ipsilateral 1-year cumulative patency was 39months.CONCLUSIONS: CIED may lead to stenosis or occlusion to one's AV access; however, primary assisted and secondary patency rates are still acceptable at 6months and 1year compared to Kidney Disease Outcomes Quality Initiative guidelines. Despite a CIED, a surgeon's algorithm should not lead to the abandonment of an ipsilateral access if the central venous system is patent.
View details for PubMedID 30339901
Comparison of Bovine Carotid Xenograft Versus Expanded Polytetrafluoroethylene Grafts for Forearm Loop Hemodialysis Access
MOSBY-ELSEVIER. 2018: E35
View details for Web of Science ID 000442339800065
Secondary Interventions in Patients With Implantable Cardiac Devices and Ipsilateral Arteriovenous Access
MOSBY-ELSEVIER. 2018: E6–E7
View details for Web of Science ID 000439318700008
Comparison of Secondary Intervention Rates in Patients With Implantable Cardiac Devices and Ipsilateral Versus Contralateral Arteriovenous Access
MOSBY-ELSEVIER. 2018: E125
View details for Web of Science ID 000433036700148
Mycotic Renal Artery Aneurysm Presenting as Critical Limb Ischemia in Culture-Negative Endocarditis
CASE REPORTS IN SURGERY
Mycotic renal artery aneurysms are rare and can be difficult to diagnose. Classic symptoms such as hematuria, hypertension, or abdominal pain can be vague or nonexistent. We report a case of a 53-year-old woman with a history of intravenous drug abuse presenting with critical limb ischemia, in which CT angiography identified a mycotic renal aneurysm. This aneurysm tripled in size from 0.46 cm to 1.65 cm in a 3-week interval. Echocardiography demonstrated aortic valve vegetations leading to a diagnosis of culture-negative endocarditis. The patient underwent primary resection and repair of the aneurysm, aortic valve replacement, and left below-knee amputation after bilateral common iliac and left superficial femoral artery stenting. At 1-year follow-up, her serum creatinine is stable and repaired artery remains patent.
View details for PubMedID 29854544
View details for PubMedCentralID PMC5964565
Post-operative infections are associated with increased risk of cardiac events in vascular patients.
Annals of vascular surgery
Despite advances in perioperative care, the rate of cardiac events in vascular patients remains high. We have previously shown that infections in trauma patients are associated with higher rates of subsequent cardiac complications, likely due to the additive effect of a second hit of an infection following the trauma. The aim of this study was to investigate whether there is an association between postoperative infections and subsequent cardiac events in vascular patients.A 5-year retrospective review of demographics, comorbidities, operative interventions, infectious, and cardiac events in all vascular patients who underwent an operative intervention at a single tertiary referral center was performed. In patients with clinical suspicion of myocardial injury, myocardial damage was defined as troponin >0.15 ng/mL and myocardial infarction (MI) as troponin >1 ng/mL. Pneumonia was diagnosed using bronchoalveolar lavage (BAL) and considered positive if BAL fluid culture contained >10,000 colony-forming units (cfu). Urinary tract infection (UTI) was diagnosed if the urine culture contained >100,000 cfu. All other infections were diagnosed by culture data. Regression analysis was performed to assess risk of cardiac events as a function of infections adjusting for age, gender, and comorbidities.We analyzed 1,835 vascular operative interventions with the mean age of the cohort 65.5 years (65.9% male). The overall infection rate was 13.2%, with UTI being the most common (60.3%). The overall rate of myocardial damage was 8.1% and the rate of MI 3.8%. Rates of both myocardial damage (15.5 vs. 7.7%; P = 0.0015) and MI (7.1 vs. 3.4%; P = 0.018) were significantly higher in patients with infections, compared to those without infections. Adjusting for age, gender, medical comorbidities, open versus endovascular cases as well as statin and steroid use, patients with UTI were more likely to subsequently develop either myocardial damage (odds ratio [OR] = 3.57 [95% confidence interval = 1.51-8.45]) or MI (OR = 4.20 [1.23-14.3]). A similar association was noted between any infections and either myocardial damage (OR = 2.97 [1.32-6.65]) or MI (OR = 4.31 [1.44-12.94]).We herein describe an association between postoperative infections, most commonly UTI, and subsequent cardiac events. Efforts should be made to minimize the risk of developing infections to ensure cardioprotection in vascular patients during perioperative period.
View details for DOI 10.1016/j.avsg.2016.09.026
View details for PubMedID 28238924
Open Revascularization Procedures Are More Likely to Influence Smoking Reduction Than Percutaneous Procedures
ANNALS OF VASCULAR SURGERY
2014; 28 (4): 990-998
Among patients with peripheral arterial disease (PAD), smokers have a higher incidence of life- and limb-threatening complications, including lower extremity ischemic rest pain, myocardial infarction, and cardiac death, highlighting the need for smoking reduction. Several studies have previously investigated the perioperative period as a teachable moment for smoking cessation. The purpose of this study is to determine whether the type of revascularization for PAD (percutaneous versus open) is associated with smoking reduction.Study participants included patients seen at a tertiary academic medical center in Providence, RI, between 2005 and 2010 and assigned International Classification of Diseases, Ninth Revision code diagnoses indicative of PAD. This study uses patient-answered surveys and retrospective chart review to assess changes in smoking habits after medical, percutaneous, or open revascularization. Surveys also assessed patient perceptions regarding the influence of intervention on smoking reduction and how strongly patients associate PAD with their smoking habits.Of 54 patients who were active smokers at the time of intervention, 8 (67%) in the medical management group, 12 (50%) in the percutaneous group, and 15 (83%) in the open intervention group reduced smoking by 50% after intervention. After controlling for several confounders, open revascularization was independently associated with smoking reduction when compared with percutaneous intervention (odds ratio, 8.26; 95% confidence interval, 1.18, 76.7; P = 0.043). Surveys revealed that 94% of the patients believed that smoking was a significant contributor to their PAD.Patients with PAD who undergo open revascularization are more likely to reduce smoking than those who undergo percutaneous revascularization. The perioperative period provides an opportunity to improve rates of smoking reduction.
View details for DOI 10.1016/j.avsg.2013.05.017
View details for Web of Science ID 000335655700029
View details for PubMedID 24556178
A 14-year experience with blunt thoracic aortic injury.
Journal of vascular surgery
2013; 58 (2): 380-385
This study reviewed the natural history of blunt thoracic aortic trauma (BTAT) over a 14-year period at our level 1 trauma center and compared open vs endovascular treatment.All patients with BTAT presenting to a level 1 trauma center from 1998 to 2011 were included in a retrospective analysis. Multiple data points and short-term and midterm outcomes were ascertained through a retrospective record review.We identified 129 patients with BTAT. Of these, 32 (25%) were dead on arrival, 38 (29%) underwent a resuscitative thoracotomy and died, 33 (26%) underwent open repair, 14 (11%) underwent endovascular repair, 9 (7%) underwent simultaneous procedures, and 3 (2%) were managed nonoperatively. Mean Injury Severity Scores and Revised Trauma Scores were similar (P = .484, P = .551) between the open repair group (n = 36) and the endovascular repair group (n = 14). In the open repair group, there were 14 deaths (42%) ≤ 30 days of injury, 3 strokes (9%), 2 patients (6%) with paralysis, 2 myocardial infarctions (MIs; 6%), and 3 patients (9%) who required hemodialysis. In the endovascular group, there was 1 death (7%) ≤ 30 days of injury, 1 (7%) stroke, and 1 (7%) stent collapse. No paralysis, MI, or renal failure requiring hemodialysis was noted in the endovascular group. The average length of stay was 15 days for patients treated with endovascular repair vs 24 days for those treated with open repair (P = .003).The incidence of BTAT is low but the mortality associated with it is significant. During the 14-year period studied, there was a clear change in management preference from open repair to endovascular repair at our level 1 trauma center. Outcomes, including stroke, MI, renal failure, paralysis, length of stay, and death, appear to be reduced in the endovascular group.
View details for DOI 10.1016/j.jvs.2013.01.045
View details for PubMedID 23756339
Primary Extracranial Vertebral Artery Aneurysms
ANNALS OF VASCULAR SURGERY
2013; 27 (4): 418-423
Extracranial vertebral artery aneurysms are uncommon and are usually associated with trauma or dissection. Primary cervical vertebral aneurysms are even rarer and are not well described. The presentation and natural history are unknown and operative management can be difficult. Accessing aneurysms at the skull base can be difficult and, because the frail arteries are often afflicted with connective tissue abnormalities, direct repair can be particularly challenging. We describe the presentation and surgical management of patients with primary extracranial vertebral artery aneurysms.In this study we performed a retrospective, multi-institutional review of patients with primary aneurysms within the extracranial vertebral artery.Between January 2000 and January 2011, 7 patients, aged 12-56 years, were noted to have 9 primary extracranial vertebral artery aneurysms. All had underlying connective tissue or another hereditary disorder, including Ehler-Danlos syndrome (n=3), Marfan's disease (n=2), neurofibromatosis (n=1), and an unspecified connective tissue abnormality (n=1). Eight of 9 aneurysms were managed operatively, including an attempted bypass that ultimately required vertebral ligation; the contralateral aneurysm on this patient has not been treated. Open interventions included vertebral bypass with vein, external carotid autograft, and vertebral transposition to the internal carotid artery. Special techniques were used for handling the anastomoses in patients with Ehler-Danlos syndrome. Although endovascular exclusion was not performed in isolation, 2 hybrid procedures were performed. There were no instances of perioperative stroke or death.Primary extracranial vertebral artery aneurysms are rare and occur in patients with hereditary disorders. Operative intervention is warranted in symptomatic patients. Exclusion and reconstruction may be performed with open and hybrid techniques with low morbidity and mortality.
View details for DOI 10.1016/j.avsg.2012.08.002
View details for Web of Science ID 000318464700004
View details for PubMedID 23540677
Endovascular Repair of Mycotic Aneurysm of the Descending Thoracic Aorta
ANNALS OF VASCULAR SURGERY
2013; 27 (1): 23-28
Mycotic thoracic aortic aneurysms (MTAAs) are a rare yet life-threatening disease. The current standard of care consists of surgical resection, in situ or extra-anatomic revascularization, and antibiotic therapy. Despite this treatment, mortality remains high (range, 5-40%). The endovascular repair of degenerative thoracic aortic aneurysms has been shown to be safe and effective, but its use in the treatment of MTAAs is still controversial. The purpose of this study is to review the use of endovascular repair for MTAAs.A 10-year retrospective chart review was conducted of patients who underwent endovascular repair of MTAAs between March 2001 and March 2011. The surgical results of this single-institution review are reported.Seven patients underwent endovascular repair of MTAAs. One patient died 2 days postoperatively, which gave an in-hospital survival rate of 85.7%. The 1-year survival rate was 71.4%. The mean follow-up time was 25 months (range, 0-72 months), with a survival rate at that time of 57.1%. All patients were free of infection during their follow-up period.In this single-center case series, endovascular repair of MTAAs was associated with favorable perioperative and short-term mortality and morbidity.
View details for DOI 10.1016/j.avsg.2012.06.004
View details for Web of Science ID 000312530800004
View details for PubMedID 23084733
Escherichia coli primary aortitis presenting as sequelae of incompletely treated urinary tract infection
JOURNAL OF VASCULAR SURGERY
2012; 55 (6): 1779-1781
We report a rare case of nonaneurysmal infectious aortitis (IA) with the causative microorganism being Escherichia coli. The patient was a 78-year-old man who presented with a 3-week history of abdominal pain, fevers, and anorexia after treatment for a urinary tract infection. The patient had positive blood cultures and a computed tomography scan that had signs of IA. He was treated with intravenous antibiotics and extra-anatomic revascularization with excision and debridement of the infected aortic segment with a good outcome. IA is an uncommon condition with a high mortality rate; however, if diagnosed early, it can be successfully treated.
View details for DOI 10.1016/j.jvs.2011.12.074
View details for Web of Science ID 000304206000036
View details for PubMedID 22386143
Are Carotid Stent Fractures Clinically Significant?
CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY
2012; 35 (2): 263-267
Late stent fatigue is a known complication after carotid artery stenting (CAS) for cervical carotid occlusive disease. The purpose of this study was to determine the prevalence and clinical significance of carotid stent fractures.A single-center retrospective review of 253 carotid bifurcation lesions treated with CAS and mechanical embolic protection from April 2001 to December 2009 was performed. Stent integrity was analyzed by two independent observers using multiplanar cervical plain radiographs with fractures classified into the following types: type I = single strut fracture; type II = multiple strut fractures; type III = transverse fracture; and type IV = transverse fracture with dislocation. Mean follow-up was 32 months.Follow-up imaging was completed on 106 self-expanding nitinol stents (26 closed-cell and 80 open-cell stents). Eight fractures (7.5%) were detected (type I n = 1, type II n = 6, and type III n = 1). Seven fractures were found in open-cell stents (Precise n = 3, ViVEXX n = 2, and Acculink n = 2), and 1 fracture was found in a closed-cell stent (Xact n = 1) (p = 0.67). Only a previous history of external beam neck irradiation was associated with fractures (p = 0.048). No associated clinical sequelae were observed among the patients with fractures, and only 1 patient had an associated significant restenosis (≥ 80%) requiring reintervention.Late stent fatigue after CAS is an uncommon event and rarely clinically relevant. Although cell design does not appear to influence the occurrence of fractures, lesion characteristics may be associated risk factors.
View details for DOI 10.1007/s00270-011-0149-3
View details for Web of Science ID 000304162400007
View details for PubMedID 21431966
Emergent Repair of Acute Thoracic Aortic Catastrophes A Comparative Analysis
ARCHIVES OF SURGERY
2012; 147 (3): 243-249
To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR).Single-center retrospective review (April 2001-January 2010).Academic medical center.One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2).Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months.Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001).Patients presenting with ACDTA are best treated with TEVAR whenever feasible.
View details for Web of Science ID 000301637200009
View details for PubMedID 22430904
View details for PubMedCentralID PMC3978207
Does a Contralateral Carotid Occlusion Adversely Impact Carotid Artery Stenting Outcomes?
ANNALS OF VASCULAR SURGERY
2012; 26 (1): 40-45
Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood.A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years).Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant).A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.
View details for DOI 10.1016/j.avsg.2011.07.005
View details for Web of Science ID 000298325900006
View details for PubMedID 21963325
View details for PubMedCentralID PMC3242852
Endovascular Treatment of Delayed Type 1 and 3 Endoleaks
CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY
2011; 34 (4): 751-757
Endovascular aortic aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. Type I and III endoleaks require prompt, definitive repair or explantation. We review a single center experience of endovascular treatment of type I and III endoleaks.Retrospective review of 22 patients who underwent endovascular intervention for remediation of proximal or distal seal zone endoleaks.Median age was 77 years. Median time interval from EVAR to reintervention was 4 years (range, 1 month-11 years). Sixteen patients (73%) had radiological evidence of endoleak and/or expanding sac size and 6 (27%) had contained rupture. Nine patients underwent a total of 12 endovascular reinterventions before this salvage procedure. Stent grafts used at the original procedure were: AneuRx (n = 10), Excluder (n = 7), Ancure (n = 3), Zenith (n = 1), and custom made (n = 1). Endoleaks treated were type Ia (n = 11), Ib (n = 12), and type III (n = 3). Interventions included: proximal cuff insertion with or without Palmaz stent insertion (n = 8), distal limb extension (n = 2), stent graft relining (n = 6), embolization of hypogastric artery and iliac limb extension (ILE) (n = 5), and aorto-uni-iliac stent graft (AUI) with femoral-femoral crossover (n = 1). One patient who had a rupture died of multiorgan failure. Two patients needed additional reinterventions for endoleaks. Median length of hospital stay was 1 day.Lifelong surveillance after EVAR is advocated because of the potential of delayed type I or III endoleaks, which mandate definitive treatment. Fortunately, most delayed type I and III endoleaks can be successfully corrected with endoluminal interventions rather than resorting to explantation of the endograft.
View details for DOI 10.1007/s00270-010-0020-y
View details for Web of Science ID 000294815400009
View details for PubMedID 21107984
Complicated Acute Type B Thoracic Aortic Dissections: Endovascular Treatment For Visceral Malperfusion And Pseudoaneurysms
VASCULAR AND ENDOVASCULAR SURGERY
2011; 45 (3): 219-226
Morbidity and mortality of acute type B thoracic aortic dissections remain alarmingly high. Endoluminal options are promising.A single-center 5-year review of 17 acute type B aortic dissections complicated by visceral malperfusion (11) or pseudoaneurysm formation (6) treated with endovascular intervention. Interventional techniques included endografting (15) and/or percutaneous fenestration (4). Median follow-up is 28 months (range 0-76 months).Median age was 55 years; 30-day death, stroke, and paraplegia rates were 0%, 17.6%, and 5.9%. Success reversing visceral ischemia or sealing a pseudoaneurysm was 100%. Cross-sectional imaging demonstrated that the false lumen was thrombosed in 9 patients, partially thrombosed in 6 patients. Late events include 1 delayed proximal type I endoleak, 1 delayed rupture of the thoracic aorta requiring successful emergent open surgical repair, and 2 unrelated late deaths.Endovascular approaches to type B dissections presenting with visceral malperfusion and/or pseudoaneurysm can achieve acceptable early results.
View details for DOI 10.1177/1538574410395039
View details for Web of Science ID 000288827400001
View details for PubMedID 21478244
Intimal angiosarcoma causing abdominal aortic rupture
JOURNAL OF VASCULAR SURGERY
2011; 53 (3): 818-821
Intimal angiosarcomas are rare and difficult to diagnose preoperatively. Complete surgical resection is essential, but long-term survival is unlikely. We report a patient who presented with a contained ruptured infrarenal aorta with clinical and radiologic findings suggestive of infectious aortitis. Surgical resection, regional debridement, and reconstruction were completed using a cadaveric arterial homograft. However, pathologic evaluation revealed a high-grade intimal sarcoma.
View details for DOI 10.1016/j.jvs.2010.10.090
View details for Web of Science ID 000287788200046
View details for PubMedID 21215575
Techniques in endovascular aneurysm repair.
International journal of vascular medicine
2011; 2011: 964250-?
Endovascular repair of infrarenal abdominal aortic aneurysms (EVARs) has revolutionized the treatment of aortic aneurysms, with over half of elective abdominal aortic aneurysm repairs performed endoluminally each year. Since the first endografts were placed two decades ago, many changes have been made in graft design, operative technique, and management of complications. This paper summarizes modern endovascular grafts, considerations in preoperative planning, and EVAR techniques. Specific areas that are addressed include endograft selection, arterial access, sheath delivery, aortic branch management, graft deployment, intravascular ultrasonography, pressure sensors, management of endoleaks and compressed limbs, and exit strategies.
View details for DOI 10.1155/2011/964250
View details for PubMedID 22121487
View details for PubMedCentralID PMC3202090
- Regulatory TEVAR clinical trials JOURNAL OF VASCULAR SURGERY 2010; 52: 22S-25S
Carotid Artery Reconstruction for Infected Carotid Patches
EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
2010; 40 (4): 492-498
Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP.Single-center retrospective study.10-year review of the surgical treatment of ICPP.Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery (n = 6), cadaveric homograft (n = 3), long saphenous vein (n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus (n = 3), Corynebacterium propionibacterium (n = 1) and Streptococcus anginous (n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3-108 months).Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.
View details for DOI 10.1016/j.ejvs.2010.07.005
View details for Web of Science ID 000284683600016
View details for PubMedID 20705492
Zone I Gunshot Neck Injury Treated with Common Carotid and Esophageal Stent Grafts
JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY
2010; 21 (9): 1448-1451
Management of zone I gunshot injuries to the neck is controversial. Endovascular and endoscopic therapies are appealing minimally invasive alternatives, but they are still evolving. This case report demonstrates effective stent grafting of an arterial and an esophageal zone I neck injury after a civilian gunshot.
View details for DOI 10.1016/j.jvir.2010.05.014
View details for Web of Science ID 000281620600021
View details for PubMedID 20691609
Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries Seven-Year Single-Center Experience
ARCHIVES OF SURGERY
2010; 145 (7): 679-683
Thoracic endovascular aortic repair (TEVAR) for acute blunt thoracic aortic injury has good early and mid-term results.Single-center retrospective 7-year review from January 2001 to December 2008.Urban tertiary care hospital.Twenty-four consecutive patients with acute blunt thoracic aortic injury treated with TEVAR.Procedure-related mortality, stroke, or paraplegia; injury severity score; and complications.Among the 24 treated patients (mean age, 41 years; range, 20-71 years), the mean injury severity score was 43 (range, 25-66). Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedure-related death, stroke, or paraplegia. Access to the aorta was obtained through an open femoral/iliac approach (n = 7) or an entirely percutaneous groin approach (n = 17). Systemic heparin was not used in 84% of cases. Two access complications (8%) occurred, requiring an iliofemoral bypass in one patient and a thrombectomy in another. One patient required secondary intervention for device collapse, which was treated successfully with repeat endografting. There have been no delayed device failures or complications among the entire cohort at mid-term follow-up.Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity.
View details for Web of Science ID 000279994200010
View details for PubMedID 20644131
Eight-year institutional review of carotid artery stenting
JOURNAL OF VASCULAR SURGERY
2010; 51 (5): 1145-1151
Vascular surgeons have increasingly become proficient in carotid artery stenting (CAS) as an alternative treatment modality for cervical carotid artery occlusive disease. We analyzed our early and late outcomes of CAS over the last 8 years.We report a single-center retrospective review of 388 carotid bifurcation lesions treated with CAS using cerebral embolic protection from May 2001 to July 2009. Data analysis includes demographics, procedural records, duplex exams, arteriograms, and two-view plain radiographs over a mean follow-up time of 23.0 months (interquartile range, 10.9-35.4).At the time of treatment, the mean age of the entire cohort (76% men and 24% women) is 71 years; 13% were >/=80 years of age, and 31% had a prior history of either carotid endarterectomy (CEA) and/or external beam neck irradiation (XRT). The mean carotid stenosis is 80%, and asymptomatic lesions represent 69% of the group. Overall 30-day rates of death, stroke, and myocardial infarction are 0.5%, 1.8%, and 0.8%, respectively. The combined death/stroke rate at 30 days is 2.3%. The 30-day major/minor stroke rates for analyzed subgroups are statistically significant only for XRT/recurrent stenosis vs de novo lesions, 0% and 2.6% (P = .03), but not for asymptomatic vs symptomatic patients, 1.9% and 1.7% (P = .91) and age <80 vs >/=80, 2.0% and 1.8% (P = .52), respectively. At long-term, the freedom from all strokes at 12, 24, 36, and 48 months was 99.2%, 97.6%, 96.7%, and 96.7%, respectively. At late follow-up, the restenosis rate is 3.5%. Restenosis rates for recurrent stenosis/XRT vs de novo lesions are 2.7% and 3.4% (P = .39). Among the restenotic lesions were two associated type III stent fractures in de novo lesions, both of which were closed-cell stents. An additional two other type I fractures have been identified, yielding a stent fracture rate of 5.5%. The late death rate for the entire group is 16.8%, with one stent-related death secondary to ipsilateral stroke at 20 months (0.3% death rate).Vascular surgeons performing CAS with embolic protection can achieve good early and late outcomes that are comparable to CEA benchmarks. Late stent failures (stroke, restenosis, and/or stent fatigue), while uncommon, are a recognized delayed problem.
View details for DOI 10.1016/j.jvs.2009.12.025
View details for Web of Science ID 000277216000011
View details for PubMedID 20304594
- Endovascular Repair of Complicated Type B Aortic Dissection Following Coronary Artery Bypass Grafting JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY 2010; 21 (3): 403-405
Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring
JOURNAL OF VASCULAR SURGERY
2009; 49 (6): 1374-1378
The routine use of intraoperative electroencephalography (EEG) monitoring with selective shunt placement during carotid endarterectomy (CEA) has been shown to be safe and effective. We attempt to identify the anatomic and clinical factors associated with significant EEG changes requiring shunt placement during CEA.Between January 2005 and June 2007, 242 CEAs were performed with selective shunt placement for significant EEG changes. Risk factors assessed include severity of both ipsilateral and contralateral disease, presence of ipsilateral preoperative symptoms, hypertension, coronary artery disease, diabetes, age, gender, and preemptive intraoperative blood pressure manipulation to >or=20% above baseline before cross-clamping. Data were analyzed with the chi(2) test (P < .05 was significant).CEA was performed for asymptomatic disease in 177 of 242 patients (73.1%). The perioperative stroke rate was 0.8% (2 of 242), and the overall morbidity rate was 4.5%. No patients died. Significant EEG changes requiring shunt occurred in 35 patients (14.46%). Factors associated with carotid shunt placement were moderate ipsilateral carotid artery stenosis (50% to 79%) compared with severe (>or=80%) disease (30.6% vs 11.7%, P = .003) and degree of contralateral carotid stenosis (0% to 49%, 10.8%; 50% to 79%, 10.9%; 80% to 99%, 23.2%; occlusion, 50%; P = .0003). Presence of symptoms, gender, age, hypertension, diabetes, or coronary artery disease, and preemptive intraoperative manipulation of blood pressure were not significant predictors of shunt placement.CEA performed with routine EEG monitoring and selective shunt placement is associated with a low risk of perioperative stroke. Identified predictors of significant EEG changes were anatomic factors including degree of contralateral carotid artery disease and moderate ipsilateral carotid artery stenosis (50% to 79%). Although contralateral carotid occlusion has been accepted as indication for shunt placement in the absence of cerebral monitoring, this study suggests that high-grade contralateral disease and moderate ipsilateral carotid stenosis are associated with cerebral ischemia resulting in EEG changes and should prompt consideration for nonselective shunting.
View details for DOI 10.1016/j.jvs.2009.02.206
View details for Web of Science ID 000266681000002
View details for PubMedID 19497494
- Relative adrenal insufficiency in the adult burn intensive care unit: A report of four cases BURNS 2008; 34 (3): 421-424