Marc L Schermerhorn

Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States

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Publications (126)382.33 Total impact

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    ABSTRACT: The successful use of customized branched or fenestrated devices to treat elective thoracoabdominal aneurysm (TAAA) has already been described. However the device customization is a lengthy process that necessitates a delay in treatment of more than a month. This case reports an emergency treatment of TAAA, in a 80 years old patient, refused to open repair, admitted with abdominal pain, using a new technique, modifying Gore C3 Excluder® (WL Gore & Associates, Flagsteff, AZ, USA), including branches, to enable the emergency endovascular treatment of TAAA preserving visceral artery flow and excluding aneurysm.
    Annals of Vascular Surgery 08/2014; · 0.99 Impact Factor
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    ABSTRACT: Postoperative readmission, recently identified as a marker of hospital quality in the Affordable Care Act, is associated with increased morbidity, mortality, and health care costs, yet data on readmission after lower extremity amputation (LEA) are limited. We evaluated risk factors for readmission and postdischarge adverse events after LEA in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
    Journal of vascular surgery. 06/2014;
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    ABSTRACT: OBJECTIVE: To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis. BACKGROUND: The optimal treatment strategy for patients with restenosis after CEA remains unknown. METHODS: A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA. RESULTS: In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications. CONCLUSIONS: In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.
    Annals of surgery 06/2014; · 7.90 Impact Factor
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    ABSTRACT: In medically high-risk patients the choice between carotid artery stenting (CAS) and carotid endarterectomy (CEA) can be difficult. The purpose of this study was to compare risk-stratified outcomes of CAS and CEA.
    Journal of vascular surgery. 06/2014;
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    ABSTRACT: Readmission is associated with high mortality, morbidity, and cost. We used the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) to determine risk factors for readmission after lower extremity bypass (LEB). We identified all patients who received LEB in the 2011 ACS-NSQIP database. Multivariable logistic regression was used to assess independent predictors of 30-day readmission. We also identified our institutional contribution of LEB patients to the ACS-NSQIP from 2005 to 2011 to determine our institution's rate of readmission and readmission indications. Among 5018 patients undergoing LEB, ACS-NSQIP readmission analysis was performed on 4512, excluding those whose readmission data were unavailable, who suffered a death on index admission, or who remained in the hospital at 30 days. Overall readmission rate was 18%, and readmission rate of those with NSQIP-captured complications was 8%. Multivariable predictors of readmission were dependent functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.08-1.79), dyspnea (OR, 1.28; 95% CI, 1.02-1.60), cardiac comorbidity (OR, 1.46; 95% CI, 1.16-1.84), dialysis dependence (OR, 1.44; 95% CI, 1.05-1.97), obesity (OR, 1.28; 95% CI, 1.07-1.53), malnutrition (OR, 1.42; 95% CI, 1.12-1.79), critical limb ischemia operative indication (OR, 1.40; 95% CI, 1.10-1.79), and return to the operating room on index admission (OR, 8.0; 95% CI, 6.68-9.60). The most common postdischarge complications occurring in readmitted patients included wound complications (55%), multiple complications (22%), and graft failure (5%). Our institutional data contributed 465 LEB patients to the ACS-NSQIP from 2005 to 2012, with an overall readmission rate of 14%. Unplanned readmissions related to the original LEB (related unplanned) made up 75% of cases. The remainder 25% included readmissions that were planned staged procedures related to the original LEB (related planned, 11%) and admissions for a completely unrelated reason (unrelated unplanned, 14%). The most common readmission indications included wound infection (37%) and graft failure (10%). Readmissions were attributable to NSQIP-captured postdischarge complications in 44% of cases, an additional 44% had a non-NSQIP-defined reason for readmission, and the remainder (12%) included patients admitted for complications described in NSQIP but not meeting strict NSQIP criteria. Readmissions are common after LEB. Optimization of select chronic conditions, closer follow-up of patients in poor health and those who required return to the operating room, and early detection of surgical site infections may improve readmission rates. Our finding that 25% of readmissions after LEB are not procedure related informs the broader discussion of how a readmission penalty affects vascular surgery in particular.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2014; · 3.52 Impact Factor
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    ABSTRACT: Objectives The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI. Methods We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI. Results A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3–15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2–2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3–3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4–3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5–1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3–2.5, p = .80). Conclusions As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.
    European Journal of Vascular and Endovascular Surgery. 01/2014; 47(1):2–7.
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    ABSTRACT: Objective Women have been shown to have up to a fourfold higher risk of abdominal aortic aneurysm (AAA) rupture at any given aneurysm diameter compared with men, leading to recommendations to offer repair to women at lower diameter thresholds. Although this higher risk of rupture may simply reflect greater relative aortic dilatation in women who have smaller aortas to begin with, this has never been quantified. Our objective was therefore to quantify the relationship between rupture and aneurysm diameter relative to body size and determine whether a differential association between aneurysm diameter, body size, and rupture risk exists for men and women. Methods We performed a retrospective review of all patients in the Vascular Study Group of New England (VSGNE) database who underwent endovascular or open AAA repair. Height and weight were used to calculate each patient's body mass index and body surface area (BSA). Next, indices of each measure of body size (height, weight, body mass index, BSA) relative to aneurysm diameter were calculated for each patient. To generate these indices, we divided aneurysm diameter (in cm) by the measure of body size; for example, aortic size index (ASI) = aneurysm diameter (cm)/BSA (m2). Along with other relevant clinical variables, we used these indices to construct different age-adjusted and multivariable-adjusted logistic regression models to determine predictors of ruptured repair vs elective repair. Models for men and women were developed separately, and different models were compared using the area under the curve. Results We identified 4045 patients (78% male) who underwent AAA repair (53% endovascular aortic aneurysm repairs). Women had significantly smaller diameter aneurysms, lower BSA, and higher BSA indices than men. For men, the variable that increased the odds of rupture the most was aneurysm diameter (area under the curve = 0.82). Men exhibited an increased rupture risk with increasing aneurysm diameter (<5.5 cm: odds ratio [OR], 1.0; 5.5-6.4 cm: OR, 0.9; 95% confidence interval [CI], 0.5-1.7; P = .771; 6.5-7.4 cm: OR, 3.9; 95% CI, 1.9-1.0; P < .001; ≥7.5 cm: OR, 11.3; 95% CI, 4.9-25.8; P < .001). In contrast, the variable most predictive of rupture in women was ASI (area under the curve = 0.81), with higher odds of rupture at a higher ASI (ASI >3.5-3.9: OR, 6.4; 95% CI, 1.7-24.1; P = .006; ASI ≥4.0: OR, 9.5; 95% CI, 2.3-39.4; P = .002). For women, aneurysm diameter was not a significant predictor of rupture after adjusting for ASI. Conclusions Aneurysm diameter indexed to body size is the most important determinant of rupture for women, whereas aneurysm diameter alone is most predictive of rupture for men. Women with the largest diameter aneurysms and the smallest body sizes are at the greatest risk of rupture.
    Journal of Vascular Surgery. 01/2014; 59(5):1209–1216.
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    ABSTRACT: Objective Evidence is emerging that abdominal aortic aneurysm (AAA) formation cannot completely be explained by systemic atherosclerosis and is in part due to other pathophysiological mechanisms such as local immune reactions. The aim of the present study was to study variance in AAA wall inflammation, and relate that to clinical patient characteristics. Methods Ventral walls from 201 patients with intact AAAs undergoing open repair were prospectively collected and processed for histology and protein measurements. Patients were monitored for 3 years postoperatively. Results The amount of lymphocytic infiltrate was used to distinguish 96 lymphocyte-poor AAAs from 105 lymphocyte-rich AAAs. The walls of lymphocyte-rich AAAs had higher concentrations of various inflammatory markers, including interleukin (IL) 6, IL8, matrix metalloproteinase (MMP) 8; however, MMP9 levels were comparable. Patients with lymphocyte-poor AAAs had more atherosclerotic risk factors: type 2 diabetes (22% vs. 9%, P = .008), hypertension (81% vs 66%, P = .019), and serum cholesterol levels (mean[SD] 5.2[2.5] vs. 4.2[1.0] mmol/L, P = .023). Intimal lesions in the AAAs revealed more frequently an extracellular lipid pool in lymphocyte-poor AAAs (66% vs. 52%, P = .026). Lymphocyte poor AAAs were associated with a worse survival during 3 years of follow-up, although this association did not reach statistical significance when correcting for other cardiovascular predictors (24% vs. 14%; HR 1.9–2.3). Conclusion Low amount of inflammation in AAAs is associated with more atherosclerotic risk factors, more advanced local atherosclerotic lesions and more postoperative atherosclerotic adverse events. This observation supports the view that AAA development is a multi-factorial process in which part of the patient population has a closer relation with systemic atherosclerotic disease, while in other patients local inflammatory reactions might play a larger role.
    Atherosclerosis 01/2014; 235(2):632–641. · 3.71 Impact Factor
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    ABSTRACT: Background Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid angioplasty and stenting (CAS) are unclear. We compared perioperative results and durability of CAS vs CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of reintervention compared with primary procedures. Methods Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database. End points included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge, and restenosis ≥70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome. Results Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%; P = .8) and symptomatic patients (6.6% vs 5.8%; P = 1.0). No significant difference in restenosis ≥70% was identified between redo CEA and CAS after prior CEA (5.2% vs 3.0%; P = .5). Redo CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%; P = .05) and asymptomatic patients 4.4% vs 1.7%; P = .03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (odds ratio, 2.1; 95% confidence interval, 1.3-3.5). No difference in cranial nerve injury was identified between redo CEA and primary CEA (5.2% vs 4.7%; P = .8). Conclusions In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA. However, regardless of symptom status, the risk of reintervention was increased compared with patients undergoing primary CEA.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2014; 59(1):8–15.e2. · 3.52 Impact Factor
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    ABSTRACT: Women have been shown to have up to a fourfold higher risk of abdominal aortic aneurysm (AAA) rupture at any given aneurysm diameter compared with men, leading to recommendations to offer repair to women at lower diameter thresholds. Although this higher risk of rupture may simply reflect greater relative aortic dilatation in women who have smaller aortas to begin with, this has never been quantified. Our objective was therefore to quantify the relationship between rupture and aneurysm diameter relative to body size and determine whether a differential association between aneurysm diameter, body size, and rupture risk exists for men and women. We performed a retrospective review of all patients in the Vascular Study Group of New England (VSGNE) database who underwent endovascular or open AAA repair. Height and weight were used to calculate each patient's body mass index and body surface area (BSA). Next, indices of each measure of body size (height, weight, body mass index, BSA) relative to aneurysm diameter were calculated for each patient. To generate these indices, we divided aneurysm diameter (in cm) by the measure of body size; for example, aortic size index (ASI) = aneurysm diameter (cm)/BSA (m(2)). Along with other relevant clinical variables, we used these indices to construct different age-adjusted and multivariable-adjusted logistic regression models to determine predictors of ruptured repair vs elective repair. Models for men and women were developed separately, and different models were compared using the area under the curve. We identified 4045 patients (78% male) who underwent AAA repair (53% endovascular aortic aneurysm repairs). Women had significantly smaller diameter aneurysms, lower BSA, and higher BSA indices than men. For men, the variable that increased the odds of rupture the most was aneurysm diameter (area under the curve = 0.82). Men exhibited an increased rupture risk with increasing aneurysm diameter (<5.5 cm: odds ratio [OR], 1.0; 5.5-6.4 cm: OR, 0.9; 95% confidence interval [CI], 0.5-1.7; P = .771; 6.5-7.4 cm: OR, 3.9; 95% CI, 1.9-1.0; P < .001; ≥7.5 cm: OR, 11.3; 95% CI, 4.9-25.8; P < .001). In contrast, the variable most predictive of rupture in women was ASI (area under the curve = 0.81), with higher odds of rupture at a higher ASI (ASI >3.5-3.9: OR, 6.4; 95% CI, 1.7-24.1; P = .006; ASI ≥4.0: OR, 9.5; 95% CI, 2.3-39.4; P = .002). For women, aneurysm diameter was not a significant predictor of rupture after adjusting for ASI. Aneurysm diameter indexed to body size is the most important determinant of rupture for women, whereas aneurysm diameter alone is most predictive of rupture for men. Women with the largest diameter aneurysms and the smallest body sizes are at the greatest risk of rupture.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2013; · 3.52 Impact Factor
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    ABSTRACT: Patients with abdominal aortic aneurysms (AAAs) are usually treated with endovascular aneurysm repair (EVAR), which has become the standard of care in many hospitals for patients with suitable anatomy. Clinical evidence indicates that EVAR is associated with superior perioperative outcomes and similar long-term survival compared with open repair. Since the randomized, controlled trials that provided this evidence were conducted, however, the stent graft technology for infrarenal AAA has been further developed. Improvements include profile downsizing, optimization of sealing and fixation, and the use of low porosity fabrics. In addition, imaging techniques have improved, enabling better preoperative planning, stent graft placement, and postoperative surveillance. Also in the past few years, fenestrated and branched stent grafts have increasingly been used to manage anatomically challenging aneurysms, and experiments with off-label use of stent grafts have been performed to treat patients deemed unfit or unsuitable for other treatment strategies. Overall, the indications for endovascular management of AAA are expanding to include increasingly complex and anatomically challenging aneurysms. Ongoing studies and optimization of imaging, in addition to technological refinement of stent grafts, will hopefully continue to broaden the utilization of EVAR.
    Nature Reviews Cardiology 12/2013; · 10.40 Impact Factor
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    ABSTRACT: Endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used for emergent treatment of ruptured AAA (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications, and rates of reintervention of EVAR vs open aortic repair of rAAA in Medicare beneficiaries. We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a United States hospital from 2001 to 2008. Patients were matched by propensity score on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair. Sensitivity analyses were performed to evaluate the effect of bias that might have resulted from unmeasured confounders. Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality was 33.8% for EVAR and 47.7% for open repair (P < .001), and this difference persisted for >4 years. At 36 months, EVAR patients had higher rates of AAA-related reinterventions than open repair patients (endovascular reintervention, 10.9% vs 1.5%; P < .001), whereas open patients had more laparotomy-related complications (incisional hernia repair, 1.8% vs 6.2%; P < .001; all surgical complications, 4.4% vs 9.1%; P < .001). Use of EVAR for rAAA increased from 6% of cases in 2001 to 31% in 2008, whereas during the same interval, overall 30-day mortality for admission for rAAA, regardless of treatment, decreased from 55.8% to 50.9%. EVAR for rAAA is associated with lower perioperative and long-term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized for rAAA during the last decade.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2013; · 3.52 Impact Factor
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    ABSTRACT: Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality. We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey. From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons). There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2013; · 3.52 Impact Factor
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    ABSTRACT: End-stage renal disease is a significant negative predictor of limb salvage and patient survival in patients with limb ischemia, but little is known of the overall effects of renal transplantation. Endovascular management may be less morbid than open surgery, but technical success and durability in these patients is not well established. All patients with functioning renal transplants and critical limb ischemia (CLI) treated with endovascular techniques between 2003 and 2010 were retrospectively reviewed for limb salvage, reintervention, pre- and postprocedure creatinine, and estimated glomerular filtration rate (eGFR), and overall survival. Contralateral common femoral access, low-profile techniques, and isosmolar contrast were standard for all interventions. Endovascular interventions were performed on 57 limbs in 28 patients with renal transplants. Mean age was 54 years, 78% were male, 85% were diabetic, 100% were hypertensive, and 64% had a positive smoking history. All patients were treated for CLI. Treated regions included 16 iliac, 19 superficial femoral, 16 popliteal, and 12 tibial arteries, as well as 1 bypass graft with initial technical success of 100% and 0% 30-day mortality. Of all lesions, 43% required reintervention during the follow-up period, the majority in the first year. There was no significant change in eGFR or creatinine comparing pre- and post-angiogram value. Limb salvage and 1-year survival were 83% and 82%, respectively. Endovascular management of CLI in renal transplant patients results in good technical success and can be accomplished without a measurable change in transplant kidney function, although it requires repeat interventions. Endovascular therapy is a reasonable first-line treatment option for this high-risk group.
    Annals of Vascular Surgery 09/2013; · 0.99 Impact Factor
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    ABSTRACT: Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data. State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches. We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches. Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 08/2013; · 3.52 Impact Factor
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    ABSTRACT: Lower extremity amputation is often performed in patients where both lower extremities are at risk due to peripheral arterial disease or diabetes, yet the proportion of patients who progress to amputation of their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral lower extremities following initial amputation. We conducted a retrospective review of all patients undergoing lower extremity amputation (exclusive of trauma or tumor) at our institution from 1998 to 2010. We used International Classification of Diseases-Ninth Revision codes to identify patients and procedures as well as comorbidities. Outcomes included the proportion of patients at 1 and 5 years undergoing contralateral and ipsilateral major and minor amputation stratified by initial major vs minor amputation. Cox proportional hazards regression analysis was performed to determine predictors of major contralateral amputation. We identified 1715 patients. Mean age was 67.2 years, 63% were male, 77% were diabetic, and 34% underwent an initial major amputation. After major amputation, 5.7% and 11.5% have a contralateral major amputation at 1 and 5 years, respectively. After minor amputation, 3.2% and 8.4% have a contralateral major amputation at 1 and 5 years while 10.5% and 14.2% have an ipsilateral major amputation at 1 and 5 years, respectively. Cox proportional hazards regression analysis revealed end-stage renal disease (hazard ratio [HR], 3.9; 95% confidence interval [CI], 2.3-6.5), chronic renal insufficiency (HR, 2.2; 95% CI, 1.5-3.3), atherosclerosis without diabetic neuropathy (HR, 2.9; 95% CI, 1.5-5.7), atherosclerosis with diabetic neuropathy (HR, 9.1; 95% CI, 3.7-22.5), and initial major amputation (HR, 1.8; 95% CI, 1.3-2.6) were independently predictive of subsequent contralateral major amputation. Rates of contralateral limb amputation are high and predicted by renal disease, atherosclerosis, and atherosclerosis with diabetic neuropathy. Physicians and patients should be alert to the high risk of subsequent amputation in the contralateral leg. All patients, but particularly those at increased risk, should undergo close surveillance and counseling to help prevent subsequent amputations in their contralateral lower extremity.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 08/2013; · 3.52 Impact Factor
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    ABSTRACT: Optimal management of renal artery stenosis (RAS) remains unclear. Recent randomized controlled trials have shown no clear benefit with percutaneous transluminal angioplasty with or without stenting (PTRA/S) over medical management. We hypothesize that interventions for RAS are decreasing nationally. The Nationwide Inpatient Sample, 1988-2009, was used to identify patients with a diagnosis of renal artery atherosclerosis undergoing open surgical repair (bypass or endarterectomy) or PTRA/S. The rate of interventions, in-hospital death, and perioperative outcomes were analyzed over time. Additionally, we used individual state inpatient and ambulatory databases to better understand the influence of outpatient procedures on current volume and trends. We identified 308,549 PTRA/S and 33,147 open surgical repairs. PTRA/S increased from 1.9/100K adults in 1988 to 13.7 in 2006 followed by a decrease to 6.7 in 2009. Open surgical repair steadily decreased from 1.3/100K adults in 1988 to 0.3 in 2009. In 2009, PTRA/S procedures (6.4/100K adults) greatly outnumbered procedures done by open repair alone (0.1/100K), combined open renal and aortic repair (0.2/100K), and combined PTRA/S and endovascular aneurysm repair (0.3/100K). From 2005 to 2009 33,953 patients underwent PTRA/S in the states of New Jersey Maryland, Florida, and California combined. The total number of PTRA/S performed in the outpatient setting remained stable from 2005 (3.8/100K) to 2009 (3.7/100K), whereas the total number of inpatient procedures mirrored the national trend, declining from 2006 (7.9/100K) to 2009 (4.2/100K). PTRA/S had lower in-hospital mortality (0.9% vs 4.1%; P < .001) compared with open repair. PTRA/S patients were more likely to be discharged home (86.2% vs 76.3%; P < .001) and had a shorter length of stay (4.4 vs 12.3 days; P < .001). Mortality was higher after combined open renal and open aortic surgery compared to open repair alone (6.5% vs 4.1%; P < .001). Mortality was similar for combined PTRA/S and endovascular aneurysm repair compared with PTRA/S alone (1.2% vs 0.9%; P = .04). The performance of PTRA/S procedures for the management of RAS has decreased significantly after 2006. An increasing proportion of these procedures are performed in the outpatient setting. PTRA/S remains the dominant revascularization procedure for RAS with lower in-hospital mortality and morbidity than surgery.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is uncommon. Mortality rates of 20% are reported in studies using national data and are 5% to 8% in single-institution studies. Clinical trials are currently evaluating branched and fenestrated endografts. The purpose of this study is to establish a benchmark for future comparisons with endovascular trials using open repair of TAAAs in the National Surgical Quality Improvement Program (NSQIP) database. METHODS: We identified all patients undergoing open elective and emergency surgical repair of intact TAAAs in NSQIP (2005 to 2010) using Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases, 9th Edition codes. We analyzed demographics, comorbidities, 30-day mortality, postoperative complications, and length of stay. Multivariable logistic regression was used to identify predictors of mortality. RESULTS: We identified 450 patients who underwent open surgical repair (418 elective, 32 emergent) of an intact TAAA. Mean age was 69.4 years, 60.7% were male, and 85.6% were white. Comorbidities included hypertension (87.1%), chronic obstructive pulmonary disease (27.3%), prior stroke or transient ischemic attack (16.7%), diabetes (11.6%), and peripheral vascular disease (9.6%). Thirty-day mortality was 10.0%. Pulmonary complications were the most common: failure to wean from ventilator (39.1%), pneumonia (23.1%), and reintubation (13.8%). Acute renal failure requiring dialysis occurred in 10.7% of patients. Multivariable analysis (odds ratio [95% confidence interval]) showed predictors of mortality were emergent repair (3.3 [1.03-10.83]; P = .04), age >70 years (3.5 [1.03-7.56], P = .001), preoperative dialysis (8.4 [1.90-37.29], P = .005), cardiac complication (2.9 [1.05-8.21], P = .04), and renal complications (8.4 [3.41-20.56], P < .001). CONCLUSIONS: In this study of NSQIP hospitals, the first to analyze open surgical repair of TAAAs, the 30-day mortality rate of 10.0% is similar to single-institution reports. However, morbidity and mortality after open TAAA repair remain high, confirming the need for less invasive procedures.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2013; · 3.52 Impact Factor
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    ABSTRACT: BACKGROUND: Long-term adhesion-related complications and incisional hernias after abdominal surgery are common and costly. There are few data on the risk of these complications after different abdominal operations. STUDY DESIGN: We identified Medicare beneficiaries who underwent endovascular repair of an abdominal aortic aneurysm from 2001-2008 who presumably are not at risk for laparotomy-related complications. We identified all laparoscopic and open operations involving the abdomen, pelvis, or retroperitoneum and categorized them into 5 groups according to invasiveness. We then identified laparotomy-related complications for up to 5 years after the index operation and compared these with the baseline rate of complications in a control group of patients who did not undergo an abdominal operation. RESULTS: We studied 85,663 patients, 7,513 (8.8%) of which underwent a laparotomy, including 2,783 major abdominal operations, 709 minor abdominal operations, 963 ventral hernia repairs, 493 retroperitoneal/pelvic operations, and 2,565 laparoscopic operations. Mean age was 76.7 years and 82.0% were male. Major abdominal operations carried the highest risk for adhesion-related complications (14.3% and 25.0% at 2 and 5 years compared with 4.0% and 7.8% for the control group; p < 0.001) and incisional hernias (7.8% and 12.0% compared with 0.6% and 1.2% for the control group; p < 0.001). Laparoscopic operations (4.6% and 10.7% for adhesions, 1.9% and 3.2% for incisional hernias) carried the lowest risk. CONCLUSIONS: Late-onset laparotomy-related complications are frequent and their risk extends through 5 years beyond the perioperative period. With the advancement and expansion of laparoscopic techniques and its attendant lower risk for long-term complications, these results can alter the risk-to-benefit profile of various types of abdominal operations and can also strengthen the rationale for additional development of laparoscopic approaches to abdominal operations.
    Journal of the American College of Surgeons 04/2013; · 4.50 Impact Factor
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    ABSTRACT: BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) have established guidelines that outline patients who are considered "high risk" for complications after carotid endarterectomy (CEA) for which carotid artery stenting (CAS) may provide benefit. The validity of these high-risk criteria are yet unproven. In this study, we stratified patients who underwent CAS or CEA by CMS high-risk criteria and symptom status and examined their 30-day outcomes. METHODS: A nonrandomized, retrospective cohort study was performed by chart review of all patients undergoing CEA or CAS from January 1, 2005, to December 31, 2010, at our institution. Demographic data and data pertaining to the presence or absence of high-risk factors were collected. Patients were stratified using symptom status and high-risk status as variables, and 30-day adverse events (stroke, death, myocardial infarction [MI]) were compared. RESULTS: A total of 271 patients underwent CAS, with 30-day complication rates of stroke (3.0%), death (1.1%), MI (1.5%), stroke/death (3.7%), and stroke/death/MI (5.2%). A total of 830 patients underwent CEA with 30-day complication rates of stroke (2.0%), death (0.1%), MI (0.6%), stroke/death (1.9%), and stroke/death/MI (2.7%). Among symptomatic patients, physiologic high-risk status was associated with increased stroke/death (6 of 42 [14.3%] vs 2 of 74 [2.7%]; P < .01), and anatomic high-risk status was associated with a trend toward increased stroke/death (5 of 31 [16.1%] vs 0 of 20 [0.0%]; P = .14) in patients who underwent CAS vs CEA. Analysis of asymptomatic patients showed no differences between the two groups overall, except for a trend toward a higher rate of MI after CAS than after CEA (3 of 71 [4.2%] vs 0 of 108 [0.0%]; P = .06) in those who were physiologically at high risk. Among symptomatic patients who underwent CAS, patients with physiologic and anatomic high-risk factors had a higher rate of stroke/death than non-high-risk patients (6 of 42 [14.3%] vs 0 of 24 [0.0%] and 5 of 31 [16.1%] vs 0 of 24 [0.0%], respectively; both P ≤ .05). CONCLUSIONS: Physiologic high-risk status was associated with increased stroke/death, whereas anatomic high-risk status showed a trend toward increased stroke/death in symptomatic patients undergoing CAS compared with non-high-risk patients undergoing CAS or physiologically high-risk patients undergoing CEA. Our results suggest that the current national criteria for CAS overestimate its efficacy in patients who are symptomatic and at high risk.
    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

Publication Stats

1k Citations
382.33 Total Impact Points

Institutions

  • 2005–2014
    • Beth Israel Deaconess Medical Center
      • • Division of Vascular and Endovascular Surgery
      • • Department of Surgery
      Boston, Massachusetts, United States
  • 2013
    • Central Maine Medical Center
      Lewiston, Maine, United States
  • 2005–2011
    • Harvard Medical School
      • • Department of Health Care Policy
      • • Department of Surgery
      Boston, MA, United States
  • 2000–2008
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
  • 2004
    • New York Presbyterian Hospital
      • Department of Vascular Surgery
      New York City, New York, United States
  • 2003
    • Geisel School of Medicine at Dartmouth
      Hanover, New Hampshire, United States