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Ebertz DP, Bose S, Smith JA, Sarode AL, Ambani RN, Cho JS, Kumins NH, Kashyap VS, Colvard BD. Direct oral anticoagulants over warfarin at discharge associated with improved survival and patency in infra-geniculate bypasses with prosthetic conduits. J Vasc Surg 2024; 79:609-622.e2. [PMID: 37984756 DOI: 10.1016/j.jvs.2023.11.019] [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: 08/24/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE There is no consensus on the optimal anticoagulant regimen following lower extremity bypass. Historically, warfarin has been utilized for prosthetic or compromised vein bypasses. Direct-acting oral anticoagulants (DOACs) are increasingly replacing warfarin in this context, but their efficacy in bypass preservation has not been well-studied. Recent studies have shown that DOACs may improve outcomes following bypasses; however, it is unclear if this is dependent upon type of bypass conduit. The goal of this study was to evaluate whether a difference exists between vein and prosthetic infra-geniculate bypasses outcomes based on the anticoagulant utilized on discharge, warfarin or DOAC. METHODS The Vascular Quality Initiative infra-inguinal bypass database was queried for all patients who underwent an infra-geniculate bypass and were anticoagulation-naive at baseline but were discharged on either warfarin or DOACs. A survival analysis was performed for patients up to 1 year to determine whether the choice of discharge anticoagulation was associated with differences between those with vein vs prosthetic conduits in overall survival, primary patency, risk of amputation, or risk of major adverse limb events (MALE). A multivariable Cox proportional hazards analysis was performed to control for differences in baseline demographic factors between the groups. RESULTS During the study period (2003-2020), 57,887 patients underwent infra-geniculate bypass. Of these, 3230 (5.5%) were anticoagulated on discharge. There was a similar distribution of anticoagulation between vein (n = 1659; 51.4%) and prosthetic conduits (n = 1571; 48.6%). Thirty-two percent were discharged on DOACs, and 68.0% were discharged on warfarin. For prosthetic conduits, being discharged on a DOAC was associated with improved outcomes on univariate and multivariable analyses revealing lower risk of overall mortality (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.41-0.93; P = .021), loss of primary patency (HR, 0.70; 95% CI, 0.55-0.89; P = .003), risk of amputation (HR, 0.71; 95% CI, 0.54-0.93; P = .013), and risk of MALE (HR, 0.80; 95% CI, 0.64-1.00; P = .048). Patients with a vein bypass had improved univariate outcomes for survival and primary patency; however, with multivariable analysis, there were no significant differences in outcomes between DOAC and warfarin. CONCLUSIONS Anticoagulation-naive patients who underwent an infra-geniculate prosthetic bypass had higher rates of overall survival, bypass patency, amputation-free survival, and freedom from MALE when discharged on a DOAC compared with warfarin. Those with vein bypasses had similar outcomes regardless of the choice of anticoagulation.
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Affiliation(s)
- David P Ebertz
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH.
| | - Saideep Bose
- Division of Vascular and Endovascular Surgery, Department of Surgery, St Louis University, St Louis, MO
| | - Justin A Smith
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Anuja L Sarode
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH
| | - Ravi N Ambani
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Jae S Cho
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Norman H Kumins
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Vikram S Kashyap
- Division of Vascular Surgery, Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Benjamin D Colvard
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
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Kumins NH, Ambani RN, Bose S, King AH, Cho JS, Colvard B, Kashyap VS. Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2023; 57:680-688. [PMID: 36961838 DOI: 10.1177/15385744231165988] [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] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE. METHODS We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE. RESULTS Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process. CONCLUSION Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.
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Affiliation(s)
- Norman H Kumins
- Department of Vascular Surgery, The Heart and Vascular Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Saideep Bose
- Division of Vascular and Endovascular Surgery, Department of Surgery, St Louis University, St Louis, MO, USA
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery, Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
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Chung J, Kumins NH, Smith J, Motaganahalli RL, Schneider PA, Kwolek CJ, Kashyap VS. Physiologic risk factors increase risk of myocardial infarction with transcarotid artery revascularization in prospective trials. J Vasc Surg 2023; 77:1192-1198. [PMID: 36563712 DOI: 10.1016/j.jvs.2022.12.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/18/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Patients can be considered at high risk for carotid endarterectomy (CEA) because of either anatomic or physiologic factors and will often undergo transcarotid artery revascularization (TCAR). Patients with physiologic criteria will be considered to have a higher overall surgical risk because of more significant comorbidities. Our aim was to study the incidence of stroke, myocardial infarction (MI), death, and combined end points for patients who had undergone TCAR stratified by the risk factors (anatomic vs physiologic). METHODS An analysis of prospectively collected data from the ROADSTER (pivotal; safety and efficacy study for reverse flow used during carotid artery stenting procedure), ROADSTER 2 (Food and Drug Administration indicated postmarket trial; postapproval study of transcarotid artery revascularization in patients with significant carotid artery disease), and ROADSTER extended access TCAR trials was performed. All 851 patients were considered to be at high risk for CEA and were included and stratified using high-risk anatomic criteria (ie, contralateral occlusion, tandem stenosis, high cervical artery stenosis, restenosis after previous endarterectomy, bilateral carotid stenting, hostile neck anatomy with previous neck irradiation, neck dissection, cervical spine immobility) or high-risk physiologic criteria (ie, age >75 years, multivessel coronary artery disease, history of angina, congestive heart failure New York Heart Association class III/IV, left ventricular ejection fraction <30%, recent MI, severe chronic obstructive pulmonary disease, permanent contralateral cranial nerve injury, chronic renal insufficiency). For trial inclusion, asymptomatic patients were required to have had ≥80% carotid stenosis and symptomatic patients to have had ≥50% stenosis. The primary outcome measures were stroke, death, and MI at 30 days. The data were statistically analyzed using the χ2 test, as appropriate. RESULTS A total of 851 high surgical risk patients were categorized into two groups: those with anatomic-only risk factors (n = 372) or at least one physiologic risk factor present (n = 479). Of the 851 patients, 74.5% of those in the anatomic subset were asymptomatic, and 76.6% in the physiologic subset were asymptomatic. General anesthesia was used similarly in both groups (67.7% anatomic vs 68.1% physiologic). MI had occurred in eight patients in the physiologic group (1.7%), all of whom had been asymptomatic and in none of the anatomic patients (P = .01). The combined stroke, death, and MI rate was 2.1% in the anatomic cohort and 4.2% in the physiologic cohort (P = .10). Stratification of each group into asymptomatic and symptomatic patients did not yield any further differences. CONCLUSIONS The patients who had undergone TCAR in the present prospective, neurologically adjudicated trial because of high-risk physiologic factors had had a higher rate of MI compared with the patients who had qualified for TCAR using anatomic criteria only. These patients had experienced comparable rates of combined stroke, death, and MI rates. The anatomic patients represented a healthier and younger subset of patients, with notably low overall event rates.
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Affiliation(s)
- Jane Chung
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, OH
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, OH
| | - Justin Smith
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, OH
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Department of General Surgical Services, Massachusetts General Hospital, Boston, MA
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, OH.
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Kumins NH, Wogsland AA, Smith J, Patel A, Cho JS, Colvard B, Kashyap VS. Management and Outcome of Non-Aneurysmal Primary Aortic Infection. Vasc Endovascular Surg 2023; 57:222-229. [PMID: 36453193 DOI: 10.1177/15385744221143659] [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: 12/03/2022]
Abstract
INTRODUCTION Aortic infection without prior intervention or aneurysm is exceedingly rare. We report the presentation, diagnosis, management, and outcome of patients with this unusual entity. METHODS Retrospective chart and imaging review of patients with primary aortic infection. RESULTS 5 patients (3 male, mean age 71.2 years) presented between 2014 and 2022. All had abdominal, back, or flank pain. Four had constitutional symptoms. All were evaluated with a complete blood count; 3 had leukocytosis. Both serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated in the 4 patients evaluated with these tests. All were studied with peripheral blood culture on the first hospital day prior to any antibiotic administration. Blood culture was positive in only 1 patient. Computed tomography (CT) scan showed periaortic inflammation without aneurysm in all. Fluorodeoxyglucose positron emission tomography (PET) was obtained in 3 and a radiolabeled leukocyte single-photon emission CT (SPECT) scan was performed in 2. All demonstrated periaortic concentration of the radioisotope consistent with inflammation or infection. Intraoperative cultures were positive in 3. One patient who had a negative intraoperative culture was examined with broad range polymerase chain reaction (PCR) and DNA sequencing which identified a causative bacterium. The other patient with a negative intraoperative culture had periaortic abscess but was on antibiotics preoperatively, potentially confounding the culture. All patients underwent in-situ repair with rifampin impregnated polyester (N = 2), cryopreserved aortic allograft (N = 2), or autogenous femoral vein (N = 1). No patient developed recurrent infection or aortic related complications following surgery with an average follow up of 31.8 months (range 8-88 months). CONCLUSIONS Patients with primary aortic infection present similarly with the triad of abdominal or back pain, laboratory markers of infection, and imaging demonstrating periaortic inflammation. Patients were treated successfully with in-situ repair. Preoperative identification of a causative organism was difficult, and PCR may be useful to help identify an organism.
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Affiliation(s)
- Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Aric A Wogsland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Justin Smith
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Avkash Patel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Smith JA, So KL, Kashyap VS, Cho JS, Colvard B, Kumins NH. Outcome after revascularization with paclitaxel-coated devices in patients with chronic limb-threatening ischemia. J Vasc Surg 2023; 77:1742-1750. [PMID: 36754247 DOI: 10.1016/j.jvs.2023.01.195] [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: 11/10/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Data regarding the safety and efficacy of paclitaxel (PTX)-coated peripheral arterial devices for femoropopliteal artery (FPA) atherosclerotic disease is derived from studies that mainly evaluated patients with claudication. Outcomes of PTX treatment for patients with chronic limb-threatening ischemia (CLTI) is incompletely defined. This study compares outcome in patients with CLTI treated with and without PTX. METHODS We retrospectively studied patients who underwent FPA intervention for an indication of CLTI in the Vascular Quality Initiative peripheral vascular intervention database from 2016 to 2020. Patients who had concomitant iliac or tibial interventions were included. One limb per patient was studied. Propensity score matching based on demographics, comorbidities, indication, and pharmacological therapy was performed to generate balanced cohorts. Kaplan-Meier survival analysis and multivariate Cox regression compared limb salvage, overall survival, primary patency, and major adverse limb events (MALE) between patients treated with and without PTX. RESULTS Demographics, comorbidities, indications, and procedural details were similar between 14,065 PTX and 14,065 non-PTX propensity-matched patients. Kaplan-Meier analysis at 18-month follow-up demonstrated that the PTX group compared with the non-PTX group had a significantly higher rates of limb salvage (89.2% vs 86.5%; P < .001), primary patency (80.3% vs 76.9%; P < .001), and freedom from MALE (72.6% vs 67.9%; P < .001). Multivariate analysis also showed that PTX treatment was associated with a lower risk of major amputation (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.67-0.82; P < .001), loss of primary patency (HR, 0.80; 95% CI, 0.74-0.87; P < .001), and MALE (HR, 0.77; 95% CI, 0.72-0.82; P < .001). Overall, 21% of patients had a prior ipsilateral peripheral vascular intervention. Removing these patients from the analysis yielded similar results at 18 months. Overall survival at 54 months was not statistically different between the PTX and non-PTX groups in the overall cohort (73.5 vs 71.3%; P = .07), but significant in the de-novo treated patients (73.9% vs 70.7%; P = .02).Multivariate analyses showed a lower mortality risk in the PTX patients (HR, 0.93; 95% CI, 0.87-0.98; P = .02). CONCLUSIONS FPA intervention with a PTX-coated device is associated with improved limb salvage, primary patency, and freedom from MALE at the 18-month follow-up compared with uncoated devices. This benefit was not associated with an increase in all-cause mortality out to 4.5 years. Further study is necessary to determine the optimal role for PTX in the treatment of the FPA for patients with CLTI and to understand its long-term outcome.
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Affiliation(s)
- Justin A Smith
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Kristine L So
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH.
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Smith JA, Chen L, Yang L, Wong V, Harth K, Kumins NH, Cho JS, Kashyap VS, Colvard B. Intravascular Ultrasound Confers No Benefit in Aortoiliac Revascularization. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.444] [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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Chung J, Kumins NH, Motaganahalli RL, Schneider PA, Kwolek C, Kashyap VS. Physiologic Risk Factors Increase the Risk of Myocardial Infarction but Not Stroke or Death After Transcarotid Artery Revascularization in Prospective Trials. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.067] [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: 12/01/2022]
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So KL, Smith JA, Colvard B, Kashyap VS, Cho J, Kumins NH. Paclitaxel-coated Devices Improve Outcomes in Patients Presenting With Chronic Limb-Threatening Ischemia. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.643] [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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Patel AJ, Ambani RN, Sarode AL, King AH, Baeza CR, Elgudin Y, Colvard BD, Kumins NH, Kashyap VS, Sabik JF, Cho JS. Outcomes of Great Vessel Debranching to Facilitate Thoracic Endovascular Aortic Repair. J Vasc Surg 2022; 76:53-60.e1. [PMID: 35149157 DOI: 10.1016/j.jvs.2022.01.127] [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: 06/21/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES With the expanding application of endovascular technology, the need to deploy into zone 0 has been encountered on occasion. This study evaluates the outcomes of great vessel debranching (GVD) as a method of extending the proximal landing zone (PLZ) to facilitate thoracic endovascular aortic repair (TEVAR). METHODS A single-center retrospective review of all patients who underwent GVD followed by TEVAR between May 2013 and December 2020 was conducted. The primary outcome was primary patency of all targeted vessels, with all-cause perioperative mortality as a secondary outcome. Kaplan-Meier analysis was used to account for censoring the mortality and primary patency. The extent of hybrid aortic repairs was characterized into type I: GVD + TEVAR without ascending aorta or aortic arch reconstruction; type II: GVD + TEVAR with ascending aorta reconstruction; and type III: GVD + TEVAR with ascending aorta and aortic arch reconstruction with an elephant trunk (surgical or "frozen"). RESULTS There were 42 patients (23 males [54.8%], mean age of 62.2 ± 11.2 years) who underwent GVD with 122 vessels revascularized (42 innominate, 42 left common carotid [LCCA], and 38 left subclavian [LSA] arteries). The indication for TEVAR was aneurysmal degeneration from aortic dissection in 32 (76.2%) patients, thoracic aneurysm in 9 (21.4%) patients, and perforated aortic ulcer in 1 (2.4%) patient. Median duration between GVD and TEVAR was 82 days. Mean follow-up was 25.7 ± 23.5 months. Type I repair was performed in 4, type II in 16, and type III in 22 patients. Perioperative mortality, stroke, and paraplegia rates were 9.5%, 7.1%, and 2.4%, respectively. Neither the extent of repair (p = 0.80) nor a prior history of aortic repair (p = 0.90) was associated with early mortality. Late deaths (>30 days) occurred in 6 of 38 patients who survived the perioperative period. At 36 months, the survival estimate was 68.6% (95% CI: 45.7% - 83.4%); the overall primary patency of the innominate artery, LCCA, and LSA was 100%, 89.5%, and 94.1%, respectively. The primary assisted patency rate was 100% for all vessels. CONCLUSIONS GVD is a safe and effective means of extending the PLZ into zone 0 with outstanding primary patency rates. Further studies are needed to confirm the safety and longer-term durability in these patients.
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Affiliation(s)
- Avkash J Patel
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Anuja L Sarode
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Cristian R Baeza
- Division of Cardiothoracic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Yakov Elgudin
- Division of Cardiothoracic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D Colvard
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Joseph F Sabik
- Division of Cardiothoracic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Ebertz D, Bose S, Colvard B, Cho JS, Harth KC, Wong VL, Kashyap VS, Kumins NH. Atherectomy of the Femoropopliteal Artery (fpa) Is Associated with Reduced Mortality and Major Amputation in Patients Treated for Chronic Limb Threatening Ischemia (clti). J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.633] [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: 10/20/2022]
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So KL, Smith JA, Sarode AL, Kashyap VS, Colvard B, Harth KC, Wong VL, Kumins NH. Paclitaxel (PTX)-Coated Devices Improve Outcome of Patients Presenting with Chronic Limb Threatening Ischemia (CLTI). J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.659] [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: 10/20/2022]
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King AH, Kim AH, Kwan S, Lee J, Schmaier AH, Kumins NH, Harth KC, Wong VL, Colvard BD, Kashyap VS, Cho JS. Elevated Neutrophil to Lymphocyte Ratio is Associated with Worse Outcomes after Carotid Endarterectomy in Asymptomatic Patients. J Stroke Cerebrovasc Dis 2021; 30:106120. [PMID: 34597986 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/10/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Management of carotid artery stenosis (CAS) remains controversial and proper patient selection critical. Elevated neutrophil to lymphocyte ratio (NLR) has been associated with poor outcomes after vascular procedures. The effect of NLR on outcomes after carotid endarterectomy (CEA) in asymptomatic and symptomatic patients is assessed. MATERIALS AND METHODS A retrospective review was conducted of all patients between 2010 and 2018 with carotid stenosis >70% as defined by CREST 2 criteria. A total of 922 patients were identified, of whom 806 were treated with CEA and 116 non-operatively with best medical therapy (BMT). Of patients undergoing CEA, 401 patients (290 asymptomatic [aCEA], 111 symptomatic [sCEA]) also had an available NLR calculated from a complete blood count with differential. All patients treated with BMT were asymptomatic and had a baseline NLR available. Kaplan-Meier analysis assessed composite ipsilateral stroke or death over 3 years. RESULTS In sCEA group, the 3-year composite stroke/death rates did not differ between NLR < 3.0 (22.9%) vs NLR > 3.0 (38.1%) (P=.10). In aCEA group, patients with a baseline NLR >3.0 had an increased risk of 3-year stroke/death (42.6%) compared to both those with NLR <3.0 (9.3%, P<.0001) and those treated with BMT (23.6%, P=.003). In patients with NLR <3.0, aCEA showed a superior benefit over BMT with regard to stroke or death (9.3% vs. 26.2%, P=.02). However, in patients with NLR >3.0, there was no longer a benefit to prophylactic CEA compared to BMT (42.6% vs. 22.2%, P=.05). Multivariable analysis identified NLR >3.0 (HR, 3.23; 95% CI, 1.93-5.42; P<.001) and congestive heart failure (HR, 2.18; 95% CI, 1.33-3.58; P=.002) as independent risk factors for stroke/death in patients with asymptomatic carotid artery stenosis. CONCLUSIONS NLR >3.0 is associated with an increased risk of late stroke/death after prophylactic CEA for asymptomatic carotid artery stenosis, with benefits not superior to BMT. NLR may be used to help with selecting asymptomatic patients for CEA. The effect of NLR and outcomes in symptomatic patients requires further study. Better understanding of the mechanism(s) for NLR elevation and medical intervention strategies are needed to modulate outcome risk in these patients.
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Affiliation(s)
- Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Ann H Kim
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Stephen Kwan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Jasmine Lee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Alvin H Schmaier
- Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Karem C Harth
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Benjamin D Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
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King AH, Kwan S, Schmaier AH, Kumins NH, Harth KC, Colvard BD, Wong VL, Kashyap VS, Cho JS. Elevated neutrophil to lymphocyte ratio is associated with decreased amputation-free survival after femoropopliteal percutaneous revascularization. INT ANGIOL 2021; 40:442-449. [PMID: 34142540 DOI: 10.23736/s0392-9590.21.04699-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND An elevated neutrophil-lymphocyte ratio (NLR) is a biomarker associated with adverse outcomes after cardiovascular surgery. This study evaluates the association of preoperative NLR with clinical outcomes after peripheral vascular intervention (PVI) of the femoropopliteal segments. METHODS A retrospective review identified 488 patients who underwent percutaneous interventions of femoropopliteal arteries between 2011 and 2018 and had a pre-procedural complete blood count with differential with normal white blood cell count within 30 days prior to intervention. Amputation-free survival (AFS), survival, and freedom from major amputation were assessed using Kaplan-Meier methods. Cohorts of patients with NLR <3 (Low), 3-4 (Mid), and >4 (High) were compared using univariate and multivariable statistical models. In these analyses NLR was analyzed as a continuous variable to correlate with clinical outcomes. RESULTS Mean age was 71.7 ± 12.8 years and males constituted 55.5%. The majority of patients presented with chronic limb threatening ischemia (CLTI, 78.5%). Increasing NLR was correlated with increasing rates of comorbidities, except for smoking history. The 30-day mortality rates increased with increasing NLR: 1.4%, 4.3%, and 7.0% for Low (<3), Mid (3-4) and High (>4) NLR groups, respectively (P =.005). Patients with a lower pre-operative NLR achieved significantly greater amputation-free survival at 4-year follow-up: low NLR, 65.5%; mid NLR, 37.5%; and high NLR, 17.6% (P <.0001). By multivariable analysis, increasing NLR, advanced age, CLTI, and dialysis-dependent renal failure reduced AFS. CONCLUSIONS Elevated NLR is an independent predictor of decreased AFS following percutaneous interventions of femoropopliteal segments. Further research on identification and modulation of risk factors for high NLR are warranted.
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Affiliation(s)
- Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stephen Kwan
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alvin H Schmaier
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Karem C Harth
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Colvard
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University, Cleveland, OH, USA -
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Kumins NH, King AH, Ambani RN, Cho JS, Harth KC, Wong VL, Colvard B, Bose S, Thomas JP, Kashyap VS. Paclitaxel-coated peripheral arterial devices are associated with improved overall survival and limb salvage in patients with chronic limb-threatening ischemia. J Vasc Surg 2021; 74:1682-1688.e1. [PMID: 34090989 DOI: 10.1016/j.jvs.2021.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/02/2020] [Accepted: 05/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Paclitaxel (PTX)-coated peripheral arterial devices have been shown to decrease femoropopliteal artery restenosis and the need for reintervention compared with non-PTX-coated devices. The data regarding PTX efficacy and safety come from randomized controlled trials that almost exclusively enrolled patients with claudication. The outcomes of PTX treatment in patients who present with chronic limb-threatening ischemia (CLTI) are unknown. This study compares long-term outcomes in patients with CLTI treated with and without PTX. METHODS We retrospectively reviewed 983 patients with CLTI treated with femoropopliteal artery angioplasty, atherectomy, stent, or combination between 2011 and 2019. Procedures were performed with additional proximal or distal tibial interventions as needed. Kaplan-Meier survival analysis and multivariable Cox-regression analysis compared overall survival (OS), amputation-free survival (AFS), freedom from major amputation (ff-MA), and freedom from target vessel revascularization (ff-TVR) between patients treated with and without PTX. RESULTS Demographics, comorbidities, and Rutherford class were similar between 574 PTX (58.5%) and 409 non-PTX (41.6%) patients except that non-PTX patients were more likely to be male (56.2% vs 49.7%), dialysis dependent (19.6% vs 14.3%), and have higher average creatinine (2.3 vs 1.8 mg/dL). Through 4-year follow-up, the PTX group demonstrated a significant increase in OS (56.2% vs 43.9%, P = .013), AFS (52.6% vs 36.1%, P < .0001), ff-MA (87.4% vs 78.7%, P = .0007), and ff-TVR (77.6% vs 70.6%, P = .012). Multivariable Cox-regression analysis demonstrated that PTX treatment was associated with improved OS, AFS, ff-MA, and ff-TVR. CONCLUSIONS In patients with CLTI, treatment with a PTX-coated device is associated with improved OS, AFS, ff-MA, and ff-TVR through 4-year follow-up. PTX-coated devices may be especially beneficial in patients who present with CLTI.
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Affiliation(s)
- Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio.
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Karem C Harth
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Saideep Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jones P Thomas
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
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Allotey JK, King AH, Kumins NH, Wong VL, Harth KC, Cho JS, Kashyap VS. Systematic review of hemostatic agents used in vascular surgery. J Vasc Surg 2020; 73:2189-2197. [PMID: 33253866 DOI: 10.1016/j.jvs.2020.10.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/17/2020] [Accepted: 10/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hemostatic agents are routinely used in vascular surgery to complement proper suture techniques and decrease the risk of perioperative bleeding. A relative lack of comparative research studies have left surgeons with the option of choosing hemostatic agents based on their personal experience. The present review has highlighted the efficacy and safety of hemostatic agents and categorized them according to their primary mechanism of action and cost. METHODS A systematic search strategy encompassing hemostatic agent products was deployed in the PubMed database. Single-center and multicenter, randomized, controlled trials with >10 patients were included in the present study. RESULTS We reviewed 12 studies on the efficacy and safety of hemostatic agents compared with manual compression or other hemostatic agents. Using the time to hemostasis as the primary end point, all studies had found hemostatic agents to be significantly more efficient than manual compression. Likewise, adhesives (high pressure sealants) and dual agents (containing biologically active and absorbable components) were found to be more efficient, but costlier, than agents with either biologically active or absorbable components only. Agents with porcine or bovine constituents were found to trigger anaphylactic reactions in rare cases. Additionally, the absence of fibrin stabilizing factor XIII in a brand of fibrin sealant was speculated to reduce the affinity of the fibrin sealant for the expanded polytetrafluoroethylene graft. The cost of agents varied greatly depending on their active ingredient. CONCLUSIONS Hemostatic agents appear to be highly effective at decreasing the risk of bleeding during surgical procedures. Although some hemostatic agents were demonstrated to achieve hemostasis faster than others, most are able to control bleeding within <10 minutes. Based on the limited data, the least expensive agents might suffice for limited suture lines used in routine procedures.
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Affiliation(s)
- Jonathan K Allotey
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Karem C Harth
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Kumins NH, Kashyap VS. Learning curve and proficiency of transcarotid artery revascularization compared to transfemoral carotid artery stenting. Semin Vasc Surg 2020; 33:16-23. [PMID: 33218612 DOI: 10.1053/j.semvascsurg.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Both transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) are competing endovascular alternatives to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. TF-CAS is an endovascular procedure associated with a long learning curve and higher periprocedural stroke and death rates during an operator's early experience. Estimates suggest that more than 50 cases are required to achieve outcomes similar to carotid endarterectomy. TCAR is a novel hybrid procedure combining direct common carotid artery access and cerebral blood flow reversal with carotid stent placement. In distinction from TF-CAS, TCAR has a rather short learning curve. A multi-institutional analysis showed that operators achieved technical proficiency after approximately 10 to 15 cases. This was reinforced by a large Society for Vascular Surgery, Vascular Quality Initiative Transcarotid Artery Revascularization Surveillance Project analysis that demonstrated that expertise peaked after approximately 20 cases. Both studies found that TCAR was not associated with an increased rate of stroke or death during operator's early experience. These data suggest that TCAR is readily learned and patients are not at increased risk during a surgeon's early experience.
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Affiliation(s)
- Norman H Kumins
- Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, LKS 7060, Cleveland, OH 44106-7060
| | - Vikram S Kashyap
- Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, LKS 7060, Cleveland, OH 44106-7060.
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Harrison King A, Kwan S, Kim A, Kang D, Kumins NH, Schmaier A, Clementina Harth K, Louise Wong V, Kashyap VS, Cho J. Effect of the Neutrophil/Lymphocyte Ratio on Outcome after Carotid Endarterectomy and Carotid Artery Disease Progression. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.695] [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: 10/23/2022]
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Ravishankar P, Harrison King A, Thomas JP, Clementina Harth K, Colvard BD, Louise Wong V, Cho JS, Kumins NH, Kashyap VS. Time to Traverse Lesion Association with Outcomes in Lower Extremity Revascularization for Peripheral Artery Disease. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.729] [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: 10/23/2022]
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Ambani RN, King A, Kashyap VS, Cho JS, Louise Wong V, Clementina Harth K, Colvard B, Bose S, Thomas J, Kumins NH. Paclitaxel-Coated Peripheral Arterial Devices Increase Survival, Amputation-Free Survival, and Decrease Major Amputation and Target Vessel Revascularization in Patients with Chronic Limb-Threatening Ischemia. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.712] [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: 12/01/2022]
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Kumins NH, Qin VL, Driscoll EC, Morrow KL, Kashyap VS, Ning AY, Tucker NJ, King AH, Quereshy HA, Dash S, Grobaty L, Zhou G. Computer-based video training is effective in teaching basic surgical skills to novices without faculty involvement using a self-directed, sequential and incremental program. Am J Surg 2020; 221:780-787. [PMID: 32938528 PMCID: PMC7476887 DOI: 10.1016/j.amjsurg.2020.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 04/21/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022]
Abstract
Introduction Computer-based video training (CBVT) of surgical skills overcomes limitations of 1:1 instruction. We hypothesized that a self-directed CBVT program could teach novices by dividing basic surgical skills into sequential, easily-mastered steps. Methods We developed a 12 video program teaching basic knot tying and suturing skills introduced in discrete, incremental steps. Students were evaluated pre- and post-course with a self-assessment, a written exam and a skill assessment. Results Students (n = 221) who completed the course demonstrated significant improvement. Their average pre-course product quality score and assessment of technique using standard Global Rating Scale (GRS) were <0.4 for 6 measured skills (scale 0–5) and increased post-course to ≥3.25 except for the skill tying on tension whose GRS = 2.51. Average speed increased for all skills. Students’ self-ratings (scale 1–5) increased from an average of 1.4 ± 0.7 pre-elective to 3.9 ± 0.9 post-elective across all skills (P < 0.01). Conclusion Self-directed, incremental and sequential video training is effective teaching basic surgical skills and may be a model to teach other skills or to play a larger role in remote learning. Video based training can teach medical student basic knot tying and suturing skills. This training is effective despite no faculty involvement. Students showed marked improvement in technique, speed and the end product. Remote, computer-based learning may be able to play a larger role in medical education.
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Affiliation(s)
- Norman H Kumins
- From the Division of Vascular and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA.
| | - Vivian L Qin
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Erin C Driscoll
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | | | - Vikram S Kashyap
- From the Division of Vascular and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Anne Y Ning
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Nicholas J Tucker
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Alexander H King
- From the Division of Vascular and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Humzah A Quereshy
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Siddhartha Dash
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Lauren Grobaty
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - George Zhou
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
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Ambani RN, Bose S, King AH, Kashyap VS, Cho J, Harth K, Wong V, Colvard B, Kumins NH. Utility of Single-Branched Thoracic Endograft in Patients Requiring Zone 2 Seal During Thoracic Endovascular Aortic Repair. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.064] [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: 12/01/2022]
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King AH, Ambani RN, Bose S, Turner J, Kashyap VS, Thomas J, Cho J, Harth KC, Colvard B, Kumins NH. Clinical Outcomes Differ After Femoropopliteal Artery Treatment Between Individual Paclitaxel-Coated Balloons. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.060] [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: 10/23/2022]
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Scariano GN, Kim AH, King AH, Turner JT, Cho JS, Kumins NH, Harth KC, Kashyap VS. The Clinical Impact of Incidental Findings in Neck Computed Tomography Angiography. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.090] [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: 11/17/2022]
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Kumins NH, King AH, Ambani RN, Thomas JP, Bose S, Wong VL, Harth KC, Cho JS, Colvard B, Kashyap VS. Paclitaxel-Coated Peripheral Arterial Devices are Associated with Reduced Mortality in Younger Patients. Ann Vasc Surg 2020; 70:70-78. [PMID: 32795647 DOI: 10.1016/j.avsg.2020.08.003] [Citation(s) in RCA: 2] [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] [Received: 02/25/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Paclitaxel-coated devices have been shown to decrease restenosis when used in the femoropopliteal artery. Recent reports have suggested a possible risk of increased late mortality in patients treated with paclitaxel. It has been suggested that younger patients and those with limited comorbidities may be at higher risk. Our objective was to analyze long-term mortality based on patient age comparing treatment with paclitaxel to uncoated devices. METHODS We performed a retrospective review of 1,170 consecutive patients who underwent femoropopliteal percutaneous intervention by angioplasty, atherectomy, stent placement, or combination between 2011 and 2018. Patients were grouped by age at the time of procedure: <60 years old (n = 244, 20.9%), 60-80 years old (n = 635, 54.3%), and >80 years old (n = 291, 24.9%). Within each group, patients were further divided by use of paclitaxel. The primary outcome measure was survival assessed by Kaplan-Meier analysis. Differences between the groups were analyzed with analysis of variance. Multivariable analysis was performed using Cox proportional hazard models. RESULTS Of the 1,170 patients who underwent femoropopliteal percutaneous intervention, 654 (55.9%) received a paclitaxel-coated device during treatment and 516 (44.1%) did not. Mean age of the overall patient cohort was 70.4 ± 12.6 years and 663 (56.7%) were male. When comparing the groups by age we found an increase in age but a decrease in the proportion of patients who smoke. The use of paclitaxel-coated devices was similar across the groups (<60 years old, 56.2%; 60-80 years old, 57.0%; >80 years old, 52.6%; P = 0.45). Demographics and comorbidities were similar between the patients treated with and without paclitaxel within each age group except more males in the <60-year-old group treated without paclitaxel and more patients with chronic limb threatening ischemia in the >80-year-old group treated with paclitaxel. In patients <60 and 60-80 years old paclitaxel use was associated with increased survival at 4 years: <60 (80.7% vs. 64.4%; P = 0.04); 60-80 (63.2% vs. 55.1%; P = 0.04). Survival was similar in the >80-year-old group (46.6% vs. 32.8%; P = 0.65). CONCLUSIONS Our data suggest that the use of paclitaxel-coated arterial devices is not associated with increased mortality. On the contrary, our data show that younger patients treated with paclitaxel show improved survival compared with those treated without paclitaxel. Paclitaxel-coated devices may be used with continued caution especially in patients at high risk for restenosis.
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Affiliation(s)
- Norman H Kumins
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH.
| | - Alexander H King
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Ravi N Ambani
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Jones P Thomas
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Saideep Bose
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Virginia L Wong
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Karem C Harth
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Jae S Cho
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Benjamin Colvard
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Vikram S Kashyap
- Division of Vascular and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
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King AH, Ambani RN, Harth KC, Kashyap VS, Kumins NH, Wong VL, Baele HR, Cho JS. Frequency of perigraft hygroma after open aortic reconstruction. J Vasc Surg 2020; 72:154-161. [DOI: 10.1016/j.jvs.2019.10.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 10/07/2019] [Indexed: 11/15/2022]
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King AH, Schmaier AH, Harth KC, Kumins NH, Wong VL, Zidar DA, Kashyap VS, Cho JS. Elevated neutrophil-lymphocyte ratio predicts mortality following elective endovascular aneurysm repair. J Vasc Surg 2020; 72:129-137. [PMID: 32037083 DOI: 10.1016/j.jvs.2019.10.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 05/11/2019] [Accepted: 10/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The neutrophil-lymphocyte ratio (NLR) is an inexpensive and useful inflammatory marker that incorporates the balance of the innate (neutrophil) and adaptive (lymphocyte) immune responses. Data exist on the association between NLR and mortality in various coronary diseases and in cancer surgery, but there is a paucity of data on the impact of preoperative NLR on vascular surgical outcomes. The aim of this study was to evaluate the relationship between preoperative NLR and elective endovascular aortic aneurysm repair (EVAR) outcome. METHODS A retrospective review of all patients who underwent elective EVAR at a single institution between 2010 and 2018 was conducted (n = 373). Only patients who had a preoperative complete blood count with differential within 30 days of their operation were included. The NLR was computed by dividing the absolute neutrophil count by the absolute lymphocyte count. A receiver operating characteristic curve was used to determine the optimal cutoff value of NLR with the strongest association with mortality. NLR was dichotomized so that patients with NLR above the threshold were at increased risk of mortality compared with those below it. Continuous variables were analyzed using Wilcoxon nonparametric signed-rank test and categorical variables with the Fisher exact test. A comparison of NLR and mortality was completed using Kaplan-Meier survival analysis. Cox regression analysis was used to evaluate factors associated with mortality through 5-year follow-up. RESULTS Overall, 108 patients were included in this study. An NLR ≥ 4.0 was found to be associated with mortality (P < .0001). Thirty-two patients composed the High-NLR (NLR ≥ 4.0) group and the remaining 76 patients formed the Low-NLR (NLR < 4.0) group. Baseline characteristics were similar between groups, except that the High-NLR group was older (77.9 vs 74.4; P = .047). At a mean of 36.4 months follow-up, the overall mortality rate was 32.4%. Although there were no differences in the perioperative period, the Kaplan-Meier estimates of mortality were significantly greater in the High-NLR group at 1, 2, and 5 years postoperatively (P < .0001). The mean preoperative NLR of the deceased was higher (5.94 ± 5.20; median, 4.75; interquartile range, 3.17-7.83) than those who survived (2.87 ± 1.61; median, 2.53; interquartile range, 1.97-3.49) (P < .0001). Secondary interventions and sac enlargement rates were similar between groups. On univariable analysis, NLR (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.10-1.23; P < .0001), age (HR, 1.06; 95% CI, 1.02-1.11; P = .004), and aneurysm diameter (HR, 1.04; 95% CI, 1.01-1.07; P = .003) were associated with mortality. On multivariable analysis, NLR (HR, 1.19; 95% CI, 1.12-1.27; P < .0001), age (HR, 1.06; 95% CI, 1.01-1.11; P = .026), and aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.07; P = .003) were associated with mortality. CONCLUSIONS Patients with an elevated preoperative NLR, irrespective of other comorbidities, may represent a previously unrecognized subset of patients who are at heightened risk of mortality after elective EVAR. A complete blood count with differential is an inexpensive test that may be used as a prognostic indicator for outcome after EVAR. Further research is warranted to identify clinical, pathological, or anatomical factors associated with an elevated NLR and to determine modifiable factors, which may help improve long-term survival.
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Affiliation(s)
- Alexander H King
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alvin H Schmaier
- Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Karem C Harth
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Virginia L Wong
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - David A Zidar
- Division of Cardiology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vikram S Kashyap
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae S Cho
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Kumins NH, King AH, Ambani RN, Thomas JP, Bose S, Shishehbor MH, Li J, Wong VL, Harth KC, Cho JS, Kashyap VS. Paclitaxel-coated peripheral artery devices are not associated with increased mortality. J Vasc Surg 2020; 72:968-976. [PMID: 31917036 DOI: 10.1016/j.jvs.2019.10.100] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 06/20/2019] [Accepted: 10/13/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Long-term safety concerns have been raised that the use of paclitaxel-coated balloons and stents is linked to excess mortality. Our objective was to compare outcomes in patients treated with paclitaxel vs uncoated devices and to analyze long-term mortality. METHODS We conducted a retrospective single-institution review of 1170 consecutive patients who underwent femoropopliteal percutaneous revascularization by angioplasty, atherectomy, stent placement, or combination between 2011 and 2018. The primary outcome measure was all-cause mortality. Groups were divided into patients who received paclitaxel (n = 652) and those who did not (n = 518). Categorical variables were assessed using χ2 analysis and continuous variables with the Wilcoxon signed rank test. A multivariable analysis was performed using multivariable logistic regression models. Mortality was compared using Kaplan-Meier survival analysis. RESULTS Demographics, risk factors, and Rutherford class were similar between the groups, except that the paclitaxel group was more likely to have diabetes (60.9% vs 55.0%; P = .04), was less likely to be on dialysis (10.7% vs 14.9%; P = .04), and had lower average creatinine concentration (1.6 ± 1.8 mg/dL vs 2.0 ± 2.3 mg/dL; P = .003). There were no differences in all-cause mortality through 2 years between paclitaxel and no-paclitaxel cohorts (25.5% vs 30.3%; log-rank, P = .098). At 3 years and 3.5 years, mortality was significantly lower in the paclitaxel group: year 3, 32.1% vs 39.4% (log-rank, P = .041); year 3.5, 35.2% vs 43.9% (log-rank, P = .027). Survival rates were not significantly different in examining subgroups by diabetes, chronic kidney disease, presence of chronic limb-threatening ischemia, or paclitaxel-coated balloon manufacturer. Multivariable analysis demonstrated that age, dialysis, chronic limb-threatening ischemia, chronic kidney disease, and congestive heart failure were independent risk factors for mortality, whereas paclitaxel use was associated with lower mortality. CONCLUSIONS The use of paclitaxel-coated balloons and stents does not increase mortality compared with uncoated devices out to 3.5 years. Paclitaxel-coated devices can be used with continued caution, especially in patients at increased risk of restenosis. Further long-term studies are needed to determine the risk of late mortality.
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Affiliation(s)
- Norman H Kumins
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio.
| | - Alexander H King
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Ravi N Ambani
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jones P Thomas
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Saideep Bose
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jun Li
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Virginia L Wong
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Karem C Harth
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jae S Cho
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Vikram S Kashyap
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
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King AH, Ambani RN, Harth KC, Wong VL, Kumins NH, Kashyap VS, Cho JS. FJVIS 21. Frequency of Perigraft Hygroma After Aortic Reconstruction Using Expanded Polytetrafluoroethylene Versus Dacron Grafts. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.08.205] [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: 10/25/2022]
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King AH, Harth KC, Kumins NH, Wong V, Zidar DA, Kashyap VS, Cho JS. Elevated Neutrophil-Lymphocyte Ratio Predicts Mortality after Elective Open and Endovascular Abdominal Aortic Aneurysm Repair. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.716] [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: 10/25/2022]
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Kumins NH, Qin VL, Driscoll EC, Morrow KL, Kashyap VS, Ning AY, Tucker NJ, Quereshy HA. Self-Directed, Sequential and Incremental Video-Based Training is Effective in Teaching Novices Basic Surgical Skills. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.784] [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: 10/25/2022]
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King AH, Ambani RN, Bose S, Thomas JP, Chang C, Ng D, Wong VL, Harth KC, Kashyap VS, Kumins NH. Paclitaxel-Coated Peripheral Arterial Devices Are Not Associated With Increased Mortality. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.06.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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King AH, Kumins NH, Foteh MI, Jim J, Apple JM, Kashyap VS. The learning curve of transcarotid artery revascularization. J Vasc Surg 2019; 70:516-521. [DOI: 10.1016/j.jvs.2018.10.115] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/23/2018] [Indexed: 10/27/2022]
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King AH, Harth KC, Kumins NH, Wong VL, Zidar DA, Kashyap VS, Cho JS. Elevated Neutrophil-Lymphocyte Ratio Predicts Mortality After Elective Endovascular Aneurysm Repair. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.06.030] [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: 10/26/2022]
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Allotey JK, King AH, Kumins NH, Wong V, Harth KC, Cho JS, Kashyap VS. IP099. Patients Undergoing Carotid Endarterectomy With a Vascu-Guard Bovine Pericardial Patch May Be at Increased Risk of Bleeding Complications. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.173] [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: 10/26/2022]
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King AH, Harth KC, Kumins NH, Wong V, Zidar D, Kashyap VS, Cho JS. PC036. Elevated Neutrophil-Lymphocyte Ratio Predicts Mortality After Elective Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.312] [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: 10/26/2022]
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King AH, Ambani RN, Harth KC, Kashyap VS, Kumins NH, Wong V, Baele H, Cho JS. IP049. Frequency of Perigraft Hygroma After Aortic Reconstruction Using Expanded Polytetrafluoroethylene Grafts. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.149] [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: 11/16/2022]
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King AH, Kumins NH, Cho JS, Jim J, Motaganahalli RL, Apple JM, Foteh MI, Kashyap VS. IP097. The Duration of Blood Flow Reversal During Transcarotid Artery Revascularization Does Not Affect Outcomes. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.172] [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: 11/16/2022]
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Kashyap VS, King AH, Foteh MI, Janko M, Jim J, Motaganahalli RL, Apple JM, Bose S, Kumins NH. A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy. J Vasc Surg 2019; 70:123-129. [PMID: 30622007 DOI: 10.1016/j.jvs.2018.09.060] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [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: 05/04/2018] [Accepted: 09/20/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) is a novel approach to carotid intervention that uses a direct carotid cut-down approach coupled with cerebral blood flow reversal to minimize embolic potential. The initial positive data with TCAR indicates that it may be an attractive alternative to trans-femoral carotid artery stenting and possibly carotid endarterectomy (CEA) for high-risk patients. The purpose of this study was to present 30-day and 1-year outcomes after treatment by TCAR and to compare these outcomes against a matched control group undergoing CEA at the same institutions. METHODS A retrospective review of all patients who underwent TCAR at four institutions between 2013 and 2017 was performed to evaluate the use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Inc, Sunnyvale, Calif). TCAR patients had high-risk factors and were either enrolled in prospective trials or treated with a commercially available TCAR device after US Food and Drug Administration approval. Contemporaneous patients undergoing CEA at each institution were also reviewed. Patients were propensity matched in a 1:1 (CEA:TCAR) fashion with respect to preoperative comorbidities. Data were analyzed using statistical models with a P value of less than .05 considered significant. Individual and composite stroke, myocardial infarction, and death at 30 days and 1 year postoperatively were assessed. RESULTS Consecutive patients undergoing TCAR or CEA were identified (n = 663) and compared. Patients undergoing the TCAR procedure (n = 292) had higher rates of diabetes (P = .01), hyperlipidemia (P = .02), coronary artery disease (P < .01), and renal insufficiency (P < .01) compared with unmatched CEA patients (n = 371). Stroke rates were similar at 30 days (1.0% TCAR vs 1.1% CEA) and 1 year (2.8% TCAR vs 3.0% CEA) in the unmatched groups. After propensity matching by baseline characteristics including gender, age, symptom status (36.3%, 35.3%) and diabetes, 292 TCAR patients were compared with 292 CEA patients. TCAR patients were more likely to be treated preoperative and postoperatively with clopidogrel (preoperatively, 82.2% vs 39.4% [P < .01]; postoperatively, 98.3% vs 36.0% [P < .01]) and statins (preoperatively, 88.0% vs 75.0% [P < .01]; postoperatively, 97.8% vs 78.8% [P < .01]). Stroke (1.0% TCAR vs 0.3% CEA; P = .62) and death (0.3% TCAR vs 0.7% CEA; P = NS) rates were similar at 30 days and comparable at 1 year (stroke, 2.8% vs 2.2% [P = .79]; death 1.8% vs 4.5% [P = .09]). The composite end point of stroke/death/myocardial infarction at 1 month postoperatively was 2.1% vs 1.7% (P = NS). TCAR was associated with a decreased rate of cranial nerve injury (0.3% vs 3.8%; P = .01). CONCLUSIONS These early data suggest that patients undergoing TCAR, even those with high-risk comorbidities, achieve broadly similar outcomes compared with patients undergoing CEA while mitigating cranial nerve injury. Further comparative studies are warranted.
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Affiliation(s)
- Vikram S Kashyap
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Alexander H King
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Matthew Janko
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jeffrey Jim
- Division of Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | | | - Saideep Bose
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Kashyap VS, King AH, Foteh MI, Jim J, Kumins NH. PC066. A Multi-Institutional Analysis of Contemporary Outcomes After Transcarotid Artery Revascularization versus Carotid Endarterectomy. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.278] [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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Beiswenger AC, Jo A, Harth K, Kumins NH, Shishehbor MH, Kashyap VS. A systematic review of the efficacy of aspirin monotherapy versus other antiplatelet therapy regimens in peripheral arterial disease. J Vasc Surg 2018; 67:1922-1932.e6. [DOI: 10.1016/j.jvs.2018.02.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 02/27/2018] [Indexed: 10/16/2022]
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Abstract
Lower extremity venous insufficiency is a highly prevalent condition. Now it is understood that telangiectasias, reticular varicosities, and true varicose veins are physiologically similar and etiologically identical. The four main influences causing these abnormalities are heredity, female sex, gravitational hydrostatic forces, and hemodynamic muscular compartment pressure. There are clear indications and goals for intervention. A cornerstone in the treatment of venous insufficiency is elimination of sources of venous hypertension. One of these is the refluxing greater saphenous vein. Minimally invasive saphenous ablation can be achieved by radiofrequency energy and laser light energy. These new techniques eliminate the psychologic barrier to treatment caused by the term "stripping" and allow the objectives of surgery to be achieved with minimal invasion and quick recovery. Endovenous techniques show great promise. They provide minimal invasion, often under local anesthesia and intravenous sedation, thereby eliminating the need for general anesthesia. Objectives of venous insufficiency have been established and the endoluminal minimally invasive techniques developed in recent years appear to accomplish their goals.
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Affiliation(s)
- John J Bergan
- Department of Surgery, University of California, San Diego, California, USA.
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Abstract
Carotid artery angioplasty with stenting (CAS) is being increasingly used in the treatment of extracranial carotid artery stenosis. As in other catheter-based approaches to the treatment of arterial disease, surgical intervention may be required because of either acute complications or correct critical restenosis. We have reviewed our experience managing early complications and critical in-stent restenoses after CAS in a tertiary care university hospital and a Veterans Affairs Medical Center. During the last 5 years, 22 carotid arteries (21 patients) underwent CAS. One patient developed thrombosis and rupture of the carotid artery during stenting. Two other patients (3 arteries) developed critical restenosis within 12 months. Subsequent surgical reconstructions included an internal carotid artery (ICA)-to-external carotid artery (ECA) transposition and a common carotid artery (CCA)-to-ICA bypass with reversed saphenous vein (RSV). The patient who underwent CCA-to-ICA bypass later required subclavian-to-ICA bypass because of rapidly progressive intimal hyperplasia and subsequent occlusion of the CCA. The other patient has not had surgical repair because of his deteriorating condition and significant co-morbidities. During the same time period, two additional patients were referred from outside institutions specifically for surgical intervention after carotid stenting. One had delayed rupture of the carotid artery 1 day after stenting and underwent urgent surgical repair. Another patient had early, critical restenosis within the stent and underwent placement of a CCA-to-ICA interposition graft using RSV. Acute treatment failures after CAS can be successfully managed using standard surgical techniques. Patients who develop critical in-stent restenosis requiring surgical repair may need more challenging surgical reconstructions to maintain cerebral perfusion.
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Affiliation(s)
- Erik L Owens
- Division of Vascular Surgery, Department of Surgery, University of California, San Diego, CA, USA.
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Kumins NH, Owens EL, Oglevie SB, Ronaghi AH, Bergan JJ, Tripathy U, Sparks SR. Early experience using the Wallgraft in the management of distal microembolism from common iliac artery patholology. Ann Vasc Surg 2002; 16:181-6. [PMID: 11972249 DOI: 10.1007/s10016-001-0153-1] [Citation(s) in RCA: 12] [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: 10/28/2022]
Abstract
Blue toe syndrome commonly occurs as a result of aneurysmal or atherosclerotic disease in the iliac arteries. Surgery, angioplasty, or intraarterial stent placement are the most common treatment options but the optimal management has not been defined. Here we report managing distal microembolization from iliac artery atherosclerosis associated with aneurysmal dilation with the Wallgraft Endoprosthesis, a self-expanding metallic stent covered with Dacron. Three common iliac arteries in two patients were treated using this device. A 79-year-old male presented with unilateral symptoms and an 83-year-old female with bilateral disease. Arteriography demonstrated complex plaque at the aortic bifurcation associated with aneurysmal dilation of the distal common iliac artery in both patients. This complex disease was successfully covered using the Wallgraft Endoprosthesis. Postoperatively the patients received aspirin, their toe lesions healed, and neither has had a recurrence after 16 months. Covered stents offer the theoretic advantage of completely excluding the diseased segment, preventing the escape of thrombus or plaque debris, and covering aneurysmal dilation in the artery.
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Affiliation(s)
- Norman H Kumins
- Department of Surgery, Division of Vascular Surgery, University of California, San Diego and The San Diego VA Healthcare System, San Diego, CA 92161, USA.
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Sparks SR, Tripathy U, Broudy A, Bergan JJ, Kumins NH, Owens EL. Small-caliber mesothelial cell-layered polytetraflouroethylene vascular grafts in New Zealand white rabbits. Ann Vasc Surg 2002; 16:73-6. [PMID: 11904808 DOI: 10.1007/s10016-001-0133-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [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: 10/26/2022]
Abstract
Reduction in the thrombogenicity of small-caliber synthetic vascular grafts by lining them with mesothelial cell has been suggested as a method to reduce thrombosis. The purpose of this research is to determine whether creation of a mesothelial lining on the inner surface of a synthetic vascular graft would improve the patency rate of a small-caliber vascular grafts. Carotid interposition grafting was performed using mesothelial-lined grafts (MLG) in 30 New Zealand rabbits and compared with similar carotid interposition grafts using non-mesothelial-lined grafts (NLG) on the contralateral side. The mesothelial lining was created by suturing a piece of harvested peritoneum with the visceral surface toward the lumen onto a 2-mm polytetraflouroethylene (PTFE) graft. Graft patency was studied by in vivo Dopler. In vitro evaluations were done with hematoxylin-eosin stains, broadband cytokeratin staining, and monoclonal antibodies for macrophages. Explanation of the grafts was done in terminal operation at 7, 14, and 21 days. The MLG showed progressive fibroblastic proliferation in direct proportion to the age of the graft, but this did not lead to graft occlusion. However, a significant number of NLG were not patent at each time period studied. We concluded that mesothelial cell lining of smallcaliber PTFE grafts could enhance the short-term patency more than using the PTFE without the mesothelial lining. The use of such hybrid small-caliber grafts has a potential for improving the patency of these artificial vascular graft substitutes.
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Affiliation(s)
- Steven R Sparks
- Department of Surgery, Division of Vascular Surgery, University of California Medical Center, San Diego 92103, USA
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Abstract
For the 48th meeting of the International Society for Cardiovascular Surgery, North American Chapter in June 2000, we were asked to organize a presentation with the title displayed above. We welcomed this opportunity because the phrase 'growing the practice' literally means giving greater service to underserved patients with vascular disorders. Underserved individuals with vascular disorders include those with nonatherosclerotic arterial disorders, patients with lymphedema, and individuals with a variety of venous disorders including venous insufficiency. The majority of these conditions are not surgical, but venous insufficiency commands attention because its treatments are interventional. Therefore, this presentation will discuss prevalence of venous insufficiency, a unifying concept of its pathophysiology, how treatment may be selected, what the new technology provides, and then a description of coding issues and whether or not interventions are actually worthwhile from the point of view of the patient.
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Affiliation(s)
- J J Bergan
- University of California, San Diego, CA, USA.
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Kumins NH, Sparks SR, Bergan JJ, Owens EL. Internal to external carotid artery transposition to repair recurrent stenosis after carotid artery stenting. Ann Vasc Surg 2001; 15:233-6. [PMID: 11265089 DOI: 10.1007/s100160010060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [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: 10/18/2022]
Abstract
Recently, carotid artery stenting (CAS) has emerged as a treatment option for carotid artery stenosis. Since the procedure is new, management of its complications is not standardized. This case report describes one method of arterial reconstruction after failed CAS. A 64-year-old male underwent CAS of his right internal carotid artery (ICA) for an asymptomatic 65% stenosis. Seven months later the stented area had narrowed to 95%. Arteriography revealed that the common and external carotid arteries (ECA) were free of disease so we elected to perform a transposition of the distal ICA onto the proximal ECA. The ECA and its branches were completely mobilized and the ascending pharyngeal and lingual arteries divided. The ICA was divided distal to the stent. Transection of the occipital artery provided an arteriotomy for an end ICA to side ECA anastamosis, thus preserving ECA flow. Postoperative surveillance after 8 months has revealed no recurrent stenosis. Operative repair of restenosis after CAS may be challenging if standard endarterectomy is not possible. Other options for reconstruction are feasible but if the common and external carotid arteries are disease-free, an ICA to ECA transposition provides a simple all-arterial repair that avoids bypass and prosthetic material.
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Affiliation(s)
- N H Kumins
- Department of Surgery, Division of Vascular Surgery, The San Diego VA Health Care System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Kumins NH, Tober JC, Larsen PE, Smead WL. Vertical Ramus osteotomy allows exposure of the distal internal carotid artery to the base of the skull. Ann Vasc Surg 2001. [DOI: 10.1007/bf02693796] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kumins NH, Tober JC, Larsen PE, Smead WL. Vertical ramus osteotomy allows exposure of the distal internal carotid artery to the base of the skull. Ann Vasc Surg 2001; 15:25-31. [PMID: 11221940 DOI: 10.1007/s100160010010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Exposure of the distal internal carotid artery (ICA) above the level of the second cervical vertebra can be difficult and often require maneuvers such as division of the digastric muscle or mandibular subluxation. These techniques increase exposure but may not provide adequate access. We report a series of eight cases in which vertical division of the mandibular ramus provided access of the ICA up to the base of the skull. Over the last 10 years, eight patients underwent vertical ramus osteotomy (VRO) to aid in distal ICA exposure. Preoperative arteriography revealed ICA lesions within 1.5 cm of the skull base. Indications for surgery were compelling and included gunshot wounds to zone III of the neck (n = 2), transient ischemic attack (n = 2), and preocclusive stenosis (n = 4). VRO was performed through a standard vertical neck incision and was created from the depth of the sigmoid notch to the angle of the mandible after elevating the masseter muscle from the bone. Miniature titanium plates were used to reapproximate the mandible after endarterectomy (n = 5), bypass (n = 2), or arterial repair (n = 1). We found that VRO provides reliable exposure of the distal ICA up to the base of the skull. Unlike mandibular subluxation, it requires no pre-incision preparation, thus mandibulotomy can be performed after carotid artery dissection has begun, and may even be avoided. VRO is especially useful when carotid artery pathology unexpectedly extends beyond the usual field of exposure. Work on the carotid artery at the skull base is associated with significant complications and should be reserved for compelling indications.
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Affiliation(s)
- N H Kumins
- Department of Surgery, Division of Vascular Surgery, The Ohio State University Medical Center, Columbus, USA
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Kumins NH, Tober JC, Love CJ, Culbertson TA, Gerhardt MA, Irwin RJ, Smead WL. Arteriovenous fistulae complicating cardiac pacemaker lead extraction: recognition, evaluation, and management. J Vasc Surg 2000; 32:1225-8. [PMID: 11107098 DOI: 10.1067/mva.2000.107994] [Citation(s) in RCA: 12] [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: 11/22/2022]
Abstract
Transvenous pacemaker lead extraction has become a commonly performed procedure that is associated with a small but significant risk. We report two cases where lead extraction was complicated by arteriovenous fistulae between branches of the aortic arch and the left brachiocephalic vein. Presenting signs and symptoms included severe chest or back pain, persistent or copious bleeding from the venous puncture site, unexplained hypotension or anemia, superior vena cava syndrome, and signs of central venous hypertension or acute heart failure. One patient whose injury was not recognized immediately and who did not undergo repair died rapidly, whereas the other patient who was diagnosed quickly underwent successful repair. Immediate diagnosis with arteriography and rapid intervention with surgery or percutaneous techniques are indicated and may prevent mortality.
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Affiliation(s)
- N H Kumins
- Department of Surgery, Division of Vascular Surgery, Ohio State University Medical Center, Columbus, OH 43210, USA
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Abstract
BACKGROUND Most venous ulcers (VUs) will heal with conventional treatment, which focuses on improving regional venous hemodynamics. This treatment, however, often fails to heal large, recurrent VUs that are associated with severe lipodermatosclerosis (LDS). These complicated ulcers may require correction of local venous hemodynamics and replacement of the surrounding LDS with healthy tissue. We report our experience managing 24 especially difficult VUs with debridement and free flap coverage. PATIENTS AND METHODS Between 1987 and 1997, 25 free flap procedures were performed in 22 patients for 24 recalcitrant VUs. Ulcers had been present for a mean of 5.24 years and had failed to heal with conservative therapy and split-thickness skin grafts (STSGs) (mean, 2.2). Eleven patients (46%) had exposed bone, tendon, or joint. At operation the area of LDS was excised, and all perforating veins were ablated. The defects after excision ranged from 100 to 600 cm(2) (mean, 237 cm(2)). The free flap was inset within the defect and covered with an STSG. RESULTS We healed all 24 ulcers with free tissue transfer (one patient required a second flap after the first failed). There were no deaths. Local complications that required repeat STSG occurred in three (13%) of the 24 successful flap transfers. Four other flaps had minor local complications that healed with local wound care. Follow-up was available for 21 of the 24 successful flap transfers. No recurrent ulcers were identified in the territory of the flap after a mean of 58 months, but three patients had new ulcers in the same leg after 6 to 77 months. Patients with severe complications were hospitalized longer than those with minor or no complications (45.7 vs 12.8 days, P <.01), and their hospital charges were greater ($76,681 vs $30,428, P <.01). CONCLUSION Free tissue transfer can provide rapid healing and long-term relief from severe VUs that are unable to be treated with conventional therapy. This technique improves venous hemodynamics, removes all liposclerotic tissue, provides an abundant blood supply, and resolves the tissue-related components of chronic ulceration. Although further work is needed to determine the optimal indications, this technique provides a durable treatment for especially recalcitrant ulcers.
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Affiliation(s)
- N H Kumins
- Department of Surgery, University of California, San Diego and The San Diego VA Healthcare System, San Diego, CA, USA
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