Clinical Focus

  • Vascular Surgery
  • Endovascular Procedures
  • Aortic Aneurysm
  • Aneurysm, Thoracoabdominal Aortic
  • Thoracic Outlet Syndrome
  • Thoracic Aneurysm
  • Carotid Stenting
  • Fenestrated/Branched Endovascular Repair

Academic Appointments

Administrative Appointments

  • Curriculum Committee, Goodman Simulation Center (2006 - Present)
  • Director of Endovascular Surgery, Stanford Hospital and Clinics (2007 - Present)
  • Program Director, Vascular Surgery Fellowship/Residency (2011 - Present)

Professional Education

  • Residency:LA CO-Harbor-UCLA Medical Center (2004) CA
  • Board Certification: Vascular Surgery, American Board of Surgery (2007)
  • Fellowship:Stanford University Medical Center (2006) CA
  • Internship:LA CO-Harbor-UCLA Medical Center (1999) CA
  • Medical Education:University of California San Diego (1998) CA
  • Fellowship, Stanford Univ. Medical Center, Vascular Surgery (2006)
  • Residency, Harbor-UCLA Medical Center, General Surgery (2004)
  • MD, UC San Diego School of Medicine (1998)

Research & Scholarship

Current Research and Scholarly Interests

Describe your current research interest and activities

Clinical Trials

  • Feasibility Study for GORE® TAG® Thoracic Branch Endoprosthesis to Treat Proximal Descending Thoracic Aortic Aneurysms Recruiting

    The purpose of this study is to assess the feasibility of the use of the GORE® TAG® Thoracic Branch Endoprosthesis to treat aneurysms involving the proximal Descending Thoracic Aorta (DTA)

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  • PRESERVE-Zenith® Branch Endovascular Graft-Iliac Bifurcation Recruiting

    The purpose of this extended study is to collect confirmatory safety and effectiveness data on the Zenith® Branch Endovascular Graft-Iliac Bifurcation in combination with the commercially available Atrium iCAST™ covered stent in the treatment of aortoiliac and iliac aneurysms.

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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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  • Valiant Evo US Clinical Trial Recruiting

    The purpose of the Valiant Evo US Clinical Trial is to demonstrate the safety and effectiveness of the Valiant Evo Thoracic Stent Graft System in subjects with a descending thoracic aortic aneurysm (DTAA) who are candidates for endovascular repair.

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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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  • Endovascular Repair of Abdominal Aortic Aneurysms Not Recruiting

    The purpose of this study is to determine if it is safe and effective to use the TALENT AAA Stent Graft System as a treatment for AAAs in patients who are also candidates for conventional surgical aneurysm repair.

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

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  • Endovascular Repair of Descending Thoracic Aortic Aneurysms Not Recruiting

    The purpose of this study is to determine whether the system is safe and effective for the intended use of treating descending thoracic aortic aneurysms.

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

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  • Endurant Bifurcated and Aorto-Uni-Iliac (AUI) Stent Graft System Not Recruiting

    To demonstrate safety and effectiveness of the Endurant Stent Graft in the treatment of Abdominal Aortic or Aorto-Uni-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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  • Endurant Stent Graft System Post Approval Study (ENGAGE PAS) Not Recruiting

    The purpose of the study is to demonstrate the long term safety and effectiveness of the Endurant Stent Graft System for the endovascular treatment of infrarenal abdominal aortic aneurysms in a post-approval environment, through the endpoints established in this protocol. The clinical objective of the study is to evaluate the long term safety and effectiveness of the Endurant Stent Graft System assessed at 5 years through freedom from Aneurysm-Related Mortality (ARM).

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

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  • PRESERVE-Zenith® Branch Endovascular Graft-Iliac Bifurcation Clinical Study Not Recruiting

    The purpose of this extended study is to evaluate the safety and effectiveness of the Zenith® Branch Endovascular Graft-Iliac Bifurcation in combination with the commercially available Atrium iCAST™ covered stent in patients in a treatment of aortoiliac and iliac aneurysms.

    Stanford is currently not accepting patients for this trial.

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  • PRESERVE-Zenith® Iliac Branch System Clinical Extended Study Not Recruiting

    The PRESERVE-Zenith® Iliac Branch System Clinical Study is a clinical trial to collect confirmatory safety and effectiveness data on the Zenith® Branch Endovascular Graft-Iliac Bifurcation System. This system is made up of two devices: the Zenith® Branch Endovascular Graft-Iliac Bifurcation and the ConnectSX™ covered stent in the treatment of aorto-iliac and iliac aneurysms

    Stanford is currently not accepting patients for this trial.

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  • Prospective Aneurysm Trial: High Angle Aorfix™ Bifurcated Stent Graft Not Recruiting

    Purpose of this study: The purpose of the study is to evaluate the safety and effectiveness of the Lombard Medical endovascular Aorfix™ AAA bifurcated stent graft in the treatment of abdominal aortic, aorto-iliac and common iliac aneurysms with anatomies including angled aorta, angled aneurysmal body, or both, between 0° and 90°. Study hypothesis: The primary efficacy hypothesis is the proportion of grafts remaining free from endoleak, migration, and fracture at 12 months. Efficacy: The 12 month, all cause mortality rate in the Aorfix™ group will be non-inferior to the 12 month, all cause mortality rate in the Open Control group. Safety: The rates of early serious adverse events between 0 and 30 days post-operative in the Aorfix™ groups will be non-inferior to the early serious adverse event rates between 0 and 30 days post-operative in the Open Control group.

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

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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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2018-19 Courses


All Publications

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

    View details for DOI 10.1002/pen.24977

    View details for Web of Science ID 000460185500021

  • 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


    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

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


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

    View details for PubMedID 30426849

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


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

    View details for DOI 10.6004/jnccn.2018.0084

    View details for PubMedID 30442731

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


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

    View details for DOI 10.1016/j.jvs.2017.11.086

    View details for Web of Science ID 000439318700076

    View details for PubMedID 29548812

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


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

    View details for DOI 10.1177/1538574418776440

    View details for Web of Science ID 000438625000005

    View details for PubMedID 29843567

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


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

    View details for DOI 10.1016/j.jvs.2017.10.080

    View details for Web of Science ID 000436836800005

    View details for PubMedID 29395423

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


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

    View details for PubMedID 29970274

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


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

    View details for PubMedID 29400263

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


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

    View details for PubMedID 28887263

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


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

    View details for PubMedID 29195571

  • Long-Term Outcomes After Repair of Symptomatic Nonruptured Abdominal Aortic Aneurysms Trang, K., Chandra, V., Virgin-Downey, W., Lee, J. T., Harris, E., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2017: E52
  • Standard EVAR in Patients With Dilated Infrarenal Necks Requiring a 34-36 mm Endograft Is Associated With Increased Risk of Type la Endoleak and Stent Migration McFarland, G. E., Tran, K., Virgin-Downey, W., Chandra, V., Mell, M. W., Harris, E., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2017: 43S–44S
  • Long-Term Outcomes After Repair of Symptomatic Abdominal Aortic Aneurysms Trang, K., Chandra, V., Virgin-Dodwney, W., Harris, E., Lee, J. T., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2017: 151S–152S
  • Prospective, multicenter study of endovascular repair of aortoiliac and iliac aneurysms using the Gore Iliac Branch Endoprosthesis. Journal of vascular surgery Schneider, D. B., Matsumura, J. S., Lee, J. T., Peterson, B. G., Chaer, R. A., Oderich, G. S. 2017


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

    View details for DOI 10.1016/j.jvs.2017.02.041

    View details for PubMedID 28559174

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


    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


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

    View details for DOI 10.1016/j.avsg.2017.01.025

    View details for PubMedID 28479440

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


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

    View details for DOI 10.1016/j.avsg.2016.12.005

    View details for PubMedID 28390918

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


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

    View details for DOI 10.1016/j.avsg.2016.11.013

    View details for PubMedID 28341512

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


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

    View details for DOI 10.1016/j.jsurg.2016.09.003

    View details for PubMedID 27727138

  • Orientation of Renal Stent Grafts Within the Proximal Seal Zone Affects Risk of Early Type Ia Endoleaks Following Snorkel-Chimney Endovascular Aneurysm Repair Tran, K., Ullery, B. W., Itoga, N. K., Lee, J. T. MOSBY-ELSEVIER. 2017: E1
  • Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair. Journal of vascular surgery Ullery, B. W., Tran, K., Itoga, N. K., Dalman, R. L., Lee, J. T. 2017


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

    View details for DOI 10.1016/j.jvs.2016.10.085

    View details for PubMedID 28189356

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


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

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

    View details for PubMedID 28154297

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


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

    View details for DOI 10.1016/j.avsg.2016.08.006

    View details for Web of Science ID 000396441100014

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


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

    View details for PubMedID 28619644

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


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

    View details for DOI 10.1016/j.jvs.2017.08.079

    View details for PubMedID 29103932

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


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

    View details for DOI 10.1016/j.jvs.2017.08.059

    View details for PubMedID 29074111

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


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

    View details for DOI 10.1016/j.jvs.2016.07.121

    View details for PubMedID 27871490

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


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

    View details for DOI 10.1016/j.jvs.2016.08.110

    View details for PubMedID 27887854

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


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

    View details for DOI 10.1016/j.jvs.2016.02.036

    View details for PubMedID 27066949

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


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

    View details for DOI 10.1016/j.jvs.2016.01.041

    View details for Web of Science ID 000380753300002

    View details for PubMedID 27237402

  • Management of Symptomatic Unruptured Aortic Aneurysms Over the Past 20 Years 31st Annual Meeting of the Western-Vascular-Society Trang, K., Harris, E. J., Dalman, R. L., Lee, J. T., Mell, M. W., Chandra, V. MOSBY-ELSEVIER. 2016: 553–53

    View details for Web of Science ID 000380753300077

    View details for PubMedID 27763319

  • Sustained Late Branch Patency and Low Incidence of Persistent Type Ia Endoleaks Following Snorkel/chimney EVAR Shown in the Updated PERICLES Registry Lee, J. T., Pecoraro, F., Dalman, R. L., Tran, K., Torsello, G., Veith, F. J., Lachat, M., Donas, K. P. MOSBY-ELSEVIER. 2016: 145S
  • Learning Curve of Robotic-Assisted Anastomosis: Shorter than the Laparoscopic Technique? An Educational Study ANNALS OF VASCULAR SURGERY Lucereau, B., Thaveau, F., Lejay, A., Roussin, M., Georg, Y., Heim, F., Lee, J. T., Chakfe, N. 2016; 33: 39-44


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

    View details for DOI 10.1016/j.avsg.2015.12.001

    View details for PubMedID 26806248

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


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

    View details for DOI 10.1016/j.avsg.2015.11.030

    View details for PubMedID 26965797

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


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

    View details for DOI 10.1016/j.jvs.2015.10.091

    View details for Web of Science ID 000372958200012

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


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

    View details for DOI 10.1016/j.ejvs.2015.12.015

    View details for Web of Science ID 000374618400020

    View details for PubMedID 26905622

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


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

    View details for DOI 10.1053/j.semvascsurg.2016.07.002

    View details for Web of Science ID 000388056300010

    View details for PubMedID 27823593

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


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

    View details for DOI 10.1016/j.avsg.2015.08.008

    View details for PubMedID 26597236

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


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

    View details for DOI 10.1016/j.avsg.2015.04.093

    View details for Web of Science ID 000367408700001

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


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

    View details for DOI 10.1016/j.avsg.2015.07.033

    View details for PubMedID 26522581

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


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

    View details for DOI 10.1016/j.jvs.2015.09.026

    View details for PubMedID 26598123

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


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

    View details for DOI 10.1177/1538574415617554

    View details for Web of Science ID 000366160300004

    View details for PubMedID 26647427

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

    View details for DOI 10.1016/j.ejvs.2015.07.025

    View details for PubMedID 26602953

  • 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


    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

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


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

    View details for DOI 10.1016/j.jvs.2015.07.001

    View details for Web of Science ID 000365242000039

    View details for PubMedID 26506275

  • Geometric analysis of thoracic aorta and arch branches before and after TEVAR Suh, G., Hirotsu, K., Zhu, Y. D., Lee, J., Dake, M., Fleischmann, D., Cheng, C. ELSEVIER SCIENCE INC. 2015: B129
  • Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study ANNALS OF SURGERY Poultsides, G. A., Tran, T. B., Zambrano, E., Janson, L., Mohler, D. G., Mell, M. W., Avedian, R. S., Visser, B. C., Lee, J. T., Ganjoo, K., Harris, E. J., Norton, J. A. 2015; 262 (4): 632-640


    To examine the impact of major vascular resection on sarcoma resection outcomes.En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described.Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival.From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion.Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

    View details for DOI 10.1097/SLA.0000000000001455

    View details for Web of Science ID 000367999800009

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


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

    View details for PubMedID 25800354

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


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

    View details for DOI 10.1002/jbm.b.33330

    View details for Web of Science ID 000363693600016

    View details for PubMedID 25448469

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


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

    View details for DOI 10.1016/j.avsg.2015.04.078

    View details for Web of Science ID 000361629800002

    View details for PubMedID 26133994

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


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

    View details for DOI 10.1097/SLA.0000000000001405

    View details for PubMedID 26258324

  • 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


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

    View details for DOI 10.1177/1526602815590119

    View details for Web of Science ID 000358119200019

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


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

    View details for DOI 10.1016/j.jvs.2014.12.062

    View details for Web of Science ID 000355018500013

    View details for PubMedID 25704407

  • Renal Function Changes Following Fenestrated EVAR Ullery, B., Tran, K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2015: 56S
  • Comparative Geometric Analysis of Renal Artery Anatomy Before and After Fenestrated or Snorkel/Chimney EVAR Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. MOSBY-ELSEVIER. 2015: 117S–118S
  • Geometry and respiratory-induced deformation of abdominal branch vessels and stents after complex endovascular aneurysm repair JOURNAL OF VASCULAR SURGERY Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. 2015; 61 (4): 875-884


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

    View details for DOI 10.1016/j.jvs.2014.11.075

    View details for PubMedID 25601499

  • 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


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

    View details for DOI 10.1016/j.avsg.2014.07.025

    View details for PubMedID 25192823

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


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

    View details for DOI 10.1016/j.avsg.2014.08.003

    View details for PubMedID 25194549

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


    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

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


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

    View details for DOI 10.1016/j.jvs.2014.04.057

    View details for Web of Science ID 000343316600021

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


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

    View details for DOI 10.1016/j.jvs.2014.03.255

    View details for Web of Science ID 000343316600003

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


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

    View details for DOI 10.1016/j.avsg.2014.05.008

    View details for Web of Science ID 000342162000069

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


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

    View details for DOI 10.1016/j.jvs.2014.04.055

    View details for Web of Science ID 000343316600014

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


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

    View details for DOI 10.1016/j.anclin.2014.05.003

    View details for PubMedID 25113729

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


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

    View details for DOI 10.1016/j.jvs.2014.03.239

    View details for PubMedID 24785683

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


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

    View details for DOI 10.1016/j.avsg.2014.03.026

    View details for PubMedID 24704051

  • More Aggressive Anticoagulation/Antiplatelet Regimen Improves Patency Following Viabahn Stent Grafting of the SFA Ullery, B. W., Itoga, N., Tran, K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2014: 549
  • Geometry and Respiratory-Induced Deformation of Abdominal Branch Vessels Following Complex EVAR Ullery, B. W., Suh, G., Lee, J. T., Liu, B., Stineman, R., Dalman, R. L., Cheng, C. P. MOSBY-ELSEVIER. 2014: 539–40
  • 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


    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

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


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

    View details for DOI 10.1016/j.jvs.2014.01.071

    View details for PubMedID 24680241

  • Impact of Renal Artery Angulation on Procedural Complexity During Fenestrated and Snorkel EVAR Ullery, B. W., Chandra, V., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2014: 10S–11S
  • Popliteal artery entrapment syndrome JOURNAL OF CARDIOVASCULAR SURGERY Lejay, A., Ohana, M., Lee, J. T., Georg, Y., Delay, C., Lucereau, B., Thaveau, F., Gaertner, S., Chakfe, N. 2014; 55 (2): 225-237


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

    View details for Web of Science ID 000336514400025

    View details for PubMedID 24796917

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


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

    View details for DOI 10.1016/j.avsg.2013.07.005

    View details for Web of Science ID 000328646400016

    View details for PubMedID 24189012

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


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

    View details for DOI 10.1016/j.ejvs.2013.09.023

    View details for Web of Science ID 000328719200013

    View details for PubMedID 24161724

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


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

    View details for Web of Science ID 000327066800009

  • Factors impacting follow-up care after placement of temporary inferior vena cava filters 27th Annual Meeting of the Western-Vascular-Society Gyang, E., Zayed, M., Harris, E. J., Lee, J. T., Dalman, R. L., Mell, M. W. MOSBY-ELSEVIER. 2013: 440–45


    Rates of inferior vena cava (IVC) filter retrieval have remained suboptimal, in part because of poor follow-up. The goal of our study was to determine demographic and clinical factors predictive of IVC filter follow-up care in a university hospital setting.We reviewed 250 consecutive patients who received an IVC filter placement with the intention of subsequent retrieval between March 2009 and October 2010. Patient demographics, clinical factors, and physician specialty were evaluated. Multivariate logistic regression analysis was performed to identify variables predicting follow-up care.In our cohort, 60.7% of patients received follow-up care; of those, 93% had IVC filter retrieval. Major indications for IVC filter placement were prophylaxis for high risk surgery (53%) and venous thromboembolic event with contraindication and/or failure of anticoagulation (39%). Follow-up care was less likely for patients discharged to acute rehabilitation or skilled nursing facilities (P < .0001), those with central nervous system pathology (eg, cerebral hemorrhage or spinal fracture; P < .0001), and for those who did not receive an IVC filter placement by a vascular surgeon (P < .0001). In a multivariate analysis, discharge home (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.99-8.2; P < .0001), central nervous system pathology (OR, 0.46; 95% CI, 0.22-0.95; P = .04), and IVC filter placement by the vascular surgery service (OR, 4.7; 95% CI, 2.3-9.6; P < .0001) remained independent predictors of follow-up care. Trauma status and distance of residence did not significantly impact likelihood of patient follow-up.Service-dependent practice paradigms play a critical role in patient follow-up and IVC filter retrieval rates. Nevertheless, specific patient populations are more prone to having poorer rates of follow-up. Such trends should be factored into institutional quality control goals and patient-centered care.

    View details for DOI 10.1016/j.jvs.2012.12.085

    View details for PubMedID 23588109

  • Early Experience with Fenestrated Endografts Compared to the Snorkel Technique: Lessons learned Lee, G., Varu, V., Chandra, V., Lee, J., Dalman, R. MOSBY-ELSEVIER. 2013: 555
  • Midterm Changes in Renal Function Following Snorkel Repair of Juxtarenal Aneurysms Varu, V. N., Tran, K., Chandra, V., Lee, G. K., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2013: 555
  • EVAR Deployment in Anatomically Challenging Necks Outside the IFU 63rd Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) Lee, J. T., Ullery, B. W., Zarins, C. K., Olcott, C., Harris, E. J., Dalman, R. L. W B SAUNDERS CO LTD. 2013: 65–73


    Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points.A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU).IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all p < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs. 2.1%, p = .003), and needed increased fluoroscopy time (31 vs. 25 minutes, p = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, p = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05).EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.

    View details for DOI 10.1016/j.ejvs.2013.03.027

    View details for Web of Science ID 000321883200013

    View details for PubMedID 23628325

  • Creating a Vascular Skills Examination: Three New Validated Assessment Models Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) Sheahan, M. G., Sheahan, C., Gerdes, J., Bismuth, J., Lee, J., Shames, M., Wilkinson, J., Eidt, J. MOSBY-ELSEVIER. 2013: 14S–15S
  • Differences in readmissions after open repair versus endovascular aneurysm repair 26th Annual Meeting of the Western-Vascular-Society Casey, K., Hernandez-Boussard, T., Mell, M. W., Lee, J. T. MOSBY-ELSEVIER. 2013: 89–95


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

    View details for DOI 10.1016/j.jvs.2012.07.005

    View details for Web of Science ID 000312833800016

    View details for PubMedID 23164606

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


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

    View details for DOI 10.1016/j.jvs.2012.05.083

    View details for Web of Science ID 000310428200047

    View details for PubMedID 22857814

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


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

    View details for DOI 10.1016/j.jvs.2012.04.070

    View details for Web of Science ID 000310428200008

    View details for PubMedID 22743017

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

    View details for DOI 10.1001/archsurg.2012.2021

    View details for PubMedID 22987178

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


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

    View details for DOI 10.1016/j.avsg.2012.01.013

    View details for PubMedID 22794345

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


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

    View details for DOI 10.1016/j.jvs.2012.01.029

    View details for Web of Science ID 000307160400020

    View details for PubMedID 22551911

  • Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair 26th Annual Meeting of the Western-Vascular-Society Greenberg, J. I., Dorsey, C., Dalman, R. L., Lee, J. T., Harris, E. J., Hernandez-Boussard, T., Mell, M. W. MOSBY-ELSEVIER. 2012: 291–97


    Current information regarding coverage of accessory renal arteries (ARAs) during endovascular aneurysm repair (EVAR) is based on small case series with limited follow-up. This study evaluates the outcomes of ARA coverage in a large contemporary cohort.Consecutive EVAR data from January 2004 to August 2010 were collected in a prospective database at a University Hospital. Patient and aneurysm-related characteristics, imaging studies, and ARA coverage versus preservation were analyzed. Volumetric analysis of three-dimensional reconstruction computed tomography scans was used to assess renal infarction volume extent. Long-term renal function and overall technical success of aneurysm exclusion were compared.A cohort of 426 EVARs was identified. ARAs were present in 69 patients with a mean follow-up of 27 months (range, 1 to 60 months). Forty-five ARAs were covered in 40 patients; 29 patients had intentional ARA preservation. Patient and anatomic characteristics were similar between groups except that ARA coverage patients had shorter aneurysm necks (P = .03). Renal infarctions occurred in 84% of kidneys with covered ARAs. There was no significant deterioration in long-term glomerular filtration rate when compared with patients in the control group. No difference in the rate of endoleak, secondary procedures, or the requirement for antihypertensive medications was found.This study is the largest to date with the longest follow-up relating to ARA coverage. Contrary to previous reports, renal infarction after ARA coverage is common. Nevertheless, coverage is well tolerated based upon preservation of renal function without additional morbidity. These results support the long-term safety of ARA coverage for EVAR when necessary.

    View details for DOI 10.1016/j.jvs.2012.01.049

    View details for PubMedID 22480767

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


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

    View details for DOI 10.1016/j.avsg.2011.08.027

    View details for Web of Science ID 000304901500027

    View details for PubMedID 22664290

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

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

    View details for Web of Science ID 000305746100009

    View details for PubMedID 22212729

  • See One, Sim One, Do One, Teach One: Results of a Prospective Randomized Trial of Endovascular Skills Training for Surgical Residents William J. Von Liebig Forum at the Rapid Session of the Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) / Peripheral-Vascular-Surgery-Society Session Lee, J. T., Peruzzaro, A., Krummel, T., Dalman, R. L. MOSBY-ELSEVIER. 2012: 27–27
  • Spinal Cord Injury after Hybrid Endovascular Repair of Thoracoabdominal Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry William J. Von Liebig Forum at the Rapid Session of the Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) / Peripheral-Vascular-Surgery-Society Session Oderich, G. S., Timaran, C., Farber, M., Quinones-Baldrich, W., Escobar, G., Gloviczki, P., Greenberg, R. K., Black, J., Ellozy, S., Woo, E., Singh, M., Fillinger, M., Lee, J., Dosluoglu, H. H. MOSBY-ELSEVIER. 2012: 93–94
  • Outcomes of Ischemic Colitis after Hybrid Endovascular Repair of Complex Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry William J. Von Liebig Forum at the Rapid Session of the Vascular Annual Meeting of the Society-for-Vascular-Surgery (SVS) / Peripheral-Vascular-Surgery-Society Session Timaran, C. H., Oderich, G. S., Farber, M. A., Quinones-Baldrich, W., Gloviczki, P., Escobar, G., Greenberg, R. K., Black, J., Ellozy, S., Woo, E., Singh, M., Fillinger, M., Lee, J., Dosluoglu, H. H. MOSBY-ELSEVIER. 2012: 9–9
  • Selective Use of Percutaneous Endovascular Aneurysm Repair in Women Leads to Fewer Groin Complications 35th Annual Spring Meeting of the Peripheral-Vascular-Surgery-Society Al-Khatib, W. K., Zayed, M. A., Harris, E. J., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012: 476–82


    Endovascular aneurysm repair (EVAR) in women is often technically limited by smaller access vessel anatomy, particularly at the femoral and iliac artery levels. Percutaneous femoral artery access and closure using the "Preclose" technique (PERC) is a less invasive alternative to open surgical femoral arterial exposure and has been reported to be technically feasible, particularly in male cohorts. The purpose of this study was to evaluate the efficacy and access-related outcomes of PERC in women undergoing EVAR.We identified female patients in a prospectively maintained EVAR database from 2000 to 2009. An all-percutaneous approach was adopted in 2007 if technically feasible, based on preoperative computed tomography angiogram criteria including a femoral diameter >7 mm, <25% posterior plaque and lack of circumferential calcification/disease. All percutaneous EVAR procedures were performed using two Perclose Proglide devices in a standardized manner for sheath sizes ranging between 12F and 26F.In period 1 (2000-2006), most cases were performed with open femoral exposure. In period 2 (2007-2009), our group adopted a percutaneous-first approach. Of 736 EVARs performed during the study period, 120 (16.3%) were in women, leading to 178 femoral arteries requiring large sheath access. Period 1 included 90 women and period 2 included 30 women who were evaluated for percutaneous access. During period 2, of the 47 eligible femoral arteries for possible PERC, 24 (51%) met appropriate criteria, and the Preclose technique was employed. The remaining 23 femoral arteries during period 2 were accessed with surgical exposure (OPEN). Technical success rate of PERC in period 2 was 96%, with one device pulling through a thin anterior arterial wall requiring open femoral conversion. During period 2, the OPEN cohort had a higher rate of total wound complications compared with PERC (34.8% vs. 8.3%, P = 0.02), including hematomas (8.7% vs. 0%), wound breakdowns (8.7% vs. 0%), and pseudoaneurysms (4.3% vs. 0%). There were two cases of femoral artery thrombosis in the PERC group requiring repair in the immediate postoperative period; however, this was not significantly different compared with the OPEN group (8.7% vs. 8.3%).Selective percutaneous access of the femoral arteries for EVAR is safe and effective in the female population, with fewer wound complications than open exposure. Approximately one-half of femoral arteries in women are eligible for PERC access, and complications can be limited with careful selection based on preoperative imaging.

    View details for DOI 10.1016/j.avsg.2011.11.026

    View details for PubMedID 22437069



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

    View details for DOI 10.1016/j.ultrasmedbio.2011.12.016

    View details for PubMedID 22341050

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


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

    View details for DOI 10.1016/j.jvs.2011.11.041

    View details for PubMedID 22244859

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


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

    View details for DOI 10.1016/j.avsg.2011.11.007

    View details for Web of Science ID 000301847700018

    View details for PubMedID 22326296

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

    View details for DOI 10.1016/j.jvs.2011.09.076

    View details for PubMedID 22370024

  • 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


    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

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


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

    View details for DOI 10.1016/j.avsg.2011.06.005

    View details for Web of Science ID 000298325900015

    View details for PubMedID 21835579

  • 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


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

    View details for DOI 10.1016/j.jvs.2011.05.105

    View details for PubMedID 21803527

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


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

    View details for DOI 10.1016/j.avsg.2011.07.002

    View details for Web of Science ID 000296553100014

    View details for PubMedID 21945331

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


    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 Web of Science ID 000295562800042

    View details for PubMedID 21723068

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

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

    View details for Web of Science ID 000294800100005

    View details for PubMedID 21643740

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

    View details for DOI 10.1016/j.amjmed.2011.03.017

    View details for PubMedID 21683936

  • Early Experience with the Snorkel Technique for Juxtarenal Aneurysms: The Preferred Off-the-Shelf Solution for Challenging EVAR Anatomy? Lee, J. T., Greenberg, J. I., Dalman, R. L. MOSBY-ELSEVIER. 2011: 589–89
  • Who is Applying to Vascular Surgery? A Comparison of Demographics of 0+5 versus 5+2 Applicants Zayed, M. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2011: 587
  • Readmissions after Abdominal Aortic Aneurysm Repair: Differences between Open Repair and Endovascular Aneurysm Repair Casey, K. M., Hernandez-Boussard, T., Al-Khatib, W. K., Mell, M. W., Lee, J. T. MOSBY-ELSEVIER. 2011: 590–90
  • Results of a Double-Barrel Technique with Commercially Available Devices for Hypogastric Preservation during Aortoiliac EVAR DeRubertis, B. G., Quinones-Baldrich, W. J., Greenberg, J., Jimenez, J. C., Lee, J. T. MOSBY-ELSEVIER. 2011: 588–89
  • Long-Term Results after Accessory Renal Artery Coverage during Endovascular Aortic Aneurysm Repair Greenberg, J. I., Dorsey, C., Dalman, R. L., Lee, J. T., Mell, M. W. MOSBY-ELSEVIER. 2011: 588–88
  • Venous Thromboembolic Disease JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Streiff, M. B., Bockenstedt, P. L., Cataland, S. R., Chesney, C., Eby, C., Fanikos, J., Fogarty, P. F., Gao, S., Garcia-Aguilar, J., Goldhaber, S. Z., Hassoun, H., Hendrie, P., Holmstrom, B., Jones, K. A., Kuderer, N., Lee, J. T., Millenson, M. M., Neff, A. T., Ortel, T. L., Smith, J. L., Yee, G. C., Zakarija, A. 2011; 9 (7): 714-777

    View details for Web of Science ID 000292264200005

    View details for PubMedID 21715723

  • Surgery for Thoracic Outlet Syndrome: A Nationwide Perspective Vascular Annual Meeting of the Society-for-Vascular-Surgery Lee, J. T., Dua, M. M., Chandra, V., Hernandez-Boussard, T. M., Illig, K. A. MOSBY-ELSEVIER. 2011: 100S–101S
  • Interactive Online Training Improves Trainee Test Performance in Vascular Surgery Vascular Annual Meeting of the Society-for-Vascular-Surgery Zayed, M. A., Casey, K., Lilo, E., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2011: 99S–100S
  • A comparison between one- and two-stage brachiobasilic arteriovenous fistulas 25th Annual Meeting of the Western-Vascular-Surgical-Society Reynolds, T. S., Zayed, M., Kim, K. M., Lee, J. T., Ishaque, B., Dukkipati, R. B., Kaji, A. H., de Virgilio, C. MOSBY-ELSEVIER. 2011: 1632–38


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

    View details for DOI 10.1016/j.jvs.2011.01.064

    View details for Web of Science ID 000291410600026

    View details for PubMedID 21531530

  • Long-Term Impact of a Preclinical Endovascular Skills Course on Medical Student Career Choices 25th Annual Meeting of the Western-Vascular-Society Son, J. H., Zayed, M. A., Tedesco, M. M., Chandra, V., Lilo, E. A., Lee, J. T. MOSBY-ELSEVIER. 2010: 526–26
  • Early Results of a Highly Selective Algorithm for Surgery on Patients with Neurogenic Thoracic Outlet Syndrome: A Prospective Analysis 25th Annual Meeting of the Western-Vascular-Society Chandra, V., Olcott, C., Lee, J. T. MOSBY-ELSEVIER. 2010: 525–25
  • A survey of demographics, motivations, and backgrounds among applicants to the integrated 0+5 vascular surgery residency JOURNAL OF VASCULAR SURGERY Lee, J. T., Teshome, M., De Virgilio, C., Ishaque, B., Qiu, M., Dalman, R. L. 2010; 51 (2): 496-503


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

    View details for DOI 10.1016/j.jvs.2009.08.076

    View details for PubMedID 20022205

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

    View details for DOI 10.1016/j.pmrj.2009.12.001

    View details for PubMedID 20129515

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


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

    View details for DOI 10.1016/j.jsurg.2009.06.002

    View details for PubMedID 20142137

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


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

    View details for PubMedID 19642793

  • Not All "Microemboli" are Created Equal: Hypotension During Carotid Stenting May be a Cause for Some Lesions. American-Association-International-Stroke Conference 2009 Kleinman, J. T., Tedesco, M. M., Gottesman, R. F., Lane, B., Zhou, W., Dalman, R. L., Lee, J. T. LIPPINCOTT WILLIAMS & WILKINS. 2009: E175–E175
  • Reduction of postprocedure microemboli following retrospective quality assessment and practice improvement measures for carotid angioplasty and stenting JOURNAL OF VASCULAR SURGERY Tedesco, M. M., Dalman, R. L., Zhou, W., Coogan, S. M., Lane, B., Lee, J. T. 2009; 49 (3): 607-612


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

    View details for DOI 10.1016/j.jvs.2008.10.031

    View details for Web of Science ID 000263802000015

    View details for PubMedID 19135833

  • Anatomic Suitability of Ruptured Abdominal Aortic Aneurysms for Endovascular Repair 18th Annual Winter Meeting of the Peripheral-Vascular-Surgical-Society Slater, B. J., Harris, E. J., Lee, J. T. ELSEVIER SCIENCE INC. 2008: 716–22


    Mortality from ruptured abdominal aortic aneurysms (rAAAs) remains high despite improvements in anesthesia, postoperative intensive care, and surgical techniques. Recent small series and single-center experiences suggest that endovascular aneurysm repair (EVAR) for rAAAs is feasible and may improve short-term survival. However, the applicability of EVAR to all cases of rAAA is unknown. The purpose of this study was to investigate the anatomical suitability of ruptured aneurysms for EVAR as determined by preoperative cross-sectional imaging. A contemporary consecutive series of rAAAs presenting to a tertiary academic center was retrospectively reviewed. Preoperative radiographic imaging was reviewed and assessed for endovascular compatibility based on currently available EVAR devices. Patients with aneurysm morphology demonstrating neck diameter >32 mm, neck length <10 mm, neck angulation >60 degrees, severe iliac tortuosity, or external iliac diameter <6 mm were deemed noncandidates for EVAR. Forty-seven rAAAs were treated over a 10-year period, with 47% of patients presenting with free rupture and 60% of patients transferred from outside hospitals. Five (11%) patients were treated with EVAR, all over the past 2 years, while the remaining 42 patients underwent open repair. Preoperative imaging was available for review in 43 (91%) patients, and morphological measurements indicated that 49% would have been candidates for EVAR with currently available devices. Criteria precluding EVAR in this cohort were inadequate neck length in 73%, unsuitable iliac access in 23%, large neck diameter in 18%, and severe neck angulation in 14%. Overall 30-day mortality was 34%, and 1-year mortality was 42%. Candidates for EVAR were more likely than non-EVAR candidates to be male (95% vs. 68%, p = 0.046) and to have smaller sac diameters (7.0 vs. 8.5 cm, p = 0.02) and longer neck lengths (24.1 vs. 8.6 mm, p < 0.0001); less likely to have a >60 degree angulated neck (10% vs. 45%, p = 0.0002), larger external iliac diameter (8.9 vs. 7.3 mm, p = 0.015), and less blood loss during surgical repair (2.4 vs. 6.0 L, p = 0.02); and more likely to be discharged home (71% vs. 25%, p = 0.05). There were no differences in 30-day, 1-year, or overall mortality between candidates for EVAR and noncandidates. Only 49% of patients with rAAAs in this consecutive series were found to be candidates for EVAR with conventional stent-graft devices. Differences in demographics, aneurysm morphology, and outcomes between candidates and noncandidates undergoing open repair suggest that differential risks apply to ruptured aneurysm patients. Protocols and future reports of EVAR for rAAAs should be tailored to these results. Device and technique modifications are necessary to increase the applicability of EVAR for rAAAs.

    View details for DOI 10.1016/j.avsg.2008.06.001

    View details for PubMedID 18657385

  • Relationship Between Hypotension and Distribution of Microemboli on DW-MRI Following Carotid Angioplasty and Stenting 81st Annual Scientific Session of the American-Heart-Association Lee, J. T., Kleinman, J. T., Teshome, M., Raghavan, S., Tedesco, M. M., Lane, B., Zhou, W., Dalman, R. L. LIPPINCOTT WILLIAMS & WILKINS. 2008: S1077–S1077
  • Treating superficial venous thrombophlebitis. Journal of the National Comprehensive Cancer Network Lee, J. T., Kalani, M. A. 2008; 6 (8): 760-765


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

    View details for PubMedID 18926088

  • Simulation based training improves medical student performance on an endovascular simulator 94th Annual Clinical Congress of the American-College-of-Surgeons/63rd Annual Sessions of the Owen H Wangensteen Forum on Fundamental Surgical Problems Tedesco, M. M., Peterson, D. A., Song, T. K., Parent, R., Qiu, M., Lee, J. T. ELSEVIER SCIENCE INC. 2008: S87–S87
  • Venous thromboembolic disease. NCCN. Clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network Wagman, L. D., Baird, M. F., Bennett, C. L., Bockenstedt, P. L., Cataland, S. R., Fanikos, J., Fogarty, P. F., Goldhaber, S. Z., Grover, T. S., Haire, W., Hassoun, H., Hutchinson, S., Jahanzeb, M., Lee, J., Linenberger, M. L., Millenson, M. M., Ortel, T. L., Salem, R., Smith, J. L., Streiff, M. B., Vedantham, S. 2008; 6 (8): 716-753

    View details for PubMedID 18926086

  • Simulation-based endovascular skills assessment: The future of credentialing? 22nd Annual Meeting of the Western-Vascular-Society Tedesco, M. M., Pak, J. J., Harris, E. J., Krummel, T. M., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2008: 1008–14


    Simulator-based endovascular skills training measurably improves performance in catheter-based image-guided interventions. The purpose of this study was to determine whether structured global performance assessment during endovascular simulation correlated well with trainee-reported procedural skill and prior experience level.Fourth-year and fifth-year general surgery residents interviewing for vascular fellowship training provided detailed information regarding prior open vascular and endovascular operative experience. The pretest questionnaire responses were used to separate subjects into low (<20 cases) and moderate (20 to 100) endovascular experience groups. Subjects were then asked to perform a renal angioplasty/stent procedure on the Procedicus Vascular Intervention System Trainer (VIST) endovascular simulator (Mentice Corporation, Gothenburg, Sweden). The subjects' performance was supervised and evaluated by a blinded expert interventionalist using a structured global assessment scale based on angiography setup, target vessel catheterization, and the interventional procedure. Objective measures determined by the simulator were also collected for each subject. A postsimulation questionnaire was administered to determine the subjects' self-assessment of their performance.Seventeen surgical residents from 15 training programs completed questionnaires before and after the exercise and performed a renal angioplasty/stent procedure on the endovascular simulator. The beginner group (n = 8) reported prior experience of a median of eight endovascular cases (interquartile range [IQR], 6.5-17.8; range, 4-20), and intermediate group (n = 9) had previously completed a median of 42 cases (IQR, 31-44; range, 25-89, P = .01). The two groups had similar prior open vascular experience (79 cases vs 75, P = .60). The mean score on the structured global assessment scale for the low experience group was 2.68 of 5.0 possible compared with 3.60 for the intermediate group (P = .03). Scores for subcategories of the global assessment score for target vessel catheterization (P = .02) and the interventional procedure (P = .05) contributed more to the differentiation between the two experience groups. Total procedure time, fluoroscopy time, average contrast used, percentage of lesion covered by the stent, placement accuracy, residual stenosis rates, and number of cine loops utilized were similar between the two groups (P > .05).Structured endovascular skills assessment correlates well with prior procedural experience within a high-fidelity simulation environment. In addition to improving endovascular training, simulators may prove useful in determining procedural competency and credentialing standards for endovascular surgeons.

    View details for DOI 10.1016/j.jvs.2008.01.007

    View details for PubMedID 18372149

  • Developing an Arterial Bleed Detection Algorithm for Diagnostic Ultrasound IEEE Ultrasonics Symposium Wang, A. S., Bech, F., Lee, J., Taylor, C. A., Liang, D. H. IEEE. 2008: 1627–1630
  • Risk factors for developing postprocedural microemboli following carotid interventions JOURNAL OF ENDOVASCULAR THERAPY Tedesco, M. M., Coogan, S. M., Dalman, R. L., Haukoos, J. S., Lane, B., Loh, C., Penkar, T. S., Lee, J. T. 2007; 14 (4): 561-567


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

    View details for PubMedID 17696633

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


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

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

    View details for PubMedID 17600657

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


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

    View details for DOI 10.1016/j.jvs.2006.09.061

    View details for PubMedID 17263997

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


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

    View details for DOI 10.1053/j.semvascsurg.2006.06.004

    View details for PubMedID 16996415

  • Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome 20th Annual Meeting of the Western-Vascular-Society Lee, J. T., Karwowski, J. K., Harris, E. J., Haukoos, J. S., Olcott, C. MOSBY-ELSEVIER. 2006: 1236–43


    The purpose of this study was to determine the clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with nonoperative management of patients with primary subclavian vein thrombosis.Sixty-four patients treated for Paget-Schroetter syndrome from 1996 to 2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First-rib resection was performed in 29 patients (45%) within the first 3 months, with a success rate of 93%. The remaining 35 patients (55%) were treated nonoperatively and constitute this study's population.Of the 35 patients with successful nonoperative management, 8 (23%) developed recurrent thrombotic events of the same extremity at a mean follow-up time of 13 months after thrombolysis (range, 6-33 months). These eight patients subsequently underwent first-rib resection with a 100% success rate without further sequelae at a mean follow-up time of 51 months (range, 2-103 months). The other 27 patients remained symptom free at a mean follow-up interval of 55 months (range, 10-110 months). Bivariate analyses determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P = .05). The recurrence group was also significantly younger than the asymptomatic group (22 vs 36 years; P = .01). Sex, being a competitive athlete, a history of trauma, whether the dominant arm was affected, time of delay to lysis, initial clot burden, response to original lysis, use of adjunctive balloons or mechanical thrombectomy devices, residual stenosis on venography, length of time on warfarin, and patency of the vein on follow-up duplex examination were all characteristics not associated with long-term recurrence after nonoperative management.Conservative nonoperative management of primary subclavian vein thrombosis can be successfully used with acceptable long-term results. A younger age (<28 years old) and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.

    View details for DOI 10.1016/j.jvs.2006.02.005

    View details for PubMedID 16765247

  • Endovascular stent-graft repair of thoracic aortic aneurysms and dissections VASCULAR SURGERY: BASIC SCIENCE AND CLINICAL CORRELATIONS, 2ND EDITION Lee, J. T., White, R. A., White, R. A., Hollier, L. H. 2005: 554–66
  • Colonic histoplasmosis presenting as colon cancer in the nonimmunocompromised patient: Report of a case and review of the literature Annual Meeting of the Southern California Chapter of the American-College-of-Surgeons Lee, J. T., Dixon, M. R., Murrell, Z., Konyalian, V., Agbunag, R., Rostami, S., French, S., Kumar, R. R. SOUTHEASTERN SURGICAL CONGRESS. 2004: 959–63


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

    View details for Web of Science ID 000225229400005

    View details for PubMedID 15586505

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


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

    View details for DOI 10.1016/j.suc.2004.04.012

    View details for PubMedID 15364556

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


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

    View details for DOI 10.1016/j.jvs.2004.03.051

    View details for Web of Science ID 000227388100006

    View details for PubMedID 15297815

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


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

    View details for PubMedID 15185176

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


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

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

    View details for Web of Science ID 000186955400027

    View details for PubMedID 14681624

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


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

    View details for Web of Science ID 000186440000001

    View details for PubMedID 14627248

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


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

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

    View details for Web of Science ID 000185492300011

    View details for PubMedID 14500144

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


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

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

    View details for Web of Science ID 000183985900009

    View details for PubMedID 12844089

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


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

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

    View details for Web of Science ID 000182424700003

    View details for PubMedID 12616351

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


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

    View details for Web of Science ID 000179638100018

    View details for PubMedID 12431151

  • Regression of a descending thoracoabdominal aortic dissection following staged deployment of thoracic and abdominal aortic endografts JOURNAL OF ENDOVASCULAR THERAPY White, R. A., Donayre, C., Walot, I., Lee, J., Kopchok, G. E. 2002; 9: 92-97
  • Regression of a descending thoracoabdominal aortic dissection following staged deployment of thoracic and abdominal aortic endografts. Journal of endovascular therapy White, R. A., Donayre, C., Walot, I., Lee, J., Kopchok, G. E. 2002; 9: II92-7


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

    View details for PubMedID 12166848