J W Hallett

Mayo Foundation for Medical Education and Research, Scottsdale, AZ, United States

Are you J W Hallett?

Claim your profile

Publications (113)415.21 Total impact

  • Journal of vascular surgery. 12/2014; 60(6):1721.
  • [Show abstract] [Hide abstract]
    ABSTRACT: The Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) is designed to improve the quality, safety, effectiveness, and cost of vascular health care. The SVS VQI is uniquely organized as a distributed network of regional quality improvement groups across the United States. The regional approach allows for the involvement of a variety of health care professionals, the pooling of available resources and expertise, and serves as a motivating factor for each participating institution. Regional quality group sizes, administrative structure, and meeting logistics vary according to geography and regional needs. This review describes the process of forming, growing, and maintaining a regional quality improvement group of the SVS VQI.
    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
  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine carotid artery stenosis incidence after radiotherapy for head-and-neck neoplasms. This historical prospective cohort study comprised 44 head-and-neck cancer survivors who received unilateral neck radiotherapy between 1974 and 1999. They underwent bilateral carotid duplex ultrasonography to detect carotid artery stenosis. The incidence of significant carotid stenosis (8 of 44 [18%]) in the irradiated neck was higher than that in the contralateral unirradiated neck (3 of 44 [7%]), although this difference was not statistically significant (p = 0.13). The rate of significant carotid stenosis events increased as the time after radiotherapy increased. The risk of ipsilateral carotid artery stenosis was higher in patients who had undergone a neck dissection vs. those who had not. Patients with significant ipsilateral stenosis also tended to be older than those without significant stenosis. No other patient or treatment variables correlated with risk of carotid artery stenosis. For long-term survivors after neck dissection and irradiation, especially those who are symptomatic, ultrasonographic carotid artery screening should be considered.
    International Journal of Radiation OncologyBiologyPhysics 01/2006; 63(5):1361-7. · 4.52 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To ascertain whether acute aortic dissection (AAD) remains the most common aortic catastrophe, as generally believed, and to detect any improvement in outcomes compared with previously reported population-based data. We determined the incidence, operative intervention rate, and long-term survival rate of Olmsted County, Minnesota, residents with a clinical diagnosis of AAD initially made between 1980 and 1994. The incidence of degenerative thoracic aortic aneurysm (TAA) rupture was also delineated. We compared these results with other population-based studies of AAD, degenerative TAA, and abdominal aortic aneurysm (AAA) rupture. During a 15-year period, we identified 177 patients with thoracic aortic disease. We focused on 39 patients with AAD (22% of the entire cohort) and 28 with TAA rupture (16%). The annual age- and sex-adjusted incidences were 3.5 per 100,000 persons (95% confidence interval, 2.4-4.6) for AAD and 3.5 per 100,000 persons (95% confidence interval, 2.2-4.9) for TAA rupture. Thirty-three dissections (85%) involved the ascending aorta, whereas 6 (15%) involved only the descending aorta. Nineteen patients (49%) underwent 22 operations for AAD, with a 30-day case fatality rate of 9%. Among all 39 patients with AAD, median survival was only 3 days. Overall 5-year survival for those with AAD improved to 32% compared with only 5% in this community between 1951 and 1980. In other studies, the annual incidences of TAA rupture and AAA rupture are estimated at approximately 3 and 9 per 100,000 persons, respectively. This study indicates that AAD and ruptured degenerative TAA occur with similar frequency but less commonly than ruptured AAA. Although timely recognition and management remain problematic, these new data suggest that recent diagnostic and operative advances are improving long-term survival in AAD.
    Mayo Clinic Proceedings 03/2004; 79(2):176-80. · 5.79 Impact Factor
  • American Journal of Roentgenology 12/2003; 181(5):1259-65. · 2.90 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Decision-making in regard to elective repair of abdominal aortic aneurysms (AAA) requires careful assessment of factors that influence rupture risk, operative mortality, and life expectancy. Individualized consideration of these factors in each patient is essential, and the role of patient preference is of increasing importance. It is not possible or appropriate to recommend a single threshold diameter for intervention which can be generalized to all patients. Based upon the best available current evidence, 5.5 cm is the best threshold for repair in an "average" patient. However, subsets of younger, good-risk patients or aneurysms at higher rupture risk may be identified in whom repair at smaller sizes is justified. Conversely, delay in repair until larger diameter may be best for older, higher-risk patients, especially if endovascular repair is not possible. Intervention at diameter <5.5 cm appears indicated in women with AAA. If a patient has suitable anatomy, endovascular repair may be considered, and it is most advantageous for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair. With endovascular repair, perioperative morbidity and recovery time are clearly reduced; however, there is a higher reintervention rate, increased surveillance burden, and a small but ongoing risk of AAA rupture. There is no justification at present for different indications for endovascular repair, such as earlier treatment of smaller AAA. Until long-term outcome of endoluminal repair is better defined and results of randomized trials available, the choice between endovascular and open repair will continue to rely heavily on patient preference.
    Journal of Vascular Surgery 06/2003; 37(5):1106-17. · 2.88 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess the effect of demographic changes on rehabilitation of geriatric patients after amputation and the implications for future health resource allocation. Population-based study. Olmsted County, MN. Residents over the age of 65 years who had a major lower-extremity amputation because of peripheral arterial disease between 1956 and 1995. Patients who had amputations between 1956 and 1973 (earlier cohort) were compared with those who had amputations between 1974 and 1995 (later cohort). Not applicable. Demographic and clinical features, total number of amputations, amputation rates, and rate of successful prosthetic fitting over time. Of 292 patients, 93 had amputations between 1956 and 1973 and 199 between 1974 and 1995. Amputation rates declined after 1985, but the total number of amputations was unchanged. Patients in the later cohort were more likely to have a below-knee amputation (P<.001) and cerebrovascular disease (P=.008) and to be discharged to a nursing home (P<.001). There was no significant difference in median age at amputation, survival, or rates of successful prosthetic fitting over time. Although amputation rates have declined, the total number of amputations has increased. The rate of successful prosthetic fitting in the geriatric population has not changed significantly over 40 years. Amputations in the geriatric population in the United States will probably double from 28,000 to 58,000 per year by 2030, requiring considerable resources.
    Archives of Physical Medicine and Rehabilitation 10/2002; 83(10):1389-93. · 2.36 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although rare, splenic artery aneurysms (SAAs) have a definite risk of rupture. The optimal management of these aneurysms remains elusive. A retrospective chart review of all patients treated at our institutions with the diagnosis of SAA from January 1980 until December 1998 was undertaken. Follow-up was obtained via chart review and by direct phone contact of the patient or relative. No specific protocol was followed for management. From analysis of the patient data we concluded that although SAAs may rupture, not all intact aneurysms need intervention. Calcification does not appear to protect against rupture, although beta-blockade may be protective. Growth rates of SAA are slow and growth is infrequent. Selective management of SAAs is safe. Open ligation or transcatheter embolization should be considered for symptomatic aneurysms, for aneurysms > or = 2 cm in size, or for any SAA in women of childbearing years.
    Annals of Vascular Surgery 07/2002; 16(4):442-9. · 0.99 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The primary purpose of this study was to evaluate compliance, side effects, and safety associated with prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms (AAAs). A secondary goal was to determine how treatment with doxycycline influences circulating levels of matrix metalloproteinase-9 (MMP-9) in this patient population. Thirty-six patients with AAAs (30 men and 6 women; mean age, 69 +/- 1 years) were enrolled into a 6-month phase II study to evaluate treatment with doxycycline (100 mg orally twice a day). Aneurysm size was measured before and after treatment, and compliance and side effects were monitored. Plasma levels of doxycycline were measured midway through the study, and plasma MMP-9 concentrations were measured at baseline, 3 months, and 6 months. Thirty-three of the 36 patients (92%) completed 6 months of doxycycline treatment. Significant treatment-related side effects occurred in five patients (13.9%), including three with cutaneous photosensitivity reactions (8.3%), one with tooth discoloration (2.8%), and one with yeast infection (2.8%). A high rate of compliance with treatment was seen, despite minor but frequent side effects, including nonspecific gastrointestinal symptoms (25%), easily managed episodes of photosensitivity (22.2%), and reversible tooth discoloration (5.5%). The mean plasma doxycycline level after 3 months was 4.62 +/- 0.68 ug/mL (median, 3.64 microg/mL; range, 1.31 to 14.39 microg/mL; n = 23 patients). No significant change was seen in AAA diameter (42.7 +/- 1.3 mm at 6 months versus 41.0 +/- 0.9 mm at baseline), and the overall rate of AAA expansion was 0.63% +/- 0.25% per month. The mean plasma MMP-9 level (n = 19 patients) was elevated at baseline (118.9 +/- 37.9 ng/mL; upper limit of normal, 85 ng/mL) but subsequently decreased to 83.8 +/- 32.9 ng/mL at 3 months (not significant versus baseline) and to 66.4 +/- 24.2 ng/mL at 6 months (P =.022 versus baseline). Only 21% of patients had an elevated level of plasma MMP-9 after 6 months of treatment compared with 47% at baseline (P <.05). Prolonged administration of doxycycline is safe and well tolerated by patients with small asymptomatic AAAs and is associated with a gradual reduction in plasma MMP-9 levels. Further studies are needed to evaluate the long-term effects of doxycycline on the rate and extent of aneurysm growth and the potential use of plasma MMP-9 levels as a biomarker of aneurysm disease progression.
    Journal of Vascular Surgery 07/2002; 36(1):1-12. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Aortic inflammation and the genes that regulate the immune response play an important role in abdominal aortic aneurysm pathogenesis. However, the modulating effects of such genetic and other environmental factors on the severity on aneurysm inflammation is not known. The objective of this study was to determine the influence of the human leukocyte antigen (HLA) class II genes, gender, and environmental factors on degree of abdominal aortic aneurysm tissue inflammation. Aneurysm specimens were obtained at the time of operation from 96 consecutive patients who underwent abdominal aortic aneurysm repair and were graded for degree of histologic inflammation. Multivariate analysis was used to determine the association of genetic and environmental factors with degree of inflammation and to determine the HLA-associated disease risk for aneurysm. Active cigarette smoking and female gender were independently associated with high-grade tissue inflammation identified histologically (odds ratio [OR], confidence interval [CI]: 5.6, 1.6 to 19.3; and 6.0, 1.4 to 26.2, respectively), and a specific HLA allele (DR B1(*)01) was inversely associated with inflammation (OR, CI: 0.2, 0.04 to 0.7). Overall, the HLA-DR B1(*)02 and B1(*)04 alleles were significantly associated with disease risk, more than doubling risk for abdominal aortic aneurysm (OR, CI: 2.5, 1.4 to 4.3; and 2.1, 1.2 to 3.7, respectively). Active cigarette smoking and female gender are significant disease-modulating factors associated with increased abdominal aortic aneurysm inflammation. In addition, the HLA class II immune response genes possess both disease modulating and disease risk properties, which may be useful in early aneurysm detection and surveillance.
    Journal of Vascular Surgery 06/2002; 35(5):988-93. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Questions remain concerning the optimal site of graft origin and the extent of revascularization necessary to achieve excellent results for chronic mesenteric ischemia (CMI). Endovascular therapy also is performed for CMI. These factors prompted us to review our results to provide a current standard. Ninety-eight patients who underwent operation for CMI from 1989 to 1998 were reviewed. Patients with acute ischemia and arcuate ligament syndrome were excluded. Seventy-six women (78%) and 22 men (22%), with an average age of 66 years (range, 36 to 87 years), participated in the study. Abdominal pain was present in 95 patients (97%), and weight loss in 92 patients (94%). The superior mesenteric artery was severely diseased (70% to 99% stenosis or occlusion) in 90 patients (92%), the celiac artery in 81 patients (83%), and both arteries in 76 patients (78%). Bypass grafts were performed in 91 patients (93%), 77 antegrade and 14 retrograde. Of the other seven patients, five had endarterectomies, one reimplantation, and one patch angioplasty. Multivessel reconstruction was performed in 79 patients (81%), and single-vessel reconstruction in 19 (19%). Twelve patients had concomitant aortic reconstruction. Three early graft thromboses were seen. Five hospital deaths occurred (5.1%); one case had concomitant aortic reconstruction (1/12 versus 4/86; P = not significant). All five patients who died were older than 70 years (5/41 versus 0/57; P =.011). The median follow-up period was 1.9 years (range, 0 to 9.6 years). Follow-up was complete in all survivors. The 1-year, 5-year, and 8-year survival rates were 83%, 63%, and 55%, respectively. These rates were worse than the rates of the age-matched/gender-matched control subjects (P <.001). Survival was worse in patients greater than 70 years of age (P =.0013). Survival was unaffected by the number of vessels revascularized. The patients with retrograde grafts had decreased median survival rates (4.0 versus 5.7 years; P =.026), but they were older (75 versus 65 years; P =.0013). The 1-year and 5-year symptom-free survival rates were 95% and 92%, respectively. Symptoms recurred in six patients (6%): four had recurrent stenosis/occlusion and two had patent grafts. Symptom-free survival was unaffected by the number of vessels revascularized or by graft orientation. Operation for CMI was successful for most patients, with low operative mortality and excellent long-term relief of symptoms. Selective concomitant aortic procedures did not increase mortality rates. The rate of symptomatic recurrences was not different for single-vessel versus multiple-vessel reconstructions or for antegrade versus retrograde grafts. Patients older than 70 years had increased operative mortality and decreased survival rates. Endovascular therapy may be appropriate for this subset of patients.
    Journal of Vascular Surgery 05/2002; 35(5):853-9. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To determine the feasibility, safety, and clinical yield of angiographic screening among hypertensive patients undergoing coronary angiography. This study was a prospective cohort analysis of hypertensive patients who underwent cardiac catheterization at a tertiary care referral center from July 1998 to March 1999. Abdominal aortography was performed to screen for renal artery stenosis, the percentage of which was measured. The mean +/- SD age of the 297 study patients was 64.9+/-10.2 years; 58.6% were male, and 98.0% were white. Mean +/- SD systolic/diastolic blood pressure was 142.8+/-22.5/79.6+/-11.4 mm Hg. Aortography required a mean incremental dose of 62+/-9 mL of nonionic contrast agent. No complications were attributable to aortography. Of 680 renal arteries, 611 (90%) were visualized adequately. Also, 53% of patients had normal renal arteries, 28% had stenoses less than 50%, and 19.2% had stenoses of 50% or more. Renal artery stenosis was bilateral in 3.7% of patients and high grade (>70% stenosis) in 7%. Patients with renal artery stenosis were more likely to have had a previous coronary intervention. In multivariate analysis, systolic blood pressure (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.03-138; P=.02), history of stroke or transient ischemic attack (OR, 2.7; 95% CI, 1.27-5.78; P=.01), and cancer (OR, 2.0; 95% CI, 1.02-3.82; P=.04) independently correlated with renal artery stenosis of 50% or more. The prevalence of incidental renal artery stenosis among hypertensive patients undergoing coronary catheterization is significant. Therefore, screening abdominal aortography should be considered in these patients to better define their risk of cardiovascular complications.
    Mayo Clinic Proceedings 04/2002; 77(4):309-16. · 5.79 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Acute mesenteric ischemia (AMI) is a morbid condition with a difficult diagnosis and a high rate of complications, which is associated with a high mortality rate. For the evaluation of the results of current management and the examination of factors associated with survival, we reviewed our experience. The clinical data of all the patients who underwent operation for AMI between January 1, 1990, and December 31, 1999, were retrospectively reviewed, clinical outcome was recorded, and factors associated with survival rate were analyzed. Fifty-eight patients (22 men and 36 women; mean age, 67 years; age range, 35 to 96 years) underwent study. The cause of AMI was embolism in 16 patients (28%), thrombosis in 37 patients (64%), and nonocclusive mesenteric ischemia (NMI) in five patients (8.6%). Abdominal pain was the most frequent presenting symptom (95%). Twenty-five patients (43%) had previous symptoms of chronic mesenteric ischemia. All the patients underwent abdominal exploration, preceded with arteriography in 47 (81%) and with endovascular treatment in eight. Open mesenteric revascularization was performed in 43 patients (bypass grafting, n = 22; thromboembolectomy, n = 19; patch angioplasty, n = 11; endarterectomy, n = 5; reimplantation, n = 2). Thirty-one patients (53%) needed bowel resection at the first operation. Twenty-three patients underwent second-look procedures, 11 patients underwent bowel resections (repeat resection, n = 9), and three patients underwent exploration only. The 30-day mortality rate was 32%. The rate was 31% in patients with embolism, 32% in patients with thrombosis, and 80% in patients with NMI. Multiorgan failure (n = 18 patients) was the most frequent cause of death. The cumulative survival rates at 90 days, at 1 year, and at 3 years were 59%, 43%, and 32%, respectively, which was lower than the rate of a Midwestern white control population (P <.001). Six of the 16 late deaths (38%) occurred because of complications of mesenteric ischemia. Age less than 60 years (P <.003) and bowel resection (P =.03) were associated with improved survival rates. The contemporary management of AMI with revascularization with open surgical techniques, resection of nonviable bowel, and liberal use of second-look procedures results in the early survival of two thirds of the patients with embolism and thrombosis. Older patients, those who did not undergo bowel resection, and those with NMI have the highest mortality rates. The long-term survival rate remains dismal. Timely revascularization in patients who are symptomatic with chronic mesenteric ischemia should be considered to decrease the high mortality rate of AMI.
    Journal of Vascular Surgery 03/2002; 35(3):445-52. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The objectives of this study were the comparison of patients who needed mesh closure of the abdomen with patients who underwent standard abdominal closure after ruptured abdominal aortic aneurysm repair and the determination of the impact of timing of mesh closure on multiple organ failure (MOF) and mortality. We performed a case-control study of patients who needed mesh-based abdominal closure (n = 45) as compared with patients who underwent primary closure (n = 90) after ruptured abdominal aortic aneurysm repair. Before surgery, the patients who needed mesh abdominal closure had more blood loss (8 g versus 12 g of hemoglobin; P <.05), had prolonged hypotension (18 minutes versus 3 minutes; P <.01), and more frequently needed cardiopulmonary resuscitation (31% versus 2%; P <.01) than did the patients who underwent primary closure. During surgery, the patients who needed mesh closure also had more severe acidosis (base deficit, 14 versus 7; P <.01), had profound hypothermia (32 degrees C versus 35 degrees C; P <.01), and needed more fluid resuscitation (4.0 L/h versus 2.7 L/h; P <.01). With this adverse clinical profile, the patients who needed mesh closure had a higher mortality rate than did the patients who underwent primary closure (56% versus 9%; P <.01). However, the patients who underwent mesh closure at the initial operation (n = 35) had lower MOF scores (P <.05), a lower mortality rate (51% versus 70%), and were less likely to die from MOF (11% versus 70%; P <.05) than the patients who underwent mesh closure after a second operation in the postoperative period for abdominal compartment syndrome (n = 10). This study reports the largest experience of mesh-based abdominal closure after ruptured abdominal aortic aneurysm repair and defines clinical predictors for patients who need to undergo this technique. Recognition of these predictors and initial use of mesh closure minimize abdominal compartment syndrome and reduce the rate of mortality as the result of MOF.
    Journal of Vascular Surgery 02/2002; 35(2):246-53. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.
    Journal of Vascular Surgery 11/2001; 34(5):900-8. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Clinically, abdominal aortic aneurysms (AAAs) display a spectrum of inflammation that extends from apparently noninflamed (degenerative) AAAs to the classic inflammatory variant. Genes encoded in the human leukocyte antigen (HLA) region are important in the development of both variants of AAA; however, their role in progression to the inflammatory variant is unknown. The purpose of this study was to compare HLA class II genes in patients with degenerative versus classic inflammatory AAAs and to quantify their impact as disease risk factors. Genotypes of the 12 major alleles of the HLA-DR B1 locus were determined in patients with degenerative (102) and inflammatory (40) AAAs who were compared with controls (118). Univariate and multivariate logistic regression analyses were used to determine allele distributions and to quantify disease risk. Distribution of the HLA-DR B1 alleles was nonrandom and similar in both degenerative and inflammatory AAA groups compared with controls. The B1*02 and B1*04 alleles were enhanced in both degenerative (39.2% vs. 25.4%, P =.03; and 35.3% vs. 24.6%, P =.08 respectively) and inflammatory (47.5% vs. 25.4%, P =.01; and 32.5% vs. 24.6%, P =.09, respectively) AAAs compared with controls. The B1*02 and B1*04 alleles were associated with risk for both degenerative (odds ratio [OR] 2.2; 95% CI, 1.2-4.0; and OR 2.0; 95% CI, 1.1-3.7, respectively) and inflammatory AAAs (OR 3.7; 95% CI, 1.8-8.6; and OR 2.5; 95% CI, 1.1-6.1). This study demonstrates that identical HLA alleles function as genetic risk factors for both inflammatory and degenerative AAAs. These results support the concept of a common, immune-mediated pathogenesis for AAAs that may be modulated by HLA-independent factors.
    Journal of Vascular Surgery 08/2001; 34(1):84-9. · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Rupture of abdominal aortic aneurysms (AAAs) remains lethal. In a report of patients treated in the 1980s, we recommended aggressive management. Our continued experience prompted us to reevaluate this policy. We reviewed clinical variables affecting outcome, morbidity, mortality, and trends in mortality of all patients managed at our institution with ruptured AAAs between January 2, 1980, and November 30, 1998. The study group included 413 consecutive patients, 339 men and 74 women. The mean age was 74.3 years (range, 49-96); 116 (28%) patients were older than 80 years. AAA was diagnosed before rupture in 119 (29%) patients. Eighty (19%) patients had preoperative cardiac arrest. Twenty-nine (7%) patients died before operation; 65 (17%) died during the operation. The surgical mortality rate (30-day) was 37%; the overall mortality rate was 45% and was higher in women (68%) than in men (40%) (P <.001). Advanced age, APACHE (Acute Physiology and Chronic Health Evaluation) II score, initial hematocrit, and preoperative cardiac arrest were associated multivariately with 30-day mortality rates by means of stepwise logistic regression (P <.05). Twelve (23%) of 53 patients with cardiac arrest survived the operation. Logistic regression, adjusted for age, sex, and APACHE II score, demonstrated a decrease in overall and 30-day mortality rates (P <.001) over 18 years. The mean overall mortality rate was 51% from 1980 to 1984 and 42% from 1994 to 1998. The mortality rate of ruptured AAAs remains excessive, despite improvement over 18 years. Patients older than 80 years with shock or cardiac arrest have the highest mortality rate and should be evaluated for possible endovascular treatment. Because the diagnosis of AAA was unknown in more than 70% of patients, screening of the high-risk population and elective repair are recommended.
    Journal of Vascular Surgery 07/2001; 34(1):41-6. · 2.88 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine the rate of successful prosthetic fitting in geriatric vascular amputees in the community and to determine predictors of successful fit. Epidemiologic survey. General community, Olmsted County, Minnesota. All Olmsted County residents more than 65 years old who had a major lower extremity amputation (below knee amputation [BKA] or higher) for peripheral vascular disease between 1974-1995, of whom 199 were identified. Median age at amputation was 79.7 years with a median survival of 1.5 years. A retrospective chart review. Successful prosthetic fit. Amputation levels were: 64% BKA, 4.5% knee disarticulation, 31% above knee amputation (AKA), and 0.5% hip disarticulation. Only 36% of the population was successfully fitted, compared with 74% of patients referred to the Amputee Clinic. Major reasons for not being fitted included death, reamputation, cerebrovascular disease, and cognitive deficits. Increased age (p < .001), cerebrovascular disease (p < .001), dementia (p = .002), and AKA (p < .001) were associated with failure to fit. The high probability of successful prosthetic fitting reported among referral practices cannot be generalized to unselected elderly individuals. However, selected individuals can successfully be fitted with a prosthesis; knowledge of predictors of prosthetic fitting may facilitate setting of realistic goals during presurgical counseling in this age group.
    Archives of Physical Medicine and Rehabilitation 06/2001; 82(6):776-9. · 2.36 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1, 1990, and January 1, 1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients (2%) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.
    Vascular surgery 01/2001; 35(1):1-9.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate duplex ultrasonographic criteria for the determination of 50% or more and 70% or more stenosis of the diameter of the internal carotid artery based on conventional angiography in order to align ultrasonographic diagnostic categories with current clinical management schemes. Between January 1, 1995, and June 30, 1999, 915 patients underwent both carotid duplex ultrasonography and cerebral angiography within 30 days at Mayo Clinic, Rochester, Minn. Of these patients, 294 were excluded from this study because of occlusion of one or both of the internal carotid arteries or atypical flow characteristics. In the remaining 621 patients (61 % male, 39% female; mean age, 67.7 years [range, 14-88 years]), 1218 vessels were available for correlation. Several Doppler ultrasonographic velocity variables were compared with the angiographic findings by use of receiver operating characteristic curve analysis. The primary end point was verification of optimal ultrasonographic criteria to diagnose 70% or more internal carotid artery stenosis. The secondary end point was establishment of threshold values to detect stenosis of 50% or more. At angiography, 382 patients had internal carotid arteries with 70% or more stenosis. Peak systolic and end diastolic velocities of the internal carotid artery and internal carotid artery:common carotid artery peak systolic velocity ratios were measured. For an internal carotid artery stenosis of 70% or more, a peak systolic velocity of 230 cm/s or more resulted in a sensitivity of 86.4%, a specificity of 90.1%, a positive predictive value of 82.7%, a negative predictive value of 92.3%, and an accuracy of 88.8%. An end diastolic velocity of 70 cm/s or more and an internal carotid artery:common carotid artery ratio of 3.2 or more yielded similar values. For an internal carotid artery stenosis of 50% or more, a peak systolic velocity of 130 cm/s or more resulted in a sensitivity of 92.1 %, a specificity of 89.5%, a positive predictive value of 90.3%, a negative predictive value of 91.3%, and an overall accuracy of 90.8%. An internal carotid artery:common carotid artery ratio of 1.6 or more yielded similar values. In our ultrasonography laboratory, a carotid artery stenosis of 70% or more (for which carotid endarterectomy is typically recommended in symptomatic patients) is diagnosed reliably with the following duplex ultrasonographic criteria: a peak systolic velocity of 230 cm/s or more, an end diastolic velocity of 70 cm/s or more, or an internal carotid artery:common carotid artery ratio of 3.2 or more.
    Mayo Clinic Proceedings 12/2000; 75(11):1133-40. · 5.79 Impact Factor

Publication Stats

5k Citations
415.21 Total Impact Points

Institutions

  • 1988–2006
    • Mayo Foundation for Medical Education and Research
      • • Department of Radiation Oncology
      • • Department of Radiology
      • • Division of Vascular Surgery
      • • Department of Surgery
      • • Mayo Medical School
      • • Division of Cardiovascular Diseases
      Scottsdale, AZ, United States
  • 1987–2006
    • Mayo Clinic - Rochester
      • Department of Surgery
      Rochester, Minnesota, United States
  • 2002
    • Mayo Clinic - Scottsdale
      Scottsdale, Arizona, United States
  • 1994
    • Oregon Health and Science University
      Portland, Oregon, United States
  • 1993
    • University of Minnesota Rochester
      Rochester, Minnesota, United States