G M Deeb

Concordia University–Ann Arbor, Ann Arbor, Michigan, United States

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Publications (142)629.04 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: The incidence of acute kidney injury (AKI) after thoracic aortic endovascular repair (TEVAR) is variably reported at 1% to 34%. This study utilized the RIFLE (risk, injury, failure) criteria to evaluate the incidence, risk factors, and late implications of AKI after TEVAR. In all, 350 patients without prior dialysis requirement underwent TEVAR (1993 to 2013). The mean age was 68.7 years (54% male). The mean preoperative glomerular filtration rate was 76.5 ± 37.6 mL/min, with 39 patients (11.7%) in chronic kidney stage 3 or 4. The TEVAR was performed for rupture in 20.6%. The mean contrast volume administered was 95.7 ± 52.9 mL. Early mortality was seen in 17 patients (4.9%). Acute kidney injury defined as RIFLE classes risk, injury, or failure was seen in 59 patients (17%; risk = 36, injury = 14, failure = 9). Independent predictors of AKI included history of saccular aneurysm, presentation with rupture, or need for arch repair or red blood cell transfusion (all p < 0.05). Only 2 patients (0.6%) needed dialysis, with none requiring permanent dialysis. Importantly, 10-year freedom from dialysis was 97.7%. Development of AKI predicted early mortality (p < 0.001, odds ratio 9.8). Ten-year survival was 38.1%. Both injury and failure AKI classes independently predicted late mortality (p < 0.05). The prevalence of AKI after TEVAR as assessed by RIFLE criteria is higher than seen in previous reports. Despite its infrequent progression to permanent dialysis dependence, AKI remains an important risk factor for both early and late mortality. Future studies should evaluate strategies to reduce the incidence of AKI after TEVAR to improve both early and late outcomes.
    The Annals of thoracic surgery 04/2014; · 3.74 Impact Factor
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    ABSTRACT: Repair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort. Of 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60 years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n = 93), hybrid (n = 11), or TEVAR (n = 33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n = 53) or fusiform (n = 30) aneurysms or dissection (n = 15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n = 30), arch (n = 40), descending (n = 24), or abdominal (n = 9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias. Early mortality was seen in nine patients (7%). Morbidity included stroke (n = 9), paraplegia (n = 1), and need for dialysis (n = 5) or tracheostomy (n = 10). A composite outcome of death and stroke was independently predicted by advancing age (P = .055) and performance of a hybrid procedure (P = .012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P < .05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P = .018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P = .017) and an endovascular or hybrid procedure (P = .001) independently predicted late aortic rupture or need for reintervention. Isolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2014; · 3.52 Impact Factor
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    ABSTRACT: Background The incidence of acute kidney injury (AKI) after thoracic aortic endovascular repair (TEVAR) is variably reported at 1% to 34%. This study utilized the RIFLE (risk, injury, failure) criteria to evaluate the incidence, risk factors, and late implications of AKI after TEVAR. Methods In all, 350 patients without prior dialysis requirement underwent TEVAR (1993 to 2013). The mean age was 68.7 years (54% male). The mean preoperative glomerular filtration rate was 76.5 ± 37.6 mL/min, with 39 patients (11.7%) in chronic kidney stage 3 or 4. The TEVAR was performed for rupture in 20.6%. The mean contrast volume administered was 95.7 ± 52.9 mL. Results Early mortality was seen in 17 patients (4.9%). Acute kidney injury defined as RIFLE classes risk, injury, or failure was seen in 59 patients (17%; risk = 36, injury = 14, failure = 9). Independent predictors of AKI included history of saccular aneurysm, presentation with rupture, or need for arch repair or red blood cell transfusion (all p < 0.05). Only 2 patients (0.6%) needed dialysis, with none requiring permanent dialysis. Importantly, 10-year freedom from dialysis was 97.7%. Development of AKI predicted early mortality (p < 0.001, odds ratio 9.8). Ten-year survival was 38.1%. Both injury and failure AKI classes independently predicted late mortality (p < 0.05). Conclusions The prevalence of AKI after TEVAR as assessed by RIFLE criteria is higher than seen in previous reports. Despite its infrequent progression to permanent dialysis dependence, AKI remains an important risk factor for both early and late mortality. Future studies should evaluate strategies to reduce the incidence of AKI after TEVAR to improve both early and late outcomes.
    The Annals of Thoracic Surgery. 01/2014;
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    ABSTRACT: Marfan syndrome is a relatively common connective tissue disorder that causes skin, ocular, skeletal, and cardiovascular abnormalities. High morbidity and mortality occur with aortic aneurysm and dissection. Other large-artery aneurysms, including carotid, subclavian, and iliac artery aneurysms, have also been associated with Marfan syndrome. It is not clear whether small- to medium-sized artery aneurysms are associated with Marfan syndrome. This report describes 4 patients with Marfan syndrome who have associated small- to medium-sized artery aneurysms with several complications. Additional investigations are needed to determine whether Marfan syndrome can cause small- to medium-sized artery aneurysms and how patients with these aneurysms should be treated.
    Annals of Vascular Surgery 07/2013; · 0.99 Impact Factor
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    ABSTRACT: During the diagnostic evaluation of a 31-year-old male with Marfan syndrome, an acute type B aortic dissection, and rising creatinine, the retrograde loop of our selective catheter inadvertently engaged the entry tear of the dissection in the mid-descending aorta. Traction on the catheter led to a full circumferential dehiscence of the remaining lumen, causing an intimointimal intussusception down to the level of the celiac artery with complete collapse of the true lumen and visceral and renal artery obstruction. Balloon fenestration and supramesenteric stenting of the true lumen decompressed the intussuscepted intimal flap and restored normal perfusion pressures.
    The Annals of thoracic surgery 05/2013; 95(5):1776-8. · 3.74 Impact Factor
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    ABSTRACT: BACKGROUND: Risk factors and outcomes after iliofemoral complications after thoracic aortic endovascular repair remain poorly characterized. This study was performed to characterize factors influencing perioperative iliofemoral complications during thoracic aortic endovascular repair. METHODS: All patients undergoing transfemoral thoracic aortic endovascular repair since 2005 with adequate preoperative aortoiliac 3-dimensional imaging (n = 126) were identified. Assessment of imaging was blinded with regard to occurrence of iliofemoral complications, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy. RESULTS: The complication rate was 12% (n = 15). Univariate analysis identified that female gender, preoperative ankle-brachial index, average and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score (calculated by combining iliac tortuosity, calcification, and vessel diameter) were associated with iliofemoral complications (all P < .05). Multivariate analysis identified the (1) difference between average iliac diameter and sheath size (P = .014), (2) iliac artery morphology score (P = .033), and (3) ankle-brachial index (P = .012) as independent predictors for iliofemoral complications. Early mortality was higher in those with complications (13.3% vs 1.8%, P = .069). Four-year freedom from limb loss, claudication, or revascularization was 97.9%. Iliofemoral complications reduced late survival primarily as a result of increased mortality within the first year (P = .047). CONCLUSIONS: Thoracic aortic endovascular repair can be performed safely via a transfemoral approach. Alternative access in patients with high preoperative iliac artery morphology scores and device delivery size requirements over the native iliofemoral size may reduce iliofemoral complications. If early complications occur, prompt repair results in low rates of ischemic limb complications at late follow-up.
    The Journal of thoracic and cardiovascular surgery 03/2013; · 3.41 Impact Factor
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    ABSTRACT: BACKGROUND: Aortic repair for acute (<2 weeks) or subacute (2 to 8 weeks) type B dissection is performed for rupture, impending rupture, or malperfusion. Thoracic aortic endovascular repair (TEVAR) has been suggested as a more suitable, less invasive alternative to open descending aortic repair for type B dissection, but a comparative analysis is warranted. METHODS: Seventy-three patients with type B dissection (1995 to 2012) underwent early open descending aortic repair (n = 24) or TEVAR (n = 49). Mean age was 66.3 years. Intervention occurred in the acute (n = 53) or subacute (n = 20) period for malperfusion (n = 8), rupture (n = 22), or factors portending rupture, including rapid expansion (n = 26), uncontrolled pain (n = 18), aortic size greater than 5.0 cm (n = 26), or refractory hypertension (n = 2). Twenty-six had multiple indications. Patients undergoing TEVAR were older and had an increased incidence of coronary artery disease and renal impairment (all p < 0.05). RESULTS: Thirty-day mortality was 12% (n = 9). Morbidity included stroke (n = 7), dialysis (n = 6), paralysis (n = 4), and tracheostomy (n = 7). A composite outcome of mortality and these morbidities independently correlated with presentation with frank rupture (p < 0.01) or limb ischemia (p = 0.03), but not treatment strategy (p = 0.3). Ten-year Kaplan-Meier survival was 57.5% and similar between groups (p = 0.74). Independent predictors of late mortality included perioperative stroke and presentation with rupture during late follow-up (both p < 0.02). Five-year freedom from aortic reintervention or rupture was similar between TEVAR (80.0%) and open descending aortic repair (82.8%; p = 0.45). CONCLUSIONS: Early aortic repair for complicated type B dissection is associated with high rates of morbidity, late mortality, and reintervention. Despite its use in a higher risk group, outcomes seen with TEVAR were similar to open repair, thus supporting the recent paradigm shift toward an endovascular approach.
    The Annals of thoracic surgery 03/2013; · 3.74 Impact Factor
  • Himanshu J Patel, G Michael Deeb
    Annals of cardiothoracic surgery. 03/2013; 2(2):181-3.
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    ABSTRACT: OBJECTIVE: To investigate whether wall growth during aneurysm development spares the aortic wall between the intercostal or lumbar arteries or, alternatively, is uniform around the circumference. METHODS: Computed tomography scans of 155 patients with aortic aneurysms (40 thoracic, 50 thoracoabdominal, and 65 abdominal) in a single hospital of a large academic institution were retrospectively inspected. Computed tomography studies of 100 control subjects (40 thoracic and 60 abdominal) were also reviewed. In all 255 patients, the ratio of the arc length between the origins of the intercostal or lumbar arteries (interbranch arc length) to the remainder of the aortic residual circumference was calculated. These ratios were compared between all subjects with aneurysms and the controls at each vertebral body level and between those with thoracic or thoracoabdominal or abdominal aneurysms and controls at each vertebral body level. RESULTS: Interbranch arc lengths and residual aortic circumferences were larger in aneurysm patients than in control subjects, but the differences were statistically significant only at T4 and from T8 to L4 (P = .009 to P < .001) and from T4 to L4 (P < .001), respectively. The ratio of interbranch arc length to residual circumference in aneurysmal aortas was significantly smaller than that in controls at 12 out of 13 levels from T4 to L4 (P = .004 to P < .001). There was a statistically significant smaller ratio at 8 out of 9 levels for thoracic aneurysms (P = .006 to P < .001), 12 out of 13 levels for thoracoabdominal aneurysms (P = .008 to P < .001), and 3 out of 4 levels for abdominal aneurysms compared with controls (P = .006 to P < .001). CONCLUSIONS: Wall growth in aortic aneurysms is asymmetric, with greater aneurysmal growth in the anterior aorta wall and relative sparing of the portion of aortic wall between the intercostal or lumbar arteries. The mechanisms effecting this asymmetric growth have not been fully characterized.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2012; · 3.52 Impact Factor
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    ABSTRACT: Penetrating aortic ulcers (PAU) often occur in a debilitated elderly population. Although early results of repair for PAU are well described, late outcomes remain poorly characterized and are the focus in this report. Ninety-five patients (mean age 70.7 years) underwent distal arch/descending aortic repair for PAU (1993 to 2011). Indications for intervention included rupture, saccular aneurysm, or symptoms. Associated intramural hematoma (IMH) was present in 41. Treatment was by open descending aortic repair (DTAR, n=37) or thoracic endovascular aortic repair (TEVAR, n=58). The DTAR group was younger (68 years versus TEVAR 72.5 years, p=0.02), and less frequently presented with rupture (24% versus TEVAR 43%, p=0.09). Early morbidity included death (9 patients; 9.5%), stroke (8), permanent paraplegia (2), and dialysis (5). Early adverse events were independently predicted by rupture, total descending repair, and DTAR (all p<0.01). Ten-year survival was 47.9%. Predictors of late mortality included advancing age (p=0.016) and urgent presentation (p=0.002), but not repair type. Ten-year freedom from aortic reintervention/rupture was 71.4%. Associated IMH increased the risk for reintervention/rupture (5-year freedom PAU 97.1% versus PAU/IMH 72.1%, p=0.01), primarily because of decreased efficacy after TEVAR for PAU/IMH (5-year freedom 57.7% versus DTAR 100%, p=0.05). Despite the presence of an older, more complex TEVAR group, late outcomes after repair for PAU were affected more by age and type of presentation than by treatment strategy. Recognizing the perils of intervention in this high-risk population, TEVAR emerges as the therapy of choice to reduce early morbidity and provide similar late survival.
    The Annals of thoracic surgery 05/2012; 94(2):516-22; discussion 522-3. · 3.74 Impact Factor
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    ABSTRACT: To document the natural history of branch artery pseudoaneurysms (BAPs), which are sequelae of aortic dissection with false lumen thrombosis that have been distinguished anatomically from penetrating ulcers. Serial computed tomography (CT) scans in 50 patients with at least two CT scans greater than 1 month apart were retrospectively studied. Mean follow-up was 29 months, with longitudinal analyses of 119 BAPs. Changes in BAPs, false lumen thrombosis, and aortic diameter were assessed. No patient had an aortic rupture or other poor outcome. All BAPs eventually disappeared (ie, thrombosed), with 50% thrombosed within 18 months. Aortas were ectatic, with a mean diameter of 36 mm. There was no statistically significant change in total aortic diameters; however, there was a significant increase in true lumen diameters (P < .0001) and a significant decrease in false lumen thickness (P < .0001) at the level of the BAP over time (mean 50% reduction in maximum thickness of thrombosed false lumen). There were no significant associations between BAP thrombosis and vertebral level, presence of more than one BAP, presence of branch artery in communication with the BAP, history of smoking, diabetes mellitus or hypertension, or treatment with β-blockers, other antihypertensive medication, statins, or anticoagulation therapy. After controlling for other variables, BAPs were less likely to thrombose if an ulcerlike projection was present (P = .003), in men (P = .02), in subjects with hypertension (P = .04), and in older patients (P = .05). Most BAPs spontaneously thrombose, and associated intramural hematoma regresses/disappears. Isolated BAPs were not associated with poor clinical outcomes.
    Journal of vascular and interventional radiology: JVIR 05/2012; 23(7):859-865.e3. · 1.81 Impact Factor
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    ABSTRACT: Hybrid thoracic endovascular aneurysm repair (H-TEVAR) to include visceral and renal debranching has emerged as a potential therapeutic option for thoracoabdominal aneurysms (TAAA). This study was performed to characterize the frequently noted development of postoperative fluid collections surrounding the bypass grafts. All patients undergoing H-TEVAR from 2000-2010 (n = 39, 43.6% male) were identified. One hundred thirty-two bypasses were constructed (median 4 per patient) using either polyester (30), thin-walled polytetrafluoroethylene (ePTFE, 100) or saphenous vein (2). Follow-up computed tomography (CT) imaging was routinely performed at 1 and 6 months, and annually thereafter. Of the 37 patients with one follow-up CT, 20 (54.1%) were found to have fluid collections. The natural history of the 17 patients with collections and further follow-up imaging was variable, with 2 resolving, 6 stable, and 9 enlarging. Two patients with collections developed evidence of graft infection requiring reoperation. Two patients with enlarging sterile collections required evacuation for symptoms. By multivariate analysis, both preoperative creatinine (P = .005) and number of bypasses constructed (P = .04) independently correlated with the development of a fluid collection. Postoperative fluid collections following hybrid debranching procedures identified in this series represent a unique complication not previously described. The subsequent clinical course of these fluid collections is variable and ranges from benign to frank graft infection and relate both to patient factors, as well as specific operative strategies. Longer-term studies with more robust numbers of patient numbers are warranted to determine whether this complication may limit the long-term durability of this procedure.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 07/2011; 54(6):1623-8. · 3.52 Impact Factor
  • Article: Reply.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2011; 53(6):1757-8. · 3.52 Impact Factor
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    ABSTRACT: Recent advancements in thoracic endovascular aortic repair, such as branched endografts or hybrid debranching/thoracic endovascular aortic repair, have extended the option of endoluminal therapy into the realm of the aortic arch. A contemporary assessment of open arch repair to provide long-term data for comparative analysis for these newer therapies is timely, warranted, and presented in this article. Since the inception of our thoracic endovascular aortic repair program in 1993, 721 patients (mean age of 59.3 years, 68.9% were male) have undergone median sternotomy and open arch reconstruction with hypothermic circulatory arrest. Extended arch repair was performed in 42.7% with construction of bypasses to the innominate (296 patients), left carotid (216 patients), and subclavian (75 patients) arteries or elephant trunk procedures (42 patients). Concomitant aortic valve or aortic root replacement was required in 403 patients, and root reconstruction was required in 222 patients. Retrograde (641 patients) or antegrade (400 patients) cerebral perfusion was used for neuroprotection during hypothermic circulatory arrest. The operative procedure was urgent or emergency in 316 patients (43.8%) and included repair of type A dissection in 284 patients (39.3%). A total of 111 patients (15.4%) had undergone prior cardiac surgery. Primary outcomes in this study were early and late mortality. Follow-up was 100% complete (mean, 52.6 months). Thirty-day morbidity included death (36 patients [5%]), stroke (34 patients [4.7%]), and permanent dialysis (14 patients [1.9%]). Independent predictors of early mortality included advancing age, prolonged bypass times, and impaired ejection fraction (all P < .05). Actuarial survival at 10 years was 65%. Independent predictors of late mortality included advancing age, prolonged lower body circulatory arrest times, and increasing creatinine (all P < .05). By Kaplan-Meier analysis, 10-year survival was significantly reduced after operative procedures for type A dissection (non-type A 69.1% vs type A 58%, P = .003). Freedom from aortic reoperation (any segment) was 72.6% at 10 years. Open aortic arch repair can be accomplished with excellent early and late results. These outcomes provide objective data for comparison and suggest that newer endovascular therapies should be evaluated first in high-risk groups, such as those with advanced age or impaired renal function before broader application in all patients.
    The Journal of thoracic and cardiovascular surgery 04/2011; 141(6):1417-23. · 3.41 Impact Factor
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    ABSTRACT: Previous studies have focused on early outcomes of open (descending thoracic aortic repair [DTAR]) and endovascular (thoracic endovascular aneurysm repair [TEVAR]) repair of blunt aortic injury (blunt thoracic aortic injury [BTAI]). Late results remain ill-defined and are the focus of this study. One hundred nine patients (1992-2010) underwent repair for BTAI. Mean age was 39.0 years (73.4% male). DTAR was performed in 90, with left heart bypass (85) or hypothermic arrest (5). TEVAR was used in 19 of 45 patients treated since 2002. A strategy of selective delayed repair has been used since 1997, with 54 of 75 patients treated with delayed repair in this interval. The primary outcome was vital status (100% follow-up; mean, 103.9 months). Mean Injury Severity Score was 39.5. Thirty-day mortality was 4.6% (n = 5). Early morbidity included permanent spinal cord ischemia (SCI, 1.8%), stroke (2.8%), and need for permanent dialysis (1.8%). Independent predictors of a composite outcome of early mortality and these morbidities included age >60 years (odds ratio [OR], 8.4; P = .015), increasing preoperative creatinine (OR, 7.9; P = .017), and occurrence of postoperative sepsis (OR, 9.6; P = .021). Fifteen-year Kaplan-Meier survival was 81.3%. Independent predictors of late mortality included age >60 years (Cox hazard ratio [HR], 4.1; P = .01), increasing creatinine (HR, 9.1; P < .001), or occurrence of postoperative SCI (HR, 20.6; P < .001), but not repair type (P = .73). Endograft collapse occurred in one patient, necessitating reintervention. Freedom from aortic reintervention at 4 years was higher after open repair (DTAR 100% vs TEVAR 94%; P = .03). With careful selection, open or endovascular repair of BTAI has excellent early and late results. Although TEVAR has an increased risk for reintervention, factors other than treatment strategy impact late survival. These data support the growing role of an endoluminal approach for BTAI in anatomically appropriate patients.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2011; 53(3):615-20; discussion 621. · 3.52 Impact Factor
  • The Journal of thoracic and cardiovascular surgery 12/2010; 140(6 Suppl):S98-S100; discussion S142-S146. · 3.41 Impact Factor
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    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2010; 52(4 Suppl):37S-40S. · 3.52 Impact Factor
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    ABSTRACT: Hybrid visceral-renal debranching procedures with endovascular repair have recently been proposed as a less invasive alternative to conventional thoracoabdominal aortic aneurysm (TAAA) surgery. This study provides a concurrent assessment of hybrid and open TAAA repair. One hundred two consecutive patients (mean age, 63.0 years) underwent open (73) or hybrid (29) Crawford type 1 (19), 2 (50), or 3 (33) TAAA repair from 2000 to 2009. Hybrid debranching procedures were selected for patients considered poor operative risk for standard TAAA repair (27) or for patient preference (2). The TAAAs were fusiform atherosclerotic (68), dissection (30), or pseudoaneurysm (4). Fifty-seven patients (55.9%) had previously undergone aortic repair. Outcomes were analyzed with 100% follow-up (mean, 30.5 months). Operative procedures were urgent or emergent in 16 (15.6%). Early mortality occurred in 13 (12.7%), and was independently predicted by use of hypothermic circulatory arrest (p = 0.005). Early morbidity included permanent paraplegia (12), stroke (1), need for dialysis (22), or tracheostomy (7). Independent correlates of a composite outcome comprised of early mortality and these early morbidities included an urgent-emergent presentation (p = 0.002) or open TAAA repair (p = 0.021). Kaplan-Meier survival was similar between open and hybrid TAAA groups (p = 0.88). Late mortality was independently predicted by the presence of diabetes (p = 0.052) or the need for dialysis at the time of TAAA repair (p < 0.001). Hybrid debranching procedures may reduce early morbidity and yield similar late survival, even in a group considered high risk for open surgery. These data support the increasing utilization of a hybrid debranching and endovascular approach for patients requiring thoracoabdominal aneurysmectomy.
    The Annals of thoracic surgery 05/2010; 89(5):1475-81. · 3.74 Impact Factor
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    ABSTRACT: The presence of penetrating aortic ulcers (PAUs) of the descending thoracic aorta has been associated with a poor long-term prognosis. Although early results have suggested acceptable outcomes for thoracic endovascular aortic repair (TEVAR) for PAU, few studies have described the late outcomes of this approach. From 1993 to 2009, 37 patients (43.2% male; mean age, 72 years) underwent TEVAR for PAU. Associated intramural hematoma was present in 19. Comorbidities included hypertension in 31, chronic obstructive pulmonary disease in 16, coronary artery disease in 22, and renal failure (mean preoperative creatinine, 1.4 mg/dL). Urgent or emergent indications were identified in 22 patients (59.5%), including presentation with rupture in 15 (40.5%). TEVAR was successfully performed in all patients. Arch repair was performed in 14 and total descending repair in 13. Concomitant procedures included coronary artery bypass grafting (CABG) and total arch debranching in one patient electively presenting with an asymptomatic PAU. Early morbidity included stroke (5.4%), temporary paraplegia (5.4%), and need for dialysis (2.7%). In-hospital or 30-day mortality was seen in two patients (5.4%). By Kaplan-Meier analysis, median survival was 89.8 months. Independent predictors of late mortality included urgent or emergent presentation (odds ratio, 14.7; P = .007). Actuarial freedom from TEVAR treatment failure (ie, need for open or endovascular aortic reintervention, aortic rupture, or aortic-related death) was 81.6% +/- 7.8% at 5 years. Analysis stratified by type of pathology (PAU vs PAU and intramural hematoma) showed no significant baseline differences in age, comorbidities, or extent of repair. By Kaplan-Meier analysis, however, presentation with PAU and intramural hematoma was associated with an increased risk for TEVAR treatment failure (P = .033). TEVAR can be safely accomplished for patients presenting with PAU. The presence of associated intramural hematoma may adversely affect the late outcomes of therapy, highlighting the need for careful planning, prudent balancing of the benefits of immediate vs delayed treatment of the fragile aortic wall, and the imperative nature of attentive follow-up in patients with PAU.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2010; 51(4):829-35. · 3.52 Impact Factor
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    ABSTRACT: Open repair for acute type B dissection with malperfusion is associated with significant morbidity. Thoracic aortic endovascular repair has been proposed as a less-invasive therapy for acute type B dissection with malperfusion. Benefits of thoracic aortic endovascular repair include the potential for false lumen thrombosis. Its risks include both early morbidity and mortality, and uncertain late results with potentially unstable landing zones. We present the first long-term analysis of an alternative endovascular approach consisting of percutaneous flap fenestration with true lumen and branch vessel stenting to restore end-organ perfusion. Outcomes were analyzed for 69 patients presenting with acute type B dissection with malperfusion from 1997 to 2008. All patients were evaluated with angiography and treated with a combination of flap fenestration, true lumen, or branch vessel stenting where appropriate. Mean age was 57.3 years. Identified malperfused vascular beds included spinal cord (5), mesenteric (40), renal (51), and lower extremity (47). Major morbidity included dialysis need (11), stroke (3), paralysis (2), and 30-day mortality (n = 12, 17.4%). Mean Kaplan-Meier survival was 84.3 months. Although late mortality was associated with age (P < .0001), neither the type nor the number of malperfused vascular beds correlated with vital status at last follow-up (P > .4). Freedom from aortic rupture or open repair at 1, 5, and 8 years was 80.2%, 67.7%, and 54.2%, respectively. Presentation with acute type B dissection with malperfusion carries a significant risk for both early and late mortality. Percutaneous approaches allow for rapid restoration of end-organ perfusion with acceptable results. These long-term results can serve as comparative data by which to evaluate newer therapies for acute type B dissection with malperfusion, such as thoracic aortic endovascular repair.
    The Journal of thoracic and cardiovascular surgery 09/2009; 138(2):300-8. · 3.41 Impact Factor

Publication Stats

4k Citations
629.04 Total Impact Points

Institutions

  • 1989–2014
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 1988–2013
    • University of Michigan
      • • Department of Radiology
      • • Department of Surgery
      • • Department of Cardiac Surgery
      • • Department of Internal Medicine
      • • Division of Pediatric Cardiology
      • • Section of Thoracic Surgery
      Ann Arbor, Michigan, United States
  • 2002
    • Emory University
      • Department of Anesthesiology
      Atlanta, GA, United States