Bio


Dr. Chandra is a board certified vascular surgeon who specializes in cutting edge approaches to aortic aneurysmal disease, peripheral vascular disease and limb salvage.

Clinical Focus


  • Vascular Surgery
  • Aortic Aneurysm
  • Peripheral Arterial Disease
  • Fenestrated and branched repair of the aorta
  • Limb Salvage
  • Critical Limb Ischemia
  • Advanced endovascular surgery techniques
  • Thoracic Aortic Aneurysms
  • Carotid Artery Diseases
  • Women's Health
  • Peripheral Vascular Diseases
  • Amputation prevention
  • Aortic Diseases
  • Intermittent Claudication
  • Diabetic Foot Ulcers
  • Mesenteric Vascular Occlusion
  • Iliac Aneurysm
  • Aneurysm
  • Aortic Dissection
  • Dissecting Aneurysm
  • Peripheral Arterial Aneurysm and Dissection
  • Popliteal aneurysm
  • Suprarenal Aneurysm
  • Ruptured Aneurysm
  • Peripheral ARterial Embolism and Thrombosis

Academic Appointments


Administrative Appointments


  • Program Director, Stanford Vascular Surgery Residency and Fellowship (2020 - Present)
  • Associate Program Director, Stanford Vascular Surgery Fellowship (2014 - 2020)
  • Medical Student Clerkship Director, Stanford Vascular Surgery (2013 - Present)
  • Stanford South Asian Translational Heart Institute (SSATHI) Member, Stanford University (2013 - Present)
  • Clinical Competency Committee, Stanford Vascular Surgery (2013 - Present)
  • Program Evaluation Committee, Stanford Vascular Surgery (2014 - Present)

Honors & Awards


  • Excellence in Teaching Award, Stanford School of Medicine (2010)
  • Glasgow-Rubin Achievement Award, AMWA (2004)
  • Inductee, Alpha Omega Alpha (2004)

Boards, Advisory Committees, Professional Organizations


  • Member, Society for Vascular Surgery (2015 - Present)
  • Member, Western Vascular Surgery Society (2015 - Present)
  • Member, San Francisco Surgical Society (2014 - Present)
  • Member, Northern California Vascular Surgery Society (2015 - Present)

Professional Education


  • Board Certification: American Board of Surgery, Vascular Surgery (2014)
  • Fellowship: Stanford University (2013) CA
  • Board Certification: American Board of Surgery, General Surgery (2012)
  • Residency: Stanford University (2011) CA
  • Residency: Stanford University (2006) CA
  • Internship: Stanford University (2005) CA
  • Medical Education: University of Chicago Pritzker (2004) IL

Patents


  • Venita Chandra, Richard Vecchiotti, Ross Venook, Tatun Tarin, Joel Goldsmith. "United States Patent US8986188 B2 Dynamic and Adjustable Support Devices", The Board of Trustees of the Leland Stanford Junior University, Mar 24, 2015

Clinical Trials


  • Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia Recruiting

    This study will compare the effectiveness of best available surgical treatment with best available endovascular treatment in adults with critical limb ischemia (CLI) who are eligible for both treatment options.

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  • Global Registry for Endovascular Aortic Treatment (GREAT) Recruiting

    Prospective, observational Registry to obtain data on device performance and clinical outcomes.

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  • PRESERVE-Zenith® Iliac Branch System Clinical Study Recruiting

    The PRESERVE-Zenith® Iliac Branch System Clinical Study is a clinical trial to study the safety and effectiveness of the Zenith® Branch Endovascular Graft-Iliac Bifurcation in combination with the Zenith® Connection Endovascular Stent/ConnectSX™ covered stent in the treatment of aorto-iliac and iliac aneurysms.

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  • Study to Evaluate the Safety and Efficacy of CHAM* for the Treatment of Diabetic Foot Ulcers Recruiting

    A Multicenter, Randomized, Single-Blind Study with an Open-Label Extension Option to Further Evaluate the Safety and Efficacy of Cryopreserved Human Amniotic Membrane for the Treatment of Chronic Diabetic Foot Ulcers

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  • Zenith® p-Branch® Endovascular Graft Pivotal Study Recruiting

    The Zenith® p-Branch® Pivotal Study is a clinical trial approved by FDA to study the safety and effectiveness of the Zenith® p-Branch® endovascular graft in combination with the Atrium iCAST™ covered stents in the treatment of abdominal aortic aneurysms.

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  • Zenith(R) Low Profile AAA Endovascular Graft Clinical Study Not Recruiting

    The Zenith® Low Profile AAA Endovascular Graft Clinical Study is a clinical trial approved by US FDA to study the safety and effectiveness of the Zenith® Low Profile AAA Endovascular Graft to treat abdominal aortic, aorto-iliac, and iliac aneurysms.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jason Lee, (650) 725 - 5227.

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2020-21 Courses


Stanford Advisees


Graduate and Fellowship Programs


  • Vascular Surgery (Fellowship Program)

All Publications


  • Validity of the Global Vascular Guidelines in Predicting Outcomes Based on First-Time Revascularization Strategy. Annals of vascular surgery Lou, V., Dossabhoy, S. S., Tran, K., Yawary, F., Ross, E. G., Stern, J. R., Dalman, R. L., Chandra, V. 2023

    Abstract

    The Global Vascular Guidelines (GVG) recommend selecting an endovascular vs open-surgical approach to revascularization for chronic limb-threatening ischemia (CLTI), based on the Global Limb Anatomic Staging System (GLASS) and Wound, Ischemia, and Foot Infection (WIfI) classification systems. We assessed the utility of GVG-recommended strategies in predicting clinical outcomes.We conducted a single-center, retrospective review of first-time lower-extremity revascularizations within a comprehensive limb-preservation program from 2010-2018. Procedures were stratified by 1) treatment concordance with GVG-recommended strategy (concordant vs non-concordant groups), 2) GLASS stages I-III, and 3) endovascular vs open strategies. The primary outcome was 5-year freedom from major adverse limb events (FF-MALE), defined as freedom from reintervention or major amputation, and secondary outcomes included 5-year overall survival, freedom from major amputation, freedom from reintervention, and immediate technical failure during initial revascularization. Kaplan-Meier (KM) survival analysis and multivariate analysis with Cox proportional hazard models were performed on the primary and secondary outcomes, RESULTS: Of 281 first-time revascularizations for CLTI, 251 (89.3%) were endovascular and 186 (66.2%) were in the concordant group, with a mean clinical follow-up of 3.02±2.40 years. Within the concordant group alone, 167 (89.8%) of revascularizations were endovascular. The concordant group had a higher rate of chronic kidney disease (60.8% vs 45.3%, P=.02), WIfI foot infection grade (0.81±1.1 vs 0.56±0.80, P=.03), and WIfI stage (3.1±0.79 vs 2.8±1.2, P<.01) compared to the non-concordant group. After both KM and multivariate analyses, there were no significant differences in 5-year FF-MALE or overall survival between concordant and non-concordant groups. There was higher freedom from major amputation in the non-concordant group on KM analysis (83.9% vs 74.2%, P=.025), though this difference was non-significant on multivariate analysis (HR 0.49, 95% CI 0.21-1.15, P=.10). The open group had lower MALE compared to the endovascular group (HR 0.39, 95% CI 0.17-0.91, P=.029) attributed to a lower reintervention rate in the open group (HR 0.31, 95% CI 0.11-0.87, P=.026). GLASS stage was not associated with significant differences in outcomes, but the severity of GLASS stage was associated with immediate technical failure (2.1% in stage 1, 6.4% in stage 2, and 11.7% in stage 3, P=.01).In this study, CLTI treatment outcomes did not differ significantly based on whether treatment was received in concordance with GVG-recommended strategy. There was no difference in overall survival between the endovascular and open groups, though there was a higher reintervention rate in the endovascular group. The GVG guidelines are an important resource to help guide the management of CLTI patients. However, in this study, both concordance with GVG guidelines and GLASS staging were found to be indeterminate in differentiating outcomes between complex CLTI patients treated primarily with an endovascular-first approach. The revascularization approach for a CLTI patient is a nuanced decision that must take into account patient anatomy and clinical status, as well as physician skill and experience and institutional resources.

    View details for DOI 10.1016/j.avsg.2023.02.001

    View details for PubMedID 36828135

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2023.01.198

    View details for PubMedID 36758909

  • Multidisciplinary extremity preservation program improves quality of life for patients with advanced limb threat. Annals of vascular surgery Fereydooni, A., Yawary, F., Sen, S., Chou, L., Murphy, M., Dalman, R. L., Stern, J. R., Chandra, V. 2022

    Abstract

    The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution.Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions.From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P<0.044) and emotional role limitation (OR:8.1; P=0.042), while patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P<0.049). Conversely, patients with a smoking history had less improvement in energy level (OR:0.4; P=0.044) and patients with dialysis-dependence had less improvement in social function (OR:0.2; P=0.034).Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Further study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.

    View details for DOI 10.1016/j.avsg.2022.05.047

    View details for PubMedID 35803456

  • Filamentous bacteriophage delays healing of Pseudomonas-infected wounds. Cell reports. Medicine Bach, M. S., de Vries, C. R., Khosravi, A., Sweere, J. M., Popescu, M. C., Chen, Q., Demirdjian, S., Hargil, A., Van Belleghem, J. D., Kaber, G., Hajfathalian, M., Burgener, E. B., Liu, D., Tran, Q., Dharmaraj, T., Birukova, M., Sunkari, V., Balaji, S., Ghosh, N., Mathew-Steiner, S. S., El Masry, M. S., Keswani, S. G., Banaei, N., Nedelec, L., Sen, C. K., Chandra, V., Secor, P. R., Suh, G. A., Bollyky, P. L. 2022; 3 (6): 100656

    Abstract

    Chronic wounds infected by Pseudomonas aeruginosa (Pa) are characterized by disease progression and increased mortality. We reveal Pf, a bacteriophage produced by Pa that delays healing of chronically infected wounds in human subjects and animal models of disease. Interestingly, impairment of wound closure by Pf is independent of its effects on Pa pathogenesis. Rather, Pf impedes keratinocyte migration, which is essential for wound healing, through direct inhibition of CXCL1 signaling. In support of these findings, a prospective cohort study of 36 human patients with chronic Pa wound infections reveals that wounds infected with Pf-positive strains of Pa are more likely to progress in size compared with wounds infected with Pf-negative strains. Together, these data implicate Pf phage in the delayed wound healing associated with Pa infection through direct manipulation of mammalian cells. These findings suggest Pf may have potential as a biomarker and therapeutic target in chronic wounds.

    View details for DOI 10.1016/j.xcrm.2022.100656

    View details for PubMedID 35732145

  • Utilization of lateral anterior lumbar interbody fusion for revision of failed prior TLIF: illustrative case. Journal of neurosurgery. Case lessons Haider, G., Wagner, K. E., Chandra, V., Cheng, I., Stienen, M. N., Veeravagu, A. 2022; 3 (23): CASE2296

    Abstract

    BACKGROUND: The use of the lateral decubitus approach for L5-S1 anterior lumbar interbody fusion (LALIF) is a recent advancement capable of facilitating single-position surgery, revision operations, and anterior column reconstruction. To the authors' knowledge, this is the first description of the use of LALIF at L5-S1 for failed prior transforaminal lumbar interbody fusion (TLIF) and anterior column reconstruction. Using an illustrative case, the authors discuss their experience using LALIF at L5-S1 for the revision of pseudoarthrosis and TLIF failure.OBSERVATIONS: The patient had prior attempted L2 to S1 fusion with TLIF but suffered from hardware failure and pseudoarthrosis at the L5-S1 level. LALIF was used to facilitate same-position revision at L5-S1 in addition to further anterior column revision and reconstruction by lateral lumbar interbody fusion at the L1-2 level. Robotic posterior T10-S2 fusion was then added to provide stability to the construct and address the patient's scoliotic deformity. No complications were noted, and the patient was followed until 1 year after the operation with a favorable clinical and radiological result.LESSONS: Revision of a prior failed L5-S1 TLIF with an LALIF approach has technical challenges but may be advantageous for single position anterior column reconstruction under certain conditions.

    View details for DOI 10.3171/CASE2296

    View details for PubMedID 35733821

  • Remote Access to Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents Ho, V., Sgroi, M., Chandra, V., Asch, S., Chen, J. H., Lee, J. T. MOSBY-ELSEVIER. 2022: E135
  • How to build a limb salvage program. Seminars in vascular surgery Martinez-Singh, K., Chandra, V. 2022; 35 (2): 228-233

    Abstract

    Patients with chronic limb-threatening ischemia (CLTI) are medically complex and continue to experience high rates of amputation, despite improved diagnosis and treatment. Limb salvage programs and multidisciplinary teams provide comprehensive patient care and have been associated with reduced amputation rates. Recent societal guidelines suggest the adoption of limb salvage programs to improve care of patients with CLTI. In this article, we describe the critical components of a limb salvage program and outline the following steps to aid in their construction: community and institution assessment, formation of a multidisciplinary team, provision of patient care, and monitoring outcomes and processes refinement.

    View details for DOI 10.1053/j.semvascsurg.2022.04.011

    View details for PubMedID 35672113

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2022.03.887

    View details for PubMedID 35598821

  • Embolic protection devices are not associated with improved outcomes of atherectomy for lower extremity revascularization. Annals of vascular surgery Fereydooni, A., Bai, H., Baril, D., Chandra, V., Ochoa Chaar, C. I. 2022

    Abstract

    OBJECTIVE: Atherectomy is associated with a risk of distal embolization, but the role of embolic protection devices (EPD) during atherectomy is not well-defined. This study examines the utilization and impact of EPD on the outcomes of atherectomy during peripheral vascular interventions (PVI).METHODS: The annual trend in utilization of EPD during atherectomy in the Vascular Quality Initiative PVI files (2010-2018) was derived. Patients with concomitant open surgery, acute limb ischemia, emergent-status, concomitant thrombolysis, missing indication, missing EPD use, missing long-term follow up data were excluded. The characteristics of patients undergoing atherectomy with and without EPD were compared. Propensity matching based on age, gender, race, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), end-stage renal disease (ESRD), prior PVI, indication, urgent-status, TransAtlantic interSociety Consensus (TASC) classification and anatomical location of lesion was performed. The perioperative and 1-year outcomes of the matched groups were compared.RESULTS: EPD was used in 23.3% of atherectomy procedures (N=5,013 / 21,500). The utilization of EPD with atherectomy increased from 8.8% to 22.7% (P=0.003) during the study period. Patients undergoing atherectomy without EPD were more likely to have ESRD (7.8% vs 5.2%; P<0.001), tissue loss (31% vs 23.1; P<0.001), tibial intervention (39.6% vs 23.3%; P<0.001), higher number of arteries treated (1.78 ±0.92 vs 1.68±0.93; P=0.001), and longer length of lesion (21.15±21.14 vs 19±20.27cm; P=0.004). Conversely, patients undergoing atherectomy with EPD were more likely to be white (81.1% vs 74%; P<0.001), have a history of smoking (80.6% vs 74.5%; P<0.001), COPD (24.8% vs 21.6%; P<0.037), CAD (38.5% vs 33.2%; P=0.002), prior PCI (24.3% vs 19.9%, P=0.005), prior CABG (32.3% vs 24.9%; P<0.001), prior PVI (49.2% vs 45.1%; P=0.023). After propensity matching, there were 1,007 patients in each group with no significant difference in baseline characteristics. There was no significant difference in short-term outcomes including rate of distal embolization, technical success, dissection, perforation, discharge to home, and 30-day mortality. The use of EPD was, however, associated with longer fluoroscopy time. At 1-year, there was also no difference in primary patency, ipsilateral minor or major amputation, ABI improvement, reintervention or mortality rate between patients who underwent atherectomy with and without EPD.CONCLUSION: EPD has been increasingly utilized in conjunction with atherectomy especially in patients with claudication and femoropopliteal disease. However, the use of EPD during atherectomy does not seem to impact the outcomes. Further research is needed to justify the additional cost and fluoroscopy time associated with the use of EPD during atherectomy.

    View details for DOI 10.1016/j.avsg.2022.04.045

    View details for PubMedID 35589031

  • Society for Vascular Surgery best practice recommendations for use of social media. Journal of vascular surgery Gifford, E. D., Mouawad, N. J., Bowser, K. E., Bush, R. L., Chandra, V., Coleman, D., Genovese, E., Han, D. K., Humphries, M. D., Mills, J. L., Mitchell, E. L., Moreira, C. C., Nkansah, R., Siracuse, J. J., Stern, J. R., Suh, D., West-Livingston, L. 2021

    Abstract

    The use of social media (SoMe) in medicine has demonstrated the ability to advance networking among clinicians and other healthcare staff, disseminate research, increase access to up-to-date information, and inform and engage medical trainees and the public at-large. With increasing SoMe use by vascular surgeons and other vascular specialists, it is important to uphold core tenets of our commitment to our patients by protecting their privacy, encouraging appropriate consent and use of any patient-related imagery, and disclosing relevant conflicts of interest. Additionally, we recognize the potential for negative interactions online regarding differing opinions on optimal treatment options for patients. The Society for Vascular Surgery (SVS) is committed to supporting appropriate and effective use of SoMe content that is honest, well-informed, and accurate. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members to help guide novice as well as veteran SoMe users on best practices for advancing medical knowledge-sharing in an online environment. These recommendations are presented here with the goal of elevating patient privacy and physician transparency, while also offering support and resources for infrequent SoMe users to increase their engagement with each other in new, virtual formats.

    View details for DOI 10.1016/j.jvs.2021.08.073

    View details for PubMedID 34673169

  • A gender-based analysis of predictors and sequelae of burnout among practicing American vascular surgeons. Journal of vascular surgery Drudi, L. M., Mitchell, E. L., Chandra, V., Coleman, D. M., Hallbeck, M. S., Mannoia, K., Money, S. R., Brown, K. R. 2021

    Abstract

    Surgeons report higher burnout and suicidal ideation (SI) rates than the general population. This study sought to identify the prevalence and gender-specific risk factors for burnout and SI among men and women vascular surgeons to guide future interventions.In 2018, active Society for Vascular Surgery members were surveyed confidentially using the Maslach Burnout Index embedded in a questionnaire that captured demographic and practice-related characteristics. Results were stratified by gender. Univariate and multivariate logistic regression models were developed to identify predictors for the end points of burnout and SI.Overall survey response rate was 34.3% (N = 878) of practicing vascular surgeons. A higher percentage of women responded (19%) than compose membership in the Society for Vascular Surgery (13.7%). Women respondents were significantly younger, with fewer years in practice, and were less likely to be in private practice than the men who responded. Women were also less likely to be married/partnered, or to have children. The prevalence of burnout was similar for women and men (42.3% and 40.9%; P = nonsignificant); however, the prevalence of SI was significantly higher in women (12.9% vs 6.6%; P < .007). Whereas there was no difference in mean hours worked or call taken, women were more likely to have had a recent conflict between work and home responsibilities and to have resolved this conflict in favor of work. Although men and women had the same incidence of reported recent medical errors, women were less likely to self-report a recent malpractice suit or to think that a fair resolution was reached. There was no gender difference in reported work-related pain. Multivariable analysis revealed that not enough family time and work-related pain were predictors for burnout in both men and women. Additional factors were associated with burnout in men, such as malpractice and electronic medical record dissatisfaction. Multivariable analysis revealed that work-related pain was an independent predictor for SI for the entire cohort.The prevalence of burnout among vascular surgeons is high. Women vascular surgeons have double the rates of SI compared with male vascular surgeons. Taken together, this study demonstrated that many of the same factors are associated with burnout in women and men, which include not enough family time, conflict between work and personal life, and work-related pain. Additional factors in men included conflict between work and family, work-related pain, and electronic medical record dissatisfaction.

    View details for DOI 10.1016/j.jvs.2021.09.035

    View details for PubMedID 34634416

  • Open Abdominal Aortic Surgery in the Endovascular Era-Will we have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E418
  • Validity of the Global Vascular Guidelines in Predicting Outcomes in a Comprehensive Wound Care Program Lou, V., Tran, K., Dossabhoy, S. S., Yawary, F., Ross, E. G., Stern, J. R., Lee, J. T., Harris, E., Dalman, R. L., Chandra, V. MOSBY-ELSEVIER. 2021: E405-E406
  • Open Abdominal Aortic Surgery in the Endovascular Era - Will We Have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V. T., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E259-E260
  • Temporal Changes in Women Representation With in the Vascular Surgery Workforce Cui, C. L., Khan, M. A., Marmor, R. A., Chandra, V., Shortell, C. K., Malas, M. B. MOSBY-ELSEVIER. 2021: E282-E283
  • The State of Vascular Surgery Virtual Away Rotations in the Time of a Pandemic Brahmandam, A., Chandra, V., Humphries, M. D., Coleman, D. M., Wooster, M. D., Sheahan, M. G., Ottinger, M. E., Cardella, J. A. MOSBY-ELSEVIER. 2021: E157
  • Popliteal Scoring Assessment for Vascular Extremity Injuries in Trauma Score Fulfills the Need for a New Reporting Standard in Lower Extremity Vascular Trauma O'Banion, L., Yoon, W., Politano, A., Brooke, B. S., Fox, C. J., Kiang, S. C., Chandra, V., Zhou, W., Bowens, N., Woo, K., Vartanian, S. M., Magee, G. A. MOSBY-ELSEVIER. 2021: E197
  • Embolic Protection Devices Are Not Associated With Improved Outcomes of Atherectomy for Lower Extremity Revascularization Fereydooni, A., Bai, H., Baril, D., Chandra, V., Chaar, C. MOSBY-ELSEVIER. 2021: E38-E39
  • Validity of the Global Vascular Guidelines in Predicting Outcomes in a Comprehensive Wound Care Program Lou, V., Tran, K., Dossabhoy, S. S., Yawary, F., Ross, E. G., Stern, J. R., Lee, J. T., Harris, E., Dalman, R. L., Chandra, V. MOSBY-ELSEVIER. 2021: E250-E251
  • Multidisciplinary Extremity Preservation Program Improves Quality of Life for Patients With Advanced Limb Threat Fereydooni, A., Yawary, F., Sen, S., Chou, L., Dalman, R. L., Murphy, M., Stern, J. R., Chandra, V. MOSBY-ELSEVIER. 2021: E41-E43
  • Contemporary Outcomes of Traumatic Popliteal Artery Injury Repair from the POPSAVEIT Study. Journal of vascular surgery O'Banion, L. A., Dirks, R., Saldana-Ruiz, N., Farooqui, E., Yoon, W. J., Pozolo, C., Fox, C. J., Crally, A., Siada, S., Nehler, M. R., Brooke, B. S., Beckstrom, J. L., Kiang, S., Boggs, H. K., Chandra, V., Ho, V. T., Zhou, W., Lee, A., Bowens, N., Cho, Y., Woo, K., Ulloa, J., Magee, G. A. 2021

    Abstract

    OBJECTIVE: Traumatic popliteal artery injuries are associated with the highest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10-15%. The purpose of this study was to examine outcomes of patients undergoing operative repair for traumatic popliteal arterial injuries and identify factors independently associated with limb loss.METHODS: A multi-institutional retrospective review of all patients sustaining traumatic popliteal artery injuries from 2007-2018 was performed. All patients who had operative repair of popliteal arterial injuries were included in the analysis. Patients undergoing major lower extremity amputation (trans-tibial or trans-femoral) were compared to those with successful limb salvage at last follow-up. Significant predictors (p<0.05) for amputation on univariate analysis were included in a multivariable analysis.RESULTS: A total of 302 patients from 11 institutions were included in the analysis. Median age was 32 [IQR: 21-40] years and 79% were male. Median follow-up was 72 days [IQR: 20 - 366]. Overall major amputation rate was 13%. Primary repair was performed in 17% of patients, patch repair in 2%, and interposition/bypass in 81%. One patient underwent endovascular repair with stenting. Overall 1-year primary patency was 89%. Of patients that lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days post-op) of primary patency was 5 times more frequent in patients that went on to amputation. On multivariate regression, significant perioperative factors independently associated with major amputation included: initial POPSAVEIT score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, location of popliteal injury (P1, P2, P3), ISS, and tibial vs. popliteal distal bypass target were not independently associated with amputation.CONCLUSION: Traumatic popliteal artery injuries are associated with a significant rate of major amputation. Preoperative POPSAVEIT score remains independently associated with amputation after including perioperative factors. Lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. Postoperative antiplatelet therapy is inversely associated with amputation, perhaps indicating a protective effect.

    View details for DOI 10.1016/j.jvs.2021.04.064

    View details for PubMedID 34023429

  • Endotension; What Do We and Don't We Know about This Enigmatic Complication of EVAR. Journal of vascular surgery Parsa, P., Gupta, J. D., McNally, M., Chandra, V. 2021

    Abstract

    OBJECTIVE: As the endovascular treatment of aneurysm repair continues to surge, more and more patients are being identified with endoleaks. There are five types of endoleaks. Endotension, or type V endoleak, remains controversial due to its variable definition across studies and range of proposed treatments. What do we know and not know about this rare form of endoleak?DESIGN: A review article summarizing the literature in regard to diagnosis and treatment of this rare complication after endovascular aneurysm repair.CONCLUSION: The presence of an endoleak places patients at an increased risk for aneurysm sac enlargement and potential rupture. While additional research is essential and yet difficult to perform, we aim to provide a guide for management of this perplexing endoleak known as Endotension.

    View details for DOI 10.1016/j.jvs.2021.03.018

    View details for PubMedID 33813025

  • Interview Experience, Postinterview Communication, and Gender-Based Differences in the Integrated Vascular Surgery Residency Match Fereydooni, A., Ramirez, J. L., Morrow, K. L., Sorondo, S., Lee, J. T., Coleman, D. M., Chandra, V. MOSBY-ELSEVIER. 2021: E46
  • Popliteal Scoring Assessment for Vascular Extremity Injuries in Trauma (POPSAVEIT) Study. Journal of vascular surgery O'Banion, L. A., Dirks, R., Farooqui, E., Saldana-Ruiz, N., Yoon, W. J., Pozolo, C., Fox, C., Crally, A., Siada, S., Nehler, M. R., Brooke, B. S., Beckstrom, J. L., Kiang, S., Boggs, H. K., Chandra, V., Ho, V. T., Zhou, W., Lee, A., Bowens, N., Cho, Y., Woo, K., Ulloa, J., Magee, G. A. 2021

    Abstract

    OBJECTIVE: Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. There remains a need to evaluate predictors of amputation as previous scores were unable to be validated. This study aims to provide simplified scoring system that preoperatively risk stratifies patients with traumatic popliteal vascular injuries for amputation.METHODS: A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared to those with limb salvage at last follow-up. 80% were randomly assigned into a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (p<0.1) in univariate analysis were included in a multivariable analysis. Those with p<0.05 in the multivariable analysis were assigned points values based on relative value of their odds ratios. ROC curves were generated to determine low vs high risk scores. AUC of >0.65 was considered adequate for validation.RESULTS: 355 patients were included, with overall amputation rate of 16%. On multivariate regression, risk factors independently associated with amputation in the final model were: SBP <90 mm Hg (OR: 3.2, p = 0.027, 1 point), associated orthopedic injury (OR: 4.9, p = 0.014, 2 points), and lack of preoperative pedal Doppler signals (OR: 5.5, p = 0.002, 2 points, or 1 point for lack of palpable pedal pulses if Doppler signal data unavailable). A score of ≥3 was found to maximize sensitivity (85%) and specificity (49%) for high-risk of amputation. ROC curve for the validation group had an AUC of 0.750, meeting threshold for score validation.CONCLUSIONS: POPSAVEIT score provides a simple and practical means to effectively stratify patients preoperatively into low- and high-risk categories for major amputation.

    View details for DOI 10.1016/j.jvs.2021.02.015

    View details for PubMedID 33639233

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2021.05.060

    View details for PubMedID 34197947

  • Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force. Journal of vascular surgery Coleman, D. M., Money, S. R., Meltzer, A. J., Wohlauer, M., Drudi, L. M., Freischlag, J. A., Hallbeck, S., Halloran, B., Huber, T. S., Shanafelt, T., Sheahan, M. G. 2021; 73 (6): 1841-1850.e3

    Abstract

    Physician burnout has been linked to medical errors, decreased patient satisfaction, and decreased career longevity. In light of the increasing prevalence of cardiovascular disease, vascular surgeon burnout presents a legitimate public health concern owing to the impact on the adequacy of the vascular surgery workforce. The aims of this study were to define the prevalence of burnout among practicing vascular surgeons and identify factors that contribute to burnout to facilitate future Society for Vascular Surgery (SVS) initiatives to mitigate this crisis.In 2018, active SVS members were surveyed electronically and confidentially using the Maslach Burnout Inventory. The survey was tailored to explore specialty-specific issues, and to capture demographic and practice-related characteristics. Emotional exhaustion (EE) and depersonalization (DP) were analyzed as dimensions of burnout. Consistent with convention, surgeons with a high score on the DP and/or EE subscales of the Maslach Burnout Inventory were considered to have at least one manifestation of professional burnout. Risk factors associated with symptoms of burnout were identified using bivariate analyses (χ2, Kruskal-Wallis). Multivariate logistic regression models were developed to identify independent risk factors for burnout.Of 2905 active SVS members, 960 responded to the survey (34% participation rate). After excluding retired surgeons and incomplete submissions, responses from 872 practicing vascular surgeons were analyzed. The mean age was 49.7 ± 11.0 years; the majority of respondents (81%) were male. Primary practice settings were academic (40%), community practice (41%), veteran's hospital (3.3%), active military practice (1.5%), or other. Years in practice averaged 15.7 ± 11.7. Overall, 41% of respondents had at least one symptoms of burnout (ie, high EE and/or high DP), 37% endorsed symptoms of depression in the past month, and 8% indicated they had considered suicide in the last 12 months. In unadjusted analysis, factors significantly associated with burnout (P < .05) included clinical work hours, on-call frequency, electronic medical record and documentation requirements, work-home conflict, and work-related physical pain. On multivariate analysis, age, work-related physical pain and work-home conflict were independent predictors for burnout.Symptoms of burnout and depression are common among vascular surgeons. Advancing age, work-related physical pain, and work-home conflict are independent predictors for burnout among vascular surgeons. Efforts to promote vascular surgeon well-being must address specialty-specific challenges, including the high prevalence of work-home conflict and occupational factors that contribute to work-related pain.

    View details for DOI 10.1016/j.jvs.2020.10.065

    View details for PubMedID 33248123

  • Hyperbaric Oxygen Therapy in Management of Diabetic Foot Ulcers: Indocyanine Green Angiography May Be Used as a Biomarker to Analyze Perfusion and Predict Response to Treatment. Plastic and reconstructive surgery Hajhosseini, B. n., Chiou, G. J., Virk, S. S., Chandra, V. n., Moshrefi, S. n., Meyer, S. n., Kamperman, K. J., Gurtner, G. C. 2021; 147 (1): 209–14

    Abstract

    The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy.Therapeutic, IV.

    View details for DOI 10.1097/PRS.0000000000007482

    View details for PubMedID 33370067

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2021.05.014

    View details for PubMedID 34023431

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

    Abstract

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

    View details for DOI 10.1177/1708538120964371

    View details for PubMedID 33054678

  • Predictors and Sequelae of Burnout Among Practicing American Vascular Surgeons: A Gender-Based Analysis, on Behalf of the Society for Vascular Surgery Wellness Task Force Drudi, L. M., Mitchell, E. L., Chandra, V., Coleman, D., Hallbeck, M., Mannoia, K., Money, S., Brown, K. R. MOSBY-ELSEVIER. 2020: E70
  • We were winning JOURNAL OF VASCULAR SURGERY Chandra, V. 2020; 71 (2): 616
  • We were winning. Journal of vascular surgery Chandra, V. 2020; 71 (2): 616

    View details for DOI 10.1016/j.jvs.2019.05.033

    View details for PubMedID 32040431

  • LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology. Journal of vascular surgery Ash, J. n., Chandra, V. n., Rzucidlo, E. n., Vouyouka, A. n., Hunter, M. n. 2020

    Abstract

    Females remain underrepresented in studies of endovascular aneurysm repair (EVAR) owing to anatomic ineligibility for EVAR devices. The aim of the LUCY study is to explore the comparative safety and effectiveness of EVAR using a low-profile stent graft (Ovation; Endologix, Inc, Irvine, Calif) in females as well as males.The LUCY registry was a prospective, nonrandomized, multicenter study where patient enrollment was stratified by sex in a two-to-one ratio (male-to-female). Main outcomes were procedural data, 30-day major adverse events, device-related adverse events confirmed with contrast-enhanced computed tomography scans, secondary interventions, and hospital readmissions. Adverse events were adjudicated by a clinical events committee. Patients were followed at their 1-month and 1-year follow-up visits.A total of 225 patients (76 females, 149 males) were enrolled at 39 U.S. centers. No statistically significant sex differences were observed in demographics or medical history. Females presented with smaller access vessels (6.2 vs 7.7 mm; P < .001), statistically smaller neck diameter (22 mm vs 23 mm; P = .001), similar neck angulation (11% vs 9% angulation >45°; P = .81), and smaller maximum abdominal aortic aneurysm (AAA) diameter (50 mm vs 53 mm; P = .01), however, these factors do not seem to be clinically significant. Technical success was 99%, and the median hospital stay was 1 day. The incidence of MAE through 30 days was 1.3% in females and 2.0% in males. There were no differences between sexes observed among the 30-day perioperative outcomes. The 30-day secondary intervention rate was 0.4%. The all-cause readmission rate through 30 days was 5.3% in females and 6.7% in males. There were no reports of limb occlusion or deaths within the first 30 days. At 1 year, there were no deaths in the female arm but nine deaths (6.0%) were observed in males, two of which were AAA related (1.3%). Through 1 year, there were eight type IA endoleaks (one female, seven males; P = .27) and three cases with limb occlusion (one female, two males). There were no reports of migration, AAA rupture, or surgical conversion through the end of follow-up.Despite more complex aortic morphology in females than males, EVAR with a low-profile stent graft was associated with comparable procedural and perioperative outcomes through 1 year between the sexes.

    View details for DOI 10.1016/j.jvs.2019.10.080

    View details for PubMedID 31918999

  • Ultrasound guided liposuction for superficialization of difficult to access arteriovenous fistulas. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Nguyen, A. n., Patel, A. A., Chandra, V. n., Nazerali, R. S. 2020

    View details for DOI 10.1016/j.bjps.2020.08.035

    View details for PubMedID 32863131

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

    Abstract

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

    View details for DOI 10.1016/j.jvsv.2020.08.006

    View details for PubMedID 32795618

  • Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage. Journal of vascular surgery Ho, V. T., Gologorsky, R., Chandra, V., Prent, A., Lee, J., Dua, A. 2019

    Abstract

    OBJECTIVE: Deep venous arterialization (DVA) is a technique aimed at providing an option for chronic limb-threatening ischemia patients with no options except amputation. In patients with no outflow distal targets permitting bypass, DVA involves creating a connection between a proximal arterial inflow and a distal venous outflow in conjunction with disruption of the vein valves in the foot. This permits blood flow to reach the foot and potentially to resolve rest pain or to assist in healing of a chronic wound. We aimed to provide an up-to-date review of DVA indications; to describe the open, percutaneous, and hybrid technique; to detail outcomes of each of the available techniques; and to relay the postoperative considerations for the DVA approach.METHODS: A literature review of relevant articles containing all permutations of the terms "deep venous arterialization" and "distal venous arterialization" was undertaken with the MEDLINE, Cochrane, and PubMed databases to find cases of open, percutaneous, and hybrid DVA in the peer-reviewed literature. The free text and Medical Subject Headings search terms included were "ischemia," "lower extremity," "venous arterialization," "arteriovenous reversal," and "lower limb salvage." Studies were primarily retrospective case series but did include two studies with matched controls. Recorded primary outcomes were patency, limb salvage, wound healing, amputation, and resolution of rest pain, with secondary outcomes of complication and overall mortality. Studies were excluded if there was insufficient discussion of technical details (graft type, target vein) or lack of reported outcome measure.RESULTS: Studies that met inclusion criteria (12 open, 3 percutaneous, 2 hybrid) were identified, reviewed, and summarized to compare technique, patient selection, and outcomes between open, percutaneous, and hybrid DVA. For open procedures, 1-year primary patency ranged from 44.4% to 87.5%; secondary patency was less reported but ranged from 55.6% at 1year to 72% at 25-month follow-up. Limb salvage rates ranged from 25% to 100%, wound healing occurred in 28.6% to 100% of cases, and rest pain resolved in 11.9% to 100% across cohorts. For the endovascular approach, primary patency ranged from 28.6% to 40% at 6-month and 10-month follow-up. Limb salvage rates ranged from 60% to 71%, with rates of major amputation ranging from 20% to 28.5%.CONCLUSIONS: This review provides an up-to-date review of DVA indications, description of various DVA techniques, patient selection associated with each approach, and outcomes for each technique.

    View details for DOI 10.1016/j.jvs.2019.10.085

    View details for PubMedID 31901360

  • Multivessel tibial revascularization does not improve outcomes in patients with critical limb ischemia. Journal of vascular surgery Lavingia, K. S., Tran, K., Dua, A., Itoga, N., Deslarzes-Dubuis, C., Mell, M., Chandra, V. 2019

    Abstract

    OBJECTIVE: Multivessel tibial revascularization for critical limb ischemia (CLI) remains controversial. The purpose of this study was to evaluate single vs multiple tibial vessel interventions in patients with multivessel tibial disease. We hypothesized that there would be no difference in amputation-free survival between the groups.METHODS: Using the Vascular Quality Initiative registry, we reviewed patients undergoing lower extremity endovascular interventions involving the tibial arteries. Patients with CLI were included only if at least two tibial vessels were diseased and adequate perioperative data and clinical follow-up were available for review. The primary outcome was amputation-free survival.RESULTS: There were 10,849 CLI patients with multivessel tibial disease evaluated from 2002 to 2017; 761 limbs had adequate data and follow-up available for review. Mean follow-up was 337± 62days. Of these, 473 (62.1%) underwent successful single-vessel tibial intervention (group SV), whereas 288 (37.9%) underwent successful multivessel (two or more) intervention (group MV). Patients in group MV were younger (69.1 vs 73.2years; P< .001), with higher tobacco use (29.5% vs 18.2%; P< .001). Group SV more commonly had concurrent femoral or popliteal inflow interventions (83.7% vs 78.1%; P= .05). Multivessel runoff on completion was significantly greater for group MV (99.9% vs 39.9%; P< .001). No differences were observed between group SV and group MV for major amputation (9.0% and 7.6%; P= .6), with similar amputation-free survival at 1year (90.6% vs 92.9%; P= .372). In a multivariate Cox model, loss of patency was the only significant predictor of major amputation (hazard ratio, 5.36 [2.7-10.6]; P= .01). A subgroup analysis of 355 (46.6%) patients with tissue loss data showed that tissue loss before intervention was not predictive of future major amputation.CONCLUSIONS: In the Vascular Quality Initiative registry, patients with CLI and occlusive disease involving multiple tibial vessels did not appear to have a limb salvage benefit from multiple tibial revascularization compared with single tibial revascularization.

    View details for DOI 10.1016/j.jvs.2019.08.251

    View details for PubMedID 31685281

  • Er:YAG Laser versus Sharp Debridement in Management of Chronic Wounds: Effects on Pain and Bacterial Load. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society Hajhosseini, B., Chiou, G. J., Dori, G., Fukaya, E., Chandra, V., Meyer, S., Gurtner, G. C. 2019

    Abstract

    Chronic wounds affect roughly 6.5 million patients in the United States annually. Current standard of therapy entails weekly sharp debridement. However, the sharp technique is associated with significant pain, while having minimal impact on the bioburden. Our study proposes the Er:YAG laser as an alternative method of debridement that may decrease procedural pain, reduce bioburden, and potentially improve overall healing. This pilot study was performed as a prospective, randomized, controlled, crossover clinical trial, containing two groups: 1) one group underwent single laser debridement session first, followed by single sharp debridement session one week later; 2) the other group underwent single sharp debridement session first, followed by single laser debridement session one week later. Variables analyzed included pain during debridement, pre- and post-debridement wound sizes, pre- and post-debridement bacterial loads and patient preference. Twenty-two patients were enrolled (12 patients in Group 1, plus 10 patients in Group 2). The mean pain score for patients undergoing laser debridement was 3.0 ±1.7 versus 4.8 ±2.6 for those undergoing sharp debridement (p=0.003). The mean percent change in wound size one-week post-laser debridement was -20.8% ±80.1%, as compared with -36.7% ±54.3% one-week post-sharp debridement (p=0.6). The percentage of patients who had a bacterial load in the Low/Negative category increased from 27.3% to 59.1% immediately after laser debridement (p=0.04), versus 54.5% to 68.2% immediately after sharp debridement (p=0.38). Moreover, there was a sustained decrease in bacterial load one-week post-laser debridement, as compared with no sustained decrease one-week post-sharp debridement (p <0.02). Overall, 52.9% of patients preferred laser debridement versus 35.3% for sharp debridement. We believe that Er:YAG laser serves as a promising technology in chronic wounds, functioning as a potentially superior alternative to sharp debridement, the current standard of therapy. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/wrr.12764

    View details for PubMedID 31587431

  • Delayed Fasciotomy Is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia ANNALS OF VASCULAR SURGERY Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V., Stern, J. R. 2019; 59: 195–201
  • Increased Vertebral Exposure in Anterior Lumbar Interbody Fusion Associated With Venous Injury and Deep Venous Thrombosis Ho, V. T., Colvard, B., Lee, J. T., Chandra, V. MOSBY-ELSEVIER. 2019: E248–E249
  • Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure. Journal of vascular surgery McFarland, G., Tran, K., Virgin-Downey, W., Sgroi, M. D., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2019; 69 (2): 385–93

    Abstract

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

    View details for PubMedID 30686336

  • Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists Armstrong, E. J., Alam, S., Henao, S., Lee, A. C., DeRubertis, B. G., Montero-Baker, M., Mena, C., Cua, B., Palena, L. M., Kovach, R., Chandra, V., AlMahameed, A., Walker, C. M. 2019: 1526602819826593

    Abstract

    Critical limb ischemia (CLI), defined as ischemic rest pain or nonhealing ulceration due to arterial insufficiency, represents the most severe and limb-threatening manifestation of peripheral artery disease. A major challenge in the optimal treatment of CLI is that multiple specialties participate in the care of this complex patient population. As a result, the care of patients with CLI is often fragmented, and multidisciplinary societal guidelines have not focused specifically on the care of patients with CLI. Furthermore, multidisciplinary care has the potential to improve patient outcomes, as no single medical specialty addresses all the facets of care necessary to reduce cardiovascular and limb-related morbidity in this complex patient population. This review identifies current gaps in the multidisciplinary care of patients with CLI, with a goal toward increasing disease recognition and timely referral, defining important components of CLI treatment teams, establishing options for revascularization strategies, and identifying best practices for wound care post-revascularization.

    View details for PubMedID 30706755

  • Benefit of multidisciplinary wound care center on the volume and outcomes of a vascular surgery practice. Journal of vascular surgery Flores, A. M., Mell, M. W., Dalman, R. L., Chandra, V. n. 2019

    Abstract

    Multidisciplinary care is recommended for the treatment of patients with ischemic and diabetic wounds. In addition to integrating care from multiple specialties, outpatient wound care centers provide an opportunity for continuity and organization of care after revascularization or hospitalization. The purpose of this study was to assess changes in the practice patterns and outcomes of patients treated by a tertiary care vascular surgery practice after the introduction of an affiliated outpatient wound care center.A prospective institutional database was used to identify patients who underwent lower-extremity revascularization, amputation, or surgical debridement during consecutive 3-year periods before (BWC; n = 735) and after (AWC; n = 1503) the opening of an affiliated wound care center. Patients were included if they underwent intervention for atherosclerotic peripheral arterial disease or diabetic foot ulcers (DFUs). Changes in case volume, surgical indication, and procedural characteristics were assessed. Clinical outcomes included freedom from lower-extremity amputations and mortality.We identified a total of 1751 procedures performed in 1249 limbs that met inclusion criteria. After the opening of the wound clinic, procedures related to limb salvage represented a greater proportion of overall cases performed by the vascular service (19% vs 26%; P < .0001). The volume of lower-extremity interventions increased by 64%, from 662 procedures in the BWC period to 1085 procedures in the AWC period. There was no difference in type of revascularization performed between the two study periods, although surgical debridements (from 8.9% to 13%; P = .01) and infrapopliteal endovascular interventions (from 21% to 28%; P = .04) significantly increased. Compared with BWC patients, AWC patients more frequently presented with DFUs (7.3% vs 13%; P = .002) and chronic wounds (39% vs 45%; P = .05). At 1 year of follow-up, major amputation rates were significantly lower in the AWC group than in the BWC cohort (5.5% vs 8.8%; P = .04). Treatment during the AWC period was associated with a reduced risk of major amputation (adjusted hazard ratio, 0.41; 95% confidence interval, 0.27-0.62; P < .001), but no difference in all-cause mortality.The opening of an outpatient wound center affiliated with a tertiary vascular surgical practice was associated with a higher volume of limb salvage patients and procedures. The risk of major amputation decreased following the opening of the wound care center. Integrating vascular surgeons into wound centers may result in a synergistic system that promotes more aggressive and effective limb salvage.

    View details for DOI 10.1016/j.jvs.2019.01.087

    View details for PubMedID 31153696

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

    Abstract

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

    View details for DOI 10.1177/1538574419887585

    View details for PubMedID 31746279

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

    Abstract

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

    View details for DOI 10.1016/j.avsg.2019.04.008

    View details for PubMedID 31201974

  • Delayed Fasciotomy is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia. Annals of vascular surgery Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V. n., Stern, J. R. 2019

    Abstract

    Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes.Patients who underwent lower extremity revascularization for ALI from 2005-2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations between patient characteristics, comorbidities, fasciotomy timing and patient outcomes were evaluated.A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford acute limb ischemia classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, p<0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, p=0.003). Ischemia time > 6 hours was noted in 66.7% of patients, though this was not significantly associated with fasciotomy occurrence (≤6 hours 21.7% fasciotomy vs. >6 hours 34.8% fasciotomy, p=0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, p=0.002).The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.

    View details for PubMedID 31034949

  • Disparities as Predictors of Non-Healing in Lower Extremity Wounds George, E. L., Trang, K., Dua, A., Parsley, J. D., Robertson, R., Fukaya, E., Sen, S. K., Gurtner, G. C., Chandra, V. ELSEVIER SCIENCE INC. 2018: E248
  • Trends in Rates of Lower Extremity Amputation Among Patients With End-stage Renal Disease Who Receive Dialysis. JAMA internal medicine Franz, D., Zheng, Y., Leeper, N. J., Chandra, V., Montez-Rath, M., Chang, T. I. 2018

    Abstract

    Patients with end-stage renal disease (ESRD) who receive dialysis are at high risk of lower extremity amputation. Recent studies indicate decreasing rates of lower extremity amputation in non-ESRD populations, but contemporary data for patients with ESRD who receive dialysis are lacking.To assess rates of lower extremity amputation among patients with ESRD who receive dialysis during a recent 15-year period; to analyze whether those rates differed by age, sex, diabetes, or geographic region; and to determine 1-year mortality rates in this population after lower extremity amputation.This retrospective study of 3 700 902 records obtained from a US national registry of patients with ESRD who receive dialysis assessed cross-sectional cohorts for each calendar year from 2000 through 2014. Adult patients with prevalent ESRD treated with hemodialysis or peritoneal dialysis covered by Medicare Part A and B on January 1 of each cohort year were included. Data analysis was conducted from August 2017 to April 2018.Age, sex, diabetes, and hospital referral region.Annual rates per 100 person-years of nontraumatic major (above- or below-knee) and minor (below-ankle) amputations.For each annual cohort, there were fewer women (47.5% in 2000, 46.2% in 2005, 44.9% in 2010, and 44.0% in 2014) than men, more than half the patients were white individuals (58.1% in 2000, 56.9% in 2005, 56.9% in 2010, and 56.7% in 2014), and a small proportion were employed (13.9% in 2000, 15.1% in 2005, 16.1% in 2010, and 16.5% in 2014). The rate of lower extremity amputations for patients with ESRD who receive dialysis decreased by 51.0% from 2000 to 2014, driven primarily by a decrease in the rate of major amputations (5.42 [95% CI, 5.28-5.56] in 2000 vs 2.66 [95% CI, 2.59-2.72] per 100 person-years in 2014). Patients with diabetes had amputation rates more than 5 times as high as patients without diabetes. Patients younger than 65 years had higher adjusted amputation rates than older patients, and men had consistently higher adjusted amputation rates than women. Adjusted 1-year mortality rates after lower extremity amputation for patients with ESRD who receive dialysis decreased from 52.2% (95% CI, 50.9%-53.4%) in 2000 to 43.6% (95% CI, 42.5%-44.8%) in 2013. In general, amputation rates decreased among all regions from 2000 to 2014, but regional variability persisted across time despite adjustment for differences in patient demographics and comorbid conditions.Although rates of lower extremity amputations among US patients with ESRD who receive dialysis decreased by 51% during a recent 15-year period, mortality rates remained high, with nearly half of patients dying within a year after lower extremity amputation. Our results highlight the need for more research on ways to prevent lower extremity amputation in this extremely high-risk population.

    View details for DOI 10.1001/jamainternmed.2018.2436

    View details for PubMedID 29987332

  • Clinical Impact of a Wound Care Center on a Vascular Surgery Practice Flores, A. M., Mell, M. W., Dalman, R. L., Chandra, V. MOSBY-ELSEVIER. 2018: E88–E89
  • Regarding "Controversies and evidence for cardiovascular disease in the diverse Hispanic population" Reply JOURNAL OF VASCULAR SURGERY Shaw, P. M., Chandra, V., Escobar, G. A., Robbins, N., Rowe, V., Macsata, R. 2018; 67 (5): 1639–40
  • Long-term outcomes after repair of symptomatic abdominal aortic aneurysms. Journal of vascular surgery Chandra, V., Trang, K., Virgin-Downey, W., Dalman, R. L., Mell, M. W. 2018

    Abstract

    OBJECTIVES: Previous studies have reported increased perioperative mortality of nonruptured symptomatic abdominal aortic aneurysms (Sx-AAA) compared with asymptomatic elective AAA (E-AAA) repairs, but no long-term-outcomes have been reported. We sought to compare long-term outcomes of Sx-AAA and E-AAA after repair at a single academic institution.METHODS: Patients receiving AAA repair for Sx-AAA and E-AAA from 1995 through 2015 were included. Ruptured AAA and suprarenal or thoracoabdominal AAA were excluded. Demographics, comorbidities, and operative approach were collected. Long-term mortality was the primary outcome, determined by chart review or link to Social Security Death Index. Additionally, long-term mortality and reinterventions were compared after groups were matched with nearest neighbor propensity to reduce bias.RESULTS: AAA repair was performed for 1054 E-AAA (383 open repair [36%], 671 endovascular aneurysm repair [EVAR] [64%]), and 139 symptomatic aneurysms (60 open repair [43%], 79 EVAR [57%]). Age (73years vs 74years; P= .13) and aneurysm diameter were similar between Sx-AAA and E-AAA (6.0cm vs 5.8cm; P= .5). The proportion of women was higher for Sx-AAA (26% vs 16%; P= .003), as was the proportion of non-Caucasians (40% vs 29%; P= .009). After propensity matching, there were no differences between groups for patient characteristics, AAA diameter, treatment modality, or comorbidities, including hypertension, coronary artery disease, congestive heart failure, diabetes, hyperlipidemia, lung disease, diabetes, renal disease, and smoking history. Women were treated for Sx-AAA at significantly smaller aortic diameters; however, compared with men (5.1cm vs 6.3cm; P< .001). Perioperative mortality was 5.0% for Sx-AAA and 2.3% for E-AAA (P= .055). By life-table analysis, Sx-AAA had lower 5-year (62% vs 71%) and 10-year (39% vs 51%) survivals (P= .01) compared with E-AAA for the entire cohort. Similar trends were observed for 5-year and 10-year mortality after propensity matching (63% and 40% vs 71% and 52%; P= .05). When stratified by repair type 5-year and 10-year survivals trended lower after open surgery (68% and 42% Sx-AAA vs 84% and 59% E-AAA; P= .08) but not EVAR (59% and 40% Sx-AAA vs 61% and 49% E-AAA; P= .4). Aneurysm-related reinterventions were similar for Sx-AAA and E-AAA (15% vs 14%; P= .8). Reinterventions were more common after EVAR compared with open repair (22% vs 7%, Sx-AAA P= .015; 20% vs 4% E-AAA; P= .007).CONCLUSIONS: Patients with Sx-AAA had lower long-term survival and similar aneurysm-related reinterventions compared with patients with E-AAA undergoing repair. Women also underwent repair for Sx-AAA at a significantly smaller size when compared with men, which emphasizes the role of gender in AAA symptomatology. Differences in long-term survival may be only partially explained by measured patient, aneurysm, and operative factors, and may reflect unmeasured social factors or suggest inherent differences in pathophysiology of Sx-AAAs.

    View details for PubMedID 29705087

  • Controversies and evidence for cardiovascular disease in the diverse Hispanic population JOURNAL OF VASCULAR SURGERY Shaw, P. M., Chandra, V., Escobar, G. A., Robbins, N., Rowe, V., Macsata, R. 2018; 67 (3): 960–69

    Abstract

    Hispanics account for approximately 17% of the U.S.They are one of the fastest growing racial/ethnic groups, second only to Asians. This heterogeneous population has diverse socioeconomic conditions, making the prevention, diagnosis, and management of vascular disease difficult. This paper discusses the cultural, racial, and social aspects of the Hispanic community in the United States and assesses how they affect vascular disease within this population. Furthermore, it explores risk factors, medical and surgical treatments, and outcomes of vascular disease in the Hispanic population; generational evolution of these conditions; and the phenomenon called the Hispanic paradox.A systematic search of the literature was performed to identify all English-language publications from 1991 to 2014 using PubMed, which draws from the National Institutes of Health and U.S. National Library of Medicine, with the words "cardiovascular disease," "prevalence," "vascular," and "Hispanic." An additional search was performed using "cardiovascular disease and Mexico," "cardiovascular disease and Cuba," "cardiovascular disease and Puerto Rico," and "cardiovascular disease and Latin America" as well as for complications, management, outcomes, surgery, vascular disease, and Hispanic paradox. The resulting publications were queried for generational data (spanning multiple well-defined age groups) regarding cardiovascular disease, and cross-references were obtained from their bibliographies. Results are segmented by country of origin.Compared with non-Hispanic whites, Hispanics face higher risks of cardiovascular diseases because of a high prevalence of high blood pressure, obesity, diabetes mellitus, and ischemic stroke. However, the incidence of peripheral arterial disease and carotid disease appears to be significantly lower than in whites. The Hispanic paradox (lower mortality in spite of higher cardiovascular risk factors) may relate to challenges in ascribing life expectancy and cause of death in this diverse population. Low socioeconomic status and high prevalence of concomitant diseases negatively influence the outcomes of all patients, independent of being Hispanic.Understanding the cultural diversity in Hispanics is important in terms of targeting preventive measures to modify cardiovascular risk factors, which affect development and outcomes of vascular disease. The available literature regarding vascular disease in the Hispanic population is limited, and further longitudinal study is warranted to improve health care delivery and outcomes in this group.

    View details for PubMedID 28951154

  • Trends in Rates of Lower Extremity Amputation Among Patients With End-Stage Renal Disease Who Receive Dialysis JAMA Internal Medicine Franz, D., Zheng, Y., Leeper, N. J., Chandra, V., Montez-Rath, M., Chang, T. I. 2018
  • How Good Ideas Die: Understanding Common Pitfalls of Medtech Innovation MEDICAL INNOVATION: CONCEPT TO COMMERCIALIZATION Blevins, K. S., Azagury, D. E., Wall, J. K., Chandra, V., Wynne, E. K., Krummel, T. M., Behrns, K. E., Gingles, B., Sarr, M. G. 2018: 117–27
  • Retrograde Pedal Access-Cutting Edge or Comical? Vascular and endovascular surgery Dua, A., Chandra, V. 2018: 1538574418780055

    Abstract

    Retrograde pedal access is a technique utilized with increasing frequency by many interventionists to address patients with advanced multilevel peripheral artery disease and significant comorbidities. This approach to revascularization is being used both in patients who fail traditional antegrade access and in some patients thought to be poor candidates for antegrade approach. However, the lack of randomized controlled trial data, or long-term results, coupled with the associated potential risks including dissection, spasm, and thrombosis have rendered retrograde pedal access a controversial topic. This article details the pros and cons associated with the debate surrounding retrograde pedal access and highlights the current literature and remaining questions regarding outcomes of this technique.

    View details for DOI 10.1177/1538574418780055

    View details for PubMedID 29932023

  • Partnerships between podiatrists and vascular surgeons in building effective wound care centers JOURNAL OF VASCULAR SURGERY Chandra, V., Glebova, N. O., Salvo, N. L., Wu, T. 2017; 66 (3): 902–5

    Abstract

    This practice memo, a collaborative effort between the Young Physicians' Program of the American Podiatric Medical Association and the Young Surgeons Committee of the Society for Vascular Surgery, is intended to aid podiatrists and vascular surgeons in the early years of their respective careers, especially those involved in the care of patients with chronic wounds. During these formative years, learning how to successfully establish an interprofessional partnership is crucial to provide the best possible care to this important population of patients.

    View details for PubMedID 28842074

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

    Abstract

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

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

    View details for PubMedID 28493108

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

    Abstract

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

    View details for DOI 10.1016/j.avsg.2017.01.025

    View details for PubMedID 28479440

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

    Abstract

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

    View details for PubMedID 28619644

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2016.07.121

    View details for PubMedID 27871490

  • Ruptured Pseudoaneurysm of the Dorsalis Pedis Artery Following Ankle Arthroscopy: A Case Report. JBJS case connector Wiske, C. P., Itoga, N. K., Ullery, B. W., Hunt, K. J., Chandra, V. 2016; 6 (4): e102

    Abstract

    We describe the case of a pseudoaneurysm of the dorsalis pedis artery that developed following a repeat ankle arthroscopy for persistent osseous impingement. The patient underwent attempted fluid aspiration for a presumed effusion, and ultimately experienced rupture of the pseudoaneurysm with substantial blood loss, which required emergency vascular repair.Anterior tibial artery and dorsalis pedis artery pseudoaneurysms are relatively rare, but they are well-documented complications of ankle arthroscopy; however, their clinical importance is poorly understood. To our knowledge, this is the first reported case of a ruptured pseudoaneurysm of the dorsalis pedis artery following ankle surgery, and it highlights the need for timely diagnosis.

    View details for DOI 10.2106/JBJS.CC.16.00069

    View details for PubMedID 29252755

    View details for PubMedCentralID PMC5901686

  • SPY technology as an adjunctive measure for lower extremity perfusion JOURNAL OF VASCULAR SURGERY Colvard, B., Itoga, N. K., Hitchner, E., Sun, Q., Long, B., Lee, G., Chandra, V., Zhou, W. 2016; 64 (1): 195-201

    Abstract

    Lack of a reliable outcome measure often leads to excessive or insufficient interventions for critical limb ischemia (CLI). SPY technology (Novadaq Technologies Inc, Bonita Springs, Fla), widely adapted by plastic and general surgeons, uses laser-assisted fluorescence angiography (LAFA) to assess tissue perfusion. We sought to determine the role of SPY as an alternative, perhaps more reliable outcome measure for vascular interventions.All patients undergoing elective or urgent revascularization for claudication and CLI were prospectively recruited from June 2012 to August 2014. LAFA using SPY technology was performed before and after revascularization procedures under a standard Institutional Review Board-approved protocol. Quantitative measures of perfusion at plantar surfaces were analyzed and compared with ankle-brachial index.A total of 93 patients with claudication or CLI underwent LAFA before and after a revascularization procedure in the study period. The mean preoperative ankle-brachial index increased from 0.60 to 0.84 (P < .001) after a revascularization procedure. Plantar perfusion as measured by LAFA also improved significantly after intervention. Ingress, defined as the rate at which fluorescence intensity increases on the plantar surface during LAFA, increased from 7.1 to 12.4 units/s (P < .001). Peak perfusion, defined as the difference between the baseline and the peak of fluorescence intensity, increased from 97.1 and 143.9 units (P < .001). Egress, defined as the rate at which intensity diminishes after reaching peak perfusion, increased from 1.0 to 1.9 units/s (P = .035). Procedure-related digital embolization was also observed in several patients despite lack of an angiographic finding.This is the largest prospective study evaluating SPY technology in peripheral vascular interventions. Our study shows that SPY is a valuable tool in visualizing real-time procedural outcomes and providing additionally useful information on regional tissue perfusion. Further investigation is warranted to standardize outpatient use and to determine threshold values that predict wound healing.

    View details for DOI 10.1016/j.jvs.2016.01.039

    View details for Web of Science ID 000378562900027

    View details for PubMedID 26994959

  • Unplanned reoperations after vascular surgery JOURNAL OF VASCULAR SURGERY Kazaure, H. S., Chandra, V., Mell, M. W. 2016; 63 (3): 731-737
  • Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition JAMA SURGERY Ullery, B. W., Tran, K., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2015; 150 (11): 1058-1065

    Abstract

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

    View details for DOI 10.1001/jamasurg.2015.1861

    View details for Web of Science ID 000367987100011

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

    Abstract

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

    View details for DOI 10.1001/jamasurg.2015.1861

    View details for PubMedID 26244272

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

    Abstract

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

    View details for DOI 10.1177/1526602815590119

    View details for Web of Science ID 000358119200019

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

    Abstract

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

    View details for DOI 10.1177/1526602815590119

    View details for PubMedID 26045462

  • Aortoiliac Elongation after Endovascular Aortic Aneurysm Repair ANNALS OF VASCULAR SURGERY Chandra, V., Rouer, M., Garg, T., Fleischmann, D., Mell, M. 2015; 29 (5): 891-897

    Abstract

    Aortoiliac elongation after endovascular aortic aneurysm repair (EVAR) is not well studied. We sought to assess the long-term morphologic changes after EVAR and identify potentially modifiable factors associated with such a change.An institutional review board-approved retrospective review was conducted for 88 consecutive patients who underwent EVAR at a single academic center from 2003 to 2007 and who also had at least 2 follow-up computed tomography angiograms (CTAs) available for review up to 5 years after surgery. Standardized centerline aortic lengths and diameters were obtained on Aquarius iNtuition 3D workstation (TeraRecon Inc., San Mateo, CA) on postoperative and all-available follow-up CTAs. Relationships to aortic elongation were determined using Wilcoxon rank-sum test or linear regression (Stata version 12.1, College Station, TX). Changes in length over time were determined by mixed-effects analysis (SAS version 9.3, Cary, NC).The study cohort was composed of mostly men (88%), with a mean age of (76 ± 8) and a mean follow-up of 3.2 years (range, 0.4-7.5 years). Fifty-seven percent of patients (n = 50) had devices with suprarenal fixation and 43% (n = 38) had no suprarenal fixation. Significant lengthening was observed over the study period in the aortoiliac segments, but not in the iliofemoral segments. Aortoiliac elongation over time was not associated with sex (P = 0.3), hypertension (P = 0.7), coronary artery disease (P = 0.3), diabetes (P = 0.3), or tobacco use (P = 0.4), but was associated with the use of statins (P = 0.03) and the presence of chronic obstructive pulmonary disease (P = 0.02). Significant aortic lengthening was associated with increased type I endoleaks (P = 0.03) and reinterventions (P = 0.03). Over the study period, 4 different devices were used; Zenith (Cook Medical Inc., Bloomington, IN), Talent (Medtronic, Minneapolis, MN), Aneuryx (Medtronic), and Excluder (W. L. Gore and Associates Inc., Flagstaff, AZ). After adjusting for differences in proximal landing zone, significant differences in aortic lengthening over time were observed by device type (P = 0.02).Significant aortoiliac elongation was observed after EVAR. Such morphologic changes may impact long-term durability of EVAR, warranting further investigation into factors associated with these morphologic changes.

    View details for DOI 10.1016/j.avsg.2014.12.041

    View details for Web of Science ID 000356994400003

    View details for PubMedID 25757989

  • Novel Approach to a Giant External Iliac Vein Aneurysm Secondary to Posttraumatic Femoral Arteriovenous Fistula VASCULAR AND ENDOVASCULAR SURGERY Thompson, P. C., Ullery, B. W., Fleischmann, D., Chandra, V. 2015; 49 (5-6): 148-151

    Abstract

    We describe a case of a 55-year-old male with a remote history of a gunshot wound to the left thigh who presented with a 1-year history of worsening high-output congestive heart failure, left lower extremity edema, and left lower abdominal discomfort. Diagnostic evaluation included a computed tomographic angiography (CTA) that demonstrated a fistulous communication between the left superficial femoral artery (SFA) and vein (SFV) as well as a 7.2-cm external iliac vein aneurysm. Given his symptomatology, an endovascular repair of his AVF was recommended, followed by antithrombotic therapy for his aneurysm. Three-month postoperative CTA confirmed AVF exclusion as well as a significant decrease in maximal diameter of the left external iliac vein aneurysm now measuring 24 mm. This case is the first reported successful mid-term repair of a iliac venous aneurysm in the setting of a traumatic arteriovenous fistula using an endovascular approach.

    View details for DOI 10.1177/1538574415602781

    View details for Web of Science ID 000361529700008

    View details for PubMedID 26335991

  • Gastrointestinal Mucormycosis Requiring Surgery in Adults with Hematologic Malignant Tumors: Literature Review SURGICAL INFECTIONS Forrester, J. D., Chandra, V., Shelton, A. A., Weiser, T. G. 2015; 16 (2): 194-202

    Abstract

    Gastrointestinal mucormycosis is associated with high mortality rates. Appropriate and early antifungal therapy and prompt surgical intervention are essential.Case report and literature review.Nineteen case reports were reviewed describing adults with hematologic malignant tumors who developed intestinal mucormycosis and underwent surgery. The overall survival rate was 50%.Intestinal mucormycosis is an infection associated with a high mortality rate although adults with underlying hematologic malignant have improved outcomes compared with other groups.

    View details for DOI 10.1089/sur.2013.232

    View details for Web of Science ID 000352360400015

    View details for PubMedID 25405775

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

    Abstract

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

    View details for DOI 10.1016/j.avsg.2014.07.025

    View details for PubMedID 25192823

  • Cheese Wire Fenestration of a Chronic Juxtarenal Dissection Flap to Facilitate Proximal Neck Fixation during EVAR ANNALS OF VASCULAR SURGERY Ullery, B. W., Chandra, V., Dake, M., Lee, J. T. 2015; 29 (1)

    Abstract

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

    View details for DOI 10.1016/j.avsg.2014.07.025

    View details for Web of Science ID 000346239900025

    View details for PubMedID 25192823

  • Gastrointestinal Mucormycosis Initially Manifest as Hematochezia from Arterio-Enteric Fistula DIGESTIVE DISEASES AND SCIENCES Cloyd, J. M., Brown, J., Sinclair, T., Jenks, D., Desai, J., Longacre, T., Chandra, V., Shelton, A. 2014; 59 (12): 2905-2908
  • Gastrointestinal mucormycosis initially manifest as hematochezia from arterio-enteric fistula. Digestive diseases and sciences Cloyd, J. M., Brown, J., Sinclair, T., Jenks, D., Desai, J., Longacre, T., Chandra, V., Shelton, A. 2014; 59 (12): 2905-2908

    View details for DOI 10.1007/s10620-014-3239-7

    View details for PubMedID 24906697

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2014.04.013

    View details for PubMedID 24835692

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2014.03.255

    View details for PubMedID 24785682

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2014.04.013

    View details for Web of Science ID 000343316600031

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

    Abstract

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

    View details for DOI 10.1016/j.avsg.2014.03.010

    View details for PubMedID 24704581

  • Preoperative embolization of replaced right hepatic artery prior to pancreaticoduodenectomy JOURNAL OF SURGICAL ONCOLOGY Cloyd, J. M., Chandra, V., Louie, J. D., Rao, S., Visser, B. C. 2012; 106 (4): 509-512

    Abstract

    Aberrancy of the hepatic arterial anatomy is common. Because of its course directly adjacent to the head of the pancreas, a replaced right hepatic artery (RHA) is vulnerable to invasion by peri-pancreatic malignancies. Division of the RHA at the time of pancreaticoduodenectomy, however, may result in hepatic infarction and/or bilioenteric anastomotic complications. We report two cases of patients undergoing preoperative embolization of tumor encased replaced RHAs to allow for sufficient collateralization prior to pancreaticoduodenectomy.

    View details for DOI 10.1002/jso.23082

    View details for PubMedID 22374866

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

    Abstract

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

    View details for DOI 10.1016/j.avsg.2011.10.003

    View details for PubMedID 22176878

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2011.05.105

    View details for PubMedID 21803527

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

    Abstract

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

    View details for DOI 10.1016/j.jvs.2011.04.052

    View details for PubMedID 21723068

  • A comparison of laparoscopic and robotic assisted suturing performance by experts and novices SURGERY Chandra, V., Nehra, D., Parent, R., Woo, R., Reyes, R., Hernandez-Boussard, T., Dutta, S. 2010; 147 (6): 830-839

    Abstract

    Surgical robotics has been promoted as an enabling technology. This study tests the hypothesis that use of the robotic surgical system can significantly improve technical ability by comparing the performance of both experts and novices on a complex laparoscopic task and a robotically assisted task.Laparoscopic experts (LE) with substantial laparoscopic and robotic experience (n = 9) and laparoscopic novices (LN) (n = 20) without any robotic experience performed sequentially 10 trials of a suturing task using either robotic or standard laparoscopic instrumentation fitted to the ProMIS surgical simulator. Objective performance metrics provided by ProMIS (total task time, instrument pathlength, and smoothness) and an assessment of learning curves were analyzed.Compared with LNs, the LEs demonstrated significantly better performance on all assessment measures. Within the LE group, there was no difference in smoothness (328 +/- 159 vs 355 +/- 174; P = .09) between robot-assisted and standard laparoscopic tasks. An improvement was noted in total task time (113 +/- 41 vs 132 +/- 55 sec; P < .05) and instrument pathlengths (371 +/- 163 vs 645 +/- 269 cm; P < .05) when using the robot. This advantage in terms of total task time, however, was lost among the LEs by the last 3 trials (114 +/- 40 vs 118 +/- 49 s; P = .84), while instrument pathlength remained better consistently throughout all the trials. For the LNs, performance was significantly better in the robotic trials on all 3 measures throughout all the trials.The ProMIS surgical simulator was able to distinguish between skill levels (expert versus novice) on robotic suturing tasks, suggesting that the ProMIS is a valid tool for measuring skill in robot-assisted surgery. For all the ProMIS metrics, novices demonstrated consistently better performance on a suturing task using robotics as compared to a standard laparoscopic setup. This effect was less evident for experts who demonstrated improvements only in their economy of movement (pathlength), but not in the speed or smoothness of performance. Robotics eliminated the early learning curve for novices, which was present when they used standard laparoscopic tools. Overall, this study suggests that, when performing complex tasks such as knot tying, surgical robotics is most useful for inexperienced laparoscopists who experience an early and persistent enabling effect. For experts, robotics is most useful for improving economy of motion, which may have implications for the highly complex procedures in limited workspaces (eg, prostatectomy).

    View details for DOI 10.1016/j.surg.2009.11.002

    View details for Web of Science ID 000278532300011

    View details for PubMedID 20045162

  • Intellectual property and royalty streams in academic departments: Myths and realities SURGERY Krummel, T. M., Shafi, B. M., Wall, J., Chandra, V., Mery, C., Gertner, M. 2008; 143 (2): 183-191

    View details for DOI 10.1016/j.surg.2007.11.011

    View details for Web of Science ID 000253172300009

    View details for PubMedID 18242333

  • Clinical resolution of severely symptomatic pseudotumor cerebri after gastric bypass in an adolescent SURGERY FOR OBESITY AND RELATED DISEASES Chandra, V., Dutta, S., Albanese, C. T., Shepard, E., Farrales-Nguyen, S., Morton, J. 2007; 3 (2): 198-200

    Abstract

    Pseudotumor cerebri is a disease characterized by increased intracranial pressure, often manifested by headaches, and occasionally leading to severe visual impairment or even blindness. Most cases in adolescents, as in adults, are associated with obesity. We report a 16-year-old morbidly obese adolescent girl (body mass index 42.3 kg/m(2)) with severely symptomatic pseudotumor cerebri who had progressive visual field deficits and elevated intracranial pressure (opening pressure on lumbar puncture of 50 cm H(2)O) despite intensive medical management and placement of both ventriculoperitoneal and lumboperitoneal shunts. Six months after she underwent gastric bypass surgery, she had lost 43% of her excess body weight and had had near complete regression of her visual field deficits, along with normalization of her intracranial pressures. This case demonstrates the dramatic reversal of symptoms of pseudotumor cerebri with surgically induced weight loss. Gastric bypass should be considered as a treatment option for adolescents with severe and progressive pseudotumor cerebri.

    View details for DOI 10.1016/j.soard.2006.11.015

    View details for PubMedID 17324634

  • Surgical robotics and image guided therapy in pediatric surgery: emerging and converging minimal access technologies. Seminars in pediatric surgery Chandra, V., Dutta, S., Albanese, C. T. 2006; 15 (4): 267-275

    Abstract

    Minimal access surgery (MAS) is now commonplace in the armamentarium of the pediatric surgeon, and is being applied to a growing list of pediatric surgical diseases. Robot-assisted surgery and image guided therapy (IGT) have evolved as innovative minimal access approaches, and hold the promise of advancing MAS far beyond what is currently possible. The aims of this article are to describe the currently available robotic, and image guided therapy systems, review their present and potential applications, and discuss the future directions of these converging technologies.

    View details for PubMedID 17055957