[show abstract][hide abstract] ABSTRACT: To evaluate clinical outcomes in a large group of advanced-stage carcinoid patients (stage IV) following multimodal surgical therapy.
Patients with advanced-stage carcinoid have traditionally experienced poor 5-year survival (18%-30%). Few recent series have evaluated a large number of patients treated with aggressive surgical rescue therapy.
This single-center retrospective review analyzes the records of 82 consecutive carcinoid patients treated by the same 2 surgeons, from August 1998 through August 2004 with a 3- to 72-month follow-up.
Surprisingly, one third of 26 (32%) patients were found to have intestinal obstructions; 10 being moribund at presentation. Mesenteric encasement with intestinal ischemia was successfully relieved in 10 of 12 cases. Five of eighty-two "terminal" patients were rendered free of macroscopic disease. Karnofsky performance scores improved from 65 to 85 (P < 0.0001). Two- and four-year survival for patients with no or unilateral liver metastases (n = 23) was 89%, while 2- and 4-year survival for patients with bilateral liver disease (n = 59) was 68% and 52% (P = 0.072), respectively.
We think that all patients with advanced-stage carcinoid should be evaluated for possible multimodal surgical therapy. Primary tumors should be resected, even in the presence of distant metastases to prevent future intestinal obstruction. The "wait and see" method of management of this slow-growing cancer no longer has merit. We offer an algorithm for the surgical evaluation and management of these patients.
Annals of Surgery 06/2005; 241(6):839-45; discussion 845-6. · 6.33 Impact Factor
[show abstract][hide abstract] ABSTRACT: To report a case of intimal dehiscence associated with endovascular intervention in patients with aortic dissection.
A 65-year-old man presented with a type B dissection extending to the level of the common iliac arteries. Two Talent stent-grafts were placed in the descending thoracic aorta to close the entry point, but 2 lumens remained. Three days later, abdominal pain prompted another imaging session, which demonstrated a large cylindrical filling defect in the abdominal aorta ("tube-in-tube") assumed to be a partially or completely dehisced intima. Fenestration marginally improved flow to the visceral vessels, and the patient improved clinically. However, 4 days later, recurrent ischemic symptoms prompted surgery; a complete dehiscence of the aortic intima starting at the descending aorta extended to the distal abdominal aorta. The aorta was resected, but the patient died from disseminated intravascular coagulation.
Intimal flap dehiscence associated with an endovascular procedure in the management of aortic dissection is an uncommon complication. Early detection and prompt surgical intervention of such a complication could save the patient's life. Endovascular procedures are unlikely to resolve the hemodynamic problem caused by a dehisced, distally migrated, collapsed intima.
Journal of Endovascular Therapy 03/2005; 12(1):103-9. · 2.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: To report our initial experience with a bifurcated endoprosthesis in the management of aortoiliac occlusive disease.
From May 2001 to February 2004, 112 patients were referred to our institution for the management of aortoiliac disease. Among these, 5 (6%) patients (3 men; mean age 57.8 years) with severe ischemia owing to TASC C or D iliac occlusions were selected for endovascular treatment with a bifurcated stent-graft. An Excluder stent-graft was placed after preliminary recanalization (thrombolysis and/or balloon dilation) the day before. The patients were followed clinically and ultrasonographically every 3 months during the first year and semiannually thereafter.
Technical success was achieved in all patients. Endovascular aortoiliac bifurcation reconstruction restored iliac artery flow immediately in all cases. There were no procedure-related complications. The mean ankle-brachial index (ABI) was significantly improved, from 0.66+/-0.04 before the procedure to 0.94+/-0.06 immediately after the procedure (p<0.01). The aortoiliac reconstructions remained patent during the mean 17-month follow-up (range 3-36), and the ABIs were stable. There was no mortality or amputation required in this series.
Endovascular placement of a bifurcated stent-graft appears to be technically feasible, effective, and safe in the management of aortoiliac occlusive disease.
Journal of Endovascular Therapy 03/2005; 12(1):22-7. · 2.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose. A method to create an extraluminal femoropopliteal bypass graft using endovascular techniques was evaluated in situ on cadaver extremities in an attempt to develop a minimally invasive alternative technique for the management of infrainguinal occlusive arterial disease. Methods. The endovascular placement of an extraluminal femoropopliteal bypass graft was undertaken in 5 cadaver legs. Following percutaneous access to the popliteal artery (PA) or common femoral artery (CFA), a Rosch-Uchida needle was used to perforate the vascular wall, followed by the creation of an extraluminal tract using a looped wire and catheter. Once the desired level was reached the needle was again used to perforate the vascular wall of the proximal superficial femoral artery (SFA) or PA depending on the access used. Self-expanding expanded polytetrafluoroethylene (ePTFE) stent-grafts were then deployed to establish the extraluminal femoropopliteal bypass connecting the two arterial puncture sites. Following dilatation of the stent-graft, angiography was performed to assess the endoprostheses and to look for contrast leaks. Results. Technical success was achieved in all 5 legs. Procedure time varied from 15 to 30 min. The angiographic studies performed immediately after completion of the bypass procedure showed patency of the grafts with no evidence of kinking or leakage in any of the cases. Conclusion. This study has proved that the endovascular placement of an extraluminal femoropopliteal bypass graft in human cadaver legs using endovascular techniques under fluoroscopic control is technically feasible.
CardioVascular and Interventional Radiology 01/2005; 28(4):551-551. · 2.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: A method to create an extraluminal femoropopliteal bypass graft using endovascular techniques was evaluated in situ on cadaver extremities in an attempt to develop a minimally invasive alternative technique for the management of infrainguinal occlusive arterial disease.
The endovascular placement of an extraluminal femoropopliteal bypass graft was undertaken in 5 cadaver legs. Following percutaneous access to the popliteal artery (PA) or common femoral artery (CFA), a Rosch-Uchida needle was used to perforate the vascular wall, followed by the creation of an extraluminal tract using a looped wire and catheter. Once the desired level was reached the needle was again used to perforate the vascular wall of the proximal superficial femoral artery (SFA) or PA depending on the access used. Self-expanding expanded polytetrafluoroethylene (ePTFE) stent-grafts were then deployed to establish the extraluminal femoropopliteal bypass connecting the two arterial puncture sites. Following dilatation of the stent-graft, angiography was performed to assess the endoprostheses and to look for contrast leaks.
Technical success was achieved in all 5 legs. Procedure time varied from 15 to 30 min. The angiographic studies performed immediately after completion of the bypass procedure showed patency of the grafts with no evidence of kinking or leakage in any of the cases.
This study has proved that the endovascular placement of an extraluminal femoropopliteal bypass graft in human cadaver legs using endovascular techniques under fluoroscopic control is technically feasible.
CardioVascular and Interventional Radiology 01/2005; 28(2):209-14. · 2.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purpose of this study was to develop an abdominal aortic aneurysm model that more closely resembles the morphology of human aneurysms with potential for further growth of the sac. An infrarenal abdominal aortic aneurysm (AAA) model was created with a double-layered peritoneal patch in 27 domestic swine. The patch, measuring in average from 6 to 12 cm in length and from 2 to 3 cm in width, was sutured to the edge of an aortotomy. Pre- and postsurgical digital subtraction aortograms (DSA) were obtained to document the appearance and dimensions of the aneurysm. All animals were followed with DSA for up to 5 months. Laparoscopic examination enhanced by the use of laparoscopic ultrasound was also carried out in 2 animals to assess the aneurysm at 30 and 60 days following surgery. Histological examination was performed on 4 animals. All the animals that underwent the surgical creation of the AAA survived the surgical procedure. Postsurgical DSA demonstrated the presence of the AAA in all animals, defined as more than 50% increase in diameter. The aneurysmal mean diameter increased from the baseline of 10.27 +/- 1.24 to 16.69 +/- 2.29 mm immediately after surgery, to 27.6 +/- 6.59 mm at 14 days, 32.45 +/- 8.76 mm at 30 days (p < 0.01), and subsequently decreased to 25.98 +/- 3.75 mm at 60 days. A total of 15 animals died of aneurysmal rupture that occurred more frequently in the long aneurysms (> or =6 cm in length) than the short aneurysms (<6 cm in length) during the first 2 weeks after surgery (p <0.05). No rupture occurred beyond 16 days after surgery. Four animals survived and underwent 60-day angiographic follow-up. Laparoscopic follow-up showed strong pulses, a reddish external appearance and undetectable suture lines on the aneurysmal wall. On pathology, the patches were well incorporated into the aortic wall, the luminal wall appeared almost completely endothelialized, and cellular and matrix proliferation were noted in the aneurysmal wall. A reproducible technique for the creation of an infrarenal AAA model was developed using a peritoneal patch in swine. The aneurysm model proved to have potential for further growth of the sac and a tendency to rupture. Because of the growth potential, this might be a better model than those with a noncompliant aneurysmal wall for the preclinical evaluation of stent-graft devices.
CardioVascular and Interventional Radiology 01/2003; 26(2):168-76. · 2.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: To compare a new 7 Fr. Helix thrombectomy catheter with Amplatz thrombectomy devices (ATD) with respect to clot fragmentation efficiency, hemolytic potential, and risk for vascular trauma.
Particle size was evaluated following the maceration of 8-to-10-day-old clots, each weighing 6 +/- 0.01 g. The clots were macerated using devices of various sizes, including the 7-Fr. Helix thrombectomy catheter, the 7-Fr. over-the-wire (OTW), 8-Fr. ATD and the 6-Fr. ATD. The number of particles by weight was quantified. The 7-Fr. Helix and the 8-Fr. ATD were tested in the native iliac vein of six dogs without presence of clots. Blood samples were obtained before, during, and at 1, 3, 6, 24, and 48 hours after the procedure, to monitor the hemolytic effects. The treated iliac veins were examined histologically.
Most of the clot was fragmented into particles <10 microm. The mean percentage by weight of the original clot that remained as particles larger than 10 microm was 1.59% in the 7-Fr. Helix group. This was significantly less than 3.10% with the 6-Fr. ATD, 2.57% with 7-Fr. OTW and 2.44% in the 8-Fr. ATD group (<0.01). In vivo results showed a higher plasma free hemoglobin (PFH) level starting 5 minutes after initiating the ATD activation, reaching its peak after completion of the activation, and declining afterward, with return to the baseline at 24 hours. The haptoglobin level tended to decline slightly at 10 minutes, reaching its lowest level at 24 hours, and starting to recover at 48 hours. A similar pattern of PFH and haptoglobin changes was found in both groups. There were no significant differences regarding hemolytic effect of the two tested devices. No significant changes of creatinine were observed for up to 48 hours after procedures. Focal microthrombosis was seen in two sites of two vessels treated with the 7-Fr. Helix and a focal injury of a venous valve was noted in the 8-Fr. ATD group. The media and internal elastic lamina (IEL) were intact in all cases.
The newly designed 7-Fr. Helix is more effective in fragmentation in vitro clots than the 6 Fr. ATD, 7-Fr. OTW and the 8-Fr. ATD. The 7-Fr. Helix and the 8-Fr. ATD produced hemolytic effects, but they appeared to be tolerated by the animals. The in vivo results indicated that the 7-Fr. Helix appears to be as safe as the 8-Fr. ATD.
[show abstract][hide abstract] ABSTRACT: This experiment was conducted to evaluate efficacy and safety of the Oasis thrombectomy catheter on arterial thrombosis in dogs.
Thrombosis was induced in 18 femoral arteries of nine mongrel dogs. Recanalization of the thrombosed femoral artery was performed using a thrombectomy catheter 7-10 days after thrombus induction. Pre- and postprocedural arterial status was documented by angiography. After mechanical thrombectomy, the animals were sacrificed and the femoral arteries were harvested and examined macro- and microscopically. Additionally, in vitro fragmentation was carried out to determine particle size and distribution from the recovered effluent.
Subacute thrombosis was successfully created in 15 femoral arteries. Full recanalization was achieved in 80% (12/15) of the thrombosed femoral arteries without any residual thrombus. No significant downstream embolization was documented angiographically. Endothelial denudation was observed in all the treated arteries along with occasional disruption of the internal elastic lamina. No medial injury was seen. Ninety-eight percent of thrombus was liquefied, defined as particles smaller than 15 microm, by the catheter. Particles larger than 400 microm represented 0.27% of the original clot weight.
Occluded femoral arteries with 7- to 10-day-old thrombus can be efficiently recanalized with the Oasis catheter in dogs without any significant complication. This thrombectomy catheter appears to be highly effective and safe and requires no sophisticated equipment. Blood loss was our major concern regarding use of this catheter but can be minimized by strictly controlling activation time and restricting the inflow into the vascular segment being treated.
American Journal of Roentgenology 01/2000; 173(6):1557-63. · 2.90 Impact Factor
[show abstract][hide abstract] ABSTRACT: Rationale and Objectives.The purpose of the study was to evaluate a method of producing obstruction of the common bile duct and concomitant biliary duct dilatation in an animal model.Materials and Methods.Laparoscopic placement of a double-balloon occlusion device was used to produce common bile duct obstruction and bile duct dilatation in pigs.Results.One week after the procedure, common bile duct obstruction and dilatation of the biliary tree were demonstrated with either percutaneous transhepatic cholangiography or percutaneous cholecystography.Conclusion.The use of this method is technically feasible and provides a useful subacute and chronic animal model of common bile duct obstruction and dilatation of the biliary tree for percutaneous interventional training and research purposes.
[show abstract][hide abstract] ABSTRACT: Our purpose was to study the effectiveness of thrombolytic therapy in treating acute, subacute, and chronic arterial occlusions in a multicenter retrospective study. Intraarterial urokinase infusion was performed in 235 patients for occluded native arteries. There were 70 (30%) with acute and 26 (5%) with subacute occlusions, and 141 (59%) with chronic symptoms for longer than 3 mo. Complete thrombolysis was achieved in 60 (86%) of the acute, 20 (77%) of the subacute, and 106 (75%) of the chronic occlusions. Adjunctive interventional procedures were performed as needed. Long-term follow-up revealed a primary patency of 87%, 85%, and 76% for the acute, subacute, and chronic occlusion groups, respectively. We conclude that the rate of complete thrombolysis of chronic occlusions proved slightly more efficient for acute and virtually the same for subacute occlusions. Long-term follow-up demonstrated a higher failure rate with chronic than with acute occlusions, probably due to worsened peripheral vascular runoff.
Catheterization and Cardiovascular Diagnosis 07/1998; 44(2):159-69.
[show abstract][hide abstract] ABSTRACT: To evaluate the results of primary stent placement without initial thrombolysis in the treatment of iliac occlusions.
During a 3-year period, 61 iliac artery occlusions were treated in 59 patients. The mean length of the occluded segment was 10 cm (range, 4-25 cm). The occluded arteries were treated with primary placement of self-expandable metallic stents.
Successful recanalization with primary stent placement was possible in 56 of 61 occlusions (92% technical success rate). Mean Doppler ankle/brachial index increased from 0.51 to 0.90 immediately after treatment and was 0.91 on the last follow-up (P < .05). Primary patency rate at 24 months was 73%, and secondary patency rate was 88%. Procedural complications included distal embolization (n = 4) and an episode of massive intra-abdominal bleeding. Three patients developed a hematoma at the puncture site that did not require additional therapy. Late complications included stent occlusion (n = 9) and significant stenosis related to intimal hyperplasia (n = 1). Mean follow-up period was 29 months (range, 7-55 months).
Primary stent placement is an effective therapeutic option for iliac artery occlusions.
Journal of Vascular and Interventional Radiology 01/1997; 8(6):1049-55. · 2.00 Impact Factor