Venita Chandra

All Publications

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

  Abstract

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

  View details for PubMedID 29252755

  View details for PubMedCentralID PMC5901686

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

  Abstract

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

  View details for DOI 10.1111/wrr.12764

  View details for PubMedID 31587431

• Delayed Fasciotomy Is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia ANNALS OF VASCULAR SURGERY Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V., Stern, J. R. 2019; 59: 195–201

  View details for DOI 10.1016/j.avsg.2019.01.028

  View details for Web of Science ID 000479186900025

• Increased Vertebral Exposure in Anterior Lumbar Interbody Fusion Associated With Venous Injury and Deep Venous Thrombosis Ho, V. T., Colvard, B., Lee, J. T., Chandra, V. MOSBY-ELSEVIER. 2019: E248–E249

  View details for DOI 10.1016/j.jvs.2019.04.376

  View details for Web of Science ID 000469220300368

• Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure. Journal of vascular surgery McFarland, G., Tran, K., Virgin-Downey, W., Sgroi, M. D., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2019; 69 (2): 385–93

  Abstract

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

  View details for PubMedID 30686336

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

  Abstract

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

  View details for PubMedID 30706755

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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2019.01.087

  View details for PubMedID 31153696

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

  Abstract

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

  View details for PubMedID 31034949

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2019.04.008

  View details for PubMedID 31201974

• Disparities as Predictors of Non-Healing in Lower Extremity Wounds George, E. L., Trang, K., Dua, A., Parsley, J. D., Robertson, R., Fukaya, E., Sen, S. K., Gurtner, G. C., Chandra, V. ELSEVIER SCIENCE INC. 2018: E248

  View details for DOI 10.1016/j.jamcollsurg.2018.08.675

  View details for Web of Science ID 000447772500607

• Clinical Impact of a Wound Care Center on a Vascular Surgery Practice Flores, A. M., Mell, M. W., Dalman, R. L., Chandra, V. MOSBY-ELSEVIER. 2018: E88–E89

  View details for Web of Science ID 000433036700079

• Regarding "Controversies and evidence for cardiovascular disease in the diverse Hispanic population" Reply JOURNAL OF VASCULAR SURGERY Shaw, P. M., Chandra, V., Escobar, G. A., Robbins, N., Rowe, V., Macsata, R. 2018; 67 (5): 1639–40

  View details for DOI 10.1016/j.jvs.2018.01.023

  View details for Web of Science ID 000430919000050

• Long-term outcomes after repair of symptomatic abdominal aortic aneurysms. Journal of vascular surgery Chandra, V., Trang, K., Virgin-Downey, W., Dalman, R. L., Mell, M. W. 2018

  Abstract

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

  View details for PubMedID 29705087

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

  Abstract

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

  View details for PubMedID 28951154

• Trends in Rates of Lower Extremity Amputation Among Patients With End-stage Renal Disease Who Receive Dialysis. JAMA internal medicine Franz, D., Zheng, Y., Leeper, N. J., Chandra, V., Montez-Rath, M., Chang, T. I. 2018

  Abstract

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

  View details for PubMedID 29987332

• Trends in Rates of Lower Extremity Amputation Among Patients With End-Stage Renal Disease Who Receive Dialysis JAMA Internal Medicine Franz, D., Zheng, Y., Leeper, N. J., Chandra, V., Montez-Rath, M., Chang, T. I. 2018

  View details for DOI 10.1001/jamainternmed.2018.2436

• Retrograde Pedal Access-Cutting Edge or Comical? Vascular and endovascular surgery Dua, A., Chandra, V. 2018: 1538574418780055

  Abstract

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

  View details for DOI 10.1177/1538574418780055

  View details for PubMedID 29932023

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

  Abstract

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

  View details for PubMedID 28842074

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

  Abstract

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

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

  View details for PubMedID 28493108

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2017.01.025

  View details for PubMedID 28479440

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

  Abstract

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

  View details for PubMedID 28619644

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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2016.07.121

  View details for PubMedID 27871490

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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2016.01.039

  View details for Web of Science ID 000378562900027

  View details for PubMedID 26994959

• Unplanned reoperations after vascular surgery JOURNAL OF VASCULAR SURGERY Kazaure, H. S., Chandra, V., Mell, M. W. 2016; 63 (3): 731-737

  View details for DOI 10.1016/j.jvs.2015.09.046

  View details for Web of Science ID 000370780400024

• Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition JAMA SURGERY Ullery, B. W., Tran, K., Chandra, V., Mell, M. W., Harris, E. J., Dalman, R. L., Lee, J. T. 2015; 150 (11): 1058-1065

  Abstract

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

  View details for DOI 10.1001/jamasurg.2015.1861

  View details for Web of Science ID 000367987100011

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

  Abstract

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

  View details for DOI 10.1177/1526602815590119

  View details for Web of Science ID 000358119200019

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

  Abstract

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

  View details for DOI 10.1177/1538574415602781

  View details for Web of Science ID 000361529700008

  View details for PubMedID 26335991

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2014.12.041

  View details for Web of Science ID 000356994400003

  View details for PubMedID 25757989

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

  Abstract

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

  View details for DOI 10.1089/sur.2013.232

  View details for Web of Science ID 000352360400015

  View details for PubMedID 25405775

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2014.07.025

  View details for PubMedID 25192823

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

  Abstract

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

  View details for PubMedID 26244272

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

  Abstract

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

  View details for PubMedID 26045462

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2014.07.025

  View details for Web of Science ID 000346239900025

  View details for PubMedID 25192823

• Gastrointestinal Mucormycosis Initially Manifest as Hematochezia from Arterio-Enteric Fistula DIGESTIVE DISEASES AND SCIENCES Cloyd, J. M., Brown, J., Sinclair, T., Jenks, D., Desai, J., Longacre, T., Chandra, V., Shelton, A. 2014; 59 (12): 2905-2908

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

  View details for Web of Science ID 000345322100008

• Gastrointestinal mucormycosis initially manifest as hematochezia from arterio-enteric fistula. Digestive diseases and sciences Cloyd, J. M., Brown, J., Sinclair, T., Jenks, D., Desai, J., Longacre, T., Chandra, V., Shelton, A. 2014; 59 (12): 2905-2908

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

  View details for PubMedID 24906697

• 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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2014.03.255

  View details for Web of Science ID 000343316600003

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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2014.04.013

  View details for Web of Science ID 000343316600031

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2014.03.010

  View details for PubMedID 24704581

• Comparison of fenestrated endografts and the snorkel/chimney technique. Journal of vascular surgery Lee, J. T., Lee, G. K., Chandra, V., Dalman, R. L. 2014; 60 (4): 849–56; discussion 856–57

  Abstract

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

  View details for PubMedID 24785682

• Thoracic outlet syndrome in high-performance athletes. Journal of vascular surgery Chandra, V., Little, C., Lee, J. T. 2014; 60 (4): 1012–17; discussion 1017–18

  Abstract

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

  View details for PubMedID 24835692

• Monitoring of fetal radiation exposure during pregnancy 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 Chandra, V., Dorsey, C., Reed, A. B., Shaw, P., Banghart, D., Zhou, W. MOSBY-ELSEVIER. 2013: 710–14

  Abstract

  One unique concern of vascular surgeons and trainees is radiation exposure associated with increased endovascular practice. The safety of childbearing is a particular worry for current and future women in vascular surgery. Little is known regarding actual fetal radiation exposure. This multi-institutional study aimed to evaluate the radiation dosages recorded on fetal dosimeter badges and compare them to external badges worn by the same cohort of women.All women who declared pregnancy with potential radiation exposure were required to wear two radiation monitors at each institution, one outside and the other inside the lead apron. Maternal (external) and fetal monitor dosimeter readings were analyzed. Maternal radiation exposures prior to, during, and postpregnancy were also assessed to determine any associated behavior modification.Eighty-one women declared pregnancy from 2008 to 2011 and 32 had regular radiation exposure during pregnancy. Maternal whole-body exposures ranged from 21-731 mrem. The average fetal dosimeter recordings for the cohort rounded to zero. Only two women had positive fetal dosimeter recordings; one had a single recording of 3 mrem and the other had a single recording of 7 mrem. There was no significant difference between maternal exposures prior to, during, and postpregnancy.Lack of knowledge of fetal radiation exposure has concerned many vascular surgeons, prompting them to wear double lead aprons during pregnancy, and perhaps prevented numerous other women from entering the field. Our study showed negligible radiation exposure on fetal monitoring suggesting that with the appropriate safety precautions, these concerns may be unwarranted.

  View details for DOI 10.1016/j.jvs.2013.01.052

  View details for Web of Science ID 000323616800019

  View details for PubMedID 23591191

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

  Abstract

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

  View details for DOI 10.1002/jso.23082

  View details for PubMedID 22374866

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

  Abstract

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

  View details for DOI 10.1016/j.avsg.2011.10.003

  View details for PubMedID 22176878

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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2011.05.105

  View details for PubMedID 21803527

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

  Abstract

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

  View details for DOI 10.1016/j.jvs.2011.04.052

  View details for PubMedID 21723068

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

  Abstract

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

  View details for DOI 10.1016/j.surg.2009.11.002

  View details for Web of Science ID 000278532300011

  View details for PubMedID 20045162

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

  View details for DOI 10.1016/j.surg.2007.11.011

  View details for Web of Science ID 000253172300009

  View details for PubMedID 18242333

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

  Abstract

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

  View details for DOI 10.1016/j.soard.2006.11.015

  View details for PubMedID 17324634

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

  Abstract

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

  View details for PubMedID 17055957