Brian G Derubertis

University of California, Los Angeles, Los Angeles, California, United States

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Publications (70)112.98 Total impact

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    ABSTRACT: Recurrent symptoms of thoracic outlet syndrome (TOS) following first rib resection have varying etiologies. Regrowth of a first rib is a rare event. Recurrent symptoms in the presence of a regrown rib strongly suggest a causal relationship. We report our experience with recurrent symptoms of TOS and regrown first ribs. We identified patients with recurrent TOS symptoms and regrown first ribs presenting between 1995 and 2012. Details regarding their presentation, evaluation and treatment were gathered. Eight patients (6 female, 2 male) presenting with recurrent TOS symptoms and regrown first ribs underwent 10 decompression surgeries. Prior surgeries included supraclavicular first rib resection (5), trans-axillary first rib resection (5), scalenectomy (5), cervical rib resection (1). The average period between initial surgery and reoperation was 4.7 years. Average age at current presentation was 40.8 yrs (range 29-52). All patients (8) represented with neurogenic symptoms and 1 patient with concomitant venous TOS symptoms. Presenting symptoms included pain (10), numbness and tingling (7), weakness (6), headache (2) and venous congestion (3). Initial treatment included physical therapy in all. Pre-operative assessment included chest x-rays (10), magnetic resonance imaging (MRI) (7), electrodiagnostic studies (8), venography (2) and anterior scalene muscle block (2). Surgical approach included trans-axillary resection of the regrown first rib (10), neurolysis of brachial plexus (10), scalenectomy (5) and lysis of subclavian vein (1). After an average follow up of 10.8 months, resolution of symptoms included: 4 complete, 4 partial. Regrowth of the first rib is a rare event. There is concordance between a regrown rib and symptoms. Patients presenting with recurrent TOS symptoms and a regrown first rib have a high probability of improvement with resection of the regrown rib.
    Annals of Vascular Surgery 01/2014; · 0.99 Impact Factor
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    ABSTRACT: Most studies recommend repair of renal artery aneurysms (RAAs) >2 cm in diameter in asymptomatic patients, but other studies have suggested that their natural history may be more benign. We hypothesized that rupture and death in patients with asymptomatic RAAs is low and that current recommendations for RAA treatment at 2 cm may be too aggressive. Retrospective review of all RAAs treated at a tertiary care medical center from 2002 to 2012. Fifty-nine RAA were identified in 40 patients (mean age at diagnosis, 56 years; male:female ratio, 17:23); 31 were saccular, 8 were fusiform, and 5 were bilobed. Twenty-nine patients were asymptomatic; the remainder of patients presented with hematuria (n = 4), abdominal pain (n = 3), difficult-to-control hypertension (n = 3), or flank pain (n = 2). Aneurysm location included the main renal artery bifurcation (n = 35), main trunk (n = 7), primary branch (n = 6), pole artery (n = 6), and secondary branch (n = 1). Operative management of RAAs included vein patch (n = 6), prosthetic patch (n = 4), primary repair (n = 3), plication (n = 1), patch and implantation (n = 1), and ex vivo repair (n = 1). Eight asymptomatic RAAs were treated surgically (mean RAA diameter = 2.4 ± 0.1 cm, range, 2-3 cm), with the remaining 33 asymptomatic RAAs being managed conservatively (mean RAA diameter = 1.4 ± 0.1 cm, range, 0.6-2.6 cm). Mean hospital length of stay was 4 days, with no late postoperative complications and 0% mortality. Non-operated patients were followed for a mean of 36 ± 9 months, with no late acute complications and 0% mortality. Mean RAA growth rate of patients with multiple imaging studies was 0.60 ± 0.16 mm/y. The rate of aneurysm rupture and death in our untreated RAA patients is zero, the growth rate is 0.60 ± 0.16 mm/y, and there were no adverse outcomes in asymptomatic RAAs >2 cm that were observed. We may currently be too aggressive in treating asymptomatic RAAs.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2014; · 3.52 Impact Factor
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    ABSTRACT: Percutaneous endovascular aneurysm repair (PEVAR) can be performed with high technical success rates and low morbidity rates. Several peer-reviewed papers regarding PEVAR have routinely combined heparin reversal with protamine before sheath removal. The risks of protamine reversal are well documented and include cardiovascular collapse and anaphylaxis. The aim of this study is to review outcomes of patients who underwent PEVAR without heparin reversal. All patients who underwent percutaneous femoral artery closure after PEVAR between 2009-2012 without heparin reversal were reviewed. Only patients who underwent placement of large-bore (12- to 24-French) sheaths were included. Patient demographics, comorbidities, operative details, and complications were reported. One hundred thirty-one common femoral arteries were repaired using the Preclose technique in 76 patients. Fifty-five patients underwent bilateral repair and 21 underwent unilateral repair. The mean age was 73.9 ± 9.1 years. The mean heparin dose administered was 79 ± 25.4 U/kg. The mean patient body mass index was 27.5 ± 4.8 kg/m(2). Ultrasound-guided arterial puncture was performed in all patients. Average operative times were 196.5 ± 103.3 min, and the mean estimated blood loss was 277.6 mL. Four femoral arteries (3%) required open surgical repair after failed hemostasis with ProGlide closure (Abbott Vascular, Abbott Park, IL). Two patients required deployment of a third ProGlide device with successful closure. Two patients had small (<3 cm) groin hematomas that had resolved at the time of the postoperative computed tomography scan. No pseudoaneurysms or arteriovenous fistulas developed in our patient cohort. No early or late thrombotic complications were noted. One patient (1.3%) with a ruptured aneurysm died 48 hours after endovascular repair unrelated to femoral closure. PEVAR may be performed with low patient morbidity after therapeutic heparinization without heparin reversal. Femoral artery repair after the removal of large-diameter sheaths using the Preclose technique can be performed in this setting with minimal rates of early and late bleeding or thrombosis.
    Annals of Vascular Surgery 09/2013; · 0.99 Impact Factor
  • Dean Wang, Brian G Derubertis
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    ABSTRACT: Osteochondromas are the most common benign tumors of the bone and are usually asymptomatic. In rare cases, they can present as a cause of lower extremity vascular injury in young patients. We report a case of a 24-year-old man who presented with an acute onset of exercise-induced lower extremity claudication and was found to have a popliteal artery occlusion secondary to a femoral exostosis. The patient underwent an excision of the exostosis and resection of the occluded segment with primary reanastomosis of the popliteal and superficial femoral arteries. Successful treatment of patients with vascular complications secondary to osteochondromas has generally required early surgical intervention.
    Perspectives in Vascular Surgery 06/2013;
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    ABSTRACT: OBJECTIVE: We evaluated our experience with segmental radiofrequency ablation (RFA) of the small saphenous vein (SSV), a less common procedure than great saphenous vein ablation, and developed a classification system and algorithm for endovenous heat-induced thrombus (EHIT), based on modifications of our prior algorithm of EHIT following great saphenous ablation. METHODS: Endovenous ablation was performed on symptomatic patients with incompetent SSVs following a minimum of 3 months of compression therapy. Demographic data, risk factors, CEAP classification, procedure details, and follow-up data were recorded. A four-tier classification system and treatment algorithm was developed, based on EHIT proximity to the popliteal vein. RESULTS: Eighty limbs (in 76 patients) were treated with RFA of the SSV between January 2008 and August 2012. Duplex ultrasound was performed between 24 and 72 hours postprocedure in all patients. Ablation was successful in 98.7% (79/80) of procedures. Sixty-eight (85%) patients had level A closures (≥1 mm caudal to popliteal vein) and 10 patients (13%) had level B closures (flush with popliteal vein) and were observed. Two limbs (3%) had EHIT extending into the popliteal vein (level C) and were treated with outpatient low-molecular-weight heparin anticoagulation. Thrombus retracted to the level of the saphenopopliteal junction in both patients following a short course of anticoagulation. No patient developed an occlusive deep vein thrombosis (DVT) (level D). Mean follow-up period was 6.2 months; no patient had small saphenous recanalization, occlusive DVT, or pulmonary embolus. The presence or absence of the Giacomini vein was not predictive of level B and C closure. CONCLUSIONS: RFA of the SSV in symptomatic patients has a high success rate with a low risk of DVT. A classification system and treatment protocol based on the level of EHIT in relation to the saphenopopliteal junction is useful in managing patients. The approach to patients with thrombus flush with the popliteal vein or bulging has not been previously defined; our outcomes were excellent, using our treatment algorithm.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: To examine outcomes following 1000 consecutive endovenous radiofrequency ablation (RFA) closures of saphenous veins and 500 ambulatory phlebectomy procedures for chronic venous insufficiency. Based on the outcomes in this patient cohort, we aim to determine whether concomitant or staged phlebectomy is preferred and examine the rate and optimal treatment of complications using a dedicated treatment algorithm based on our classification system for level of closure following these procedures. METHODS: Between 2004 and 2012, patients with symptomatic superficial venous incompetence who underwent endovenous RFA of incompetent saphenous veins were identified as well as patients with concomitant or staged microphlebectomy. Demographics, risk factors, procedural success rate, concurrent procedures, complications, and symptom relief were recorded. RESULTS: One thousand radiofrequency ablations (95.5% great saphenous vein and accessory great saphenous veins, 4.5% small saphenous vein) were performed in the ambulatory setting (patients = 735, limbs = 916); 355 limbs with large (>3 mm) symptomatic incompetent tributaries underwent concomitant phlebectomy. Additionally, 145 limbs required phlebectomy at a later setting for persistent symptoms following saphenous RFA. Indications for treatment included lifestyle-limiting pain (94.8%), swelling (66%), lipodermatosclerosis (5.3%), ulceration (9.4%), and/or bleeding (1.4%). All patients (100%) underwent a follow-up ultrasound 24 to 72 hours following the procedure to assess for successful closure and to rule out deep venous thrombosis. The majority of patients (86.7%) had relief of their symptoms at a mean follow-up of 9 months. No patients developed postoperative deep venous thrombosis; however, saphenous closure extended partially into the common femoral vein wall in 18 patients (1.8%) and flush with the saphenofemoral junction in 47 (4.7%). One patient developed a pulmonary embolus despite a normal postoperative ultrasound. No other patients required hospital admission and no deaths occurred during the follow-up period. CONCLUSION: This study represents the largest reported series of segmental thermal ablation of the saphenous vein in the current literature. The majority of patients with symptomatic chronic venous insufficiency benefit from endovenous RFA of incompetent saphenous veins with comparable results to published surgical outcomes for endovenous closure. The great majority of patients with refluxing tributary veins greater than 3 mm in diameter required phlebectomy in addition to saphenous ablation. These patients may benefit from concomitant phlebectomy along with endovenous saphenous closure.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2013; · 3.52 Impact Factor
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    ABSTRACT: BACKGROUND: Iliocaval venous lesions produce a spectrum of symptoms ranging from mild swelling to venous ulcerations. In this study we examine the management and outcomes of these patients at our center. METHODS: In this study we performed a retrospective analysis of patients with symptomatic iliocaval venous stenoses, occlusions, or venous compression syndromes, who were treated with endovascular intervention during the period 2006-2010. RESULTS: Of the 36 patients evaluated, mean age was 43.0 years; prior deep venous thrombosis (DVT), pulmonary embolism (PE), and hypercoaguable states were present in 55.5%, 25.0%, and 44.4%, respectively. Patients were stratified by the presence (group I, n = 22) or absence (group II, n = 14) of underlying May-Thurner (MT) syndrome. In group I, 11 patients had nonocclusive MT-related stenoses and 11 had acute DVT with underlying MT, causing pain/swelling (100%), venous claudication (66.7%), or CEAP class 3 (95%) or 6 (5%). Female preponderance was 2.1:1. Eighteen patients had successful intervention (angioplasty/stent with or without lysis), with clinical improvement in 94.4% and a decrease in CEAP score in 83.3%. All group II patients had chronic iliocaval occlusions causing: pain (100%); swelling (88.9%); venous claudication (44.4%); or CEAP class 3 (58%), 4 (25%), or 6 (8%). Recanalization was attempted in all patients and was successful in 71.4%. Successful recanalization was associated with clinical improvement in 88.9% and a decrease in CEAP score in 44.4%. Complications included 2 early reocclusions, 2 hematomas, and no cases of PE or death. Primary and secondary 1-year patency was 86% and 100% overall (mean follow-up 9.6 months). Primary 1-year patency for groups I and II was 87.5% and 83.3%, respectively. CONCLUSIONS: Percutaneous intervention for chronic iliocaval venous lesions is associated with excellent 1-year patency rates and a significant reduction in symptoms and decrease in CEAP score.
    Annals of Vascular Surgery 03/2013; · 0.99 Impact Factor
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    ABSTRACT: To assess technical feasibility and short-term outcome of a novel hypogastric preservation technique in patients with aortoiliac aneurysms using commercially available endografts without device modification. Multi-institution review of prospectively acquired database of patients undergoing double-barrel endograft repair of aortoiliac aneurysms. Twenty-two patients underwent endovascular aneurysm repair for aortoiliac aneurysms from 2010 to 2011, with 23 double-barrel hypogastric preservation procedures successfully completed in 21 patients. The technique involved bifurcated main body placement followed by simultaneous deployment of parallel endograft limbs into the external iliac (ipsilateral approach) and hypogastric (contralateral femoral or brachial approach) arteries. Bilateral hypogastric branches were performed in two patients, and unilateral branches with and without contralateral coil embolization were performed in nine and ten patients, respectively. Procedural success rate was 96%, technical success rate (successful implantation with immediate aneurysm exclusion and no observed endoleak) was 88%, and access was fully-percutaneous in 86%. Two type III endoleaks between branch components were noted on completion angiograms, but both resolved spontaneously on follow-up imaging. One type Ib endoleak was noted on postoperative imaging (contralateral to hypogastric branch, repaired with limb extension), as were three type II endoleaks (14%) without sac expansion. Early (<2 weeks) limb occlusion (one external iliac, two hypogastric) occurred in two patients, though no subsequent occlusions have occurred (mean follow-up, 7.2 months; range, 1-20 months). Primary patency for external iliac and hypogastric limbs at 6 months was 95% and 88%, respectively. There were no deaths; complications included groin hematoma in 10% and acute renal insufficiency in 5%. Buttock claudication (n = 4) only occurred in patients who had ipsilateral coil embolization of hypogastric arteries (n = 9) for bilateral iliac aneurysms in which only unilateral hypogastric preservation was performed, resulting in rate of 44% in these patients. The double-barrel technique for hypogastric preservation is technically feasible across multiple interventionalists using commercially available endografts without device modification. These procedures are associated with minimal morbidity, acceptable short-term limb-patency rates, and reduced buttock claudication compared with those involving contralateral hypogastric embolization.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2012; 56(5):1252-9. · 3.52 Impact Factor
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    ABSTRACT: A 67-year-old woman presented to the emergency room with progressive claudication, chest pain, and flash-pulmonary edema. Her past medical history was significant for poorly controlled hypertension requiring multiple antihypertensive medications, renal insufficiency, and tobacco abuse. Diagnostic evaluation revealed an extensive exophytic plaque localized to the paravisceral aorta resulting in high-grade stenoses of the proximal aorta as well as the celiac, superior mesenteric, and left renal arteries. She underwent surgical revascularization through a retroperitoneal aortic exposure and trapdoor aortic endarterectomy, the technical conduct of which is described in this manuscript. The patient recovered uneventfully and experienced resolution of her claudication and pulmonary symptoms, improved blood pressure control, and normalization of her creatinine. Review of the medical literature pertaining to management of proximal occlusive disease of the abdominal aorta is discussed.
    Vascular and Endovascular Surgery 06/2012; 46(6):487-91. · 0.88 Impact Factor
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    ABSTRACT: Endovenous ablation of great (GSV) and short saphenous vein (SSV) reflux has become the initial procedure for most patients with symptomatic venous insufficiency, and perforator ablation is increasingly used to assist in healing venous ulceration. Many patients have comorbid conditions, which require long-term anticoagulation with warfarin; however, the impact of a long-term anticoagulation therapy on endovenous ablation procedures is not understood. This study aims to determine the effects of chronic anticoagulation on the outcomes of endovenous ablation procedures in patients with chronic venous insufficiency (CVI). Consecutive patients undergoing endovenous ablation for to Clinical severity (CEAP) class 2 through 6 CVI between January 1, 2005 and May 1, 2011 were evaluated; 781 patients with chronic venous reflux underwent 1,180 endovenous ablation procedures. We identified 45 patients receiving long-term anticoagulation therapy who underwent 71 endovenous ablation procedures, including 37 GSVs, 12 SSVs, and 22 perforator vein procedures. All patients underwent wound examination and duplex ultrasonography within 48 to 72 hours. Outcomes evaluated included closure rate and postoperative complications. The mean age of the patients was 69.7 ± 13 years. Most patients treated presented with active venous ulceration (59% CEAP 6). Indications for anticoagulation included atrial fibrillation (n = 9, 20%), previous deep venous thrombosis (n = 16, 36%), hypercoagulable state (n = 9, 20%), prosthetic valve (n = 2, 4%), and others (n = 9, 20%). All patients receiving warfarin therapy (100%) underwent a postprocedure ultrasonography, which confirmed the successful closure of the GSVs and SSVs; successful initial perforator closure was achieved in 59% of patients (13/22). Repeat perforator ablation yielded a closure rate of 77%. Compared with a matched cohort group of 35 patients (61 perforators) undergoing perforator ablation without anticoagulation, treated during the same period, there was no significant difference in the rates of successful closure between the groups. No patients developed postoperative deep venous thrombosis or pulmonary embolus. No additional thrombotic complications were noted. Three patients (4.2%) developed a small hematoma after the procedure, which resolved with conservative treatment. No patients required postoperative hospital admission, and no postprocedure deaths occurred. Based on our protocol, patients with severe CVI who were receiving long-term warfarin therapy can be treated safely and effectively with endovenous radiofrequency ablation for incompetent GSVs, SSVs, and perforator veins. Long-term warfarin therapy did not have a significant effect on perforator closure rates compared with no anticoagulation.
    Annals of Vascular Surgery 04/2012; 26(5):607-11. · 0.99 Impact Factor
  • Southern California Vascular Surgery Society. 01/2012;
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    ABSTRACT: We assessed the impact of endovenous ablation of incompetent superficial (great saphenous [GSV] and small saphenous [SSV]) and perforator (posterior tibial [PTPV]) veins on the healing rate of venous ulcers in patients who had failed conventional compression therapy. Patients with CEAP 6 ulcers were treated with weekly compression in a dedicated wound care center. Ulcer size and depth were tracked prospectively. Those ulcers that showed no measurable improvement after >5 weeks of compression therapy underwent ablation of at least one incompetent vein. We performed 140 consecutive endovenous ablation procedures (74 superficial and 66 perforator) on 110 venous ulcers in 88 limbs. Ulcers had been present for 71 ± 6 months with an initial ulcer area of 23 ± 6 cm(2). Following successful ablation, the healing rate for healed ulcers improved from + 1.0 ± .1 cm(2)/month to -4.4 ± .1 cm(2)/month (P > .05). Ulcer healing rate for healed ulcers, based on the last vein ablated, was GSV = 6.4 cm(2)/month, SSV = 4.8 cm(2)/month, and PTPV = 2.9 cm(2)/month. After a minimum observation period of 6 months (mean follow up, 12 ± 1.25 months), 76.3% of patients healed in 142 ± 14 days. Twelve patients with 26 ulcers did not heal: two patients died from unrelated illnesses, six patients are still actively healing, and four patients have been lost to follow up. Of the healed ulcers, four patients with six ulcers (7.1%) recurred; two have rehealed. There is measurable and significant reduction in ulcer size and ultimate healing following ablation of incompetent superficial and perforator veins in patients who have failed conventional compression therapy.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2011; 55(2):458-64. · 3.52 Impact Factor
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    ABSTRACT: Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent superficial and/or perforating veins on ulcer recurrence rates in patients with CEAP 5 who have progressive lipodermatosclerosis and impending ulceration. Endovenous ablation was performed on patients with CEAP 5 disease and incompetent superficial and/or perforator veins and increasing lipodermatosclerosis and/or progressive malleolar pain. A minimum of 3 months of compressive therapy was attempted before endovenous ablation of incompetent veins. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Patients underwent duplex ultrasound scans before ablation to assess for deep, superficial, and perforator venous incompetence as well as postoperatively to confirm successful ablation. Twenty-eight endovenous ablation procedures (superficial = 19; perforator = 9) were performed on 20 patients (limbs = 21). The mean patient age was 73 years old (range, 45-93 years) and the mean body mass index was 29.5 (18.9-58.4). Ninety-five percent of patients previously wore compression stockings (20-30 mm Hg = 9; 30-40 mm Hg = 10; none = 1) for a mean time of 23.3 months (range, 3-52 months) since the prior ulcer healed. Indications for venous ablation were increasing malleolar pain (55%) and/or lipodermatosclerosis (70%). Technical success rates for the ablation procedures were 100% for superficial veins and 89% for perforators (96.4% overall). All patients underwent closure of at least one incompetent vein. Postoperatively, 95% of patients were compliant with wearing compression stockings (20-30 mm Hg = 8; 30-40 mm Hg = 11; none = 1). Ulcer recurrence rates were 0% at 6 months and 4.8% at 12 and 18 months. These data compare with prior studies showing an ulcer recurrence rate up to 67% at 12 months with compression alone. Patients with CEAP 5 healed venous ulcers that undergo endovenous ablation of incompetent superficial and perforating veins and maintain compression have reduced ulcer recurrence rates compared with historical controls that are treated with compression alone.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2011; 55(2):446-50. · 3.52 Impact Factor
  • Brian G DeRubertis
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    ABSTRACT: A significant percent of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) have concomitant common iliac artery aneurysms. While most of these patients will tolerate sacrifice of the hypogastric artery during repair, a subset will develop sequelae of hypogastric occlusion. EVAR was performed in two patients using a bifurcation-sparing unibody endograft (Powerlink, Endologix, Irvine, CA, USA). To avoid simultaneous bilateral hypogastric occlusion, one side was treated with coil embolization while the other was treated with a hypogastric graft (Viabahn, W L Gore and Associates, Flagstaff, AZ, USA). Access to the preserved hypogastric artery was obtained from a sheath inserted from the contralateral femoral artery and brought over the aortic bifurcation with the assistance of a 'rail-wire' traversing from the contralateral to ipsilateral femoral sheaths. The hypogastric limb was deployed simultaneously with the ipsilateral external iliac limb extension, creating a double-barrel flow lumen preserving both hypogastric and external iliac flow. At a mean follow-up of 5.1 months, both hypogastric limbs are patent and no endoleaks were observed. In conclusion, until commercially-produced branched hypogastric endografts are widely available, techniques such as those described above can allow for hypogastric preservation during aortoiliac aneurysm repair without the need for device modification or brachial access for hypogastric limb delivery.
    Vascular 10/2011; 20(2):107-12. · 0.86 Impact Factor
  • Brian G DeRubertis
    Archives of surgery (Chicago, Ill.: 1960) 09/2011; 146(9):1009-10. · 4.32 Impact Factor
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    ABSTRACT: Thrombosis and embolization are the most frequent complications associated with the vascular presentation of thoracic outlet syndrome (VTOS). Therefore, surgery for these conditions requires careful balancing of anticoagulation and hemostasis. Our goal is to identify the optimal postoperative anticoagulation management of these patients. A prospective database of consecutive patients who have presented to our institution with the diagnosis of thoracic outlet syndrome was reviewed from 1996 through 2010 for instances of postoperative hemorrhage. All venous cases were managed with transaxillary first rib resection followed by postoperative venography and percutaneous angioplasty when required. All arterial cases first underwent thrombolysis, then decompression with transaxillary first and cervical rib resection with concomitant arterial repair when indicated. Over the study period, 423 patients diagnosed with thoracic outlet syndrome underwent 551 procedures. Of these, 108 presented with VTOS (12 arterial and 96 venous). Mean age of the patients in the cohort was 33.7 ± 11.5 years, with 53 women and 55 men. Postoperative hemorrhage occurred in four patients (4%): three venous cases and one arterial case. Three patients required tube thoracostomy (average blood return: 800 mL) and two required video-assisted thoracoscopic surgery for decortication. Age, gender, preoperative anticoagulation, interval from thrombolysis to surgery, operative duration, and operative blood loss had no effect on the risk of bleeding. No hemorrhage occurred in patients treated with postoperative coumadin alone (82 patients) or with no anticoagulant (24 patients). The four cases of hemorrhage occurred only in patients treated with postoperative low-molecular-weight heparin (LMWH; 14 patients; p < 0.01). Postoperative hemorrhage was not a common complication of first rib resection for VTOS. In our experience, it occurred exclusively in patients receiving LMWH postoperatively. Postoperative LMWH should be used with caution in patients with VTOS.
    Annals of Vascular Surgery 07/2011; 25(5):624-9. · 0.99 Impact Factor
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    ABSTRACT: Rationnelle La thrombose et l'embolisation sont les complications les plus fréquentes liées aux formes vasculaires du syndrome du défilé thoracique (SDTBV). Par conséquent, la chirurgie pour ces conditions exige l'équilibrage soigneux de l'anti-coagulation et de l'hémostase. Notre but est d'identifier la gestion postopératoire optimale d'anti-coagulation de ces patients. Méthodes Une base de données prospective des patients consécutifs qui se sont présentés à notre établissement avec le diagnostic de syndrome du défilé thoraco-brachial a été examinée de 1996 à 2010 à la recherche de cas d'hémorragie postopératoire. Tous les cas veineux ont été traités par résection par voie axillaire de la première cote suivie de phlébographie postopératoire et d'angioplastie percutanée si nécessaire. Tous les cas artériels ont été initialement traités par thrombolyse, puis décompression par voie axillaire avec résection de la première cote et de la cote cervicale et réparation artérielle concomitante si nécessaire. Résultats Au cours de la période d'étude, 423 patients diagnostiqués avec le syndrome du défilé thoraco-brachial ont subi 551 procédures. Parmi ceux-ci, 108 avaient un SDTBV (12 artériels et 96 veineux). L'âge moyen des patients dans la cohorte était de 33,7 ± 11,5 ans, avec 53 femmes et 55 hommes. Une hémorragie postopératoire s'est produite chez quatre patients (4%) : trois cas veineux et un cas artériel. Trois patients ont eu besoin d'un drainage thoracique (volume moyen de sang drainé : 800 ml) et une chirurgie thoracoscopique vidéo-assistée a été nécessaire chez deux patients pour décortication. L'âge, le sexe, l'anti-coagulation préopératoire, l'intervalle thrombolyse chirurgie, la durée d'intervention, et la perte de sang per opératoire n'ont eu aucun effet sur le risque de saignement. Aucune hémorragie ne s'est produite chez les patients traités par coumadine postopératoire seule (82 patients) ou sans anticoagulant (24 patients). Les quatre cas d'hémorragie se sont produits seulement chez des patients traités par héparine de bas poids moléculaire postopératoire (HBPM ; 14 patients ; p < 0,01). Conclusion L'hémorragie postopératoire n'est pas une complication commune de la résection de la première cote pour SDTBV. Dans notre expérience, elle s'est produite exclusivement chez les patients recevant des HBPM en postopératoire. Les HBPM postopératoires devraient être employées avec prudence chez les patients avec SDTBV.
    Annales de Chirurgie Vasculaire. 07/2011; 25(5):668–674.
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    ABSTRACT: Endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing; however, there is little information about the effectiveness of perforator ablation (PA) in healing recalcitrant venous ulcers. We report our experience with PA with venous ulcers unresponsive to prolonged compression therapy. Patients with nonhealing venous ulcers of >3 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Patients who had either no saphenous incompetence or persistent ulcers after saphenous ablation underwent PA of incompetent perforating veins >3 mm that demonstrated reflux; initial treatment was performed on the perforator vein adjacent to the ulcer with additional incompetent veins treated if ulcer healing failed. Seventy-five ulcers with 86 associated incompetent perforating veins were treated with PA in 45 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (61%), calf (37%), and lateral ankle (2%). Initial success of PA, assessed by postprocedure duplex ultrasound, was 58%; repeat ablation was 90% successful and 71% had eventual successful perforator closure. No complications (skin necrosis, infection, or nerve injury) occurred. Failure of ulcer healing with successful perforator closure occurred in 10% and was due to intercurrent illness, patient noncompliance, and patient death due to unrelated causes. Of patients who healed their ulcers, the healing occurred at a mean of 138 days; an average PA of 1.5 incompetent veins per ulcer was required for healing. Ninety percent of ulcers healed when at least one perforator was closed; no ulcer healed without at least one perforator being closed. This experience demonstrates both the feasibility and effectiveness of PA for a selected group of patients with venous ulcers who fail conventional therapy with compression.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2011; 54(3):737-42. · 3.52 Impact Factor
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    ABSTRACT: Anatomic distortion associated with radiation-induced tissue changes may pose challenges for patients with prior cervical irradiation undergoing carotid stenting. We sought to evaluate the effect of these changes on carotid intervention. Carotid angioplasty and stenting (CAS) for high-grade stenosis was performed in 203 patients. In all, 12 consecutive patients with prior ipsilateral cervical irradiation were age-/sex-matched to 24 controls. Degree of internal carotid (IC) tortuosity was assessed by 4 methods: (a) deviation of IC from common carotid (CCA) axis, (b) number of intersections between this axis and the course of the IC, (c) total degrees of angulation along the course of the extracranial IC, and (d) the IC length to straight-line distance ratio. Carotid angioplasty and stenting was successful in all patients. Mean age was 72.8 ± 10 years; 58.4% were male. Twenty-nine percent were symptomatic (14.4% transient ischemic attack [TIA], 8.5% cardiovascular accident [CVA], and 6.5% amaurosis). Comorbidities were similar between the entire cohort and the subgroups of irradiated/control patients. The IC revealed a higher degree of deviation from the axis of the CCA in the previously irradiated patients compared to those without radiation (29.2° ± 4.5° vs 13.0° ± 2.0°, P = .001) and was more likely to intersect this axis in those with a history of cervical irradiation (83.3% vs 14.3%, P < .05). Irradiated patients also exhibited a significantly greater degree of tortuosity versus nonirradiated patients when assessed by total angulation along the course of the carotid (171.8° ± 26.0° vs 74.2° ± 20.2°, P = .014) and by the IC length:distance ratio (1.14 ± 0.05 vs 1.04 ± 0.03, P = .020). Despite increased IC tortuosity in patients with prior irradiation, all procedures were successfully completed and there did not appear to be a predilection for a specific filter type. A history of cervical irradiation is associated with increased tortuosity of the IC, leading to potential challenges for filter and stent deployment. However, this increased procedural complexity did not affect technical success rate or device selection in this series.
    Vascular and Endovascular Surgery 06/2011; 45(7):619-26. · 0.88 Impact Factor
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    ABSTRACT: Introduction Le Gadolinium (Gd) est traditionellement utilisé comme une alternative non néphrotoxique aux produits de contraste iodés pour la réalisation d'artériographies numérisées de soustraction (ANS) chez les patients présentant une insuffisance rénale chronique. Néanmoins, son utilisation a été remise en cause en raison de sa potentielle néphrotoxicité et de son association récemment décrite avec des cas de fibrose néphrogénique systémique (FNS), complication potentiellement léthale. Les données actuellement disponibles sur l'innocuité du Gd sont donc incertaines. L'objectif de cette étude a été d'évaluer le risque de néphropathie induite par le produit de contraste et de FNS après exposition au Gd dans une large population de patients azotémiques et ayant bénéficié d'une ANS. Methode Un registre complet comprenant les données de tous les patients bénéficiant d'une ANS entre Juin 2003 et Décembre 2007 à l'hôpital Presbyterian a été analysé rétrospectivement. Les patients recevant soit du Gd seul soit une combinaision de Gd et de produit de contraste iodé au cours d'une ANS ont été identifiés et leurs données analysées. L'insuffisance rénale aigue (IRC) a été définie comme une élévation de la crétininémie (Cr) > >0.5 mg/dL dans les 48 premières heures suivant l'exposition. Le suivi clinique a été effectué par analyse des dossiers et par interviews téléphoniques des patients et des médecins traitants. Résultats Au total, 153 patients ont été exposés à 179 injections de Gd seul (33%) ou à une combinaison de Gd et de produit de contraste iodé (67%). La durée moyenne du suivi a été de 27,1 mois. La Cr moyenne a été de 1,94 ± 0,78 mg/dL et 1,96 ± 1,1 mg/dL avant et après ANS, respectivement. Il y a eu 20(11,2%) cas d'IRA. La Cr moyenne avant ANS était plus élevée chez les patients ayant présenté une IRA en comparaison au groupe sans IRA (2,7 ± 1,1 mg/dL vs. 1,9 ± 0,7 mg/dL, p = 0,004). Dans le group IRA, 12 patients ont retrouvé une Cr équivalente à celle de la période ayant précédé l'ANS, quatre ont présenté une détérioration irréversible de leur fonction rénale, et quatre ont nécessité une dialyse (incidence de l'insuffisance rénal chronique: 4,5%). Durant la période de l'étude, 19 décès sont survenus (12,4%). Le risque le plus élevé de développer une IRA après exposition au Gd a été observé chez les patients ayant une Cr >3.0 mg/dL avant ANS et chez ceux recevant des doses >0.4 mmol/kg de Gd. Chez les patients ayant reçu une combinaison de Gd et de produit de contraste iodé, il existait une tendance à un risque accru de développer une IRA en comparaison au groupe ne recevant que du Gd. Aucun cas de FNS n'a été observé chez les patients recevant du Gd en intra-artériel. Conclusions De façon similaire aux produits de contraste iodés, l'administration de Gd est associée à un risque de toxicité rénale, mais les risques d'insuffusance rénale irréversible et de dialyse sont peu élevés. Les interventions pour menace vitale ou sauvetage de membre ne doivent pas être évitées même en présence d'une élévation de la Cr. Nos résultats devraient aider à guider la bonne utilisation du Gd chez les patients insuffisants rénaux.
    Annales de Chirurgie Vasculaire. 04/2011; 25(3):393–403.

Publication Stats

632 Citations
112.98 Total Impact Points

Institutions

  • 2008–2014
    • University of California, Los Angeles
      • Division of Vascular Surgery
      Los Angeles, California, United States
    • Gracie Square Hospital, New York, NY
      New York City, New York, United States
  • 2011
    • University of Rochester
      • Division of Vascular Surgery
      Rochester, NY, United States
  • 2010–2011
    • Harbor-UCLA Medical Center
      Torrance, California, United States
  • 2005–2011
    • New York Presbyterian Hospital
      • Department of Vascular Surgery
      New York City, New York, United States
  • 2004–2008
    • Cornell University
      • Department of Surgery
      Ithaca, NY, United States
  • 2004–2007
    • Weill Cornell Medical College
      • Division of Vascular Surgery
      New York City, New York, United States