Emeritus Faculty-Med Ctr Line, Surgery
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
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
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
We sought to assess the effects of cardiopulmonary bypass and profound hypothermic circulatory arrest on plasma cefazolin levels administered for antimicrobial prophylaxis in cardiovascular surgery.Four groups (10 patients per group) were prospectively studied: vascular surgery without cardiopulmonary bypass (group A), cardiac surgery with a cardiopulmonary bypass time of less than 120 minutes (group B), cardiac surgery with a cardiopulmonary bypass time of greater than 120 minutes (group C), and cardiac surgery with cardiopulmonary bypass and profound hypothermic circulatory arrest (group D). Subjects received cefazolin at induction and a second dose before wound closure. Arterial blood samples were obtained preceding cefazolin administration, at skin incision, hourly during the operation, and before redosing. Cefazolin plasma concentrations were determined by using a radial diffusion assay, with Staphylococcus aureus as the indicator microorganism. Cefazolin plasma concentrations were considered noninhibitory at 8 microg/mL or less, intermediate at 16 mug/mL, and inhibitory at 32 microg/mL or greater.In group A cefazolin plasma concentrations remained greater than 16 microg/mL during the complete surgical procedure. In group B cefazolin plasma concentrations diminished to 16 microg/mL or less in 30% of the patients but remained greater than 8 microg/mL. In group C cefazolin plasma concentrations decreased to less than 16 microg/mL in 60% of patients and were less than 8 microg/mL in 50% of patients. In group D cefazolin plasma concentrations reached 16 microg/mL in 66% of the patients but decreased to 8 microg/mL in only 1 patient.For patients undergoing cardiac surgery with a cardiopulmonary bypass time of greater than 120 minutes, a single dose of cefazolin before skin incision with redosing at wound closure does not provide targeted antimicrobial cefazolin plasma levels during the entire surgical procedure. Patients undergoing profound hypothermic circulatory arrest are better protected, but the described protocol of prophylaxis is not optimal.
View details for DOI 10.1016/j.jtcvs.2005.11.047
View details for PubMedID 16733167
Athletes are susceptible to a variety of vascular injuries, yet clinical presentation may be subtle and the extent of injury underestimated.To evaluate Stanford University's experience with the diagnosis and management of vascular injuries incurred during athletic competition.Between June 1994 and June 2001, 29 patients with athletic competition-related vascular injuries were treated by our service. Clinical presentation, type of athletic competition, location of injury, type of therapy, and degree of rehabilitation were analyzed.Mean patient age was 23.8 years. In total, 17 arterial and 12 venous injuries were treated. Arterial injuries consisted of 8 axillary or subclavian branch artery aneurysms with embolization, 6 popliteal artery injuries, and 3 external iliac artery injuries. Subclavian vein thrombosis (SVT) accounted for all venous complications. Sixteen (94%) patients with arterial injuries required surgical repair. Fifteen reconstructions maintained primary patency with a mean follow-up of 43.9 months. All patients with SVT received lytic therapy and anticoagulation. Eight of these (67%) required thoracic outlet decompression and venolysis. All patients with SVT have remained stable without further venous thrombosis.Athletes are susceptible to vascular injuries that may not be easily recognized. However, a high index of suspicion, appropriate imaging, and prompt treatment allow athletes to return to competition in most cases.
View details for Web of Science ID 000182060800009
View details for PubMedID 20086465
To compare early and late functional outcomes, as well as survival and recovery, following endovascular or open repair of abdominal aortic aneurysm (AAA).Between 1996 and 2000, 294 patients underwent AAA repair (141 open and 153 endovascular); 57 patients from each group had 12-month follow-up for functional outcome assessment. Recovery was measured as hospital length of stay, skilled nursing requirement, and hospital readmission within 1 year to determine cumulative hospital utilization. Early (<6 months) functional outcomes were measured by activity level and convalescence days following surgery. Late (>6 months) functional outcomes were measured as ambulation, independent living, and employment status pre- and postoperatively.Operative mortality for open repair was 5 (3.5%) compared to 1 (0.6%) after an endovascular procedure (p<0.05). The endovascular group had a shorter hospital stay (2.8+/-2.8 versus 8.3+/-4.5 days) and fewer skilled nursing requirements (0% versus 26%; p<0.001). Cumulative hospital utilization over 12 months was 3.8 days for endovascular patients and 13.8 days for open repair (p<0.001). Recovery time was 99.3+/-84.1 days (range 14-365) in conventionally treated patients and 32.1+/-43.5 days (range 7-180) in the stent-graft group (p<0.001). At 6 months, 43 (75%) open and 54 (95%) endovascular patients had full recovery (p<0.01). Activity levels decreased in 13 (23%) open and 3 (5%) endovascular patients after surgery (p<0.01). There were no differences in ambulation, independent living, or employment status before and after treatment.Periprocedural survival following aneurysm repair is improved with endovascular grafting compared to open surgery, and recovery is more rapid, with a 78% reduction in total hospital days. Early functional outcomes are markedly improved with endovascular repair, while there is no difference in late functional outcomes between the procedures.
View details for Web of Science ID 000183272900002
View details for PubMedID 12751922
To compare systemic complications between standard surgery and endovascular repair of abdominal aortic aneurysms (AAA) for both primary and late secondary procedures.At a single center between July 1993 and May 2000, 297 patients (255 men; mean age 73.4 +/- 8.1 years, range 50-93) were treated with open surgical repair; beginning in 1996, 200 (166 men; mean age 73.6 +/- 8.0 years, range 45-96) patients were treated with the AneuRx stent-graft. In a comparison of the cohorts, which were similar in terms of age, gender, and aneurysm diameter, the main outcomes were early major systemic morbidity following the primary procedure to treat the aneurysm and late (>30 days) organ system morbidity for any secondary procedures.Mean length of follow-up for open patients was 20.1 +/- 17.1 months (range 1-150) compared to 12.4 +/- 9.6 months (range 1-60) after endovascular repair (p<0.05). There were 36 (12.1%) systemic complications after the primary open surgery and 15 (7.5%) after endovascular repair (p=NS). There were 43 (14.5%) combined primary and secondary morbidities in the open surgery group versus 15 (7.5%) for patients undergoing endovascular repair (p<0.01). The need for invasive procedures to treat these primary and secondary systemic complications was 4 times greater in the open group (17, 5.7%) than in endograft patients (3, 1.5%) (p<0.05). After secondary procedures (32 in the open group and 30 in the endovascular patients) for graft-related complications, there were 7 (21.9%) adverse events in the open group versus none (0%) for endograft patients (p<0.01). Hospital lengths of stay following both primary and secondary procedures were lower for the endograft patients (p<0.01 and p<0.001, respectively).Endovascular stent-graft repair compared to open surgery has reduced the early and late morbidity by half. Complications that require invasive or secondary surgical procedures and hospitalization are reduced with endovascular repair.
View details for Web of Science ID 000181102400001
View details for PubMedID 12546569
The optimal surgical management of subclavian vein effort thrombosis remains a dilemma because outcomes after different treatment strategies are only on the basis of small retrospective series. SVT treatment should be on the basis of the cause of thrombosis. Primary effort thrombosis or Paget-Schroetter syndrome frequently necessitates a surgical approach. The type of surgery has to be individualized after careful diagnostic evaluation. We report a congenital clavicular exostosis that had not been identified with chest radiograph and computed tomographic scan that caused SVT in a young woman. This unusual cause of Paget-Schroetter syndrome was treated with a unique approach.
View details for DOI 10.1067/mva.2002.125846
View details for Web of Science ID 000178099600045
View details for PubMedID 12218991
The purpose of this study was to utilize an objective endpoint analysis of aneurysm treatment, which is based on the primary objective of aneurysm repair, and to apply it to a consecutive series of patients undergoing open and endovascular repair.Aneurysm-related death was defined as any death that occurred within 30 days of primary aneurysm treatment (open or endovascular), within 30 days of a secondary aneurysm or graft-related treatment, or any death related to the aneurysm or graft at any time following treatment. We reviewed 417 consecutive patients undergoing elective infrarenal aortic aneurysm repair: 243 patients with open repair and 174 patients with endovascular repair.There was no difference between the groups (open vs endovascular) with regard to mean age +/- standard deviation (73 +/- 8 years vs 74 +/- 8 years) or aneurysm size (64 +/- 2 mm vs 58 +/- 10 mm) (P = not significant [NS]). The 30-day mortality for the primary procedure after open repair was 3.7% (9/243) and after endovascular repair was 0.6% (1/174, P <.05). The 30-day mortality for secondary procedures after open repair was 14% (6/41) compared to 0% after endovascular repair (P <.05). The aneurysm-related death rate was 4.1% (10/243) after open surgery and 0.6% (1/174) after endovascular repair (P <.05). Mean follow-up was 5 months longer following open repair (P <.05). Secondary procedures were performed in 41 patients following open surgery and 27 patients following endovascular repair (P = NS). Secondary procedures following open repair were performed for anastomotic aneurysms (n = 18), graft infection (n = 6), aortoenteric fistula (n = 5), anastomotic hemorrhage (n = 4), lower extremity amputation (n = 4), graft thrombosis (n = 3), and distal revascularization (n = 1). Secondary procedures following endovascular repair consisted of proximal extender cuffs (n = 11), distal extender cuffs (n = 11), limb thrombosis (n = 3), and surgical conversion (n = 2). The magnitude of secondary procedures following open repair was greater with longer operative time 292 +/- 89 minutes vs 129 +/- 33 minutes (P <.0001), longer length of stay 13 +/- 10 days vs 2 +/- 2 days (P <.0001) and greater blood loss 3382 +/- 4278 mL vs 851 +/- 114 mL (P <.0001).The aneurysm-related death rate combines early and late deaths and should be used as the primary outcome measure to objectively compare the results of open and endovascular repair in the treatment of infrarenal abdominal aortic aneurysms. In our experience, endovascular aneurysm repair reduced the overall aneurysm-related death rate when compared to open repair. Secondary procedures are required after both open and endovascular repair. However, the magnitude, morbidity, and mortality of secondary procedures are reduced significantly with endovascular repair.
View details for DOI 10.1067/mva.2002.126314
View details for Web of Science ID 000177489000015
View details for PubMedID 12170210
Duplex ultrasound scan (DUS) criteria for grading >50% carotid artery stenosis is typically divided into broad categories such as 50-79% stenosis, 80-99% stenosis, and occlusion. The purpose of this study is to validate DUS criteria for stratifying 50 to 100% carotid stenosis into 10% intervals using digital substraction cerebral angiography (DSCA) as the standard of comparison. Between 1996 and 2001, 163 patients were evaluated with duplex ultrasound and angiography. A total of 326 carotid arteries were studied using DUS in an accredited ICAVL vascular laboratory. Threshold velocity criteria for determining the degree of carotid stenosis was defined according to seven categories: <50%, 50-59%, 60-69%, 70-79%, 80-89%, 90-99%, and occlusion. Treatment decisions were based on the angiographic findings. In cases where the degree of stenosis as defined by duplex velocity criteria did not correlate with angiographically defined stenosis, each record was reviewed to determine whether the angiographic findings altered the surgeon's treatment decision. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for DUS-defined degree of stenosis as compared to angiographically defined stenosis were determined. There was a high correlation (R = 0.96) between duplex scan and angiography in 93% (302/326) of the cases. Clinical management was altered in only 3% (10/326) of the cases because of the results of angiography. The DUS velocity criteria to grade the severity of carotid disease in 10% intervals is reliable and accurate. Clinical management of patients with carotid stenosis can be based solely on carotid DUS in 97% of patients considered for treatment of carotid artery disease.
View details for DOI 10.1007/s10016-001-0175-8
View details for Web of Science ID 000177802500003
View details for PubMedID 12118345
To compare the outcomes of open versus endovascular repair of abdominal aortic aneurysm (AAA) in a cohort of patients who fulfill morphological criteria for endovascular repair.A retrospective review of 229 consecutive AAA patients treated over a 3-year period identified 149 patients who were candidates for endovascular repair based on preoperative computed tomography and angiography. Of the 149 patients, 79 (68 men; mean age 74 +/- 8 years) underwent endovascular repair with the AneuRx stent-graft; the remaining 70 (56 men; mean age 72 +/- 8 years) had open repair. Short-term outcome measures were 30-day mortality and procedure-related morbidity, length of stay in the intensive care unit and hospital, intraoperative blood loss, interval to oral diet, and time to ambulation. Long-term outcome measures included death and secondary procedures.There was no difference in the 30-day mortality between endovascular repair (2, 2.5%) and open repair (2, 2.9%), even though endovascular patients had more comorbidities (p<0.05). Overall length of stay was reduced for endovascular patients (3.9 +/- 2.4 days versus 7.7 +/- 3.1 days for surgical patients, p<0.0001). Fewer endograft patients had complications (24% versus 40% for open repair, p<0.05), and the severity of these complications was less, as evidenced by the shorter hospital stays for endovascular patients with complications compared to conventionally treated patients with complications (6.7 +/- 2.4 days versus 22.5 +/- 35.2 days, p<0.05). There were no aneurysm ruptures or late surgical conversions in either group.Patients with AAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. Despite increased comorbidities in the endograft patients, there was no increase in mortality compared to open repair. Both treatments required secondary procedures and appeared to be equally effective in preventing aneurysm rupture up to 3 years.
View details for Web of Science ID 000176993800001
View details for PubMedID 12096937
The objective of this study was to evaluate gender differences in the selection, procedure, and outcome of endovascular abdominal aortic aneurysm repair (EVAR).Between October 1996 and January 2001, 378 patients were evaluated for EVAR and 189 patients underwent EVAR with the Medtronic AneuRx stent graft at a single center.Women constituted 17% of patients considered for EVAR. Their eligibility rate (49%) did not differ significantly from that of men (57%), and they constituted 14% of patients who underwent EVAR (26/189). Women who underwent EVAR were older (77.9 +/- 6.3 years versus 73.1 +/- 8.1 years; P <.005) with a higher rate of chronic obstructive lung disease (50% versus 28%; P <.05). Maximal aneurysm diameter (57.2 +/- 10.9 mm versus 57.8 +/- 9.4 mm; not significant) did not differ between men and women. Mean diameters of the proximal neck (20.4 +/- 2.3 mm versus 22.3 +/- 2.0 mm; P <.01), common iliac arteries (11.4 +/- 1.2 mm versus 13.5 +/- 3.6 mm; P <.001), and external iliac arteries (7.9 +/- 0.7 mm versus 9.4 +/- 1.4 mm; P <.001) were all smaller in women, and abdominal aortic aneurysm/neck diameter ratio was larger (2.82 +/- 0.59 versus 2.60 +/- 0.49; P <.05). The length of the proximal aortic neck was shorter in women (20.7 +/- 8.2 mm versus 24.5 +/- 11.8 mm; P <.05). Women had significantly more intraoperative complications (31% versus 13%; P <.05), primarily related to arterial access, and needed more frequent arterial reconstruction (42% versus 21%; P <.05), without a difference in postoperative mortality rate (0/26 versus 2/163; not significant) and complication rate (23% versus 20%: not significant). During a follow-up period of 13.8 +/- 11.7 months, no gender-related difference was found in survival rate, endoleak rate, or reintervention rate or in the rate of change in aneurysm diameter or volume.Eligibility rates of women for EVAR are similar to those of men. Women are at an increased risk for access-related complications during EVAR, but outcome is equivalent to that of men.
View details for DOI 10.1067/mva.2002.123754
View details for Web of Science ID 000175919100014
View details for PubMedID 12021702
The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery.The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training.Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 +/- 4.9 (range, 68-77) and increased to 124.7 +/- 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 +/- 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 +/- 6.6 (range, 48-56) before endovascular repair versus 47.0 +/- 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 +/- 1.0 (range, 9-11) before endovascular repair compared with 19.0 +/- 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 +/- 3.0 (range, 4-11) before endovascular repair compared with 7.6 +/- 2.3 (range, 5-9) after.Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training.
View details for DOI 10.1067/mva.2001.118816
View details for Web of Science ID 000172305700035
View details for PubMedID 11700491
The purpose of this study was to evaluate our experience with the diagnosis and management of vascular injuries in a group of high-performance athletes.Between June 1994 and June 2000, we treated 26 patients who sustained vascular complications as a result of athletic competition. Clinical presentation, type of athletic competition, location of injury, type of therapy, and degree of rehabilitation were analyzed retrospectively.The mean age of the patients was 23.8 years (range, 17-40). Twenty-one (81%) patients were men, and five (19%) were women. Athletes included 8 major-league baseball players, 7 football players, 2 world-class cyclists, 2 rock climbers, 2 wind surfers, 1 swimmer, 1 kayaker, 1 weight lifter, 1 marksman, and 1 volleyball player. There were 14 (54%) arterial and 12 (46%) venous complications. Arterial injuries included 7 (50%) axillary/subclavian artery or branch artery aneurysms with secondary embolization, 6 (43%) popliteal artery injuries, and 1 (7%) case of intimal hyperplasia and stenosis involving the external iliac artery. Subclavian vein thrombosis (SVT) accounted for all venous complications. Five of the seven patients with axillary/subclavian branch artery aneurysms required lytic therapy for distal emboli, and six required operative intervention. All popliteal artery injuries were treated by femoropopliteal bypass graft with autogenous saphenous vein. The external iliac artery lesion, which occurred in a cyclist, was repaired with limited resection and vein patch angioplasty. All 12 patients with SVT were treated initially with lytic therapy and anticoagulation. Eight patients required thoracic outlet decompression and venolysis of the subclavian vein. Thirteen arterial reconstructions have remained patent at an average follow-up of 31.9 months (range, 2-74). One patient with a popliteal artery injury required reoperation at 2 months for occlusion of his bypass graft. Eleven of the patients with an arterial injury were able to return to their prior level of competition. All of the patients with SVT have remained stable without further venous thrombosis and have returned to their usual level of activity.Athletes are susceptible to a variety of vascular injuries that may not be easily recognized. A high level of suspicion, a thorough workup including noninvasive studies and arteriography/venography, and prompt treatment are important for a successful outcome.
View details for Web of Science ID 000168687300004
View details for PubMedID 11331831
Technetium-99m-labeled sulfur colloid lymphoscintigraphy is useful to evaluate lower extremity lymphatic circulation in cases of possible lymphedema and to reveal abnormal lymphatic collections. Groin lymphatic fistulas and lymphoceles are known complications of peripheral vascular surgical procedures. The authors describe a patient with ascites that developed into right lower extremity swelling after surgical repair of a femoral artery injury. Even after surgical ligation of multiple lymphatic channels, the patient continued to have lymphorrhea. It was unclear whether this was attributable to a persistent lymphatic leak or an ascitic leak from a postsurgical defect resulting in an abnormal connection with the peritoneal cavity.Lymphoscintigraphy of the lower extremities was performed using Tc-99m sulfur colloid. Images were obtained at several intervals after injection of the radiotracer. Images were also acquired after the wound packing was removed.The images revealed an accumulation of radiotracer in the right groin, confirming the lower extremity lymphatic origin of the collection.Lymphoscintigraphy is useful to evaluate the origin of serous collections in the groin, a region in which lymphatic complications of vascular surgery are not uncommon.
View details for Web of Science ID 000165887400004
View details for PubMedID 11139046
The creation of an arteriovenous fistula for long-term hemodialysis access is one of the most commonly performed procedures in vascular and transplantation surgery. Prosthetic conduits are frequently prone to failure within their first year of construction, and after one or two revisions, they are left in their thrombosed state as permanent subcutaneous foreign bodies in the extremities. Conventional teaching has regarded these chronically thrombosed grafts to have a benign natural history, and their removal has been considered unnecessary. We describe an unusual late complication of distal thromboemboli from a chronically occluded arteriovenous graft that was implanted 10 years before and appeared as acute hand ischemia.
View details for DOI 10.1067/mva.2000.109741
View details for Web of Science ID 000165847400034
View details for PubMedID 11107099
To evaluate of the impact of endovascular aneurysm repair on the rate of open surgical repair and on the overall treatment of abdominal aortic aneurysms (AAAs).All patients with AAA who were treated during two consecutive 40-month periods were reviewed. During the first period, only open surgical repair was performed; during the subsequent 40 months, endovascular repair and open surgical repair were treatment options.A total of 727 patients with AAA were treated during the entire period. During the initial 40 months, 268 patients were treated with open surgical repair, including 216 infrarenal (81%), 43 complex (16%), and 9 ruptured (3%) aortic aneurysms. During the subsequent 40 months, 459 patients with AAA were treated (71% increase). There was no significant change in the number of patients undergoing open surgical repair and no significant difference in the rate of infrarenal (238 [77%]) and complex (51 [16%]) repairs. A total of 353 patients were referred for endovascular repair. Of these, 190 (54%) were considered candidates for endovascular repair based on computed tomography or arteriographic morphologic criteria. Analyzing a subgroup of 123 patients, the most common primary reasons for ineligibility for endovascular repair were related to morphology of the neck in 80 patients (65%) and of the iliac arteries in 35 patients (28%). A total of 149 patients underwent endovascular repair. Of these, the procedure was successful in 147 (99%), and 2 (1%) patients underwent surgical conversion. The hospital death rate was 0%, and the 30-day death rate was 1%. During a follow-up period of 1 to 39 months (mean 12 +/- 9), 21 secondary procedures to treat endoleak (20) or to maintain graft limb patency (1) were performed in 17 patients (11%). There were no aneurysm ruptures or aneurysm-related deaths.Endovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA. Patients who previously were not candidates for repair because of medical comorbidity may now be safely treated with endovascular repair.
View details for Web of Science ID 000089602400009
View details for PubMedID 10998648
The purpose of this study was to determine the rate of eligibility among patients with abdominal aortic aneurysms (AAAs) considered for endovascular repair and to examine the effect of an endovascular program on the institutional pattern of AAA repair.All patients evaluated for endovascular AAA repair since the inception of an endovascular program were reviewed for determination of eligibility rates and eventual treatment. Open AAA repairs were categorized as simple (uncomplicated infrarenal), complex (juxtarenal, suprarenal, thoracoabdominal, infected), or ruptured, and their rates before and after initiation of an endovascular program were compared.Over 3 years, 324 patients were considered for endovascular AAA repair; 176 (54%) were candidates, 138 (43%) were not candidates, and 10 (3%) did not complete the evaluation. The rate of eligibility increased significantly from 45% (66/148 patients) during the first half of this period to 63% (110/176 patients) during the second half (P <. 001). Candidates were significantly younger (74.4 +/- 7.6 years) than noncandidates (78.3 +/- 6.7 years) (P <.01), and their aneurysm diameter tended to be smaller (57.6 +/- 9.2 mm compared with 60.8 +/- 12.3 mm; P =.06). The most common reason for ineligibility was an inadequate proximal aortic neck. Of 176 candidates, 78% underwent endovascular repair, and 6% underwent open repair. Of 138 noncandidates, 56% underwent surgical repair. Over a period of 6 years, 542 patients with AAAs (429 simple, 86 complex, 27 ruptured) underwent open repair. The total number and ratio of simple to complex open repairs for nonruptured aneurysms during the 3 years before the initiation of the endovascular program (213 simple, 44 complex) were not significantly different from the repairs over the subsequent 3-year period (216 simple, 42 complex). Similarly, no difference in the total number and the ratio of simple to complex open repairs was found between the first and the second 18-month periods since the initiation of the endovascular program.The rate of eligibility of patients with AAA for endovascular repair appears to be higher than previously reported. The presence of an active endovascular program has not decreased the number or shifted the distribution of open AAA repair.
View details for PubMedID 10957658
Surgeon-directed institutional peer review, associated with positive physician feedback, can decrease the morbidity and mortality rates associated with carotid endarterectomy.Case series.Tertiary care university teaching hospital.All patients undergoing carotid endarterectomy at our institution during a 5-year period ending August 1998.Stroke rate decreased from 3.8% (1993-1994) to 0% (1997-1998). The mortality rate decreased from 2.8% (1993-1994) to 0% (1997-1998). Length of stay decreased from 4.7 days (1993-1994) to 2.6 days (1997-1998). The total cost decreased from $13,344 (1993-1994) to $9548 (1997-1998).An objective, confidential peer review process that provides ongoing feedback of performance to surgeons and documents that performance in relationship with that of peers seems to be effective in reducing the morbidity and mortality rate associated with carotid endarterectomy. In addition, the review process lowered the hospital cost of performing carotid endarterectomy.
View details for Web of Science ID 000088639300017
View details for PubMedID 10922256
The role of thoracic outlet decompression in the treatment of primary axillary-subclavian vein thrombosis remains controversial. The timing and indications for surgery are not well defined, and thoracic outlet procedures may be associated with infrequent, but significant, morbidity. We examined the outcomes of patients treated with or without surgery after the results of initial thrombolytic therapy and a short period of outpatient anticoagulation.Patients suspected of having a primary deep venous thrombosis underwent an urgent color-flow venous duplex ultrasound scan, followed by a venogram and catheter-directed thrombolysis. They were then converted from heparin to outpatient warfarin. Patients who remained asymptomatic received anticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptoms of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent thoracic outlet decompression and postoperative anticoagulation for 1 month.Twenty-two patients were treated between June 1996 and June 1999. Of the 18 patients who received catheter-directed thrombolysis, complete patency was achieved in eight patients (44%), and partial patency was achieved in the remaining 10 patients (56%). Nine of 22 patients (41%) did not require surgery, and the remaining 13 patients underwent thoracic outlet decompression through a supraclavicular approach with scalenectomy, first-rib resection, and venolysis. Recurrent thrombosis developed in only one patient during the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surgery sustained durable relief of their symptoms and a return to their baseline level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging.Not all patients with primary axillary-subclavian vein thrombosis require surgical intervention. A period of observation while patients are receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persistent symptoms and venous obstruction should be offered thoracic outlet decompression. Chronic anticoagulation is not required in these patients.
View details for Web of Science ID 000088172500013
View details for PubMedID 10876207
To analyze the complications of internal iliac artery (IIA) embolization in conjunction with stent-graft treatment of aortoiliac aneurysms.Seventy-one patients with aortoiliac (n = 47) or iliac (n = 24) aneurysms were treated with endoluminal placement of stent-grafts. Thirty-two patients (31 men, one woman; mean age, 73 years; range, 56-88 years) had embolization or occlusion of one (n = 27) or both (n = 5) IIAs. Status of the IIAs and the collateral circulation was assessed by retrospective review of angiographic images. Follow-up consisted of a standardized patient questionnaire and review of radiologic and medical records.The mean follow-up time was 35 months (range, 5-64 months). Eleven of the 47 patients with abdominal aortic aneurysms (AAA) (23%) and 19 of the 24 patients with iliac aneurysms (79%) required IIA embolization. One patient with AAA and another with iliac aneurysm had unintentional occlusion of an IIA by extension of the stent-graft over their origins. A total of seven patients had bilateral occlusion of the IIAs after the procedure. Additionally, the inferior mesenteric arteries (IMAs) of two other patients with AAA were also embolized. In six patients, all three vessels were occluded after placement of the stent-grafts. Symptoms were reported in nine of the 20 (45%) patients with iliac aneurysms and in three of the 12 (25%) patients with AAA. Symptoms consisted of buttock claudication (nine of 32, 28%), new sexual dysfunction (two of 16, 12%), and transient urinary retention (3%). Seven of the claudicants had resolution of symptoms after a mean interval of 14 months (range, 1-36 months). There were no instances of bowel ischemia, neurologic sequelae, or buttock necrosis related to these procedures.Embolization of the IIA is associated with symptoms in a significant number of patients. While symptoms are transient in most patients, they can be problematic. Efforts should be made to preserve the pelvic circulation if possible.
View details for Web of Science ID 000087118200003
View details for PubMedID 10834485
Patients with recurrent carotid artery stenosis are sometimes referred for carotid angioplasty and stenting because of reports that carotid reoperation has a higher complication rate than primary carotid endarterectomy. The purpose of this study was to determine whether a difference exists between outcomes of primary carotid endarterectomy and reoperative carotid surgery.Medical records were reviewed for all carotid operations performed from September 1993 through March 1998 by vascular surgery faculty at a single academic center. The results of primary carotid endarterectomy and operation for recurrent carotid stenosis were compared.A total of 390 operations were performed on 352 patients. Indications for primary carotid endarterectomy (n = 350) were asymptomatic high-grade stenosis in 42% of the cases, amaurosis fugax and transient ischemic symptoms in 35%, global symptoms in 14%, and previous stroke in 9%. Indications for reoperative carotid surgery (n = 40) were symptomatic recurrent lesions in 50% of the cases and progressive high-grade asymptomatic stenoses in 50%. The results of primary carotid endarterectomy were no postoperative deaths, an overall stroke rate of 1.1% (three postoperative strokes, one preoperative stroke after angiography), and no permanent cranial nerve deficits. The results of operations for recurrent carotid stenosis were no postoperative deaths, no postoperative strokes, and no permanent cranial nerve deficits. In the primary carotid endarterectomy group, the mean hospital length of stay was 2.6 +/- 1. 1 days and the mean hospital cost was $9700. In the reoperative group, the mean length of stay was 2.6 +/- 1.5 days and the mean cost was $13,700. The higher cost of redo surgery is accounted for by a higher preoperative cerebral angiography rate (90%) in redo cases as compared with primary endarterectomy (40%).In this series of 390 carotid operations, the procedure-related stroke/death rate was 0.8%. There were no differences between the stroke-death rates after primary carotid endarterectomy and operation for recurrent carotid stenosis. Operation for recurrent carotid stenosis is as safe and effective as primary carotid endarterectomy and should continue to be standard treatment.
View details for Web of Science ID 000081410700007
View details for PubMedID 10394151
Therapeutic options for subclavian vein thrombosis (SVT) include anticoagulation, thrombolysis, endovascular repair, and direct surgical intervention. The most effective method of treatment remains undetermined. We reviewed our institutional experience over 7 years with SVT patients to compare the results of treatment based on etiology of thrombosis. Nineteen patients suffered SVT secondary to malignancy, catheter placement, radiation, or hypercoagulability. Thirteen were Paget-Schroetter (PSS), or primary effort-related SVT. Patients with dialysis access procedures were excluded. Thrombolysis was initiated in 31/32 patients. Success was defined as complete obliteration of clot. Adjunctive treatment to relieve external compression or improve lumenal contour was performed on 16/32 patients (eight PSS, eight secondary SVT). Success of adjunctive treatment was defined as return to baseline activity without symptoms. Objective follow up (venography or duplex scanning) was included when available. Adjunctive treatment included balloon angioplasty (6), stent placement (5), first rib resection and scalenectomy (4), and vein reconstruction (4). Initial treatment success with thrombolysis was achieved in 26/31 patients (84%). Angioplasty failed in three PSS and three secondary SVT patients. Stent placement was successful in 2/5 patients (both secondary SVT). Surgery was performed only on PSS patients: first rib resection and scalenectomy succeeded 4/4 times, vein reconstruction 2/4. Twenty-eight patients were given long-term therapy with oral anticoagulation with good long-term results. Seven patients experienced complications, including one death. Results of SVT therapy including thrombolysis and oral anticoagulation are very good. Angioplasty and stent placement in secondary SVT patients appears to add little long term benefit. Surgery may improve outcome in selected PSS patients, although the additional benefit could not be determined by the design of this study. Evaluation and treatment limited only to PSS excludes the majority of SVT patients.
View details for Web of Science ID A1997WW54300006
View details for PubMedID 9140599
The purpose of this study was to evaluate the incidence of thrombotic complications in patients with deep vein thrombosis (DVT) who were treated with percutaneous inferior vena caval interruption in place of anticoagulation.A retrospective review of all percutaneously placed inferior vena cava filters for 1 year, August 1993 through July 1994, was performed.Thirty-three percutaneous inferior vena cava filters were placed in 32 patients. The underlying disease was pulmonary embolism in 15 (47%) and DVT in 17 (53%) patients. Of patients with pulmonary embolism, 11 had a documented DVT, and four were not evaluated for DVT. There were 14 men and 18 women, with a mean age of 63.5 years (range 24 to 93 years). Indications for vena caval interruption were recurrent pulmonary embolism with therapeutic anticoagulation (n = 2 [6%]), prophylactic insertion with documented pulmonary embolism and therapeutic anticoagulation (n = 8 [25%]), documented pulmonary embolism and absolute contraindication to anticoagulation (n = 5 [16%]), documented DVT and absolute contraindication to anticoagulation (n = 2 [6%]), prophylactic insertion with documented DVT and therapeutic anticoagulation (n = 5 [16%]), and documented DVT with relative contraindication to anticoagulation (n = 10 [31%]). Of the 32 patients with inferior vena cava filters, 17 were not given anticoagulants (7 absolute contraindications, 10 relative contraindications), and 15 were given anticoagulants. Insertion of a percutaneous inferior vena cava filter in patients who were not given anticoagulants was followed by the development of phlegmasia cerulea dolens in four patients (24%), which was bilateral in two patients; one patient eventually died. No patients treated with inferior vena cava filter and anticoagulation had development of phlegmasia.Percutaneous inferior vena caval interruption effectively prevents pulmonary embolism in patients with DVT but does not impact the underlying thrombotic process and in fact may contribute to progressive thrombosis in patients who are not given anticoagulants. Anticoagulation with intravenous heparin in safe and effective therapy for DVT in most patients. We believe that percutaneous insertion of vena cava filters should not replace anticoagulation in routine proximal DVT, and those patients who require an inferior vena cava filter for failure of anticoagulation should continue to receive heparin to treat the primary thrombotic process. We caution that relative contraindications to anticoagulation should be carefully scrutinized before recommending vena cava interruption as a primary therapy for DVT.
View details for Web of Science ID A1995TF30600016
View details for PubMedID 7494363
Most complications of embolectomy with the Fogarty balloon catheter are recognized early and have received ample attention in the surgical and radiologic literature. However, the delayed complication of diffuse arterial narrowing causing severe ischemia has received little emphasis, perhaps because follow-up arteriography is not always performed. This report describes five patients--women 43 to 62 years of age--with progressive leg ischemia discovered 2 to 4 months after embolectomy with the balloon catheter. Angiography showed a characteristic pattern of severe, smooth narrowing of that portion of the artery in which balloon embolectomy was performed. Pathologic examination of arterial specimens, available in two of the five patients, revealed marked intimal cellular proliferation, which narrowed the arteries severely without evidence of thrombosis, significant atheromatosis, or active arteritis. The cause appears to be intimal damage by the balloon. Embolectomy with the balloon catheter should be done especially carefully in relatively young women.
View details for Web of Science ID A1988M891900001
View details for PubMedID 3352065
Popliteal artery compression may be caused by a Baker's cyst as documented by this case report. Typically this occurs in a relatively young patient without other evidence of atherosclerosis. The ischemic symptoms may be intermittent. Treatment should include resection of the offending cyst and any damaged popliteal artery.
View details for Web of Science ID A1986E362600018
View details for PubMedID 3761486
Improved technology has made available the technique of video angioscopy. When applied routinely, it can provide a high yield of important technical detail in a graphically precise and easily applicable manner, at the time of a great variety of vascular reconstructions, and complications are rare. Although not entirely replacing intraoperative arteriography, its multiple attractive characteristics make it substantially more useful in many circumstances. Familiarity with the technique will enable vascular surgeons to more rapidly utilize new methods of therapy, such as lasers, as well as improve already existing ones.
View details for Web of Science ID A1986D199900025
View details for PubMedID 3728808
Seventeen patients with arteriographic findings consistent with the carotid "string" sign are presented. Five separate clinicopathologic categories were present, and each required special consideration for proper management. The arteriographic findings alone were insufficient to allow categorization or to predict intraoperative findings. Special emphasis is placed on the importance of examining the apparently occluded carotid artery for signs of the carotid string sign which, if found, indicates continued patency. Familiarity with the broad spectrum of clinicopathologic entities associated with the carotid string sign facilitates management of these often complicated problems.
View details for Web of Science ID A1980JZ81100021
View details for PubMedID 7396077