Publications (22)53.23 Total impact
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Article: Comparison of interventional outcomes according to preoperative indication: a single center analysis of 2,240 limb revascularizations.
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ABSTRACT: Outcomes after lower extremity revascularization are usually reported according to the level of peripheral arterial disease (PAD, aortoiliac or infrainguinal) or the method of treatment (open or endovascular surgery). Outcomes stratified by indication, ie, claudication or critical limb ischemia (rest pain and tissue loss), have not been well studied. The purpose of this study was to compare postoperative outcomes according to the preoperative indications. Outcomes of 2,240 consecutive limb revascularizations in 1,732 patients from January 1998 through December 2005 were stratified and examined according to preoperative indication: claudication (n=999 limbs), ischemic rest pain (n=464 limbs), or tissue loss (n=777 limbs). End points measured included primary and secondary interventional or operative patency, limb salvage, survival, amputation-free survival, maintenance of ambulation, maintenance of independence, and resolution of presenting symptoms. The proportion of medical comorbidities and the severity of disease increased significantly by cohort from claudication to rest pain to tissue loss. With a mean followup of 1,089 days (range 0 to 3,689 days), overall outcomes performance declined consistently according to indication for all end points measured at 5 years (claudication, rest pain, tissue loss, p value): secondary reconstruction patency (93%, 80%, 66%, respectively; p < 0.001), limb salvage (99%, 81%, 68%, respectively; p < 0.001), survival (78%, 46%, 30%, respectively; p < 0.001), amputation-free survival (78%, 42%, 25%, respectively; p < 0.001), maintenance of ambulation (96%, 78%, 68%, respectively; p < 0.001), maintenance of independence (98%, 85%, 75%, respectively; p < 0.001), and resolution of presenting symptoms (79%, 61%, 42%, respectively; p < 0.001). There is a declining spectrum of outcomes performance from claudication to rest pain to tissue loss. These findings question the accuracy of all previously published data for critical limb ischemia, for which rest pain and tissue loss are usually blended and reported as a single outcomes value.Journal of the American College of Surgeons 05/2009; 208(5):770-8; discussion 778-80. · 4.55 Impact Factor -
Article: Contemporary outcomes of iliofemoral bypass grafting for unilateral aortoiliac occlusive disease: a 10-year experience.
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ABSTRACT: Current treatment of complex aortoiliac occlusive disease (AIOD) includes the aortobifemoral bypass or the femoral-femoral bypass. However, because of bilateral groin exposure and associated risks, there is a significant morbidity associated with these procedures. In appropriate patients with unilateral AIOD, the iliofemoral bypass graft (IFBPG) via a lower abdominal retroperitoneal incision can be an acceptable alternative. The purpose of this study is to review the safety and efficacy as well as long-term outcomes of IFBPG in patients with unilateral AIOD. From July 1997 through June 2006, 40 patients (64.3 +/- 11.2-years-old, range 41-89-years-old, 57.5% critical limb ischemia, 70% male, 95% smokers) with unilateral AIOD were treated with IFBPG. Perioperative complications and symptom resolution were measured and Kaplan-Meier life table analysis was used to analyze outcomes of primary and secondary patency, survival, limb salvage, contralateral intervention, and maintenance of ambulation and independent living status. The perioperative complication rate was 12.5 per cent (n = 5) including one patient who developed atrial-fibrillation and one who developed acute renal failure. Both patients experienced resolution of these symptoms before discharge. Other complications included one limb thrombosis and two wound infections. There were no perioperative deaths. Secondary patency was 97.5 per cent and 93.3 per cent at 1 and 5 years. Limb salvage in patients with critical limb ischemia (CLI) was 85.1 per cent and 79.1 per cent at 1 and 5 years. Limb amputation occurred due to infection (n = 2), or failed IFBPG (n = 2). Thirty-one patients (77.5%) experienced symptom resolution including 15 (88.2%) of the patients treated for claudication. Two patients (5%) required contralateral iliac intervention. Patient survival was 97.5 per cent and 64.5 per cent at 1 and 5 years. Greater than 90 per cent of patients maintained their functional independence at 5 years. IFBPG achieved excellent technical and functional outcomes, particularly in patients treated for vasculogenic claudication. This procedure is relatively safe and efficacious in a population of patients with complex unilateral AIOD and can be an acceptable alternative to the aortobifemoral bypass or fem-fem procedure.The American surgeon 07/2008; 74(6):555-9; discussion 559-60. · 1.28 Impact Factor -
Article: Do current outcomes justify more liberal use of revascularization for vasculogenic claudication? A single center experience of 1,000 consecutively treated limbs.
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ABSTRACT: The purpose of this study was to reconsider current recommended treatment guidelines for vasculogenic claudication by examining the contemporary results of surgical intervention. We performed a retrospective review of 1,000 consecutive limbs in 669 patients treated for medically refractory vasculogenic claudication and prospectively followed. Outcomes measured included procedural complication rates, reconstruction patency, limb salvage, maintenance of ambulatory status, maintenance of independent living status, survival, symptom resolution, and symptom recurrence. Of the 1,000 limbs treated, endovascular therapy was used in 64.3% and open surgery in 35.7% of patients; aortoiliac occlusive disease was treated in 70.1% and infrainguinal disease in 29.9% of patients. The overall 30-day periprocedural complication rate was 7.5%, with no notable difference in complication rates when comparing types of treatment or levels of disease. Overall reconstruction primary patency rates were 87.7% and 70.8%; secondary patencies were 97.8% and 93.9%; limb salvage, 100% and 98.8%; and survivals, 95.4% and 76.9%, at 1 and 5 years, respectively. More than 96% of patients maintained independence and ambulatory ability at 5 years. Overall symptom resolution occurred in 78.8%, and symptom recurrence occurred in 18.1% of limbs treated, with slightly higher resolution and recurrence noted in patients treated with endovascular therapy. Contemporary treatment of vasculogenic claudication is safe, effective, and predominantly endovascular. These data support a more liberal use of revascularization for patients with claudication and suggest that current nonoperative treatment guidelines may be based more on surgical dogma than on achievable outcomes.Journal of the American College of Surgeons 06/2008; 206(5):1053-62; discussion 1062-4. · 4.55 Impact Factor -
Article: Is surgical thrombectomy to salvage failed autogenous arteriovenous fistulae worthwhile?
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ABSTRACT: The Dialysis Outcomes Quality Initiatives guidelines emphasize placement of autogenous arteriovenous (AV) fistulae for patients on hemodialysis. This recommendation is based on studies that demonstrate enhanced patency for AV fistulae compared with grafts. However, closer review of the data demonstrates that although primary patency of AV fistulae is superior to grafts, the secondary patency rates are equivalent. This suggests that secondary procedures to maintain fistula patency are inferior to those performed on arteriovenous grafts. Surgical thrombectomy of AV fistulae can be challenging. It is often difficult to completely remove thrombus adjacent to the anastomosis of the fistula, and pseudoaneurysms within the fistula can prevent passage of the thrombectomy catheter and complete removal of thrombus from the fistula. Consequently, some surgeons simply abandon thrombosed AV fistulae and place a new access. We have developed a method for completely clearing thrombus from failed AV fistulae by locating the fistulotomy close to the arterial anastomosis and using a technique to manually extract thrombus from the fistula before passing a thrombectomy catheter. The purpose of this study was to review our results with this procedure. Between 2001 and 2004, 10 patients with a previously functioning AV fistula presented with thrombosis. There were seven brachiocephalic fistulae and three radiocephalic fistulae. All patients underwent surgical thrombectomy and fistulography. Five patients underwent balloon angioplasty of a venous stenosis and one patient underwent surgical revision of an arterial stenosis. Technical success, defined as being able to completely clear thrombus from the fistula and treat the cause for fistula failure, was achieved in 70 per cent (7/10) of cases. Technical failure was caused by vein rupture during the balloon angioplasty in two cases and a central venous occlusion that could not be treated in one case. The 6-month primary and secondary patency for cases that were technically successful was 51 and 69 per cent, respectively. Our conclusion was that surgical thrombectomy can significantly extend fistula functionality in patients who present with thrombosis.The American surgeon 01/2007; 72(12):1231-3. · 1.28 Impact Factor -
Article: The mid-thigh loop arteriovenous graft: patient selection, technique, and results.
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ABSTRACT: As patient longevity on hemodialysis has increased, surgeons are increasingly challenged to provide vascular access to patients who have exhausted options for access in the upper extremity. A common operation performed on these patients has been the loop thigh arteriovenous (AV) graft based off the common femoral vessels. However, there are several disadvantages of placing prosthetic grafts in proximity to the groin. Our group has modified the thigh loop AV graft procedure by moving the anastomoses to the mid-superficial femoral artery and vein. The advantage of this location is that it preserves the proximal femoral vessels for graft revision and avoids the node-bearing tissue and overhanging panniculus of the groin. The purpose of this study was to review our technique, patient selection, and experience with the mid-thigh loop AV graft procedure. Between 2001 and 2003, 46 mid-thigh loop AV grafts were placed in 38 patients. Patient hospital, office, and dialysis clinic records were reviewed. The primary and secondary patency for AV grafts in this study by life-table was 40 per cent and 68 per cent at 1 year and 18 per cent and 43 per cent at 2 years. There were 10 infections (21%) requiring graft removal. Four patients underwent subsequent placement of a proximal loop thigh AV graft after mid-thigh graft failure. Patient survival was 86 per cent at 1 year and 82 per cent at 2 years. There were no patient deaths related to thigh graft placement. Our results with the mid-thigh loop AV graft compare favorably with published results for thigh loop AV grafts. The procedure preserves the proximal vasculature, permitting graft revision or subsequent proximal graft placement, and may be associated with fewer infectious complications. The mid-thigh loop AV graft procedure should be considered before placement of a thigh loop AV graft based off the common femoral artery and vein.The American surgeon 10/2006; 72(9):825-8. · 1.28 Impact Factor -
Article: Does obesity predict functional outcome in the dysvascular amputee?
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ABSTRACT: Limited information is available concerning the effects of obesity on the functional outcomes of patients requiring major lower limb amputation because of peripheral arterial disease (PAD). The purpose of this study was to examine the predictive ability of body mass index (BMI) to determine functional outcome in the dysvascular amputee. To do this, 434 consecutive patients (mean age, 65.8 +/- 13.3, 59% male, 71.4% diabetic) undergoing major limb amputation (225 below-knee amputation, 27 through-knee amputation, 132 above-knee amputation, and 50 bilateral) as a complication of PAD from January 1998 through May 2004 were analyzed according to preoperative BMI. BMI was classified according to the four-group Center for Disease Control system: underweight, 0 to 18.4 kg/m2; normal, 18.5 to 24.9 kg/m2; overweight, 25 to 29.9 kg/m2; and obese, > or = 30 kg/m2. Outcome parameters measured included prosthetic usage, maintenance of ambulation, survival, and maintenance of independent living status. The chi2 test for association was used to examine prosthesis wear. Kaplan-Meier curves were constructed to assess maintenance of ambulation, survival, and maintenance of independent living status. Multivariate analysis using the multiple logistic regression model and a Cox proportional hazards model were used to predict variables independently associated with prosthetic use and ambulation, survival, and independence, respectively. Overall prosthetic usage and 36-month ambulation, survival, and independent living status for the entire cohort was 48.6 per cent, 42.8 per cent, 48.1 per cent, 72.3 per cent, and for patients with normal BMI was 41.5 per cent, 37.4 per cent, 45.6 per cent, and 69.5 per cent, respectively. There was no statistically significant difference in outcomes for overweight patients (59.2%, 50.7%, 52.5%, and 75%) or obese patients (51.8%, 46.2%, 49.7%, and 75%) when compared with normal patients. Although there were significantly poorer outcomes for underweight patients for the parameters of prosthetic usage when compared with the remaining cohort (25%, P = 0.001) and maintenance of ambulation when compared with overweight patients (20.8%, P = 0.026), multivariate analysis adjusting for medical comorbidities and level of amputation showed that BMI was not a significant independent predictor of failure for any outcome parameter measured. In conclusion, BMI failed to correlate with functional outcome and, specifically, obesity did not predict a poorer prognosis.The American surgeon 08/2006; 72(8):707-12; discussion 712-3. · 1.28 Impact Factor -
Article: Postoperative outcomes according to preoperative medical and functional status after infrainguinal revascularization for critical limb ischemia in patients 80 years and older.
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ABSTRACT: The purpose of this study was to provide outcomes after intervention for critical limb ischemia (CLI) in elderly patients (> or =80 years) according to medical and functional status at presentation. From January 1998 to September 2003, 140 limbs/122 patients (age range 80-97 years) were treated (57 patients/66 limbs, infrainguinal bypass; 65 patients/74 limbs, infrainguinal angioplasty) for CLI. At presentation, 71 (58.2%) patients were functionally ambulatory, 41 (33.6%) were homebound ambulators, and 10 (8.2%) were transfer-only ambulators. Overall end points after treatment as well as outcomes according to type of treatment and preoperative medical and functional status were determined. End points included reconstruction patency, limb salvage, survival, amputation-free survival, and maintenance of ambulatory and independent living status. Results for the 140 limbs/122 patients at 3 years (Kaplan-Meier curves) include primary patency, 55.3%; secondary patency, 73.2%; limb salvage, 78.3%; survival, 62.5%; amputation-free survival, 49.7%; maintenance of ambulation, 77.8%; and maintenance of independent living status, 82.9%. There was essentially no difference in outcomes based on type of treatment (endovascular vs open operation). When analyzing 2-year outcomes by functional status (ambulatory vs homebound vs transfer), there was deterioration in outcomes according to declining functional status at presentation for mortality (84.7% vs 66.4% vs 42%; P < 0.001), amputation-free survival (73.3% vs 48.2% vs 36.9%; P < 0.001), limb salvage (86% vs 66.5% vs 71.9%; P = 0.022), and secondary patency (84.3% vs 61.5% vs 69.2%; P = 0.005) regardless of treatment. Homebound ambulators were two times and transfer-only patients five times more likely to experience death (Cox hazard model); diabetics were four times more likely to lose a limb and experience a decline in ambulation and living status. Overall medical and functional status at presentation predicts postoperative functional outcomes. These data support a policy of aggressive vascular intervention in the functional elderly and clinical restraint in the functionally impaired patient with CLI.The American surgeon 08/2005; 71(8):640-5; discussion 645-6. · 1.28 Impact Factor -
Article: Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients.
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ABSTRACT: Despite being a major determinant of functional independence, ambulation after major limb amputation has not been well studied. The purpose, therefore, of this study was to investigate the relationship between a variety of preoperative clinical characteristics and postoperative functional outcomes in order to formulate treatment recommendations for patients requiring major lower limb amputation. From January 1998 through December 2003, 627 major limb amputations (37.6% below knee amputations, 4.3% through knee amputations, 34.5% above knee amputations, and 23.6% bilateral amputations) were performed on 553 patients. Their mean age was 63.7 years; 55% were men, 70.2% had diabetes mellitus, and 91.5% had peripheral vascular disease. A retrospective review was performed correlating various preoperative presenting factors such as age at presentation, race, medical comorbidities, preoperative ambulatory status, and preoperative independent living status, with postoperative functional endpoints of prosthetic usage, survival, maintenance of ambulation, and maintenance of independent living status. Kaplan-Meier survival curves were constructed and compared by using the log-rank test. Odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals were constructed by using multiple logistic regressions and Cox proportional hazards models. Statistically significant preoperative factors independently associated with not wearing a prosthesis in order of greatest to least risk were nonambulatory before amputation (OR, 9.5), above knee amputation (OR, 4.4), age > 60 years (OR, 2.7), homebound but ambulatory status (OR, 3.0), presence of dementia (OR, 2.4), end-stage renal disease (OR, 2.3), and coronary artery disease (OR, 2.0). Statistically significant preoperative factors independently associated with death in decreasing order of influence included age > or = 70 years (HR, 3.1), age 60 to 69 (HR, 2.5), and the presence of coronary artery disease (HR, 1.5). Statistically significant preoperative factors independently associated with failure of ambulation in decreasing order of influence included age > or = 70 years (HR, 2.3), age 60 to 69 (HR, 1.6), bilateral amputation (HR, 1.8), and end-stage renal disease (HR, 1.4). Statistically significant preoperative factors independently associated with failure to maintain independent living status in decreasing order of influence included age > or = 70 years (HR, 4.0), age 60 to 69 (HR, 2.7), level of amputation (HR, 1.8), homebound ambulatory status (HR, 1.6), and the presence of dementia (HR, 1.6). Patients with limited preoperative ambulatory ability, age > or = 70, dementia, end-stage renal disease, and advanced coronary artery disease perform poorly and should probably be grouped with bedridden patients, who traditionally have been best served with a palliative above knee amputation. Conversely, younger healthy patients with below knee amputations achieved functional outcomes similar to what might be expected after successful lower extremity revascularization. Amputation in these instances should probably not be considered a failure of therapy but another treatment option capable of extending functionality and independent living.Journal of Vascular Surgery 08/2005; 42(2):227-35. · 3.21 Impact Factor -
Article: The surgically created arteriovenous fistula: a forgotten alternative to venous access.
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ABSTRACT: The care of patients requiring lifelong intravenous access was revolutionized with the development of tunneled catheters and implantable ports. These devices are not without complications, however, and selected patients may benefit from alternative modalities to maintain access for such therapies as parenteral nutrition, phlebotomy, or chemotherapy. Use of surgically created arteriovenous (AV) fistulae as an alternative to central venous access has been described. This report reviews our experience using AV access for central venous access. An AV access database of more than 800 active patients was reviewed and all patients who had autogenous or synthetic AV fistulae created exclusively for central venous access between July 1, 2001, and December 31, 2003, were identified. Outcomes were assessed. A total of 853 new accesses were placed during the time period. Six fistulae in six patients (0.7%) were placed for central access. All patients (5 males, 1 female, mean age, 42.8 years) required access for intermittent parenteral nutrition or intravenous fluids secondary to short-gut syndrome (n = 5) or gastroparesis (n = 1). All patients had failed at least two prior catheter-based accesses before access placement was considered. Procedures were all brachial artery based and included autogenous brachiobasilic vein fistulae with elevation or transposition (n = 3), autogenous brachiocephalic fistula (n = 1), autogenous brachiobasilic graft with transposed greater saphenous vein (n = 1), and a prosthetic brachiobasilic graft with ePTFE (n = 1). There was one perioperative autogenous fistula thrombosis treated with thrombectomy and revision. A total of seven late revisions (thrombectomy, thrombectomy with venous outflow revision, fistula elevation, and 4 percutaneous angioplasties) in four patients were required. All fistulae were patent and functional at the end of the review period (mean follow-up, = 393 days; range, 35-757 days). Daily access was performed by family members (n = 2) or nurses (n = 4). One patient received small bowel transplantation and no longer required use of his patent fistula. One patient died of liver failure 382 days after fistula placement with a patent fistula. These results show that, while often forgotten and infrequently used, AV access can be a durable alternative to catheter-based venous access.Annals of Vascular Surgery 12/2004; 18(6):635-9. · 1.03 Impact Factor -
Article: Can carotid angiography be performed by vascular surgeons? A critical evaluation of indications, technique, and results.
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ABSTRACT: The purpose of this report is to examine the contemporary indications for diagnostic carotid arteriography and evaluate its utility and safety when performed by vascular surgeons. The records of all patients having selective carotid arteriography from September 2000 through March 2002 at our institution were reviewed. One hundred sixty-four consecutive patients had selective arteriography of the extracranial carotid arteries for the following indications: hemispheric symptoms with stenosis <80% by duplex ultrasound (20.6%), suspected brachiocephalic trunk stenosis (15.8%), unclear anatomy by duplex (10.3%), recurrent carotid stenosis (10.3%), symptomatic high-grade (>80% by duplex) internal carotid stenosis (9.8%), ipsilateral internal carotid artery occlusion (7.1%), bilateral high-grade internal carotid artery stenoses (7.1%), vertebral-basilar ischemia (7.0%), contralateral internal carotid occlusion (5.4%), duplex ultrasound from a nonaccredited vascular laboratory (3.3%), and evaluation of nonatherosclerotic carotid disease (3.3%). There were no transient ischemic attacks, strokes, or deaths related to the index procedure. Selective angiography of the extracranial carotid arteries remains an important adjunct in the evaluation of patients with carotid disease. This procedure can be performed safely by vascular surgeons.Annals of Vascular Surgery 11/2004; 18(6):710-3. · 1.03 Impact Factor -
Article: Invasive treatment of chronic limb ischemia according to the Lower Extremity Grading System (LEGS) score: a 6-month report.
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ABSTRACT: The invasive treatment of chronic lower extremity peripheral arterial disease (PAD) has become inconsistent. To standardize treatment at our institution, the Lower Extremity Grading System (LEGS) score was devised, based on arteriographic findings, symptoms, functional status, comorbid conditions, and technical factors. The scoring system was used to direct the invasive treatment approach in patients with lower extremity PAD. The purpose of this study was to prospectively assess outcomes of invasive treatment of lower extremity ischemia as directed by LEGS. From March 2002 through December 2002, 332 limbs in 227 patients with indications for intervention were scored and treated according to the LEGS score and followed for 6 months. Of the 227 patients, 66.1% were male; median age was 65 years. Diabetes mellitus was present in 44.9% of patients, claudication in 48.5%, and limb-threatening ischemia in 51.5%. Results of treatment as directed by LEGS were judged with the treatment outcome measures of reconstruction patency, limb salvage, mortality, change in ambulatory status, change in independent living status, and change in the short-form health survey (SF-36). Of 332 limbs, 61.5% with a score of 10 to 19 underwent endovascular therapy; 34% with a score of 0 to 9 underwent open revascularization; and 4.5% with a score greater than 20 underwent primary limb amputation. Interventions for the entire cohort as directed by LEGS resulted in 6-month primary reconstruction patency of 82.4%; secondary reconstruction patency, 92.6%; limb salvage, 90%; survival, 89.1%; maintenance of ambulatory status, 85.6%; maintenance of independent living, 88.4%; and statistically significant improvement in health assessment, regardless of treatment type, as determined with the SF-36. There was no statistically significant variability when comparing results according to treatment (open surgery, 0-9 vs endovascular therapy, 10-19) or smaller score group categories (0-5, 6-9, 10-13, 14-19). At 6 months, treatment as directed by LEGS score resulted in acceptable outcomes. This project is the first reported prospectively confirmed standardization tool for treatment of lower extremity PAD, and, pending independent confirmation by others, provides a comparative baseline against which other standardization efforts can be measured.Journal of Vascular Surgery 07/2004; 39(6):1268-76. · 3.21 Impact Factor -
Article: Has the emergence of endovascular treatment for aneurysmal and occlusive aortic disease increased the complexity and difficulty of open aortic operations?
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ABSTRACT: With the emergence of endovascular surgery, there is a perception that open aortic procedures for aneurysmal and occlusive disease have become more difficult. To test this hypothesis, two consecutive groups of patients undergoing open aortic surgery for aneurysmal (AAA) and occlusive (AIOD) disease before and after the establishment of an endovascular program (EP) were analyzed. The pre-EP patient group (January 1996 through December 1997) consisted of 112 patients (52 with AAA, 60 with AIOD) and the post-EP patient group (January 2000 through December 2001) consisted of 142 patients (72 with AAA, 70 with AIOD). The pre-EP AAA group was compared with the post-EP AAA group and the pre-EP AIOD group was compared with the post-EP AIOD group. Factors analyzed included patient demographics, comorbidities, and operative outcomes. Statistical comparisons were carried out using Fisher's exact test for proportions and the Wilcoxon rank-sum test for medians. There were no statistical differences in patient demographics between the pre-EP and post-EP groups, regardless of procedure. When considering AAA repair, there was a higher rate of hypertension and hypercholesterolemia in the pre-EP group and a higher number of total comorbidities per patient in the post-EP group. There was also an increased incidence of perioperative blood transfusion in the post-EP group. When considering open procedures for AIOD, there was an increased rate of hypertension and history of previous abdominal operation in the post-EP group. There also was an increased incidence of perioperative blood transfusion. Other than these factors, there were no statistically significant differences between the pre- and post-EP groups with regard to mortality, complication rate, length of procedure, blood loss, length of ICU stay, or length of hospital stay for either the aneurysmal patients or the occlusive disease patients. With only minor exception, endovascular surgery has not appreciably increased the complexity of open aortic operations performed for either AAA or AIOD.Annals of Vascular Surgery 04/2004; 18(2):212-7. · 1.03 Impact Factor -
Article: Prosthetic thigh arteriovenous access: outcome with SVS/AAVS reporting standards.
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ABSTRACT: Differences in the reporting methods of results for arteriovenous (AV) access can dramatically affect apparent outcome. To enable meaningful comparisons in the literature, the Society for Vascular Surgery and the American Association for Vascular Surgery (SVS/AAVS) recently published reporting standards for dialysis access. The purpose of the present study was to determine infection rates, patency rates, and possible predictive factors for prosthetic thigh AV access outcomes with the reporting standards of the SVS/AAVS. A retrospective analysis was performed of all patients who underwent placement of thigh AV access by the Surgical Teaching Service at Greenville Memorial Hospital between 1989 and 2001. Outcomes were determined based on SVS/AAVS Standards for Reports Dealing with AV Accesses. The rate of revision per year of access patency was also determined; this end point more accurately reflects the true cost and morbidity associated with AV access than do patency or infection rates alone. One hundred twenty-five polytetrafluoroethylene thigh AV accesses were placed in 100 patients. Nine accesses were excluded from the study, six because there was no patient follow-up and 3 as a result of deaths unrelated to the access procedure and which occurred less than 30 days after access placement. There were six (4%) late access-related deaths. There were 18 (15%) early access failures, related to infection in 14 cases (12%), thrombosis in three cases (2%), and steal in one case (1%). Early failure was more common in patients with diabetes mellitus (P =.036). The primary and secondary functional patency rates were 19% and 54%, respectively, at 2 years. Infection occurred in 48 (41%) accesses. The patency and infection rates were not influenced by patient age, gender, body mass index, or diabetes mellitus. The median number of interventions per year of access patency was 1.68, and this outcome was positively correlated with body mass index (P <.001). Prosthetic AV access in the thigh is associated with higher morbidity compared with that reported for the upper extremity, and should be considered only if no upper extremity AV access option is available. Early access failure and the requirement for an increased number of interventions to reestablish and maintain access patency are more common in patients with diabetes mellitus and obesity. The number of interventions per year of access patency is a valuable end point when assessing the outcome of AV access procedures.Journal of Vascular Surgery 03/2004; 39(2):381-6. · 3.21 Impact Factor -
Article: Can the Perclose suture-mediated closure system be used safely in patients undergoing diagnostic and therapeutic angiography to treat chronic lower extremity ischemia?
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ABSTRACT: Mechanical closure devices for arterial hemostasis after angiography, such as the Perclose suture-mediated closure system, are designed to decrease time to ambulation and improve patient comfort. Although these devices are safe and efficacious, to date there has been little reported about use of the Perclose device in a cohort consisting exclusively of patients with lower extremity peripheral vascular disease. The purpose of this study was to determine the safety and efficacy of routine use of the Perclose system in patients with documented peripheral vascular disease undergoing angiography to treat chronic lower extremity ischemia. The Perclose device was placed for arterial closure after femoral artery access in 500 consecutive patients with documented peripheral vascular disease (ankle-brachial index, <0.8) who underwent diagnostic angiography or percutaneous intervention because of chronic lower extremity ischemia. These 500 patients composed 91% of all patients who underwent angiography because of chronic lower extremity ischemia between January 1, 2001, and April 1, 2002. All complications associated with the Perclose device were identified and reviewed. Of the 500 arteries, 54% were accessed for diagnostic angiography and 46% for intervention. Perclose device placement was successful in 475 attempts (95%). Overall major complication rate was 1.4% (7 of 500 arteries). Complications included one death from retroperitoneal hemorrhage; three episodes of limb ischemia, two requiring operation and one requiring lytic therapy; two pseudoaneurysms; and one hematoma, which prolonged hospitalization. The hematoma was the only complication in the 25 patients with failed Perclose device placement. There were no infections requiring admission or operation. The Perclose suture-mediated closure device is efficacious and can be used safely in selected patients with documented peripheral vascular disease. Complications associated with this device tend to be more severe than those historically reported for manual compression. Substantial experience with use of this device is required to achieve excellent results in patients with difficult anatomy.Journal of Vascular Surgery 12/2003; 38(6):1305-8. · 3.21 Impact Factor -
Article: An analysis of standard open and endovascular surgical repair of abdominal aortic aneurysms in octogenarians.
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ABSTRACT: While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. There were 11 females in the open group and 1 female in the endovascular group. There were no statistically significant differences in preoperative patient comorbidities between groups. Total mortality for the entire series was 11.8 per cent but this included 5 ruptured AAAs, all of which patients died, and 11 additional AAAs that were symptomatic, of which 1 patient died. Total nonruptured mortality for the entire series was 2.2 per cent (0% for the endo-group and 3.3% for the open group). There were statistically significant differences between the endovascular versus the open groups when comparing aneurysm diameter (5.6 cm vs. 6.2 cm; P = 0.016), estimated blood loss (225 cc vs. 2100 cc; P < 0.001), ICU days (0 vs. 3; P < 0.001), length of hospital stay (2 days vs. 12 days; P < 0.001), and patients with blood transfusions (1 vs. 27; P < 0.001). When comparing postoperative morbidities, 4 of the endovascular patients (25%) and 25 of the open patients (68.6%) had a complication (P = 0.006). In conclusion, endovascular stent graft treatment of nonruptured infrarenal AAAs in octogenarians led to significantly better outcomes and should probably be considered the preferred treatment whenever anatomically appropriate. Endovascular exclusion of ruptured AAAs may potentially improve future outcomes in this high-risk group.The American surgeon 10/2003; 69(9):744-7; discussion 748. · 1.28 Impact Factor -
Article: The LEGS score: a proposed grading system to direct treatment of chronic lower extremity ischemia.
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ABSTRACT: To prospectively compare the Lower Extremity Grading System (LEGS)-derived "recommended treatment" to the actual treatment performed and to analyze LEGS intergrader scoring consistency by comparing blinded scoring results between physician graders. Due to technical advances and the increased medical complexity of the aging population, the most appropriate treatment for chronic lower extremity ischemia-open surgery versus endovascular-is again in flux. In an attempt to standardize management, the LEGS score, based on the best available outcomes data, was devised by the physicians of an established vascular service. From March to June 2002, all chronically ischemic lower extremities that met standard indications for revascularization were prospectively enrolled and independently graded with the LEGS score by an "endovascular surgeon" and an "open surgeon" for comparative analysis. The results were then blindly evaluated to determine whether the LEGS-derived "recommended treatment" agreed with the actual treatment rendered and to assess for intergrader consistency. Agreement was assessed using kappa statistical analysis. Of the 137 presenting limbs (mean patient age 66.4 yo; 43% claudication, 57% limb-threatening ischemia), 107 were treated (65% endovascular, 30% open surgery, 5% amputation), 16 were pending treatment, and 14 were not treated because of patient refusal (n = 13) or death (n = 1). The LEGS score predicted the actual or offered clinical treatment in 90% of cases. The LEGS score comparison between physician graders resulted in identical "recommended treatment" in 116 of 128 cases for a 90.6% agreement. A reproducible scoring system to guide the treatment of patients with chronic lower extremity ischemia is possible. While systems like the LEGS score may have potential clinical application, their use as a treatment standardization tool for future prospective outcomes comparisons between open and endovascular surgery will be essential.Annals of Surgery 07/2003; 237(6):812-8; discussion 818-9. · 7.49 Impact Factor -
Article: Management of renal artery stenosis: effects of a shift from surgical to percutaneous therapy on indications and outcomes.
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ABSTRACT: The treatment of choice for renal artery occlusive disease has shifted from open repair to percutaneous angioplasty and stenting in many institutions. Whether this change in treatment modality will lead to altered and, perhaps, relaxed indications for intervention is unclear. We reviewed our experience to determine if a shift from open surgery to percutaneous management of renal occlusive disease was associated with changes in either indications for intervention or patient outcomes. Over an 8-year period, 165 patients had intervention for renal artery stenosis by our vascular surgery teaching service. Over the period there was a dramatic increase in interventions per year (4 patients 1994 to 57 patients 2001). There was also a shift from open to endovascular management. Patient demographics and indications for intervention showed no difference between open and endovascular groups. Outcome analysis revealed similar technical success rates between groups but a significantly higher morbidity and mortality rate in the surgical group. A shift from open to percutaneous treatment of renal artery occlusive disease led to a significant increase in patient volume. This increase occurred without a change in patient demographics or indications for therapy, and appeared to reflect an increase in patient referrals.Annals of Vascular Surgery 02/2003; 17(1):54-9. · 1.03 Impact Factor -
Article: Has endovascular surgery reduced the number of open vascular operations performed by an established surgical practice?
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ABSTRACT: Driven by new technology and the trend toward minimally invasive techniques, vascular surgeons have eagerly begun performing catheter-based arterial interventional procedures, a subspecialty termed endovascular surgery. How incorporation of endovascular surgery by vascular surgeons has influenced the number of standard open peripheral vascular operations is unknown. The purpose of this observational study was to examine the effect of endovascular surgery performed by the vascular surgeons of an established vascular surgery service on the volume of open peripheral vascular operations performed. With our prospective vascular registry, we compared the number of index vascular procedures from 1996 to 1998 (immediately before the start of an endovascular program) with the numbers from 1999 to 2000 (immediately after the start of an endovascular program). Differences in proportions (endovascular versus open/standard) between the two time periods were compared with the chi(2) test for homogeneity. From 1996 to 1998, 122 procedures were referred to radiology for arterial intervention versus none from 1999 to 2000, reflecting the initiation of the endovascular program. During the entire study period, annual volume (endovascular + open/standard) of vascular procedures, excluding the procedures referred to radiology, increased by 70% (1996, n = 402; to 2000, n = 685). Although open procedures from 1996 to 1999 increased 49% (n = 356 to n = 531), the number decreased by 5% from 1999 to 2000 (n = 531 to n = 507). In contrast, the endovascular volume from 1996 to 2000 increased 324% (n = 42 to n = 178). A statistically significant reduction was seen over time in the proportion of open/standard cases to endovascular cases in comparison of 1996 to 1998 with 1999 to 2000 for total cases (n = 1539, 88% open; versus n = 1341, 77% open) and for all index procedures (aortoiliac, 70% versus 55%; abdominal aortic aneurysm, 100% versus 63%; brachiocephalic, 73% versus 47%; renal, 60% versus 24%) except carotid procedures (100% versus 99%) and femoral-popliteal/tibial procedures (87% versus 87%). The integration of endovascular procedures by vascular surgeons of an established vascular practice significantly reduced the proportion of all open vascular procedures except for carotid and femoral-popliteal/tibial intervention. These data may have important implications for the future training of general and vascular surgeons.Journal of Vascular Surgery 10/2002; 36(3):514-9. · 3.21 Impact Factor -
Article: The use of cryopreserved femoral vein grafts for hemodialysis access in patients at high risk for infection: a word of caution.
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ABSTRACT: Several studies have reported success in the use of venous homografts for arteriovenous access and for arterial bypass in infected fields. On the basis of these reports and in an effort to prevent the loss of vascular access to infection, we performed arteriovenous graft placement with cryopreserved femoral vein in patients at high risk for graft infection. This study reviews the results of our experience. Of approximately 3100 dialysis access operations performed in a single vascular surgery service between October 1999 and July 2001, 20 patients received arteriovenous access grafts with cryopreserved femoral vein. All patients were judged to be at high risk for infection of the access on the basis of the presence of active infection at the time of graft implantation, the location of the graft in the thigh position, or a history of multiple access infections. The grafts were placed in three locations: thigh (n = 14), upper extremity (n = 3), and chest wall (n = 3). No early operative deaths or graft thromboses were seen. There were three late deaths: two from cardiac disease and one from a graft-related complication. Thirteen major graft related complications (65%) occurred in the 20 patients. There were three generalized graft infections (15%) and eight localized graft infections (40%) at dialysis needle access sites in 11 patients. Six of the graft infections were associated with graft rupture and frank hemorrhage, resulting in one patient death from exsanguination. Two grafts (10%) thrombosed, one of which was salvaged after thrombectomy and revision. These complications occurred between 1 and 14 months after implantation. At a mean follow-up period of 13 months (range, 1 to 17 months), only five of the 20 patients (25%) have a functioning cryopreserved femoral vein arteriovenous graft. The use of cryopreserved vein graft for hemodialysis access in patients at high risk for infection is associated with a high incidence rate of graft infection and rupture, particularly when placed in the thigh position. The routine use of cryopreserved vein graft in the thigh should be avoided. The in situ replacement of infected polytetrafluoroethylene arteriovenous grafts with cryopreserved vein should be considered if alternative sites for new access placement are unavailable.Journal of Vascular Surgery 10/2002; 36(3):464-8. · 3.21 Impact Factor -
Article: Obturator bypass: a classic approach for the treatment of contemporary groin infection.
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ABSTRACT: As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.The American surgeon 09/2002; 68(8):653-8; discussion 658-9. · 1.28 Impact Factor
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Institutions
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2003–2006
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Greenville Hospital System University Medical Center
- Department of Surgery
Greenville, SC, USA
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2004
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Clemson University
- Department of Bioengineering
Clemson, SC, USA
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