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Fisher AT, Lee JT. Diagnosis and management of thoracic outlet syndrome in athletes. Semin Vasc Surg 2024; 37:35-43. [PMID: 38704182 DOI: 10.1053/j.semvascsurg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 05/06/2024]
Abstract
The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use-related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA.
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Dossabhoy SS, Fisher AT, Chang TI, Owens DK, Arya S, Stern JR, Lee JT. Preoperative proteinuria is independently associated with mortality after fenestrated endovascular aneurysm repair. J Vasc Surg 2024:S0741-5214(24)00073-9. [PMID: 38219966 DOI: 10.1016/j.jvs.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR. METHODS A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling. RESULTS Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05). CONCLUSIONS In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrea T Fisher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Douglas K Owens
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA
| | - Shipra Arya
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA; Baszucki Vascular Surgery Biobank, Stanford University School of Medicine, Stanford, CA.
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Ho VT, Cabot JH, George EL, Garcia-Toca M, Chen JH, Asch SM, Lee JT. Expansion of Abdominal Aortic Aneurysm Screening and Ultrasound Utilization and Diagnosis. JAMA Surg 2023; 158:1349-1351. [PMID: 37851462 PMCID: PMC10585488 DOI: 10.1001/jamasurg.2023.4662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/19/2023] [Indexed: 10/19/2023]
Abstract
This cohort study uses a deidentified national administrative claims database to assess the association of eligibility expansion with abdominal aortic aneurysm screening and diagnosis.
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Affiliation(s)
- Vy Thuy Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - John H. Cabot
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth L. George
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan H. Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, California
- Division of Hospital Medicine, Stanford University School of Medicine, Palo Alto, California
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Steven M. Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California
| | - Jason T. Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Tran K, Deslarzes-Dubuis C, DeGlise S, Kaladji A, Yang W, Marsden AL, Lee JT. Patient-specific computational flow simulation reveals significant differences in paravisceral aortic hemodynamics between fenestrated and branched endovascular aneurysm repair. JVS Vasc Sci 2023; 5:100183. [PMID: 38314201 PMCID: PMC10832507 DOI: 10.1016/j.jvssci.2023.100183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background Endovascular aneurysm repair with four-vessel fenestrated endovascular aneurysm repair (fEVAR) or branched endovascular aneurysm repair (bEVAR) currently represent the forefront of minimally invasive complex aortic aneurysm repair. This study sought to use patient-specific computational flow simulation (CFS) to assess differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR. Methods Patients from two institutions who underwent four-vessel fEVAR with the Cook Zenith Fenestrated platform and bEVAR with the Jotec E-xtra Design platform were retrospectively selected. Patients in both cohorts were treated for paravisceral and extent II, II, and V thoracoabdominal aortic aneurysms. Three-dimensional finite element volume meshes were created from preoperative and postoperative computed tomography scans. Boundary conditions were adjusted for body surface area, heart rate, and blood pressure. Pulsatile flow simulations were performed with equivalent boundary conditions between preoperative and postoperative states. Postoperative changes in hemodynamic parameters were compared between the fEVAR and bEVAR groups. Results Patient-specific CFS was performed on 20 patients (10 bEVAR, 10 fEVAR) with a total of 80 target vessels (40 renal, 20 celiac, 20 superior mesenteric artery stents). bEVAR was associated with a decrease in renal artery peak flow rate (-5.2% vs +2.0%; P < .0001) and peak pressure (-3.4 vs +0.1%; P < .0001) compared with fEVAR. Almost all renal arteries treated with bEVAR had a reduction in renal artery perfusion (n = 19 [95%]), compared with 35% (n = 7) treated with fEVAR. There were no significant differences in celiac or superior mesenteric artery perfusion metrics (P = .10-.27) between groups. Time-averaged wall shear stress in the paravisceral aorta and branches also varied significantly depending on endograft configuration, with bEVAR associated with large postoperative increases in renal artery (+47.5 vs +13.5%; P = .002) and aortic time-averaged wall shear stress (+200.1% vs -31.3%; P = .001) compared with fEVAR. Streamline analysis revealed areas of hemodynamic abnormalities associated with branched renal grafts which adopt a U-shaped geometry, which may explain the observed differences in postoperative changes in renal perfusion between bEVAR and fEVAR. Conclusions bEVAR may be associated with subtle decreases in renal perfusion and a large increase in aortic wall shear stress compared with fEVAR. CFS is a novel tool for quantifying and visualizing the unique patient-specific hemodynamic effect of different complex EVAR strategies. Clinical Relevance This study used patient-specific CFS to compare postoperative hemodynamic effects of four-vessel fenestrated endovascular aneurysm repair (fEVAR) and branched endovascular aneurysm repair (bEVAR) in patients with complex aortic aneurysms. The findings indicate that bEVAR may result in subtle reductions in renal artery perfusion and a significant increase in aortic wall shear stress compared with fEVAR. These differences are clinically relevant, providing insights for clinicians choosing between these approaches. Understanding the patient-specific hemodynamic effects of complex EVAR strategies, as revealed by CFS, can aid in future personalized treatment decisions, and potentially reduce postoperative complications in aortic aneurysm repair.
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Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford Healthcare, Stanford, CA
| | | | - Sebastien DeGlise
- Division of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Adrien Kaladji
- Department of Vascular Surgery, University of Rennes, Paris, France
| | - Weiguang Yang
- Department of Mechanical Engineering, Stanford University, Stanford, CA
| | - Alison L Marsden
- Department of Mechanical Engineering, Stanford University, Stanford, CA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford Healthcare, Stanford, CA
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Dajani AHJ, Liu MB, Olaopa MA, Cao L, Valenzuela-Ripoll C, Davis TJ, Poston MD, Smith EH, Contreras J, Pennino M, Waldmann CM, Hoover DB, Lee JT, Jay PY, Javaheri A, Slavik R, Qu Z, Ajijola OA. Heterogeneous cardiac sympathetic innervation gradients promote arrhythmogenesis in murine dilated cardiomyopathy. JCI Insight 2023; 8:e157956. [PMID: 37815863 PMCID: PMC10721311 DOI: 10.1172/jci.insight.157956] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 09/29/2023] [Indexed: 10/12/2023] Open
Abstract
Ventricular arrhythmias (VAs) in heart failure are enhanced by sympathoexcitation. However, radiotracer studies of catecholamine uptake in failing human hearts demonstrate a proclivity for VAs in patients with reduced cardiac sympathetic innervation. We hypothesized that this counterintuitive finding is explained by heterogeneous loss of sympathetic nerves in the failing heart. In a murine model of dilated cardiomyopathy (DCM), delayed PET imaging of sympathetic nerve density using the catecholamine analog [11C]meta-Hydroxyephedrine demonstrated global hypoinnervation in ventricular myocardium. Although reduced, sympathetic innervation in 2 distinct DCM models invariably exhibited transmural (epicardial to endocardial) gradients, with the endocardium being devoid of sympathetic nerve fibers versus controls. Further, the severity of transmural innervation gradients was correlated with VAs. Transmural innervation gradients were also identified in human left ventricular free wall samples from DCM versus controls. We investigated mechanisms underlying this relationship by in silico studies in 1D, 2D, and 3D models of failing and normal human hearts, finding that arrhythmogenesis increased as heterogeneity in sympathetic innervation worsened. Specifically, both DCM-induced myocyte electrical remodeling and spatially inhomogeneous innervation gradients synergistically worsened arrhythmogenesis. Thus, heterogeneous innervation gradients in DCM promoted arrhythmogenesis. Restoration of homogeneous sympathetic innervation in the failing heart may reduce VAs.
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Affiliation(s)
- Al-Hassan J. Dajani
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Michael B. Liu
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Michael A. Olaopa
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Lucian Cao
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | | | - Timothy J. Davis
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Megan D. Poston
- Department of Biomedical Sciences, Quillen College of Medicine, and
- Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Elizabeth H. Smith
- Department of Biomedical Sciences, Quillen College of Medicine, and
- Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Jaime Contreras
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Marissa Pennino
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Christopher M. Waldmann
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Donald B. Hoover
- Department of Biomedical Sciences, Quillen College of Medicine, and
- Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Jason T. Lee
- Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | | | - Ali Javaheri
- Washington University School of Medicine, St. Louis, Missouri, USA
- John J. Cochran Veterans Hospital, St. Louis, Missouri, USA
| | - Roger Slavik
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Zhilin Qu
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
| | - Olujimi A. Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, and Department of Medicine, UCLA, Los Angeles, California, USA
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George EL, Smith JA, Colvard B, Lee JT, Stern JR. Precocious Rupture of Abdominal Aortic Aneurysms Below Size Criteria for Repair: Risk Factors and Outcomes. Ann Vasc Surg 2023; 97:74-81. [PMID: 37247834 DOI: 10.1016/j.avsg.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Practice guidelines recommend elective repair for abdominal aortic aneurysms (AAAs) ≥ 5.5 cm in men and ≥ 5 cm in women to prevent rupture; however, some rupture at smaller diameters. We identify risk factors for rupture AAA (rAAA) below this threshold and compare outcomes following rAAA repair above/below size criteria. METHODS The Vascular Quality Initiative (2013-2019) was queried for patients undergoing repair for rAAA and stratified based on diameter into small and large cohorts [Small: < 5.5 cm (men), < 5.0 cm (women)]. Univariate analysis was performed, and Kaplan-Meier analysis compared overall survival, aneurysm-related mortality, and reintervention at 12 months. RESULTS Five thousand one hundred sixty two rAAA were identified. Small rAAA patients [n = 588] were more likely to have hypertension (81.3% vs. 77.0%, P < 0.02), diabetes (18.2% vs. 14.9%, P < 0.04), and end-stage renal disease (2.9% vs. 0.9%, P < 0.01) and be on optimal medical therapy (32.1% vs. 26.8%, P < 0.01). Women were more likely to rupture at smaller diameters compared to men (P < 0.01). Small rAAA patients were more likely to undergo endovascular aortic repair (EVAR) (70.2% vs. 56.0%, P < 0.01) and had lower in-hospital mortality (17.7% vs. 27.7%, P < 0.01) and fewer perioperative complications across all categories. At 12 months, small rAAA patients had better overall survival, freedom from aneurysm-related mortality, and freedom from reintervention, largely driven by EVAR approach. CONCLUSIONS More than 11% of patients presenting with ruptured AAA were below the recommended size threshold for repair, and they tended to be younger, non-White, and have hypertension, diabetes, and/or renal failure. Patients with small rAAA experienced lower in-hospital morbidity and mortality and improved 1-year survival, and EVAR was associated with better outcomes than open repair. However, women more frequently rupture at smaller diameters compared to men. Given contemporary elective outcomes for women, a randomized controlled trial for EVAR versus surveillance at a sex-specific size threshold is needed.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Veterans Affairs Healthcare System, Surgical Service Line, Section of Vascular Surgery, Palo Alto, CA.
| | - Justin A Smith
- University Hospital Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Benjamin Colvard
- University Hospital Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
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Tran K, Kaladji A, Yang W, Marsden AL, Lee JT. Assessing Differences in Aortic Haemodynamics Between Two vs. Four Vessel Fenestrated Endovascular Aortic Repair using Patient Specific Computational Flow Simulation. Eur J Vasc Endovasc Surg 2023; 66:739-740. [PMID: 37536515 DOI: 10.1016/j.ejvs.2023.07.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 06/26/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford Health Care, Stanford, CA, USA.
| | - Adrien Kaladji
- Department of Vascular Surgery, University of Rennes, Paris, France
| | - Weiguang Yang
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Alison L Marsden
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford Health Care, Stanford, CA, USA
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Dossabhoy SS, Sorondo SM, Fisher AT, Ho VT, Stern JR, Lee JT. Association of Baseline Chronic Kidney Disease Stage With Short- and Long-Term Outcomes After Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2023; 97:163-173. [PMID: 37586562 PMCID: PMC10956480 DOI: 10.1016/j.avsg.2023.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short-neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short- and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR. METHODS We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury (AKI). Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by the Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography (CT) scans, and CKD stage progression were assessed at latest follow-up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics. RESULTS From 2012- to 2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3 months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs. 73.0 years, P = 0.04), had increased preoperative creatinine (1.6 vs. 0.9 mg/dL, P < 0.01), and demonstrated increased renal artery ostial calcification (37.7% vs. 21.5%, P = 0.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs. 228 ml, P = 0.01), longer operative times (186 vs. 162 min, P = 0.04), and longer length of stay (3 vs. 2 days, P < 0.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs. 95.1%, P < 0.01 and 55.4% vs. 70.8%, P = 0.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1 year (94.4% vs. 100%, P = 0.015) and 5 years (84.7% vs. 100%, P < 0.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs. CKD 3-5 14.3%, P = 0.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scans between groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P = 0.17). On multivariable modeling, age (hazard ratio 1.05, 95% confidence interval 1.01-1.09, P = 0.02) and CKD stage 4-5 (hazard ratio 6.39, 95% confidence interval 2.26-18.05, P < 0.01) were independently associated with mortality. CONCLUSIONS Preoperative CKD status did not negatively impact the durability or technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Sabina M Sorondo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrea T Fisher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Vy T Ho
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Olson EM, Dyrek P, Harris T, Fereydooni A, Lee JT, Kussman A, Roh E. Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment. Clin J Sport Med 2023; 33:467-474. [PMID: 37207307 DOI: 10.1097/jsm.0000000000001162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/13/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions. DESIGN Retrospective chart review. SETTING Single institution. PARTICIPANTS Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded. INDEPENDENT VARIABLES Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided. MAIN OUTCOME MEASURES Rate of return to play (RTP) to collegiate athletics. RESULTS Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery. CONCLUSIONS Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks. CLINICAL RELEVANCE This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.
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Affiliation(s)
| | - Paige Dyrek
- Stanford University, Department of Orthopaedic Surgery, Palo Alto
| | - Taylor Harris
- Stanford University, School of Medicine, Palo Alto and
| | | | - Jason T Lee
- Stanford University, Division of Vascular Surgery, Palo Alto
| | - Andrea Kussman
- Stanford University, Department of Orthopaedic Surgery, Palo Alto
| | - Eugene Roh
- Stanford University, Department of Orthopaedic Surgery, Palo Alto
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Bondesson J, Suh GY, Dake MD, Lee JT, Cheng CP. Cardiac Pulsatile Helical Deformation of the Thoracic Aorta Before and After Thoracic Endovascular Aortic Repair of Type B Dissections. J Endovasc Ther 2023:15266028231179592. [PMID: 37300396 DOI: 10.1177/15266028231179592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE Type B aortic dissections propagate with either achiral (nonspiraling) or right-handed chiral (spiraling) morphology, have mobile dissection flaps, and are often treated with thoracic endovascular aortic repair (TEVAR). We aim to quantify cardiac-induced helical deformation of the true lumen of type B aortic dissections before and after TEVAR. MATERIAL AND METHODS Retrospective cardiac-gated computed tomography (CT) images before and after TEVAR of type B aortic dissections were used to construct systolic and diastolic 3-dimensional (3D) surface models, including true lumen, whole lumen (true+false lumens), and branch vessels. This was followed by extraction of true lumen helicity (helical angle, twist, and radius) and cross-sectional (area, circumference, and minor/major diameter ratio) metrics. Deformations between systole and diastole were quantified, and deformations between pre- and post-TEVAR were compared. RESULTS Eleven TEVAR patients (59.9±4.6 years) were included in this study. Pre-TEVAR, there were no significant cardiac-induced deformations of helical metrics; however, post-TEVAR, significant deformation was observed for the true lumen proximal angular position. Pre-TEVAR, cardiac-induced deformations of all cross-sectional metrics were significant; however, only area and circumference deformations remained significant post-TEVAR. There were no significant differences of pulsatile deformation from pre- to post-TEVAR. Variance of proximal angular position and cross-sectional circumference deformation decreased after TEVAR. CONCLUSION Pre-TEVAR, type B aortic dissections did not exhibit significant helical cardiac-induced deformation, indicating that the true and false lumens move in unison (do not move with respect to each other). Post-TEVAR, true lumens exhibited significant cardiac-induced deformation of proximal angular position, suggesting that exclusion of the false lumen leads to greater rotational deformations of the true lumen and lack of true lumen major/minor deformation post-TEVAR means that the endograft promotes static circularity. Population variance of deformations is muted after TEVAR, and dissection acuity influences pulsatile deformation while pre-TEVAR chirality does not. CLINICAL IMPACT Description of thoracic aortic dissection helical morphology and dynamics, and understanding the impact of thoracic endovascular aortic repair (TEVAR) on dissection helicity, are important for improving endovascular treatment. These findings provide nuance to the complex shape and motion of the true and false lumens, enabling clinicians to better stratify dissection disease. The impact of TEVAR on dissection helicity provides a description of how treatment alters morphology and motion, and may provide clues for treatment durability. Finally, the helical component to endograft deformation is important to form comprehensive boundary conditions for testing and developing new endovascular devices.
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Affiliation(s)
- Johan Bondesson
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
- Division of Dynamics, Chalmers University of Technology, Gothenburg, Sweden
| | - Ga-Young Suh
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
- Department of Biomedical Engineering, California State University, Long Beach, CA, USA
| | - Michael D Dake
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
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Bondesson J, Raja S, Suh GY, Dake MD, Lee JT, Cheng CP. Longitudinal Mapping of True Lumen Morphology for Accurate Endograft Oversizing in Patients with Type B Aortic Dissections. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2023.01.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Ullery BW, Suh GY, Thompson P, Lee JT, Holden A, Dalman RL, Cheng CP. Impact of renal chimney intra-aortic stent length on branch and end-stent angle in chimney endovascular aneurysm repair and endovascular aneurysm sealing configurations. Vascular 2023; 31:234-243. [PMID: 34963378 DOI: 10.1177/17085381211059978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Practice patterns and durability of parallel stent graft techniques in complex endovascular aneurysm repair (EVAR) remain poorly defined. We aimed to quantify and compare the impact of renal chimney intra-aortic stent length (IASL) on geometric deformations of renal arteries in complex EVAR. METHODS Thirty-eight nonconsecutive patients underwent EVAR utilizing parallel stent graft techniques (chimney EVAR [chEVAR], n = 28; chimney endovascular aneurysm sealing [chEVAS], n = 10) between 2010 and 2016. A total of 59 renal chimney stent grafts were used. Geometric quantification was derived from three-dimensional model-based centerline extraction. Renal chimney intra-aortic stent length (IASL) was defined as the length of chimney stent that extended from the proximal edge of the chimney stent to the ostium of the corresponding renal artery. RESULTS Mean IASL for both left and right renal arteries in the cohort was 35.7 mm. Renal arteries containing chimney IASL <30 mm trended toward a greater branch angle (135.4 vs. 127.8°, p = .06). Left renal arteries showed significantly greater branch angle among those with IASL <40 mm (135.5 vs. 121.7°, p = .045). Mean IASL for renal arteries in chEVAR was significantly longer compared to chEVAS (39.2 vs. 26.3 mm, p = .003). No difference was noted in overall branch angle or end-stent angle based on procedure type. ChEVAR with IASL <30 mm had significantly greater end-stent angle (48.2 vs. 33.5°, p = .03). In contrast, chEVAS patients showed no difference in end-stent angle based on IASL thresholds, but did have significantly greater branch angle among those with IASL <30 mm when grouped by both all renal arteries (133.5 vs. 113.5°, p = .004) and right renal arteries (134.3 vs. 111.6°, p = .02). CONCLUSIONS Renal chimney stents with longer IASL appear to exhibit less renal artery deformation, suggesting a more gradual and perpendicular transition of the chimney stent across the renal ostium.
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Affiliation(s)
- Brant W Ullery
- 192871Providence Heart and Vascular Institute, Portland, OR, USA
| | - Ga-Young Suh
- Department of Biomedical Engineering, California State University, Long Beach, CA, USA.,Division of Vascular Surgery, 10624Stanford University, Stanford, CA, USA
| | - Patrick Thompson
- Division of Vascular Surgery, 10624Stanford University, Stanford, CA, USA
| | - Jason T Lee
- Division of Vascular Surgery, 10624Stanford University, Stanford, CA, USA
| | - Andrew Holden
- Department of Anatomy and Medical Imaging, 58991University of Auckland, New Zealand
| | - Ronald L Dalman
- Division of Vascular Surgery, 10624Stanford University, Stanford, CA, USA
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Han M, Bushong EA, Segawa M, Tiard A, Wong A, Brady MR, Momcilovic M, Wolf DM, Zhang R, Petcherski A, Madany M, Xu S, Lee JT, Poyurovsky MV, Olszewski K, Holloway T, Gomez A, John MS, Dubinett SM, Koehler CM, Shirihai OS, Stiles L, Lisberg A, Soatto S, Sadeghi S, Ellisman MH, Shackelford DB. Spatial mapping of mitochondrial networks and bioenergetics in lung cancer. Nature 2023; 615:712-719. [PMID: 36922590 PMCID: PMC10033418 DOI: 10.1038/s41586-023-05793-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/03/2023] [Indexed: 03/17/2023]
Abstract
Mitochondria are critical to the governance of metabolism and bioenergetics in cancer cells1. The mitochondria form highly organized networks, in which their outer and inner membrane structures define their bioenergetic capacity2,3. However, in vivo studies delineating the relationship between the structural organization of mitochondrial networks and their bioenergetic activity have been limited. Here we present an in vivo structural and functional analysis of mitochondrial networks and bioenergetic phenotypes in non-small cell lung cancer (NSCLC) using an integrated platform consisting of positron emission tomography imaging, respirometry and three-dimensional scanning block-face electron microscopy. The diverse bioenergetic phenotypes and metabolic dependencies we identified in NSCLC tumours align with distinct structural organization of mitochondrial networks present. Further, we discovered that mitochondrial networks are organized into distinct compartments within tumour cells. In tumours with high rates of oxidative phosphorylation (OXPHOSHI) and fatty acid oxidation, we identified peri-droplet mitochondrial networks wherein mitochondria contact and surround lipid droplets. By contrast, we discovered that in tumours with low rates of OXPHOS (OXPHOSLO), high glucose flux regulated perinuclear localization of mitochondria, structural remodelling of cristae and mitochondrial respiratory capacity. Our findings suggest that in NSCLC, mitochondrial networks are compartmentalized into distinct subpopulations that govern the bioenergetic capacity of tumours.
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Affiliation(s)
- Mingqi Han
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine (DGSOM), University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Eric A Bushong
- Department of Neurosciences, University of California San Diego (UCSD), San Diego, CA, USA
- National Center for Microscopy and Imaging Research, UCSD, San Diego, CA, USA
| | | | | | - Alex Wong
- Department of Computer Science, Yale University, New Haven, CT, USA
| | - Morgan R Brady
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine (DGSOM), University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Milica Momcilovic
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine (DGSOM), University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Dane M Wolf
- University of Cambridge, Cambridge, UK
- Imperial College, London, UK
| | - Ralph Zhang
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine (DGSOM), University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | | | - Matthew Madany
- Department of Neurosciences, University of California San Diego (UCSD), San Diego, CA, USA
- National Center for Microscopy and Imaging Research, UCSD, San Diego, CA, USA
| | - Shili Xu
- Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, UCLA, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
| | - Jason T Lee
- Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, UCLA, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
- Molecular Imaging Program, Department of Radiology, Stanford University, Stanford, CA, USA
| | | | | | - Travis Holloway
- Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, CA, USA
| | - Adrian Gomez
- Department of Chemistry and Biochemistry, UCLA, Los Angeles, CA, USA
| | - Maie St John
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
- Department of Head and Neck Surgery, DGSOM UCLA, Los Angeles, CA, USA
| | - Steven M Dubinett
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine (DGSOM), University of California Los Angeles (UCLA), Los Angeles, CA, USA
- Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
- Department of Pathology and Laboratory Medicine, DGSOM UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Carla M Koehler
- Department of Chemistry and Biochemistry, UCLA, Los Angeles, CA, USA
- Department of Biological Chemistry, UCLA, Los Angeles, CA, USA
| | - Orian S Shirihai
- Department of Endocrinology, DGSOM UCLA, Los Angeles, CA, USA
- Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
| | - Linsey Stiles
- Department of Endocrinology, DGSOM UCLA, Los Angeles, CA, USA
- Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, CA, USA
| | - Aaron Lisberg
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
- Department Hematology and Oncology, DGSOM UCLA, Los Angeles, CA, USA
| | - Stefano Soatto
- Department of Computer Science, UCLA, Los Angeles, CA, USA
| | - Saman Sadeghi
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, Ontario, Canada
| | - Mark H Ellisman
- Department of Neurosciences, University of California San Diego (UCSD), San Diego, CA, USA
- National Center for Microscopy and Imaging Research, UCSD, San Diego, CA, USA
| | - David B Shackelford
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine (DGSOM), University of California Los Angeles (UCLA), Los Angeles, CA, USA.
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA.
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Stathogiannis KE, MacArthur JW, Lee JT, Sharma RP. Percutaneous Bailout Technique for Trapping an Embolized Valve During Valve-in-Valve TAVR. J Invasive Cardiol 2023; 35:E160. [PMID: 36884365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
A complex 15-year treatment history of a 75-year-old man with New York Heart Association class III symptoms is presented via images and video. His treatment history was noteworthy of bicuspid aortic valve (AV) and a ventricular septal defect (VSD), for which he had an AV replacement and VSD closure in 2005. In 2015, he underwent redo AV replacement and root reconstruction. Echocardiography demonstrated severe bioprosthetic AV stenosis and moderate AV regurgitation. Valve-in-valve transcatheter aortic valve replacement with a Sentinel cerebral protection device was recommended. Pre-operative computed tomography scan showed dilated aortic root and descending aorta with evidence of pseudocoarcta- tion. This case highlights the need for multidisciplinary team approach and the in-depth knowledge of various devices and techniques available.
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Luo MY, Zhang X, Fang K, Guo YY, Chen D, Lee JT, Shu C. Endovascular aortic arch repair with chimney technique for pseudoaneurysm. BMC Cardiovasc Disord 2023; 23:86. [PMID: 36782127 PMCID: PMC9926684 DOI: 10.1186/s12872-023-03091-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Aortic pseudoaneurysm is a life-threatening clinical condition, and thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones. METHODS A retrospective study was conducted from October 2015 to August 2020, 32 patients with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, 12 months and yearly thereafter. RESULTS The median age of 32 patients was 68.0 years (range, 28-81) with the mean max diameter of aneurysm of 47.9 ± 12.0 mm. Forty-four related supra-aortic branches were well preserved, and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The mean follow-up times was 46.5 ± 14.3 months. One patient died due to acute myocardial infarction just 10 days after chimney TEVAR and the other 3 patients passed away at 1.5 months, 20 months, and 31 months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred. CONCLUSION For aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.
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Affiliation(s)
- Ming-yao Luo
- grid.506261.60000 0001 0706 7839State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037 China ,grid.285847.40000 0000 9588 0960Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102 China
| | - Xiong Zhang
- grid.506261.60000 0001 0706 7839State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037 China ,grid.452708.c0000 0004 1803 0208Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410013 China
| | - Kun Fang
- grid.506261.60000 0001 0706 7839State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Yuan-yuan Guo
- grid.285847.40000 0000 9588 0960Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102 China
| | - Dong Chen
- grid.506261.60000 0001 0706 7839State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Jason T. Lee
- grid.168010.e0000000419368956Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Chang Shu
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037, China. .,Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410013, China.
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16
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Ho VT, Tran K, George EL, Asch SM, Chen JH, Dalman RL, Lee JT. Most Privately Insured Patients Do Not Receive Federally Recommended Abdominal Aortic Aneurysm Screening. J Vasc Surg 2023; 77:1669-1673.e1. [PMID: 36781115 DOI: 10.1016/j.jvs.2023.01.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Since 2005, the United States Preventative Services Task Force (USPSTF) has recommended abdominal aortic aneurysm (AAA) ultrasound screening for 65- to 75-year-old male ever-smokers. Integrated health systems such as Kaiser Permanente and the Veterans Affairs (VA) healthcare system report 74-79% adherence, but compliance rates in the private sector are unknown. METHODS The IBM Marketscan® Commercial and Medicare Supplemental databases (2006 -2017) were queried for male ever-smokers continuously enrolled from age 65 to 75. Exclusion criteria were previous history of abdominal aortic aneurysm, connective tissue disorder, and aortic surgery. Patients with abdominal computed tomographic or magnetic resonance imaging from ages 65 to 75 were also excluded. Screening was defined as a complete abdominal, retroperitoneal, or aortic ultrasound. A logistic mixed-effects model utilizing state as a random intercept was used to identify patient characteristics associated with screening. RESULTS Of 35,154 eligible patients, 13,612 (38.7%, Table 1) underwent screening. Compliance varied by state, ranging from 24.4% in Minnesota to 51.6% in Montana (p <0.05, Figure 1). Screening activity increased yearly, with 0.7% of screening activity occurring in 2008 versus 22.2% in 2016 (p <0.05, Figure 2). In a logistic mixed-effects model adjusting for state as a random intercept, history of hypertension (OR 1.07, 95% CI [1.03 - 1.13]), coronary artery disease (OR 1.17, 95% CI [1.10, 1.22]), congestive heart failure (OR 1.14, 95% CI [1.01 - 1.22]), diabetes (OR 1.1, 95% CI [1.06 - 1.16]) and chronic kidney disease (OR 1.4 95% CI [1.24 - 1.53]) were associated with screening. Living outside of a census-designated metropolitan area was negatively associated with screening (OR 0.92, 95% CI [0.87 - 0.97], Table 2). CONCLUSIONS In a private claims database representing 250 million claimants, 38.7% of eligible patients received UPSTF-recommended AAA screening. Compliance was nearly half that of integrated health systems and was significantly lower for patients living outside of metropolitan areas. Efforts to improve early detection of AAA should include targeting non-metropolitan areas and modifying Medicare reimbursement and incentivization strategies to improve guideline adherence.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Kenneth Tran
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Steven M Asch
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA
| | - Jonathan H Chen
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ronald L Dalman
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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Hellings PW, Fokkens WJ, Orlandi R, Adriaensen GF, Alobid I, Baroody FM, Bjermer L, Senior BA, Cervin A, Cohen NA, Constantinidis J, De Corso E, Desrosiers M, Diamant Z, Douglas RG, Gane S, Gevaert P, Han JK, Harvey RJ, Hopkins C, Kern RC, Landis BN, Lee JT, Lee SE, Leunig A, Lund VJ, Bernal-Sprekelsen M, Mullol J, Philpott C, Prokopakis E, Reitsma S, Ryan D, Salmi S, Scadding G, Schlosser RJ, Steinsvik A, Tomazic PV, Van Staeyen E, Van Zele T, Vanderveken O, Viskens AS, Conti D, Wagenmann M. The EUFOREA pocket guide for chronic rhinosinusitis. Rhinology 2023; 61:85-89. [PMID: 36507741 DOI: 10.4193/rhin22.344] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.
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Affiliation(s)
- P W Hellings
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology Research Group, Leuven, Belgium; University Hospitals Leuven, Department of Otorhinolaryngology, Leuven, Belgium; University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium; Department of otorhinolaryngology and head/neck surgery, Amsterdam University Medical Centres, location AMC, University of Amsterdam, Amsterdam, The Nethe
| | - W J Fokkens
- Department of otorhinolaryngology and head/neck surgery, Amsterdam University Medical Centres, location AMC, University of Amsterdam, Amsterdam, The Netherland
| | - R Orlandi
- Rhinology and Skull Base, Department of Otorhinolaryngology, Hospital Clinic, Universidad de Barcelona, Centro Medico Teknon, Barcelona, Spain
| | - G F Adriaensen
- Department of otorhinolaryngology and head/neck surgery, Amsterdam University Medical Centres, location AMC, University of Amsterdam, Amsterdam, The Netherland
| | - I Alobid
- Rhinology and Skull Base, Department of Otorhinolaryngology, Hospital Clinic, Universidad de Barcelona, Centro Medico Teknon, Barcelona, Spain
| | - F M Baroody
- The University of Chicago Medicine, Chicago, IL, United States
| | - L Bjermer
- Dept of Respiratory Medicine and Allergology, Skane University Hospital, Lund, Sweden
| | - B A Senior
- Division of Rhinology, Allergy, and Endoscopic Skull Base Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A Cervin
- The university of Queensland Centra for Clinical Research, Herston, Australia; Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - N A Cohen
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - J Constantinidis
- 1st Department of ORL, Head and Neck Surgery, Aristotle University, AHEPA Hospital, Thessaloniki, Greece
| | - E De Corso
- Department of Otolaryngology Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Universita; Cattolica Sacro Cuore, Rome, Italy
| | - M Desrosiers
- Department of Otolaryngology-Head and Neck Surgery, Universita de Montreal, Montreal, Canada
| | - Z Diamant
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology Research Group, Leuven, Belgium; Dept of Respiratory Medicine and Allergology, Skane University Hospital, Lund, Sweden; Department Clinical Pharmacy and Pharmacology, University Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - R G Douglas
- Department of Surgery, The University of Auckland, New Zealand
| | - S Gane
- Royal National Ear, Nose and Throat and Eastman Dental Hospitals, London, United Kingdom
| | - P Gevaert
- University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium
| | - J K Han
- Department of Otolaryngology and Head and Neck Surgery at Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - R J Harvey
- Rhinology and Skull Base, Applied Medical Research Center, Department of Otolaryngology and Head and Neck Surgery at Eastern Virginia Medical School, Norfolk, Virginia, USA; Faculty of medicine and heath sciences, Macquarie University, Sydney, Australia
| | - C Hopkins
- Ear, Nose and Throat Department, Guys and St. Thomas Hospital, London, United Kingdom
| | - R C Kern
- Department of Otolaryngology, Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Division of Allergy-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - B N Landis
- Hopitaux Universitaires de Geneve, Geneve, Geneve, Switzerland
| | - J T Lee
- Brigham and Women's Hospital, Harvard Medical School, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Section of Rhinology and Skull Base Surgery, Massachusetts, USA
| | - S E Lee
- Department of Head and Neck Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - A Leunig
- Rhinology Center, Munich and ENT-Clinic, Munich, Germany
| | - V J Lund
- Royal National Throat, Nose and Ear Hospital, UCLH, London, UK
| | | | - J Mullol
- Rhinology Unit and Smell Clinic, ENT Department, Hospital Clinic, IDIBAPS, Universitat de Barcelona, CIBERES. Barcelona, Catalonia, Spain
| | - C Philpott
- NIHR UCLH Biomedical research Centre, London, UK; Ear Institute, University College London, London, UK
| | - E Prokopakis
- Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklion, Greece
| | - S Reitsma
- Department of otorhinolaryngology and head/neck surgery, Amsterdam University Medical Centres, location AMC, University of Amsterdam, Amsterdam, The Netherland
| | - D Ryan
- Usher institute, University of Edinburgh, Edinburgh, UK
| | - S Salmi
- Medicum, Haartman Institute, University of Helsinki, Helsinki, Finland; Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | - G Scadding
- Royal National Ear, Nose and Throat and Eastman Dental Hospitals, London, United Kingdom
| | - R J Schlosser
- Department of Otolaryngology Head and Neck surgery, Medical University of South Carolina, Charleston, SC, USA
| | | | - P V Tomazic
- Department of Otorhinolaryngology, Medical University of Graz, Graz, Austria
| | - E Van Staeyen
- University Hospitals Leuven, Department of Otorhinolaryngology, Leuven, Belgium
| | - T Van Zele
- University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium
| | - O Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium; Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium; Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - A-S Viskens
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology Research Group, Leuven, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
| | | | - M Wagenmann
- Department of Otorhinolaryngology, Universitatsklinikum Disseldorf, Dusseldorf, Germany
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Stern JR, Pham XBD, Lee JT. Reverse Cheese-Wire Septotomy to Create a Distal Landing Zone for Thoracic Endovascular Aortic Repair. J Endovasc Ther 2023; 30:38-44. [PMID: 35018867 DOI: 10.1177/15266028211070966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective of this study is to describe a novel method for creating a distal landing zone for thoracic endovascular aortic repair (TEVAR) in chronic aortic dissection. The technique is described in a patient with prior total arch and descending aortic replacement, with false lumen expansion. TECHNIQUE A cheese-wire endovascular septotomy was desired to create a single lumen above the celiac axis. To avoid dividing the septum caudally across the visceral segment, we performed a modified septotomy in a cephalad direction. Stiff wires were passed into the prior surgical graft, through true lumen on the right and false lumen on the left. An additional wire was passed across an existing fenestration at the level of the celiac axis, and snared and externalized. 7F Ansel sheaths were advanced and positioned tip-to-tip at the fenestration. Using the stiff wires as tracks, the through-wire was pushed cephalad to endovascularly cut the septum. Angiogram demonstrated successful septotomy, and TEVAR was performed to just above the celiac with successful aneurysm exclusion and no endoleak or retrograde false lumen perfusion. Follow-up computed tomography angiogram (CTA) showed continued exclusion without false lumen perfusion. CONCLUSIONS This novel modification in a reverse direction provides an alternative method for endovascular septotomy, when traditional septotomy may threaten the visceral vessels.
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Affiliation(s)
- Jordan R Stern
- Division of Vascular & Endovascular Surgery, Stanford University, Stanford, CA, USA
| | - Xuan-Binh D Pham
- Division of Vascular & Endovascular Surgery, Stanford University, Stanford, CA, USA.,Division of Vascular Surgery, Swedish Hospital, Seattle, WA, USA
| | - Jason T Lee
- Division of Vascular & Endovascular Surgery, Stanford University, Stanford, CA, USA
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Ho VT, Sorondo S, Forrester JD, George EL, Tran K, Lee JT, Garcia-Toca M, Stern JR. Female sex is independently associated with reduced inpatient mortality after endovascular repair of blunt thoracic aortic injury. J Vasc Surg 2023; 77:56-62. [PMID: 35944732 DOI: 10.1016/j.jvs.2022.07.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/21/2022] [Accepted: 07/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Female sex has been associated with decreased mortality after blunt trauma, but whether sex influences the outcomes of thoracic endovascular aortic repair (TEVAR) for traumatic blunt thoracic aortic injury (BTAI) is unknown. METHODS In this retrospective study of a prospectively maintained database, the Vascular Quality Initiative registry was queried from 2013 to 2020 for patients undergoing TEVAR for BTAI. Univariate Student's t-tests and χ2 tests were performed, followed by multivariate logistic regression for variables associated with inpatient mortality. RESULTS Of 806 eligible patients, 211 (26.2%) were female. Female patients were older (47.9 vs 41.8 years, P < .0001) and less likely to smoke (38.3% vs 48.2%, P = .044). Most patients presented with grade III BTAI (54.5% female, 53.6% male), followed by grade IV (19.0% female, 19.5% male). Mean Injury Severity Scores (30.9 + 20.3 female, 30.5 + 18.8 male) and regional Abbreviated Injury Score did not vary by sex. Postoperatively, female patients were less likely to die as inpatients (3.8% vs 7.9%, P = .042) and to be discharged home (41.4% vs 52.2%, P = .008). On multivariate logistic regression, female sex (odds ratio [OR]: 0.05, P = .002) was associated with reduced inpatient mortality. Advanced age (OR: 1.06, P < .001), postoperative transfusion (OR: 1.05, P = .043), increased Injury Severity Score (OR: 1.03, P = .039), postoperative stroke (OR: 9.09, P = .016), postoperative myocardial infarction (OR: 9.9, P = .017), and left subclavian coverage (OR: 2.7, P = .029) were associated with inpatient death. CONCLUSIONS Female sex is associated with lower odds of inpatient mortality after TEVAR for BTAI, independent of age, injury severity, BTAI grade, and postoperative complications. Further study of the influence of sex on postdischarge outcomes is needed.
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Affiliation(s)
- Vy Thuy Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA.
| | - Sabina Sorondo
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Kenneth Tran
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Jordan R Stern
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
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Schneider DB, Matsumura JS, Lee JT, Peterson BG, Chaer RA, Oderich GS. Five-year outcomes from a prospective, multicenter study of endovascular repair of iliac artery aneurysms using an iliac branch device. J Vasc Surg 2023; 77:122-128. [PMID: 35842202 DOI: 10.1016/j.jvs.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We have reported the 5-year results of a pivotal prospective, multicenter study conducted in the United States of a specifically designed iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) for endovascular repair of aortoiliac aneurysms and common iliac artery aneurysms. METHODS A total of 63 patients (98.4% male; mean age, 70 years) with aortoiliac or common iliac artery aneurysms had undergone implantation of a single IBE device and a bifurcated aortoiliac stent graft. Patients with bilateral common iliac artery aneurysms (n = 22; 34.9%) had undergone either staged occlusion or surgical revascularization of the contralateral internal iliac artery before study enrollment. At 5 years, 36 of the 63 patients had completed the final study follow-up examinations, including clinical examinations (n = 35) and computed tomography (n = 32), with the results evaluated by an independent core laboratory and adverse events adjudicated by a clinical events committee. RESULTS At 5 years, freedom from all-cause mortality was 85.7% and freedom from aneurysm-related mortality was 100%. The nine deaths that had occurred (range, 132-1898 days) were adjudicated as unrelated to the aneurysm or procedure. Primary patency of the internal and external iliac artery IBE limbs was 95.1% and 100%, respectively. No patients had experienced new-onset buttock claudication on the IBE side or self-reported new-onset erectile dysfunction. The common iliac artery diameter on the IBE side was either unchanged or had decreased by ≥5 mm in 30 of the 31 patients (96.8%) with a baseline (1 month) and 5-year (range, 1641-2006 days) computed tomography scan available. Of the 31 evaluable patients, 9 (29.0%) had had an increase of ≥5 mm in the aortic diameter, 5 of whom had had a concurrent type II endoleak. No type I or type III endoleaks or device migration were identified by the core laboratory. Six patients had undergone eight secondary interventions, including five interventions for a type II endoleak. The freedom from secondary intervention was 90.5%. CONCLUSIONS The 5-year results of our prospective, multicenter study have confirmed the safety, efficacy, and durability of the IBE device for the treatment of aortoiliac and iliac artery aneurysms. The device effectively prevented common iliac artery aneurysm rupture, maintained the patency of the internal iliac artery, and avoided the complications associated with internal iliac artery sacrifice. Although common iliac artery aneurysm enlargement was rare, abdominal aortic enlargement was more common, suggesting that the outcomes of endovascular aneurysm repair might be different for patients with or without associated common iliac artery aneurysms.
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Affiliation(s)
- Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Jon S Matsumura
- Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Brian G Peterson
- Heart and Vascular Institute, St. Luke's Hospital, Chesterfield, MO
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, TX
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Watkins AC, Dossabhoy S, Dalal AR, Yasin A, Leipzig M, Colvard B, Lee JT, Dake MD. Controlled Balloon False Lumen Obliteration for the Endovascular Management of Chronic Dissection in the Descending Thoracic Aorta. JTCVS Tech 2023. [DOI: 10.1016/j.xjtc.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Stern JR, Tran K, Dossabhoy SS, Sorondo SM, Lee JT. A fenestrated, double-barrel technique for proximal reintervention after open or endovascular abdominal aortic aneurysm repair. J Vasc Surg Cases Innov Tech 2022; 9:101091. [PMID: 36747609 PMCID: PMC9898739 DOI: 10.1016/j.jvscit.2022.101091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Proximal endovascular reintervention after prior endovascular aortic repair (EVAR) or open abdominal aortic aneurysm repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow the use of the commercially available ZFEN device using a double-barrel, kissing-limb technique. Methods Patients who underwent fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of the standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πDLIMB = πDZFEN + 2DZFEN. Results Of 235 patients who underwent repair using ZFEN from 2012 to 2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 treated using the double-barrel technique (8 EVAR, 5 OR). The distance from the flow divider to the lowest renal artery was 67 ± 24.4 mm (range, 39-128 mm), and the distance to the superior mesenteric artery (SMA) was 87 ± 30.5 mm (range, 60-164 mm). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal artery and SMA to accommodate a standard ZFEN build was 56 and 60 mm, respectively. Four patients required adjunctive snorkel grafts and two required laser fenestrations. Two patients had gutter leaks at 1 month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72%, and 48% at 1, 2, and 3 years, respectively. Conclusions This double-barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.
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Affiliation(s)
- Jordan R. Stern
- Correspondence: Jordan R. Stern, MD, Stanford University School of Medicine, 780 Welch Rd, Ste CJ350, Palo Alto, CA 94304
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Dalal AR, Dossabhoy S, Heng E, Yasin A, Leipzig MM, Bonham SA, Fischbein MP, Lee JT, Woo YJ, Watkins AC. Midterm Outcomes in Type A Aortic Dissection Repair With and Without Malperfusion in a Hybrid Operating Room. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00280-5. [PMID: 36567047 DOI: 10.1053/j.semtcvs.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Treatment approach to type A aortic dissection with malperfusion, immediate open aortic repair vs upfront endovascular treatment, remains controversial. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Starting in 2019, all type A aortic dissections were performed in a fixed-fluoroscopy, hybrid operating room. Propensity score matching was used to control baseline patient characteristics between traditional and hybrid operating room approaches. There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 41% (64/157) underwent intraoperative angiograms, and of those, 58% (37/64) received at least 1 endovascular intervention. Following propensity matching, 125 patients remained in each the traditional and hybrid groups. Thirty-day survival was significantly improved in the hybrid cohort at 96.7% (122/125) as compared to the traditional cohort at 87.2% (109/125) (P = 0.002). There were no significant differences in perioperative paralysis (1.6% vs 1.6%, P > 0.9), new hemodialysis (12% vs 9.6%, P = 0.5), fasciotomy (2.4% vs 5.6%, P = 0.20, and exploratory laparotomy (1.6% vs 4.8%, P = 0.3). The hybrid operating room approach to type A aortic dissection, provides the ability to immediately assess distal malperfusion and perform endovascular interventions at the time of open aortic repair, and is associated with significantly higher 30-day and 2-year survival when compared to a stepwise repair approach in a traditional operating room.
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Affiliation(s)
- Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Shernaz Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Elbert Heng
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Aleena Yasin
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Matthew M Leipzig
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Spencer A Bonham
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
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Lee JT, Rochell SJ, Kriseldi R, Kim WK, Mitchell RD. Functional properties of amino acids: improve health status and sustainability. Poult Sci 2022; 102:102288. [PMID: 36436367 PMCID: PMC9700297 DOI: 10.1016/j.psj.2022.102288] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
Abstract
The combination of increased genetic potential and changes in management strategies (i.e., antibiotic-free, no antibiotics ever, and every day feeding of replacement pullets) influences the nutritional needs of poultry. Traditionally, nutritionists have focused on meeting the amino acid needs for production performance and yield however, increasing specific amino acid concentrations can benefit gastrointestinal development and integrity, enhance immune response potential, influence behavior, and benefit sustainability. Commercialization of additional feed grade amino acids beyond methionine, lysine, and threonine, enables targeted increases to achieve these benefits. As such, this paper addresses the functional roles of amino acids in meeting poultry production, health, and sustainability goals.
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Affiliation(s)
- Jason T. Lee
- CJ Bio America, Downer Grove, IL, USA,Corresponding author:
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Escobar GA, Oderich GS, Farber MA, de Souza LR, Quinones-Baldrich WJ, Patel HJ, Eliason JL, Upchurch GR, H Timaran C, Black JH, Ellozy SH, Woo EY, Fillinger MF, Singh MJ, Lee JT, C Jimenez J, Lall P, Gloviczki P, Kalra M, Duncan AA, Lyden SP, Tenorio ER. Results of the North American Complex Abdominal Aortic Debranching (NACAAD) Registry. Circulation 2022; 146:1149-1158. [PMID: 36148651 DOI: 10.1161/circulationaha.120.045894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting. METHODS Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed. RESULTS A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality (P<0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency (P<0.0001). CONCLUSIONS Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.
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Affiliation(s)
| | - Gustavo S Oderich
- University of Texas Health Science Center at Houston, Houston, TX (G.S.O., E.R.T.)
| | - Mark A Farber
- University of North Carolina Health Care, Chapel Hill, NC (M.A.F.)
| | - Leonardo R de Souza
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil (L.R.d.S.)
| | | | - Himanshu J Patel
- University of Michigan Cardiovascular Center, Ann Arbor, MI (H.J.P., J.L.E.)
| | - Jonathan L Eliason
- University of Michigan Cardiovascular Center, Ann Arbor, MI (H.J.P., J.L.E.)
| | | | | | - James H Black
- Johns Hopkins Bayview Medical Center, Baltimore, MD (J.H.B)
| | - Sharif H Ellozy
- Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY (S.H.E.)
| | | | | | - Michael J Singh
- University of Pittsburgh Medical Center, Pittsburgh, PA (M.J.S.)
| | - Jason T Lee
- Stanford University Medical Center, Stanford, CA (J.T.L.)
| | - Juan C Jimenez
- University of California, Los Angeles, CA (W.J.Q.-B., J.C.J.)
| | - Purandath Lall
- Cleveland Clinic Martin Health, Port St. Lucie, FL (P.L., M.K.)
| | | | - Manju Kalra
- Cleveland Clinic Martin Health, Port St. Lucie, FL (P.L., M.K.).,Mayo Clinic, Rochester, MN (P.G., M.K.)
| | - Audra A Duncan
- Schulich School of Medicine and Dentistry, Western University, London, Ontario; Canada (A.A.D.)
| | - Sean P Lyden
- Cleveland Clinic Foundation, Cleveland, OH (S.P.L.)
| | - Emanuel R Tenorio
- University of Texas Health Science Center at Houston, Houston, TX (G.S.O., E.R.T.)
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Lawley RJ, Kasitinon D, Sisk D, Lavingia KS, Lee JT, Fredericson M. Concurrent Diagnosis of Functional Popliteal Artery Entrapment Syndrome and Chronic Exertional Compartment Syndrome in Athletes. Curr Sports Med Rep 2022; 21:366-370. [DOI: 10.1249/jsr.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Shen J, Mastrodicasa D, Al Bulushi Y, Lin MC, Tse JR, Watkins AC, Lee JT, Fleischmann D. Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection: Pre- and Postprocedural Imaging. Radiographics 2022; 42:1638-1653. [PMID: 36190862 DOI: 10.1148/rg.220028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Aortic dissection is a chronic disease that requires lifelong clinical and imaging surveillance, long after the acute event. Imaging has an important role in prognosis, timing of repair, device sizing, and monitoring for complications, especially in the endovascular therapy era. Important anatomic features at preprocedural imaging include the location of the primary intimal tear and aortic zonal and branch vessel involvement, which influence the treatment strategy. Challenges of repair in the chronic phase include a small true lumen in conjunction with a stiff intimal flap, complex anatomy, and retrograde perfusion from distal reentry tears. The role of thoracic endovascular aortic repair (TEVAR) remains controversial for treatment of chronic aortic dissection. Standard TEVAR is aimed at excluding the primary intimal tear to decrease false lumen perfusion, induce false lumen thrombosis, promote aortic remodeling, and prevent aortic growth. In addition to covering the primary intimal tear with an endograft, several adjunctive techniques have been developed to mitigate retrograde false lumen perfusion. These techniques are broadly categorized into false lumen obliteration and landing zone optimization strategies, such as the provisional extension to induce complete attachment (PETTICOAT), false lumen embolization, cheese-wire fenestration, and knickerbocker techniques. Familiarity with these techniques is important to recognize expected changes and complications at postintervention imaging. The authors detail imaging options, provide examples of simple and complex endovascular repairs of aortic dissections, and highlight complications that can be associated with various techniques. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jody Shen
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Domenico Mastrodicasa
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Yarab Al Bulushi
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Margaret C Lin
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Justin R Tse
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Amelia C Watkins
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Jason T Lee
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Dominik Fleischmann
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
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Treil L, Neumann N, Chanes N, Lejay A, Bourcier T, Bismuth J, Lee JT, Sheahan M, Rouby AF, Chakfé N, Eidt J, Georg Y, Mitchell EL, Rigberg D, Shames M, Thaveau F, Sheahan C. Objective Evaluation of Clock Face Suture Using the Objective Structured Assessment of Technical Skill (OSATS) Checklist. EJVES Vasc Forum 2022; 57:5-11. [DOI: 10.1016/j.ejvsvf.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
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Seo JW, Ajenjo J, Wu B, Robinson E, Raie MN, Wang J, Tumbale SK, Buccino P, Anders DA, Shen B, Habte FG, Beinat C, James ML, Reyes ST, Ravindra Kumar S, Miles TF, Lee JT, Gradinaru V, Ferrara KW. Multimodal imaging of capsid and cargo reveals differential brain targeting and liver detargeting of systemically-administered AAVs. Biomaterials 2022; 288:121701. [PMID: 35985893 PMCID: PMC9621732 DOI: 10.1016/j.biomaterials.2022.121701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022]
Abstract
The development of gene delivery vehicles with high organ specificity when administered systemically is a critical goal for gene therapy. We combine optical and positron emission tomography (PET) imaging of 1) reporter genes and 2) capsid tags to assess the temporal and spatial distribution and transduction of adeno-associated viruses (AAVs). AAV9 and two engineered AAV vectors (PHP.eB and CAP-B10) that are noteworthy for maximizing blood-brain barrier transport were compared. CAP-B10 shares a modification in the 588 loop with PHP.eB, but also has a modification in the 455 loop, added with the goal of reducing off-target transduction. PET and optical imaging revealed that the additional modifications retained brain receptor affinity. In the liver, the accumulation of AAV9 and the engineered AAV capsids was similar (∼15% of the injected dose per cc and not significantly different between capsids at 21 h). However, the engineered capsids were primarily internalized by Kupffer cells rather than hepatocytes, and liver transduction was greatly reduced. PET reporter gene imaging after engineered AAV systemic injection provided a non-invasive method to monitor AAV-mediated protein expression over time. Through comparison with capsid tagging, differences between brain localization and transduction were revealed. In summary, AAV capsids bearing imaging tags and reporter gene payloads create a unique and powerful platform to assay the pharmacokinetics, cellular specificity and protein expression kinetics of AAV vectors in vivo, a key enabler for the field of gene therapy.
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Affiliation(s)
- Jai Woong Seo
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Javier Ajenjo
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Bo Wu
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Elise Robinson
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Marina Nura Raie
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - James Wang
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Spencer K Tumbale
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Pablo Buccino
- Stanford Cyclotron & Radiochemistry Facility (CRF), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - David Alexander Anders
- Stanford Cyclotron & Radiochemistry Facility (CRF), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Bin Shen
- Stanford Cyclotron & Radiochemistry Facility (CRF), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Frezghi G Habte
- Stanford Center for Innovation in In vivo Imaging (SCi3), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Corinne Beinat
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Michelle L James
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Samantha Taylor Reyes
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Sripriya Ravindra Kumar
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Timothy F Miles
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Jason T Lee
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Viviana Gradinaru
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Katherine W Ferrara
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA.
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Lee DT, Lee JT, Ruan C, Rochell SJ. Influence of increasing glycine concentrations in reduced crude protein diets fed to broilers from 0 to 48 days. Poult Sci 2022; 101:102038. [PMID: 35921733 PMCID: PMC9356093 DOI: 10.1016/j.psj.2022.102038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/12/2022] [Accepted: 06/25/2022] [Indexed: 01/13/2023] Open
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Sorondo SM, Dossabhoy SS, Tran K, Ho VT, Stern JR, Lee JT. Large Fenestrations Versus Scallops for the SMA During Fenestrated EVAR: Does it Matter? Ann Vasc Surg 2022; 87:71-77. [PMID: 36058451 DOI: 10.1016/j.avsg.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE FEVAR is an established customized treatment for aortic aneurysms with three current commercially available configurations for the superior mesenteric artery (SMA) - a single-wide scallop, large fenestration, or small fenestration, with the scallop or large fenestration most utilized. Outcomes comparing SMA single-wide scallops to large fenestrations with the ZFEN device are scarce. As large fenestrations have the benefit of extending the proximal seal zone compared to scalloped configurations, we sought to determine the differences in seal zone and sac regression outcomes between the two SMA configurations. METHODS We retrospectively reviewed our prospectively maintained complex EVAR database and included all patients treated with the Cook ZFEN device with an SMA scallop or large fenestration configuration at its most proximal build. All first post-operative CT scans (1-30 days) were analyzed on TeraRecon to determine precise proximal seal zone lengths, and standard follow-up anatomic and clinical metrics were tabulated. RESULTS A total of 234 consecutive ZFEN patients from 2012-2021 were reviewed, and 137 had either a scallop or large fenestration for the SMA as the proximal-most configuration (72 scallops and 65 large fenestrations) with imaging available for analysis. Mean follow-up was 35 months. Mean proximal seal zone length was 19.5±7.9 mm for scallop vs 41.7±14.4 mm for large fenestration groups (P<.001). There was no difference in sac regression between scallop and large fenestration at one year (10.1±10.9 mm vs 11.0±12.1, P = 0.63). Overall, 30-day mortality (1.3% vs 2.5%, P=.51) and all-cause three-year mortality (72.5% vs 81.7%, P=.77) were not significantly different. Reinterventions within 30 days were primarily secondary to renal artery branch occlusions, with only one patient in the scallop group requiring reintervention for an SMA branch occlusion. CONCLUSIONS Despite attaining longer proximal seal lengths, large SMA fenestrations were not associated with a difference in sac regression compared to scalloped SMA configurations at one-year follow up. There were no significant differences in reinterventions or overall long-term survival between the two SMA strategies.
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Affiliation(s)
- Sabina M Sorondo
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kenneth Tran
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Vy T Ho
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
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Ko JH, Forsythe NL, Gelb MB, Messina KMM, Lau UY, Bhattacharya A, Olafsen T, Lee JT, Kelly KA, Maynard HD. Safety and Biodistribution Profile of Poly(styrenyl acetal trehalose) and Its Granulocyte Colony Stimulating Factor Conjugate. Biomacromolecules 2022; 23:3383-3395. [PMID: 35767465 DOI: 10.1021/acs.biomac.2c00511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Poly(styrenyl acetal trehalose) (pSAT), composed of trehalose side chains linked to a polystyrene backbone via acetals, stabilizes a variety of proteins and enzymes against fluctuations in temperature. A promising application of pSAT is conjugation of the polymer to therapeutic proteins to reduce renal clearance. To explore this possibility, the safety of the polymer was first studied. Investigation of acute toxicity of pSAT in mice showed that there were no adverse effects of the polymer at a high (10 mg/kg) concentration. The immune response (antipolymer antibody and cytokine production) in mice was also studied. No significant antipolymer IgG was detected for pSAT, and only a transient and low level of IgM was elicited. pSAT was also safe in terms of cytokine response. The polymer was then conjugated to a granulocyte colony stimulating factor (GCSF), a therapeutic protein that is approved by the Federal Drug Administration, in order to study the biodistribution of a pSAT conjugate. A site-selective, two-step synthesis approach was developed for efficient conjugate preparation for the biodistribution study resulting in 90% conjugation efficiency. The organ distribution of GCSF-pSAT was measured by positron emission tomography and compared to controls GCSF and GCSF-poly(ethylene glycol), which confirmed that the trehalose polymer conjugate improved the in vivo half-life of the protein by reducing renal clearance. These findings suggest that trehalose styrenyl polymers are promising for use in therapeutic protein-polymer conjugates for reduced renal clearance of the biomolecule.
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Affiliation(s)
- Jeong Hoon Ko
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
| | - Neil L Forsythe
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
| | - Madeline B Gelb
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
| | - Kathryn M M Messina
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
| | - Uland Y Lau
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
| | - Arvind Bhattacharya
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
| | - Tove Olafsen
- Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095-1569, United States
| | - Jason T Lee
- Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095-1569, United States
| | - Kathleen A Kelly
- Department of Pathology and Lab Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095-1569, United States
| | - Heather D Maynard
- Department of Chemistry and Biochemistry and California NanoSystems Institute, University of California, Los Angeles, 607 Charles E. Young Drive East, Los Angeles, California 90095, United States
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Stern JR, Lee JT. Factors Associated with Sac Regression after F/BEVAR for Complex Abdominal and Thoracoabdominal Aneurysms. Semin Vasc Surg 2022; 35:306-311. [DOI: 10.1053/j.semvascsurg.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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Huber TS, Brown KR, Lee JT, Barry CL, Ibanez B, Jones AT, Perler BA, Upchurch GR. Implementation of the Vascular Surgery Board Virtual Certifying Examination. J Vasc Surg 2022; 76:1398-1404.e4. [PMID: 35760241 PMCID: PMC9365525 DOI: 10.1016/j.jvs.2022.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 12/04/2022]
Abstract
Objective The onset of the COVID-19 (coronavirus disease 2019) pandemic mandated postponement of the in-person Vascular Surgery Board 2020 certifying examination (CE). Vascular surgery virtual CEs (VVCEs) were developed for the scheduled 2020 CEs (rescheduled to January 2021) and 2021 CEs (rescheduled to July 2021) to avoid postponing the certification testing. In the present study, we have reported the development, implementation, and outcomes of the first two VVCEs. Methods The VVCE was similar to the in-person format (three 30-minutes sessions, two examiners, four questions) but required a proctor and a host. In contrast to the general surgery VCEs, the VVCE also incorporated images. The candidates and examiners were instructed on the format, and technology checks were performed before the VVCE. The candidates were given the opportunity to invalidate their examination for technology-related reasons immediately after the examination. Postexamination surveys were administered to all the participants. Results The VVCEs were completed by 356 of 357 candidates (99.7%). The pass rates for the January 2021 and July 2021 examinations were 97.6% (first time, 99.4%; retake, 70%) and 94.7% (first time, 94.6%; retake, 100%), respectively. The pass rates were not significantly different from the 2019 in-person CE (χ2 = 2.30; P = .13; and χ2 = 0.01; P = .91, for the January 2021 and July 2021 examinations, respectively). None of the candidates had invalidated their examination. The candidates (162 of 356; 46%), examiners (64 of 118; 54%), proctors (25 of 27; 93%), and hosts (8 of 9; 89%) completing the survey were very satisfied with the examination (Likert score 4 or 5: candidates, 92.6%; noncandidates, 96.9%) and found the technology domains (Zoom, audio, video, viewing images) to be very good (Likert score 4 or 5), with candidate and other responder scores of 73% to 84% and >94%, respectively. Significantly more of the candidates had favored a future VVCE compared with the examiners (87% vs 32%; χ2 = 67.1; P < .001). The free text responses from all responders had commented favorably on the organization and implementation of the examination. However, some candidates had expressed concerns about image sizes, and some examiners had expressed concern about the time constraints for the question format. The candidates appreciated the convenience of an at-home examination, especially the avoidance of travel costs. Conclusions The two Vascular Surgery Board VCEs were shown to be psychometrically sound and were overwhelmingly successful, demonstrating that image-based virtual examinations are feasible and could become the standard for the future.
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Affiliation(s)
- Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, College of Medicine, University of Florida, Gainsville, FL.
| | | | - Jason T Lee
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, College of Medicine, University of Florida, Gainsville, FL
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Dossabhoy SS, Sorondo SM, Tran K, Stern JR, Dalman RL, Lee JT. Reintervention Does Not Impact Long-term Survival After Fenestrated Endovascular Aneurysm Repair. J Vasc Surg 2022; 76:1180-1188.e8. [PMID: 35709854 DOI: 10.1016/j.jvs.2022.04.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/19/2022] [Accepted: 04/21/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in the treatment of juxtarenal aortic aneurysms and short-neck infrarenal aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource utilization. We sought to determine if REIs impact long-term survival after FEVAR. METHODS A single-institution retrospective review of all Cook ZFEN repairs was performed. Patients with ≥6 months follow-up and without adjunctive branch modifications were included. REI was defined as any aneurysm, device, target branch, or access-related intervention after the index procedure. REIs were categorized by early (<30 days) or late (≥30 days), indication (branch, endoleak, limb, access-related, or other), and target branch/device component. Patients were stratified into REI vs No REI and Branch REI vs Non-Branch REI. RESULTS Of 219 consecutive ZFEN from 2012-2021, 158 patients met inclusion criteria. Forty-one (26%) patients underwent a total of 51 REIs (10 early, 41 late) over a mean follow-up of 33.9 months. The most common indication for REI was branch-related 61% (31/51), with the renal arteries most frequently affected 51% (26/51). The only differences found in baseline, aneurysm, or device characteristics were a higher mean SVS comorbidity score (9.6 vs 7.9, P=.04) and larger suprarenal neck angle (23.3 vs 17.1 degrees, P=.04) in No REI, while REI had larger mean proximal seal zone diameter (26.3 vs 25.1 mm, P=.03) and device diameter (31.9 vs 30.0 mm, P=.002) than No REI. Technical success and operative characteristics were similar between groups, except for longer mean fluoroscopy time (74.9 vs 60.8 min, P=.01) and longer median length of stay (2 vs 2 days, P=.006) in REI. While the rate of early major adverse events (<30 days) was higher in REI (24.4% vs 6.0%, P=.001), 30-day mortality was not statistically different (4.9% vs 0.9%, P=.10). On Kaplan-Meier analysis, freedom from REI at 1- and 5-years was 85.7% and 62.6%, respectively, in the overall cohort. There was no difference in estimated 5-year survival between REI and No REI (62.8% vs 63.5%, log-rank P=.87) and Branch REI and Non-Branch REI (71.8% vs 49.9%, log-rank P=.16). In multivariate analysis, REI did not predict mortality; age, the SVS comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (HR 1.07 95% CI 1.02-1.12, P=.007; HR 1.10, 95% CI 1.01-1.18, P=.02; HR 1.05, 95% CI 1.02-1.08, P=.003 respectively). CONCLUSIONS Following ZFEN, 26% of patients required a total of 51 REIs with most occurring ≥30 days and 61% being branch-related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs do not influence 5-year post-procedural survival.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Sabina M Sorondo
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kenneth Tran
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Ronald L Dalman
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
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Tran K, Feliciano KB, Yang W, Schwarz EL, Marsden AL, Dalman RL, Lee JT. Patient-specific changes in aortic hemodynamics is associated with thrombotic risk after fenestrated endovascular aneurysm repair with large diameter endografts. JVS Vasc Sci 2022; 3:219-231. [PMID: 35647564 PMCID: PMC9133635 DOI: 10.1016/j.jvssci.2022.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/06/2022] [Indexed: 12/24/2022] Open
Abstract
Background The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. In the present study, we used patient-specific computational fluid dynamic (CFD) simulation to investigate the effect of the endograft diameter on hemodynamics after fEVAR and explore the hypothesis that diameter-dependent alterations in aortic hemodynamics can predict for thrombotic events. Methods A single-institutional retrospective study was performed of patients who had undergone fEVAR for juxtarenal aortic aneurysms. The patients were stratified into large diameter (34-36 mm) and small diameter (24-26 mm) endograft groups. Patient-specific CFD simulations were performed using three-dimensional paravisceral aortic models created from computed tomographic images with allometrically scaled boundary conditions. Aortic time-averaged wall shear stress (TAWSS) and residence time (RT) were computed and correlated with future thrombotic complications (eg, renal stent occlusion, development of significant intraluminal graft thrombus). Results A total of 36 patients (14 with a small endograft and 22 with a large endograft) were included in the present study. The patients treated with large endografts had experienced a higher incidence of thrombotic complications compared with small endografts (45.5% vs 7.1%; P = .016). Large endografts were associated with a lower postoperative aortic TAWSS (1.45 ± 0.76 dynes/cm2 vs 3.16 ± 1.24 dynes/cm2; P < .001) and longer aortic RT (0.78 ± 0.30 second vs 0.34 ± 0.08 second; P < .001). In the large endograft group, a reduction >0.39 dynes/cm2 in aortic TAWSS demonstrated discriminatory power for thrombotic complications (area under the receiver operating characteristic curve, 0.77). An increased aortic RT of ≥0.05 second had similar accuracy for predicting thrombotic complications (area under the receiver operating characteristic curve, 0.78). The odds of thrombotic complications were significantly higher if patients had met the hemodynamic threshold changes in aortic TAWSS (odds ratio, 7.0; 95% confidence interval, 1.1-45.9) and RT (odds ratio, 8.0; 95% confidence interval, 1.13-56.8). Conclusions Patient-specific CFD simulation of fEVAR in juxtarenal aortic aneurysms demonstrated significant endograft diameter-dependent differences in aortic hemodynamics. A postoperative reduction in TAWSS and an increased RT correlated with future thrombotic events after large-diameter endograft implantation. Patient-specific simulation of hemodynamics provides a novel method for thrombotic risk stratification after fEVAR. The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. Using patient-specific computational flow simulation, the present retrospective study of 36 patients with juxtarenal aortic aneurysms treated with fEVAR identified several endograft diameter-dependent changes in aortic hemodynamics associated with thrombotic complications. A postoperative reduction in aortic wall shear stress and increased particle residence time correlated with the development of intraluminal graft thrombus and renal stent occlusion in patients treated with large diameter (>34 mm) endografts. These computationally estimated hemodynamic parameters could provide a novel method for patient-specific risk stratification for adverse events after fEVAR.
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Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
- Correspondence: Kenneth Tran, MD, Department of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Ste H3600, Stanford, CA 94305-5851
| | - K. Brennan Feliciano
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
| | - Weiguang Yang
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA
| | - Erica L. Schwarz
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
| | - Alison L. Marsden
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA
| | - Ronald L. Dalman
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
| | - Jason T. Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
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Stern JR, Tran K, Dossabhoy SS, Sorondo SM, Lee JT. A Fenestrated, Double Barrel Technique for Proximal Reintervention After Open or Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ho V, Sgroi M, Chandra V, Asch S, Chen JH, Lee JT. Remote Access to Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Martinez-Singh K, Harris EJ, Lee JT, Stern JR, Ross E, Chandra V. Real-world Experience With Drug-coated Balloon Angioplasty in Dysfunctional Arteriovenous Fistulae. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Fisher AT, Tran K, Dossabhoy SS, Sorondo S, Fereydooni A, Lee JT. Anatomic factors contributing to external iliac artery endofibrosis in high performance athletes. Ann Vasc Surg 2022; 87:181-187. [PMID: 35654289 DOI: 10.1016/j.avsg.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/12/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION External iliac artery endofibrosis (EIAE) classically presents in cyclists with intimal thickening of the affected arteries. We investigated possible anatomical predisposing factors including psoas muscle hypertrophy, arterial tortuosity, inguinal ligament compression, and arterial kinking via case-control comparison of symptomatic and contralateral limbs. METHODS All patients with unilateral EIAE treated surgically at our institution were reviewed. Each patient's symptomatic side was compared with their contralateral side using paired t-tests. Psoas hypertrophy was quantified by transverse cross-sectional area (CSA) at L4, L5, and S1 vertebral levels, and inguinal ligament compression was measured as anterior-posterior distance between inguinal ligament and underlying bone. Tortuosity index for diseased segments and arterial kinking were measured on TeraRecon. RESULTS Of 33 patients operated on for EIAE from 2004-2021, 27 with available imaging presented with unilateral disease, more commonly left-sided (63%). Most (96%) had external iliac involvement and 26% had ≥2 segments affected: 19% common iliac artery, 15% common femoral artery. The symptomatic limb had greater mean L5 psoas CSA (1450 mm2 vs. 1396 mm2, mean difference 54 mm2, P=0.039). There were no significant differences in L4 or S1 psoas hypertrophy, tortuosity, inguinal ligament compression, or arterial kinking. 63% underwent patch angioplasty and 85% underwent additional inguinal ligament release. 84% reported postoperative satisfaction, which was associated with greater difference in psoas hypertrophy at L4 (p=0.022). CONCLUSIONS Psoas muscle hypertrophy is most pronounced at L5 and is associated with symptomatic EIAE. Preferential hypertrophy of the affected side correlates with improved outcomes, suggesting psoas muscle hypertrophy as a marker of disease severity.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Kenneth Tran
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Shernaz S Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Sabina Sorondo
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Arash Fereydooni
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
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George EL, Arya S, Ho VT, Stern JR, Sgroi MD, Chandra V, Lee JT. Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era. J Vasc Surg 2022; 76:1079-1086. [PMID: 35598821 DOI: 10.1016/j.jvs.2022.03.887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of and increased anatomic suitability of endovascular aortic repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees. METHODS We examined ACGME case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aorto-iliac occlusive disease (AIOD) via aorto-iliac/femoral bypass (AFB) from integrated vascular surgery residents (VSR) and fellows (VSF) graduating 2006-2017 and compared them to national estimates of total OAR (open AAA repair + AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample based on ICD-9 and ICD-10 procedural codes. Changes over time were assessed using Chi-square test, Student's t-test, and linear regression. RESULTS During the twelve-year study period, the national annual total OAR and open AAA repair estimates decreased: total OAR by 72.5% (2006: estimate (standard error) 24,255 (1185) vs. 2017: 6,690 (274); p<0.001) and open AAA repair by 84.7% (2006: 18,619 (924) vs. 2017: 2,850 (168); p<0.001); AFB estimates decreased by 33.0% (p<0.001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals significantly increased from ∼55 to 80% (all p<0.001). There was a 40.9% decrease in open AAA repairs logged by graduating VSF (mean 18.6 vs. 11) but only a 6.9% decrease in total OAR cases (mean 27.6 vs. 25.7) due to increasing AFB volumes (mean 9.0 vs. 14.7). VSR graduates consistently logged an average of ∼10 open AAA repairs and there was a 31.0% increase in total OAR (mean 23.2 vs. 30.4), again secondary to rising AFB volumes (mean 11.4 vs 17.5). Although there was an absolute decrease in open aortic experience for VSF, the rate of decline for total OAR case volumes was not significantly different after VSR programs were established (p=0.40). CONCLUSIONS As incidence decreases nationally, OAR is shifting towards teaching hospitals. While open AAA procedures for trainees are declining due to EVAR, open aortic reconstruction for AIOD is rising and plays an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be top priority for vascular surgery program directors.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California; Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Vy T Ho
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Jordan R Stern
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael D Sgroi
- Division of Vascular Surgery, Santa Clara Valley Medical Center, Santa Clara, California
| | - Venita Chandra
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
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Janko MR, Hubbard G, Back M, Shah SK, Pomozi E, Szeberin Z, DeMartino R, Wang LJ, Crofts S, Belkin M, Davila VJ, Lemmon GW, Wang SK, Czerny M, Kreibich M, Humphries MD, Shutze W, Joh JH, Cho S, Behrendt CA, Setacci C, Hacker RI, Sobreira ML, Yoshida WB, D'Oria M, Lepidi S, Chiesa R, Kahlberg A, Go MR, Rizzo AN, Black JH, Magee GA, Elsayed R, Baril DT, Beck AW, McFarland GE, Gavali H, Wanhainen A, Kashyap VS, Stoecker JB, Wang GJ, Zhou W, Fujimura N, Obara H, Wishy AM, Bose S, Smeds M, Liang P, Schermerhorn M, Conrad MF, Hsu JH, Patel R, Lee JT, Liapis CD, Moulakakis KG, Farber MA, Motta F, Ricco JB, Bath J, Coselli JS, Aziz F, Coleman DM, Davis FM, Fatima J, Irshad A, Shalhub S, Kakkos S, Zhang Q, Lawrence PF, Woo K, Chung J. In-situ Bypass Is Associated with Superior Infection-free Survival Compared to Extra-Anatomic Bypass for the Management of Secondary Aortic Graft Infections Without Enteric Involvement. J Vasc Surg 2022; 76:546-555.e3. [PMID: 35470015 DOI: 10.1016/j.jvs.2022.03.869] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/27/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS A retrospective, multi-institutional study of AGI from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS 241 patients at 34 institutions from 7 countries presented with AGI during the study period (median age 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%) and 66 endografts (27%) and 3 unknown (2%). 172 (71%) of the patients underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (NAIS) (24%), and cryopreserved allograft (41%). 69 patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier (KM) estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB versus EAB, there was a significant difference in KM estimated infection-free survival (2910 days, IQR 391, 3771 versus 180 days, IQR 27, 3750 days; p<0.001). There were otherwise no significant differences in presentation, comorbidities, nor perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (HR 2.4, 95% CI 1.6-3.6; p<0.001), polymicrobial infection (HR 2.2, 95% CI 1.4-3.5; p=0.001), MRSA infection (HR 1.7, 95% CI 1.1-2.7; p=0.02), as well as the protective effect of omental/muscle flap coverage (HR 0.59, 95% CI 0.37-0.92; p=0.02). CONCLUSIONS After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two-and-half fold higher re-infection/mortality compared to ISB. Omental and/or muscle flap coverage of the repair appear protective.
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Affiliation(s)
- Matthew R Janko
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Grant Hubbard
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Martin Back
- Division of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Samir K Shah
- Division of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Eniko Pomozi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Linda J Wang
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah Crofts
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Michael Belkin
- Department of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor J Davila
- Division of Vascular Surgery, Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Gary W Lemmon
- Division of Vascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN
| | - Shihuan K Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany
| | - Misty D Humphries
- Division of Vascular Surgery, Department of Surgery, UC Davis Health, Sacramento, CA
| | - William Shutze
- Texas Vascular Associates, The Heart Hospital Plano, Plano, TX
| | - Jin Hyun Joh
- Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sungsin Cho
- GermanVasc Research Group, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- GermanVasc Research Group, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carlo Setacci
- Department of Vascular and Endovascular Surgery, University of Siena, Sienna, Italy
| | - Robert I Hacker
- Division of Vascular Surgery, Surgical Arts of St. Louis, Bridgeton, MO
| | - Marcone Lima Sobreira
- Department of Surgery and Orthopedics, Botucatu School of Medicine, Paulista State University, São Paulo, Brazil
| | - Winston Bonetti Yoshida
- Department of Surgery and Orthopedics, Botucatu School of Medicine, Paulista State University, São Paulo, Brazil
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Kahlberg
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Anthony N Rizzo
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Ramsey Elsayed
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Donald T Baril
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Hamid Gavali
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jordan B Stoecker
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ
| | - Naoki Fujimura
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Andrew M Wishy
- Division of Vascular and Endovascular Surgery, Brooke Army Medical Center, San Antonio, TX
| | - Saideep Bose
- Division of Vascular Surgery, Department of Surgery, Saint Louis University, St Louis, MO
| | - Matthew Smeds
- Division of Vascular Surgery, Department of Surgery, Saint Louis University, St Louis, MO
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark F Conrad
- Division of Vascular Surgery, St Elizabeth's Hospital, Brighton, MA
| | - Jeffrey H Hsu
- Division of Vascular Surgery, Kaiser Permanente, Fontana, CA
| | - Rhusheet Patel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Christos D Liapis
- Department of Vascular Surgery, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos G Moulakakis
- Department of Vascular Surgery, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Fernando Motta
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers Medical School, Poitiers, France
| | - Jonathan Bath
- Cardiovascular Surgical Clinics, University of Missouri, Columbia, MO
| | - Joseph S Coselli
- Division of Vascular Surgery, Penn State Health Heart and Vascular Institute, Hershey, PA
| | - Faisal Aziz
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Dawn M Coleman
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Frank M Davis
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Javairiah Fatima
- Cardiovascular Center at Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Ali Irshad
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Qianzi Zhang
- Division of Vascular and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Peter F Lawrence
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jayer Chung
- Division of Vascular and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Lee DT, Lee JT, Ashworth AJ, Kidd MT, Mauromoustakos A, Rochell SJ. Evaluation of a threonine fermentation product as a digestible threonine source in broilers. J APPL POULTRY RES 2022. [DOI: 10.1016/j.japr.2022.100252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Silva H, Tassone C, Ross EG, Lee JT, Zhou W, Nelson D. Collagen Fibril Orientation in Tissue Specimens From Atherosclerotic Plaque Explored Using Small Angle X-Ray Scattering. J Biomech Eng 2022; 144:024505. [PMID: 34529040 PMCID: PMC10782870 DOI: 10.1115/1.4052432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 08/22/2021] [Indexed: 01/12/2023]
Abstract
Atherosclerotic plaques can gradually develop in certain arteries. Disruption of fibrous tissue in plaques can result in plaque rupture and thromboembolism, leading to heart attacks and strokes. Collagen fibrils are important tissue building blocks and tissue strength depends on how fibrils are oriented. Fibril orientation in plaque tissue may potentially influence vulnerability to disruption. While X-ray scattering has previously been used to characterize fibril orientations in soft tissues and bones, it has never been used for characterization of human atherosclerotic plaque tissue. This study served to explore fibril orientation in specimens from human plaques using small angle X-ray scattering (SAXS). Plaque tissue was extracted from human femoral and carotid arteries, and each tissue specimen contained a region of calcified material. Three-dimensional (3D) collagen fibril orientation was determined along scan lines that started away from and then extended toward a given calcification. Fibrils were found to be oriented mainly in the circumferential direction of the plaque tissue at the majority of locations away from calcifications. However, in a number of cases, the dominant fibril direction differed near a calcification, changing from circumferential to longitudinal or thickness (radial) directions. Further study is needed to elucidate how these fibril orientations may influence plaque tissue stress-strain behavior and vulnerability to rupture.
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Affiliation(s)
- Herbert Silva
- NASA, 2101 NASA Parkway Building 13 R 208, Houston, TX 77058
| | - Christopher Tassone
- Stanford Synchrotron Radiation Lightsource, 2575 Sand Hill Road, Menlo Park, CA 94025
| | - Elsie Gyang Ross
- Division of Vascular Surgery, Stanford Medical Center, 300 Pasteur Drive, Stanford, CA 94305
| | - Jason T. Lee
- Division of Vascular Surgery, Stanford Medical Center, 300 Pasteur Drive, Stanford, CA 94305
| | - Wei Zhou
- Vascular Surgery Division, College of Medicine, University of Arizona, Tucson, AZ 85724
| | - Drew Nelson
- Mechanical Engineering Department, Stanford University, Stanford, CA 94305
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Fisher AT, Tran K, Dossabhoy SS, Sorondo S, Fereydooni A, Lee JT. Anatomic Factors Contributing To External Iliac Artery Endofibrosis In High Performance Athletes. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Sorondo SM, Dossabhoy SS, Tran K, Ho VT, Stern JR, Lee JT. Large Fenestrations Versus Scallops For The SMA During Fenestrated EVAR: Does It Matter? Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Li M, Stern JR, Tran K, Deslarzes-Dubuis C, Lee JT. Predictors of sac regression after fenestrated endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2022.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stern JR, Deslarzes-Dubuis C, Tran K, Lee JT. Fenestrated Aortic Aneurysm Repair in Patients Treated Inside Versus Outside of Instructions for Use. J Endovasc Ther 2022; 29:913-920. [PMID: 34994244 DOI: 10.1177/15266028211068762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to compare outcomes of patients treated with the Cook Zenith Fenestrated (ZFEN) device for juxtarenal aortic aneurysms inside versus outside the IFU. METHODS We retrospectively reviewed our institutional ZFEN database for cases performed between 2012 and 2018, with analysis performed in 2020 in order to report midterm outcomes. The cohort was stratified based on treatment inside (IFU group) and outside (non-IFU group) the IFU for criteria involving the proximal neck: neck length 4 to 14 mm, neck diameter 19 to 31 mm, and neck angulation ≤45°. Patients with thoracoabdominal aneurysms or concurrent chimney grafting were excluded. The primary outcomes in question were mortality, type 1a endoleak, and reintervention. Univariate and multivariate analyses were performed to determine associations between adherence to IFU criteria and outcomes. RESULTS We identified 100 consecutive patients (19% female, mean age 73.6 years) for inclusion in this analysis. Mean follow-up was 21.6 months. Fifty-four patients (54%) were treated outside the IFU because of inadequate neck length (n=48), enlarged neck diameter (n=10), and/or excessive angulation (n=16). Eighteen patients were outside IFU for two criteria, and one patient was outside IFU for all three. Non-IFU patients were exposed to higher radiation doses (3652 vs 5445 mGy, p=0.008) and contrast volume (76 vs 95 mL, p=0.004). No difference was noted between IFU and non-IFU groups for 30-day mortality (0% vs 3.7%, p=0.18), or type 1a endoleak (0% vs 1.9%, p=0.41). Reintervention was also similar between cohorts (13% vs 27.8%, p=0.13). Being outside IFU for neck diameter or length was each borderline significant for higher reintervention on univariate analysis (p=0.05), but this was not significant on multivariate Cox proportional hazard modeling (HR 1.82 [0.53-6.25]; 2.03 [0.68-7.89]), respectively. No individual IFU deviations were associated with the primary outcomes on multivariate analysis, nor being outside IFU for multiple criteria. CONCLUSIONS Patients with juxtarenal aortic aneurysms may be treated with the ZFEN device with moderate deviations from the IFU. While no differences were seen in mortality or proximal endoleak, larger studies are needed to examine the potential association between IFU nonadherence and reinterventions and close follow-up is warranted for all patients undergoing such repair.
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Affiliation(s)
- Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Céline Deslarzes-Dubuis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kenneth Tran
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Debucquois A, Vento V, Neumann N, Mertz L, Lejay A, Rouby AF, Bourcier T, Lee JT, Chakfe N, Berard X, Bonnin E, Camin A, Chenesseau B, Cochennec F, Corpateaux JM, Deglise S, Delay C, Deltatto B, Duprey A, Gaudric J, Georg Y, Ghariani Z, Jean-Baptiste E, Hertault A, Meteyer V, Roussin M, Saucy F, Schneider F, Steinmetz L, Thaveau F. X-Ray Exposure Time in Dedicated Academic Simulation Programs Is Realistic To Patient Procedures. EJVES Vasc Forum 2022; 55:5-8. [PMID: 35252939 PMCID: PMC8888963 DOI: 10.1016/j.ejvsvf.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/20/2021] [Accepted: 01/14/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To ascertain whether simulated endovascular procedures are comparable to real life operating room (OR) procedures, particularly with regard to irradiation time. Methods This was a retrospective study comparing simulation with clinical data. Fluoroscopy time and overall operation time were compared between simulated abdominal aortic endovascular repair (EVAR) and iliac procedures that were performed, respectively, from 2016 to 2019 and from 2015 to 2019, and clinical EVAR and iliac procedures performed in the OR between January 2018 and November 2021. Results Within the defined periods, 171 simulated procedures (91 EVAR, 80 iliac) and 199 clinical procedures (111 EVAR, 88 iliac) were performed. For both EVAR and iliac procedures, median total procedure time was much longer during real surgery (p < .001). However, median total fluoroscopy time remained the same, whether the procedure was real surgery or performed on the simulator, for iliac procedures (8.47 minutes in the OR, 8.35 minutes on the simulator, p = .61) and for EVAR procedures (14.80 minutes in the OR, 15.00 minutes on the simulator p = .474). Conclusion Simulated endovascular procedures are comparable with real life OR procedures, particularly with regard to irradiation time when integrated in a dedicated curriculum. Simulation is a necessary tool for trainee education in vascular surgery. Simulation training must reflect real situations in the operating room. Xray exposure must be as low as possible. Radiation safety must be taught in simulation. Xray exposure time in academic simulation programs was realistic to real life.
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Tran K, Dossabhoy SS, Sorondo S, Lee JT. Bicycle exercise ankle brachial index recovery time as a novel metric for evaluating the hemodynamic significance of external iliac endofibrosis in competitive cyclists. J Vasc Surg Cases Innov Tech 2021; 7:681-685. [PMID: 34746530 PMCID: PMC8556481 DOI: 10.1016/j.jvscit.2021.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/31/2021] [Indexed: 12/02/2022]
Abstract
Subtle radiographic findings can increase the challenge of diagnosing external iliac artery endofibrosis. We evaluated a new metric, the bicycle exercise ankle brachial index recovery time (BART), in a cohort of cyclists with symptomatic external iliac artery endofibrosis. BART was defined as the time required in minutes for the ankle brachial index to return to 0.9 after a period of exercise. Surgical correction resulted in an improvement in BART postoperatively (4.5 ± 4.1 vs 9.1 ± 4.3 minutes; P < .001), with improved values correlating with better patient satisfaction. Documentation of the BARTs before and after surgical treatment provides an additional measure of postoperative hemodynamic improvement.
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Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.,Cardiovascular Institute, Stanford University School of Medicine, Stanford, Calif
| | - Shernaz S Dossabhoy
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Sabina Sorondo
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.,Cardiovascular Institute, Stanford University School of Medicine, Stanford, Calif
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