Mohit Srivastava

West Virginia University, Morgantown, West Virginia, United States

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Publications (10)29.12 Total impact

  • Journal of vascular surgery. 12/2014; 60(6):1720.
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    ABSTRACT: Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost.
    Journal of vascular surgery. 06/2014;
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    ABSTRACT: BACKGROUND: Several studies have demonstrated better outcomes for carotid endarterectomy (CEA) at high-volume hospitals and providers. However, only a few studies have reported on the impact of surgeons' specialty and volume on the perioperative outcome of CEA. METHODS: This is a retrospective analysis of CEA during a recent 2-year period. Surgeons' specialties were classified according to their Board specialties into general surgeons (GS), cardiothoracic surgeons (CT), and vascular surgeons (VS). Surgeons' annual volume was categorized into low volume (<10 CEAs), medium volume (10 to <30 CEAs), and high volume (≥30 CEAs). The primary outcome was 30-day perioperative stroke and/or death; however, other perioperative complications were analyzed. Both univariate and multivariate analyses were done to predict the effect of specialty/volume and any other patient risk factors on stroke outcome. RESULTS: Nine hundred and fifty-three CEAs were performed by 24 surgeons: 122 by seven GS, 383 by 13 CT, and 448 by 4 VS. Patients' demographics/clinical characteristics were similar between specialties, except the incidence of coronary artery disease, which was higher for CT (P < .0001). The indications for CEA were symptomatic disease in 38% for VS, 31% for GS, and 23% for CT (P < .0001). The perioperative stroke and death rates were 4.1%, 2.9%, and 1.3% for GS, CT, and VS, respectively (P = .126). A subgroup analysis showed that the perioperative stroke rates for symptomatic patients were 5.3%, 2.3%, and 2.3% (P = .511) and for asymptomatic patients were 3.6%, 3%, and 0.72% (P = .099) for GS, CT, and VS, respectively. Perioperative stroke rates were significantly higher for nonvascular surgeons (GS and CT combined) vs VS in asymptomatic patients (3.2% vs 0.72%; P = .033). Perioperative stroke/death was also significantly lower for high-volume surgeons: 1.3% vs 4.1% and 4.3% for medium- and low-volume surgeons (P = .019) (1.3% vs 4.15% for high vs low/medium combined; P = .005). More CEAs were done for asymptomatic patients in the low/medium-volume surgeons (78%) vs high-volume surgeons (64%; P < .0001) with a stroke rate of 4.6% for low/medium-volume surgeons vs 0.51% for high-volume surgeons (P = .0005). A univariate logistic analysis showed that the odds ratio of having a perioperative stroke was 0.3 (95% confidence interval [CI], 0.13-0.73; P =.008) for high-volume surgeons vs low/medium-volume surgeons, 0.4 (95% CI, 0.16-1.07; P = .069) for VS vs CT/GS and 0.2 (95% CI, 0.06-0.45; P = .0004) when patching was used. A multivariate analysis showed that the odds ratio of having a perioperative stroke for CT VS was 2.1 (95% CI, 0.71-5.92; P = .183); for GS vs VS, 1.8 (95% CI, 0.49-6.90; P = .3709); for low-volume surgeons (vs high-volume) 3.4 (95% CI, 0.96-11.77; P = .0581); medium- vs high-volume surgeons 2.2 (95% CI, 0.75-6.42; P = .1509). CONCLUSIONS: High-volume surgeons had significantly better perioperative stroke/death rates for CEA than low/medium-volume surgeons. Perioperative stroke/death rates were also higher for nonvascular surgeons in asymptomatic patients.
    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: Several studies have reported conflicting results after carotid endarterectomy in patients with chronic renal insufficiency (CRI). However, only a few used glomerular filtration rate (GFR) (Modification of Diet in Renal Disease) in their analysis. STUDY DESIGN: Nine hundred and forty carotid endarterectomies that had serum creatinine and GFR were analyzed. Patients were classified as normal (creatinine <1.5 mg/dL or GFR ≥60 mL/min/1.73 m(2)); moderate CRI (creatinine ≥1.5 to 2.9 mg/dL or GFR ≥30 to 59 mL/min/1.73 m(2)), and severe CRI (creatinine ≥3 mg/dL or GFR <30 mL/min/1.73 m(2)). RESULTS: Using creatinine, perioperative stroke and major adverse event rates for normal, moderate CRI, and severe CRI were 2%, 3.5%, and 11.1% (p = 0.091) and 2.4%, 4.4%, and 11.1% (p = 0.089) vs 1.1%, 3.7%, and 5.4% (p = 0.018) and 1.8%, 4%, and 5.4% (p = 0.086) using GFR. Univariate logistic regression analysis showed that creatinine ≥1.5 mg/dL had an odds ratio of 2.1 for having early stroke/death vs an odds ratio of 3.5 (p = 0.009) for GFR <60 mL/min/1.73 m(2). A multivariate analysis showed that GFR <60 mL/min/1.73 m(2) had an odds ratio for early stroke/death of 3.7 (p = 0.013). Using creatinine, perioperative stroke rates for symptomatic patients were 2.8%, 2.6%, and 0% and 1.6%, 4.1%, and 11.1% (p = 0.045) for asymptomatic patients with normal, moderate CRI, and severe CRI vs 1.6%, 4.7%, and 9.1% for symptomatic patients (p = 0.09) and 1%, 3.2%, and 3.9% for asymptomatic patients (p = 0.074) using GFR. Perioperative major adverse event rates for symptomatic patients using creatinine were 3.2%, 2.6%, and 0%, and for asymptomatic patients 2.1%, 5.4%, and 11.1% (p = 0.048) vs 2.1%, 4.7%, and 9.1% for symptomatic patients and 1.7%, 3.7%, and 7.7% (p = 0.193) for asymptomatic patients using GFR. Moderate/severe CRI also had more cardiac (5.7% vs 2.4%; p = 0.072) and respiratory complications (2.5% vs 0.2%; p = 0.018). CONCLUSIONS: Glomerular filtration rate (Modification of Diet in Renal Disease) was more sensitive in detecting perioperative stroke/death after carotid endarterectomy in patients with CRI. Patients with moderate/severe CRI had more major adverse events than normal patients.
    Journal of the American College of Surgeons 02/2013; · 4.50 Impact Factor
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    ABSTRACT: BACKGROUND: Several authorities have proposed stenting of the superior mesenteric artery (SMA)/celiac artery (CA) as the primary treatment for patients with chronic mesenteric ischemia. However, most of these reports had small samples and short follow-up periods. METHODS: Eighty-three patients were treated over a 10-year period. Clinical follow-up and duplex ultrasound exams were done to evaluate long-term patency. We used our newly validated duplex criteria to detect ≥70% in-stent stenosis of the SMA and CA. A Kaplan-Meier life-table analysis was used to estimate freedom from in-stent stenosis and late symptom and survival rates. RESULTS: Fifty-four SMA and 51 CA stents were analyzed. The initial technical and clinical success rates were 97% and 96%, respectively, with 2% procedure morbidity and 2% mortality. The primary late clinical success rate was 59%, and the late ≥70% in-stent stenosis rate was 51% at a mean follow-up of 31 months (range, 1-124). Freedom from late recurrent symptoms at 1, 2, 3, 4, and 5 years was 83, 77, 70, 70, and 65%, respectively. Survival rates at the same intervals were 88%, 82%, 70%, 64%, and 51%. Primary patency rates for the whole series were 69%, 48%, 39%, 28%, and 19% at 1, 2, 3, 4, and 5 years, respectively. Assisted primary patency rates for the whole series were 80%, 61%, 54%, 43%, and 34% at 1, 2, 3, 4, and 5 years, respectively. Primary patency rates for the SMA at 1, 2, 3, 4, and 5 years were 71%, 47%, 37%, 28%, and 18%, respectively; and assisted primary rates were 82%, 64%, 57%, 45%, and 32%, respectively. Primary patency rates for the CA were 68%, 50%, 40%, 29%, and 21%; and assisted primary rates were 79%, 58%, 52%, 42%, and 36% for 1, 2, 3, 4, and 5 years, respectively. There were no significant differences in either primary or assisted primary patency between the SMA and CA (P = .7729 and .8169). A secondary intervention was carried out in 30% of the series. Freedom from ≥70% in-stent stenosis for the SMA was 82%, 65%, 56%, 42%, and 34%, and that for the CA was 73%, 59%, 48%, 34%, and 25%, at 1, 2, 3, 4, and 5 years, respectively. CONCLUSIONS: Stenting of SMA/CA stenosis has high technical/early clinical success rates with a satisfactory late clinical outcome; however, it is associated with high rates of late in-stent stenosis and intervention.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2013; · 3.52 Impact Factor
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    ABSTRACT: Several published studies have reported differing results of renal duplex ultrasound (RDU) imaging in detecting significant renal artery stenosis (RAS) using different Doppler parameters. This study is the largest to date to compare RDU imaging vs angiography and assess various published Doppler criteria. RDU imaging and angiography were both done in 313 patients (606 renal arteries). RAS was classified as normal, <60%, ≥60% to 99%, and occlusion. Main outcome measurements included renal peak systolic velocity (PSV), systolic renal-to-aortic ratio (RAR), end-diastolic velocity (EDV), and kidney lengths. The mean PSVs and RARs for normal, <60%, and ≥60% stenosis were 173, 236, and 324 cm/s (P < .0001), and 2.2, 2.9, and 4.5, respectively (P < .0001). The PSV cutoff value that provided the best overall accuracy for ≥60% stenosis was 285 cm/s, with a sensitivity, specificity, and overall accuracy of 67%, 90%, and 81%, respectively. The RAR cutoff value with the best overall accuracy for ≥60% stenosis was 3.7, with a sensitivity, specificity, and overall accuracy of 69%, 91%, and 82%, respectively. A PSV of ≥180 cm/s and RAR of ≥3.5 had a sensitivity, specificity, and overall accuracy of 72%, 81%, and 78% in detecting ≥60% stenosis. A PSV of ≥200 cm/s with an RAR of ≥3.5 had a sensitivity, specificity, and overall accuracy of 72%, 83%, and 78% in detecting ≥60% stenosis. A receiver operator characteristic (ROC) curve analysis showed that the PSV and RAR were better than the EDV in detecting ≥60% stenosis: PSV area under the curve (AUC) was 0.85 (95% confidence interval [CI], 0.81-0.88), EDV AUC was 0.71, and RAR AUC was 0.82 (PSV vs EDV, P < .0001; PSV vs RAR, P = .075; EDV vs RAR, P < .0001). A PSV of 285 cm/s or RAR of 3.7 alone were better than any combination of PSVs, EDVs, or RARs in detecting ≥60% stenosis. The mean kidney length was 10.4 cm in patients with ≥60% stenosis vs 11.0 cm in patients with <60% stenosis (P < .0001). Twelve percent of patients with ≥60% stenosis had a kidney length of ≤8.5 cm vs 4% in patients with <60% stenosis (P = .0003), and 5.6% (34 of 606) had accessory renal arteries on angiography, with six detected on RDU imaging. The presence of accessory renal arteries, solitary kidneys, or renal fibromuscular dysplasia had no influence on overall accuracy of using PSV values for detecting ≥60% stenosis. A PSV of 285 cm/s or an RAR of 3.7 alone can be used in detecting ≥60% RAS. Previously published data must be validated in individual vascular laboratories.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2012; 56(4):1052-1060.e1. · 3.52 Impact Factor
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    ABSTRACT: Contrary to coronary artery literature, the effect of preprocedural clopidogrel on renal artery restenosis (RAR) has not been characterized. This study was designed to evaluate the effect of preprocedural clopidogrel on target vessel revascularization (TVR), reintervention, and restenosis for patients who underwent recurrent renal artery angioplasty. A retrospective analysis of patients treated for RAR in a single tertiary center from January 1999 to December 2009 was conducted. Patients were divided into preadmission use of (1) clopidogrel or (2) aspirin only (acetylsalicylic acid [ASA]) for the initial procedure. TVR was defined as occurrence of a tertiary procedure for symptomatic RAR. Rate of freedom from event (ie, tertiary restenosis and TVR) was analyzed using Kaplan-Meier method. Eighty-eight interventions were performed on 77 patients with RAR; 66% were females with average (mean ± SEM) age and body mass index of 68.8 ± 1.1 and 28.6 ± 0.8, respectively. Comorbidities included 96% chronic hypertension, 33% diabetes, 76% hyperlipidemia, 20% renal insufficiency, 39% tobacco use, 58% coronary artery disease, and 51% peripheral vascular disease. Clopidogrel use increased significantly during the index procedure from admission 35.2% to discharge 97.7% (P < .001, McNemar test). There was a trend toward risk reduction of a tertiary intervention (23%) for patients admitted on clopidogrel compared with ASA (P = .052). Likewise, there was a trend (P = .051) toward increased freedom from a tertiary intervention, with cumulative freedom at 8 years 93.5% for clopidogrel vs 61% for ASA. No differences were found for restenosis. The use of preprocedural clopidogrel was associated with a possible risk reduction of TVR reintervention, but this finding needs to be validated in randomized clinical trial.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2012; 56(2):416-23. · 3.52 Impact Factor
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    ABSTRACT: Several published studies with a small sample size have reported differing results of duplex ultrasound (DUS) utilizing different threshold velocities in detecting significant stenosis of superior mesenteric (SMA) or celiac arteries (CA). The present study is based on the largest number of mesenteric duplex/angiography correlations reported to date for the diagnosis of SMA/CA stenosis. One hundred fifty-three patients (151 SMA and 150 CA) had both DUS and arteriography. Receiver operator curves (ROC) were used to analyze peak systolic velocity (PSV), end diastolic velocity (EDV), and SMA or CA/aortic PSV ratio in detecting ≥50% and ≥70% stenosis. For SMA (151 arteries: 84 with ≥50% stenosis [54 of which had ≥70% stenosis] based on angiography): the PSV threshold that provided the highest overall accuracy (OA) for detecting ≥50% SMA stenosis was ≥295 cm/s (sensitivity [sens.] 87%, specificity [spec.] 89%, and OA 88%); and for detecting ≥70% SMA, it was ≥400 cm/s (sens. 72%, spec. 93%, and OA 85%). The EDV threshold that provided the highest OA for detecting ≥50% stenosis was ≥45 cm/s (sens. 79%, spec. 79%, and OA 79%); and for ≥70% stenosis was ≥70 cm/s (sens. 65%, spec. 95%, and OA 84%). ROC analysis showed that PSV was better than EDV and SMA/aortic PSV ratio for ≥50% stenosis of SMA (P = .003 and P = .0005). For celiac arteries (150 arteries: 105 with ≥50% stenosis [62 of which had ≥70% stenosis]): the PSV threshold that provided the highest OA for ≥50% stenosis was ≥240 cm/s (sens. 87, spec. 83%, and OA 86%); and for ≥70% stenosis was ≥320 cm/s (sens. 80%, spec. 89%, and OA 85%). The EDV threshold that provided the highest OA for ≥50% stenosis was ≥40 cm/s (sens. 84%, spec. 48%, and OA 73%); and for ≥70% stenosis was ≥100 cm/s (sens. 58%, spec. 91%, and OA 77%). ROC analysis showed that PSV was better than EDV and SMA/aortic PSV ratio for ≥50% stenosis of CA (P < .0001 and P = .0410.) PSV values can be used in detecting ≥50% and ≥70% SMA/CA stenosis and were better than EDVs and ratios. Previously published data must be validated in individual vascular laboratories. Our results will need prospective validation.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2011; 55(2):428-436.e6; discussion 435-6. · 3.52 Impact Factor
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    ABSTRACT: Although infection following carotid endarterectomy is rare, consequences of this seldom seen complication can be devastating. Polyester, polytetrafluoroethylene (PTFE), and vein patches have all been used by many institutions for patch angioplasty, each with reported cases of infection following surgery. Our institution has preferentially used PTFE for the majority of cases, and here, we report our experience with postoperative infection following endarterectomy over the last decade. From January 2000 through July 2009, we treated infections following carotid endarterectomy in 25 patients. Of the 25 patients undergoing treatment for postoperative infection, 21 had PTFE patches placed during the initial surgery. The remaining four consisted of two polyester patches and two bovine pericardial patches. Twenty-three of the 25 initial endarterectomies were performed at our institution, and the other two were referrals. The majority of cases (56%) were due to gram-positive organisms, with only two cases being polymicrobial. The interval from the original surgery to clinical presentation ranged from 7 days to 85 months, with 20 patients (80%) presenting within 60 days of the first operation. Thirteen patients underwent incision and drainage with antibiotics, and 12 patients underwent definitive surgical treatment. Four received patch excision with vein patch angioplasty, four received patch excision with vein interposition, and four received sternocleidomastoid flaps. The 30-day stroke rate was 8%, and the freedom from recurrent infection was 100% at a mean follow-up of 32 months. Infection following carotid endarterectomy occurs <1% of the time; however, the potential for morbidity is significant. Our results show that most infections following PTFE patch angioplasty occur in the early postoperative period (<60 days) and that simple drainage with antibiotics may be an adequate form of treatment in select cases.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2011; 53(6):1473-7. · 3.52 Impact Factor
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    ABSTRACT: Clinicians have relied on published institutional experience for interpreting carotid duplex ultrasound studies (CDUS). This study will validate the ultrasound imaging consensus criteria published in 2003. The CDUS and angiography results of 376 carotid arteries were analyzed. Receiver-operating characteristic (ROCs) curves were used to compare peak systolic velocities (PSVs), end-diastolic velocities (EDVs) of the internal carotid artery (ICA), and ICA/common carotid (CCA) ratios in detecting < 50%, 50% to 69% (ICA PSV of 125-230 cm/s), and 70% to 99% (PSV of ≥ 230 cm/s) stenosis according to the consensus criteria. The consensus criteria uses a PSV of 125 to 230 cm/s for detecting angiographic stenosis of 50% to 69%, which has a sensitivity of 93%, specificity of 68%, and overall accuracy of 85%. A PSV of ≥ 230 cm/s for ≥ 70% stenosis had a sensitivity of 99%, specificity of 86%, and overall accuracy of 95%. ROC curves showed that the ICA PSV was significantly better (area under the curve [AUC], 0.97) than EDV (AUC, 0.94) or ICA/CCA ratio (AUC, 0.84; P = .036) in detecting ≥ 70% stenosis and ≥ 50% stenosis. Pearson correlations showed a statistical difference between the correlation of PSV with angiography (0.833; 95% confidence interval [CI], 0.8-0.86), EDV with angiography (0.755; 95% CI, 0.71-0.80), and ICA/CCA systolic ratio with angiography (0.601; 95% CI, 0.53-0.66; P < .0001) in detecting 70% to 99% stenosis. Adding the EDV values or the ratios to the PSV values did not improve accuracy. The consensus criteria for diagnosing 50% to 69% stenosis can be significantly improved by using an ICA PSV of 140 to 230 cm/s, with a sensitivity of 94%, specificity of 92%, and overall accuracy of 92%. The consensus criteria can be accurately used for diagnosing ≥ 70% stenosis; however, the accuracy can be improved for detecting 50% to 69% stenosis if the ICA PSV is changed to 140 to < 230 cm/s.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2010; 53(1):53-9; discussion 59-60. · 3.52 Impact Factor