All Publications

  • Intraoperative Heparin Use Is Associated With Reduced Inpatient Mortality After Thoracic Endovascular Aortic Repair for Blunt Aortic Injury Ho, V., Rothenberg, K. A., George, E. L., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E99
  • The Effect of Interfacility Transfer in Patients With Blunt Thoracic Aortic Injury Rothenberg, K. A., George, E. L., Ho, V., Barreto, N. B., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E167
  • Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia. Annals of vascular surgery George, E. L., Colvard, B., Ho, V., Rothenberg, K. A., Lee, J. T., Stern, J. R. 2020


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

    View details for DOI 10.1016/j.avsg.2019.12.026

    View details for PubMedID 31917220

  • 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., Colvard, B., Lee, J. T., Chandra, V. 2020


    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

  • Comparison of mid-term graft patency in common femoral versus superficial femoral artery inflow for infra-geniculate bypass in the vascular quality initiative. Vascular Tran, K., Ho, V. T., Itoga, N. K., Stern, J. R. 2020: 1708538120924908


    The superficial femoral artery can be used as inflow for infra-geniculate bypass, but progressive proximal occlusive disease may affect graft durability. We sought to evaluate the effect of superficial femoral artery versus common femoral artery inflow on infra-geniculate bypass patency within a large contemporary multicenter registry.The vascular quality initiative was queried from 2013 to 2019 to identify patients with >30-day patency follow-up, Rutherford chronic limb ischemia stage 1-6, and an infra-geniculate bypass, excluding those with prior ipsilateral bypass. The cohort was stratified by inflow vessel, with primary, primary-assisted, and secondary patency serving as the primary outcome variables. Multivariate Cox-proportional hazard models and radius-based propensity-score matching were performed to reduce treatment-selection bias due to clinical covariates.A total of 11,190 bypass procedures were performed (8378 common femoral artery inflow, 2812 superficial femoral artery) on 10,110 patients, with a mean follow-up of 12.8 months (range 1-98). Patients receiving superficial femoral artery inflow bypasses were more commonly male (p = 0.002), obese (p < 0.0001) and had chronic, limb threatening ischemia (p < 0.0001), whereas those with common femoral artery inflow were older (p < 0.0004), and had higher baseline comorbidities including smoking (p < 0.0001), coronary disease (p < 0.0001), and pulmonary disease (p < 0.0001). On life-table analysis, there was no significant difference in three year estimated primary (32.1 vs 30.1%, p = 0.928), primary assisted (60.5 vs 65.8%, p = 0.191), or secondary patency (62.5 vs 66.7%, p = 0.139) between superficial femoral artery and common femoral artery inflow groups, respectively. A multivariate Cox model found no significant association between inflow vessel and primary patency (0.96 [0.88-1.04], HR [95%CI]), primary-assisted (1.07 [0.95-1.20], HR [95%CI]), or secondary patency (1.08 [0.96-1.22]). In a propensity-matched cohort (n = 11,151), there were small but statistically significant differences in primary, primary-assisted, and secondary patency at latest follow-up (non-time-to-event data) between groups. The largest difference was observed when evaluating secondary patency, with common femoral artery inflow having a marginally higher secondary patency of 88.1% compared to 85.6% for those with superficial femoral artery inflow at latest follow-up (p = 0.009).Within the vascular quality initiative, there is no significant difference in life-table determined three-year primary, primary-assisted, and secondary patency between infra-geniculate bypasses using common femoral artery inflow compared to superficial femoral artery inflow. Small, statistically significant differences exist in primary, primary-assisted, and secondary patency favoring common femoral artery inflow after propensity score matching. Long-term follow-up data are required in the vascular quality initiative to better evaluate bypass graft durability as this study was limited by a mean follow-up of one year.

    View details for DOI 10.1177/1708538120924908

    View details for PubMedID 32408857

  • 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


    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

  • 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
  • Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia George, E. L., Colvard, B., Ho, V. T., Rothenberg, K. A., Lee, J. T., Stern, J. R. MOSBY-ELSEVIER. 2019: E170–E171
  • Metformin prescription status and abdominal aortic aneurysm disease progression in the US veteran population JOURNAL OF VASCULAR SURGERY Itoga, N. K., Rothenberg, K. A., Suarez, P., Ho, T., Mell, M. W., Xu, B., Curtin, C. M., Dalman, R. L. 2019; 69 (3): 710-+
  • Early Real-World Experience with Endoanchors by Indication. Annals of vascular surgery Ho, V. T., George, E. L., Dua, A., Lavingia, K. S., Sgroi, M. D., Dake, M. D., Lee, J. T. 2019


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

    View details for DOI 10.1016/j.avsg.2019.05.006

    View details for PubMedID 31201976

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


    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

  • A Challenge for Psychocardiology: Addressing the Causes and Consequences of Patients' Perceptions of Enduring Somatic Threat AMERICAN PSYCHOLOGIST Edmondson, D., Birk, J. L., Ho, V. T., Meli, L., Abdalla, M., Kronish, I. M. 2018; 73 (9): 1160–71


    The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients' sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina-colloquially, "heart attack"). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients' EST, as revascularized patients often report being "cured." We assessed ACS patients' initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n = 65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B = -5.32, 95% confidence interval [-9.77, -0.87]), t(98.19) = -2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients' development of EST should be considered in the hospital. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

    View details for DOI 10.1037/amp0000418

    View details for Web of Science ID 000452426700015

    View details for PubMedID 30525797

  • Comparison of Bovine Carotid Xenograft Versus Expanded Polytetrafluoroethylene Grafts for Forearm Loop Hemodialysis Access Colvard, B., Lavignia, K., Ho, V. T., Itoga, N., Dua, A., Harris, E., Me, M., Sorial, E., Garcia-Toca, M. MOSBY-ELSEVIER. 2018: E35
  • Outcomes of Gracilis Muscle Flaps in the Management of Groin Complications after Arterial Bypass with Prosthetic Graft. Annals of vascular surgery Dua, A., Ho, V. T., Rao, C., Desai, S. S. 2018


    INTRODUCTION: This study details two-year outcomes of a modified gracilis muscle flap (GMF) technique in providing tissue coverage for groin complications after arterial bypass surgery with synthetic graft.METHODS: All patients who developed groin infections after lower extremity arterial bypass with synthetic graft that underwent a GMF were included from June 2014 to March 2017 from a prospectively collected, purpose-built institutional database. Modifications to the standard technique included identification of the muscle using ultrasound to ensure precise skip incisions, preservation of the segmental blood supply, widening of the tunnel through which the muscle is retroflexed, placement of a wound VAC for healing, and lifelong antibiotics. Demographics, laboratory values, bypass procedure, length of stay (LOS), disposition, and 1, 3, 6, 12, and 24 month follow up were collected. Analysis was performed via descriptive statistics.RESULTS: Over the 3-year study period, 22 patients underwent GMF following complications after arterial bypass surgery. Types of bypass included aortobifemoral (32%), axillobifemoral (14%), femoral-femoral (23%), femoral-popliteal or mixed distal (27%), and thigh graft for dialysis (4%). 45% of patients presented with graft infection, 50% with wound dehiscence and 5% with graft disruption and bleeding. Only 23% of patients were candidates for sartorius muscle flap at the time of their initial procedure. The average case length was 64+19 minutes. 64% of patients were discharged to home with home health and the remainder to a skilled nursing facility. The average LOS was 6.1+3.4 days. 54% of wounds were healed at 1 month and 100% at 3 months with adjunctive VAC therapy and life-long antibiotics. 60% of patients were still alive at 24 months, with 33% of grafts still patent at that time. Median survival was 18.1 months, and median graft patency was 17.9 months.CONCLUSIONS: GMF is a safe and effective treatment for groin complications following arterial bypass surgery with synthetic graft. Due to its versatility, area of coverage, ease of use, and durability it potentially should be considered as a primary form of muscle coverage for groin complications.

    View details for DOI 10.1016/j.avsg.2018.02.009

    View details for PubMedID 29660388

  • Thrombolysis for Venous Thromboembolism During Pregnancy: A Literature Review. Vascular and endovascular surgery Ho, V. T., Dua, A., Lavingia, K., Rothenberg, K., Rao, C., Desai, S. S. 2018: 1538574418777822


    BACKGROUND: Pregnancy is a hypercoagulable state, conferring an increased risk of venous thromboembolism (VTE). However, treatment algorithms for deep venous thrombosis and pulmonary embolism are based on studies of nonpregnant patients.METHODS: A literature review of cases in which thrombolysis was used for the treatment of VTE during pregnancy was conducted using the PubMed (National Institutes of Health) database.RESULTS: A PubMed database search of English language articles for reports of thrombolysis for the treatment of VTE in pregnancy identified 215 cases, including 183 cases of systemic thrombolysis, 19 cases of catheter-directed thrombolysis, and 13 cases of mechanical thrombectomy. For systemic thrombolysis, the maternal complication rate was 4.40% and the fetal complication rate was 1.65%. For catheter-directed thrombolysis, the maternal complication rate was 14.75% and the fetal complication rate was 5.2%. In cases of mechanical thrombectomy, there were no reported maternal or fetal complications.CONCLUSIONS: Although conservative strategies are preferred in pregnancy, thrombolysis is an adjunct for limb or life-threatening VTE. Review of past reports suggests low rates of maternal and fetal complications following systemic thrombolysis and mechanical thrombectomy but higher rates of complications after catheter-directed thrombolysis in the treatment of VTE during pregnancy.

    View details for DOI 10.1177/1538574418777822

    View details for PubMedID 29804522

  • Septic Pulmonary Emboli From Peripheral Suppurative Thrombophlebitis: A Case Report and Literature Review. Vascular and endovascular surgery Ho, V. T., Rothenberg, K. A., McFarland, G., Tran, K., Aalami, O. O. 2018: 1538574418779469


    BACKGROUND: We report the case of a 90-year old woman who presented with septic pulmonary emboli due to suppurative thrombophlebitis at an old peripheral intravenous site.METHODS: After unsuccessful treatment with antibiotics, the patient was taken to the operating room for excision and drainage of the purulent superficial vein.RESULTS: We review the literature and discuss the presentation, risk factors, treatment options, and complications of this often-overlooked disease entity.CONCLUSIONS: Suppurative thrombophlebitis is a rare but morbid disease that requires a high level of clinical suspicion to diagnose.

    View details for DOI 10.1177/1538574418779469

    View details for PubMedID 29909751

  • Mycotic Renal Artery Aneurysm Presenting as Critical Limb Ischemia in Culture-Negative Endocarditis CASE REPORTS IN SURGERY Vy Thuy Ho, Itoga, N. K., Wu, T., Sorial, E., Garcia-Toca, M. 2018: 7080813


    Mycotic renal artery aneurysms are rare and can be difficult to diagnose. Classic symptoms such as hematuria, hypertension, or abdominal pain can be vague or nonexistent. We report a case of a 53-year-old woman with a history of intravenous drug abuse presenting with critical limb ischemia, in which CT angiography identified a mycotic renal aneurysm. This aneurysm tripled in size from 0.46 cm to 1.65 cm in a 3-week interval. Echocardiography demonstrated aortic valve vegetations leading to a diagnosis of culture-negative endocarditis. The patient underwent primary resection and repair of the aneurysm, aortic valve replacement, and left below-knee amputation after bilateral common iliac and left superficial femoral artery stenting. At 1-year follow-up, her serum creatinine is stable and repaired artery remains patent.

    View details for PubMedID 29854544

    View details for PubMedCentralID PMC5964565