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Liu IH, El Khoury R, Hiramoto JS, Gasper WJ, Schneider PA, Vartanian SM, Conte MS. Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program. J Vasc Surg 2024:S0741-5214(24)00399-9. [PMID: 38401777 DOI: 10.1016/j.jvs.2024.02.022] [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: 11/20/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. METHODS This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). RESULTS Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. CONCLUSIONS In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.
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Affiliation(s)
- Iris H Liu
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Rym El Khoury
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Jade S Hiramoto
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Warren J Gasper
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Peter A Schneider
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Shant M Vartanian
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Michael S Conte
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA.
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Chaney M, Joshi G, Serrato JC, Rashid M, Jacobs A, Jacobs CE, White JV, Schwartz LB, El Khoury R. Morbidity and mortality of common femoral endarterectomy. J Vasc Surg 2024:S0741-5214(24)00271-4. [PMID: 38360191 DOI: 10.1016/j.jvs.2024.01.211] [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: 12/19/2023] [Revised: 01/21/2024] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Common femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. METHODS Consecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. RESULTS A total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). CONCLUSIONS Although commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.
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Affiliation(s)
- Michael Chaney
- Homer Stryker School of Medicine, Western Michigan University, Kalamazoo, MI
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | | | - Mohammad Rashid
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Abraham Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health Systems, Evanston, IL.
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Ghandour H, Cataneo JL, Asha A, Jaeger JK, Jacobs CE, Schwartz LB, El Khoury R. Slowly moving the needle away from Fistula First. J Vasc Surg 2024; 79:382-387. [PMID: 37952784 DOI: 10.1016/j.jvs.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE In 2019, the management of end-stage kidney disease (ESKD) shifted away from "Fistula First" (FF) to "ESKD Life-Plan: Patient Life-Plan First then Access Needs." Indeed, some patients exhibit such excessive comorbidity that even relatively minor vascular surgery may be complicated. The purpose of this study was to retrospectively assess complications and mortality (and delineate operative futility) in patients undergoing arteriovenous fistula (AVF) creation in the FF era. METHODS Consecutive AVFs created in a single institution before 2021 were retrospectively reviewed. Operative futility was defined as never-accessed fistula, no initiation of dialysis, failure of access maturation (despite secondary intervention), hemodialysis access-induced distal ischemia requiring ligation, early loss of secondary patency, and/or patient mortality within the first 6 postoperative months. RESULTS A total of 401 AVFs were created including radial-cephalic (44%), brachial-cephalic (41%), and brachial-basilic (15%) constructions. Patients exhibited a mean age of 69 ± 15 years; 63% were male, and most (74%) were already being hemodialyzed at the time of fistula creation. Forty-five patients (11%) suffered a cardiac event, and five patients died (1%) within 90 days of their access surgery. Perioperative cardiac events were significantly more common after age 80 (19% vs 8%; P = .004); age >80 years was an independent predictor of major 90-day complications (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.04-3.39; P = .036) and the sole independent predictor of major morbidity defined as cardiopulmonary complications, stroke, or death within the first year (OR, 2.01; 95% CI, 1.24-3.25; P = .004). Operative futility was encountered in 52% of the cohort (n = 208 patients): 40% (n = 160) of primary AVFs failed to mature despite assistance, 19% (n = 77) had lost secondary patency by 6 months, 13% of patients (n = 53) were never started on dialysis after access creation, 4% (n = 16) were dead by 6 months, 2% of AVFs (n = 10) matured but were never accessed, and 2% (n = 9) required ligation for hemodialysis access-induced distal ischemia. Not surprisingly, the sole independent protector against operative futility was that catheter-based dialysis had been established prior to AVF creation (OR, 0.36; 95% CI, 0.22-0.59; P < .01). CONCLUSIONS Approximately 50% of primary AVF operations performed in the aggressive FF era were deemed futile. Octogenarians were particularly prone to futility and complications during this era. A paradigm shift, from FF to an "ESKD Life-Plan" will, hopefully, more thoughtfully match vascular access strategies to individual patient needs.
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Affiliation(s)
- Hani Ghandour
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Jose L Cataneo
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Ahmad Asha
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Jessica K Jaeger
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health Systems, Evanston, IL.
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El Khoury R, Bush RL. Lymphedema: The understudied vascular condition of an under-represented population. J Vasc Surg Venous Lymphat Disord 2023; 11:1241-1242. [PMID: 37863548 DOI: 10.1016/j.jvsv.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Rym El Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Ruth L Bush
- Department of Educational Affairs and Department of Surgery, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX
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Huynh C, Liu I, El Khoury R, Zhou B, Braun H, Conte MS, Hiramoto J. Iliac artery calcification score stratifies mortality risk estimation in patients with chronic limb-threatening ischemia undergoing revascularization. J Vasc Surg 2023; 78:184-192. [PMID: 36898509 DOI: 10.1016/j.jvs.2023.02.019] [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: 12/18/2022] [Revised: 02/26/2023] [Accepted: 02/27/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVE Patients with chronic limb-threatening ischemia (CLTI) are at high risk for adverse limb outcomes and mortality. Using the Vascular Quality Initiative (VQI) prediction model to estimate mortality after revascularization can assist with clinical decision-making. We aimed to improve the discrimination of the 2-year VQI risk calculator by incorporating a common iliac artery (CIA) calcification score based on computed tomography scans. METHODS This was a retrospective analysis of patients who underwent infrainguinal revascularization for CLTI from January 2011 to June 2020 and had a computed tomography scan of the abdomen/pelvis 2 years before or up to 6 months after revascularization. CIA calcium morphology, circumference, and length were scored. Bilateral scores were summed for the total calcium burden (CB) score, which was trichotomized (mild, 0-15; moderate, 16-19; severe, 20-22). The VQI CLTI model was used to categorize patients as low, medium, or high risk for mortality. RESULTS A total of 131 patients with a mean age of 69±12 years were included in the study, and 86 (66%) were men. CB scores were mild in 52 (40%), moderate in 26 (20%), and severe in 53 (40%) patients. Older patients (P = .0002) and those with coronary artery disease (P = .06) had higher CB scores. Patients with severe CB scores were more likely to undergo infrainguinal bypass compared with those with mild or moderate CB scores (P = .006). The 2-year VQI mortality risk was calculated to be low in 102 (78%), medium in 23 (18%), and high in 6 (4.6%) patients. In the "low-risk" VQI mortality subgroup, 46 (45%) patients had mild, 18 (18%) had moderate, and 38 (37%) had severe CB scores, and patients with severe CB scores had significantly higher risk of mortality compared with those with mild or moderate scores (hazard ratio, 2.5; 95% confidence interval, 1.2-5.1; P = .01). In this "low-risk" VQI mortality subgroup, CB score further stratified the risk of mortality (P = .04). CONCLUSIONS Higher total CIA calcification was significantly associated with mortality in patients undergoing infrainguinal revascularization for CLTI, and preoperative assessment of CIA calcification may help with perioperative risk stratification and guide clinical decision making in this population.
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Affiliation(s)
- Cindy Huynh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Iris Liu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Rym El Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Bo Zhou
- Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Hillary Braun
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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El Khoury R, Tzvetanov I, Estrada EA, McCarroll E, Goor JB, Guy LG, Laflamme M, Schwartz LB. Drug-eluting, balloon-expandable, bioresorbable vascular scaffolds reduce neointimal thickness and stenosis in an animal model of percutaneous peripheral intervention. JVS Vasc Sci 2023; 4:100114. [PMID: 37546529 PMCID: PMC10403740 DOI: 10.1016/j.jvssci.2023.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/31/2023] [Indexed: 08/08/2023] Open
Abstract
Objective Recanalization with balloon angioplasty and/or self-expanding stents (SES) has become the endovascular treatment of choice for symptomatic femoropopliteal occlusive disease. These strategies generate suboptimal clinical results, however, because they fail to expand the artery fully and ineffectively prevent recoil, neointimal hyperplasia, and restenosis. Balloon-expandable stents, given their greater radial force and rigid structure, represent a more effective treatment strategy, but only short lengths can be implanted safely in arteries that deform and bend with skeletal motion. The purpose of this preclinical experiment was to test the hypothesis that simultaneous implantation of a series of short, resorbable, balloon-expandable, paclitaxel-eluting scaffolds would prevent neointimal hyperplasia and stenosis compared with SES in an animal model of percutaneous femoropopliteal intervention. Methods We extruded 6 × 60 mm Efemoral Vascular Scaffold Systems (EVSS) from copolymers of poly-L-lactic acid, coated with paclitaxel 3 μg/mm2, crimped onto a single delivery balloon, and implanted percutaneously into the iliofemoral arteries of eight Yucatan mini-swine. We implanted 7- to 8-mm × 60 mm SES into the contralateral experimental arteries. The animals were serially imaged with contrast angiography and optical coherence tomography after 30, 90, 180, 365, and 730 days. The primary end point of this study was neointimal morphometry over time. Secondary end points included acute deformation and angiographic and optical coherence tomography-derived measurements of chronic vascular response. Results Over the 2-year study period, one SES was found to be completely occluded at 90 days; all EVSS were widely patent at all time points. Arteries treated with SES exhibited profound neointimal hyperplasia with in-stent stenosis. In contrast, arteries treated with EVSS exhibited only modest vascular responses and minimal stenosis. After 2 years, the mean neointimal thickness (0.45 ± 0.12 vs 1.31 ± 0.91 mm; P < .05) and area (8.41 ± 3.35 vs 21.86 ± 7.37 mm2; P < .05) were significantly decreased after EVSS implantation. By 2 years, all scaffolds in all EVSS-treated arteries had resorbed fully. Conclusions In this preclinical animal model of peripheral endovascular intervention, the EVSS decreased neointimal hyperplasia and stenosis significantly compared with SES, then dissolved completely between the first and second years after implantation.
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Affiliation(s)
| | | | | | | | | | | | | | - Lewis B. Schwartz
- Efemoral Medical, Inc., Los Altos, CA
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
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El Khoury R, Dardik A. Toward a targeted approach to diabetes-related peripheral arterial occlusive disease. JVS Vasc Sci 2023; 4:100112. [PMID: 37496885 PMCID: PMC10366572 DOI: 10.1016/j.jvssci.2023.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Affiliation(s)
- Rym El Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, CA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
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El Khoury R, Tzvetanov I, Estrada EA, McCarroll E, Guy LG, Laflamme M, Schwartz LB. Drug-Eluting, Balloon-Expandable, Bioresorbable Vascular Scaffolds Reduce Neointimal Thickness and Stenosis in an Animal Model of Percutaneous Peripheral Intervention. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2023.01.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Gomez-Sanchez C, Werlin E, Sorrentino T, El Khoury R, Lancaster E, Parks C, Goodman B, Dini M, Iannuzzi J, Reyzelman A, Conte MS, Gasper W. Open revascularization approach is associated with healing and ambulation after transmetatarsal amputation in patients with chronic limb threatening ischemia. J Vasc Surg 2023; 77:1147-1154.e3. [PMID: 36581012 DOI: 10.1016/j.jvs.2022.12.035] [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: 10/31/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Transmetatarsal amputation (TMA) allows for maintenance of ambulatory function for patients with significant forefoot tissue loss. Effective revascularization is key to optimizing limb salvage for patients with chronic limb threatening ischemia (CLTI). We hypothesized that CLTI patients requiring TMA will have better healing and functional outcomes with open bypass than with endovascular revascularization. METHODS Consecutive TMAs performed at three affiliated centers between 2008 and 2020 were retrospectively reviewed. The baseline characteristics, including WIfI (wound, ischemia, foot infection) stage, noninvasive vascular studies, healing, and ambulatory outcomes, were collected. Catheter-based angiographic images were evaluated using the GLASS (global limb anatomic staging system). The primary outcomes were TMA healing and community ambulation. The secondary outcomes were TMA that had healed at study end, any ambulatory function postoperatively, major amputation, and mortality. Descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses were performed. RESULTS A total of 346 TMAs had been performed in 318 patients, 209 of whom had had peripheral artery disease (PAD). The median follow-up was 2.5 years. Patients with PAD had had significantly lower rates of healing compared with those without PAD (64% vs 77%; P = .007). Revascularization was performed in 185 limbs, with 102 treated endovascularly and 83 with open surgery. The patients who had undergone endovascular surgery were significantly less likely to have had the TMA healed at any point (55% vs 76%; P = .003) and less likely to have remained healed at study end (49% vs 66%; P = .02). Patients with GLASS stage 3 anatomy were significantly more likely to have healed after open surgery (75% vs 45%; P = .003). Long-term ambulation data were available for 72% of the revascularized patients. Endovascular surgery was associated with a lower likelihood of community ambulation after TMA (34% vs 57%; P = .002). On multivariable analysis, open surgery was significantly associated with TMA healing (odds ratio, 2.8; P = .007) and ambulation (odds ratio, 2.9; P = .001). CONCLUSIONS For patients with CLTI and significant tissue loss requiring TMA, an initial open approach to revascularization was associated with improved healing and higher rates of ambulation compared with endovascular interventions. The metabolic requirement for healing of a TMA in patients with CLTI might be better met by open revascularization.
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Affiliation(s)
- Clara Gomez-Sanchez
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA.
| | - Evan Werlin
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Thomas Sorrentino
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Rym El Khoury
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Elizabeth Lancaster
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Charles Parks
- Department of Orthopedic Surgery, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Brooke Goodman
- Division of Vascular Surgery, Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Monara Dini
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - James Iannuzzi
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA; Division of Vascular Surgery, Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Alexander Reyzelman
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Warren Gasper
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA; Division of Vascular Surgery, Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA
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Liu IH, El Khoury R, Wu B, Gasper WJ, Schneider PA, Hiramoto JS, Vartanian SM, Conte MS. Presenting limb severity is associated with long-term outcomes after infrainguinal revascularization for chronic limb-threatening ischemia. J Vasc Surg 2023; 77:1137-1146.e3. [PMID: 36584906 DOI: 10.1016/j.jvs.2022.12.036] [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: 10/06/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The SVS Wound, Ischemia, foot Infection (WIfI) limb staging system was established to estimate risk of major amputation in chronic limb-threatening ischemia (CLTI) and better stratify outcomes comparisons. There is little data on treatment outcomes beyond 1 year based on presenting WIfI stage. METHODS This is a single-institution retrospective study of 413 patients who underwent infrainguinal revascularization for CLTI (2011-2021) with data available for WIfI staging. Patient characteristics and outcomes were gathered from the electronic medical record. Data were analyzed based on presenting WIfI stage and initial treatment received at our center. RESULTS Presenting WIfI stages were 1 to 2 (23%), 3 (27%), and 4 (50%). Index revascularization approach was endoluminal (59%), autogenous vein bypass (29%), or non-autogenous bypass (13%). Operative mortality within 30 days was 2.9% and was not associated with WIfI stage or revascularization approach. Median limb follow-up time was 502 days (interquartile range [IQR], 112-1256 days), and median survival follow-up time was 932 days (IQR, 343-1770 days). Major amputation or death occurred in 19% and 46% of patients at median times of 119 days (IQR, 28-314 days) and 739 days (IQR, 204-1475 days), respectively. WIfI stage was independently associated with major amputation (P = .001), as was initial revascularization approach (P = .01). In a Cox proportional hazards model, factors independently associated with major amputation were male sex (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.04-2.0; P = .03), diabetes (HR, 1.8; 95% CI, 1.3-2.5; P = .001), WIfI stage 4 (HR, 2.3; 95% CI, 1.5-3.5; P < .001), and non-autogenous bypass (HR, 2.9; 95% CI, 2.1-4.2; P < .001). In a Cox proportional hazards model for mortality, independently associated factors were age (HR, 1.04; 95% CI, 1.02-1.05; P < .001), end-stage renal disease (HR, 2.8; 95% CI, 1.9-4.0; P < .001), congestive heart failure (HR, 1.9; 95% CI, 1.4-2.5; P < .001), chronic obstructive pulmonary disease (HR, 1.5; 95% CI, 1.1-2.1; P = .02), and WIfI stage 4 (HR, 1.6; 95% CI, 1.04-2.2; P = .03). Among those presenting with WIfI stage 4 limbs, Kaplan-Meier estimated rates of freedom from major amputation or death at 2 years were 71% ± 3.7% and 68% ± 3.5%, respectively. In an inverse propensity weighted Cox proportional hazards model, non-white race (HR, 1.5; 95% CI, 1.01-2.2; P = .047), diabetes (HR, 2.0; 95% CI, 1.2-3.3; P = .008), Global Anatomic Staging System infrapopliteal grade (HR, 1.2; 95% CI, 1.05-1.3; P = .005), non-autogenous bypass (HR, 3.2; 95% CI, 1.9-5.3; P < .001), and endoluminal revascularization (HR, 2.6; 95% CI, 1.6-4.3; P < .001) were independently associated with major amputation in the WIfI stage 4 subgroup. CONCLUSIONS Presenting WIfI stage is strongly associated with long-term risks of major amputation and death following infrainguinal revascularization for CLTI and should be used to stratify outcomes comparisons. Effective revascularization is critical in WIfI stage 4 disease, and autogenous vein bypass provides durable long-term limb preservation.
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Affiliation(s)
- Iris H Liu
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Rym El Khoury
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Bian Wu
- Kaiser Permanente San Francisco, San Francisco, CA
| | - Warren J Gasper
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Peter A Schneider
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Jade S Hiramoto
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Shant M Vartanian
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Michael S Conte
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA.
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Pollini T, Wong P, Kone LB, Khoury RE, Kabir C, Maker VK, Banulescu M, Maker AV. Drain Placement After Pancreatic Resection: Friend or Foe For Surgical Site Infections? J Gastrointest Surg 2023; 27:724-729. [PMID: 36737592 DOI: 10.1007/s11605-023-05612-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite multiple studies and randomized trials, there remains controversy over whether drains should be placed, and if so for how long, after pancreas resection. The aim was to determine if post-pancreatectomy drain placement and timing of drain removal were associated with differences in infectious outcomes and, if so, which specific procedures and infectious sites were most at risk. METHODS The ACS-NSQIP targeted pancreatectomy database was utilized to identify patients who underwent pancreatectomies between 2015 and 2020 with postoperative drain placement for retrospective cohort analysis. A propensity score matching analyses was conducted to determine associations between drain placement and surgical site infections (SSI). RESULTS Of 39,057 pancreatic resections, 66.4% were proximal pancreatectomies, and 33.6% were distal pancreatectomies. After propensity score matching, drain placement was not associated with significantly lower rates of superficial SSI (7% vs 9%, p = 0.755) or organ/space SSI (17% vs 16%, p = 0.647) after proximal pancreatectomy. After distal pancreatectomy, drain placement was associated with higher rates of organ/space SSI (12% vs 9%, p = 0.010). Drain removal on or after postoperative day 3 was significantly associated with higher rates of SSI in both proximal and distal pancreatectomy. CONCLUSIONS Drain placement is associated with an increased rate of organ/space SSI after distal pancreatectomy and not after pancreaticoduodenectomy. When drains are utilized, early removal is associated with a reduction of SSI after all types of pancreatectomy. In surgical units where post-pancreatectomy SSI is a concern, selective drain placement for high-risk glands or after distal pancreatectomy, combined with early drain removal, may be considered.
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Affiliation(s)
- Tommaso Pollini
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Paul Wong
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Lyonell B Kone
- Department of Surgery, University of Illinois at Chicago, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Rym El Khoury
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Chris Kabir
- Department of Surgery, University of Illinois at Chicago, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Department of Surgery, University of Illinois at Chicago, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, University of Illinois at Chicago, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA.
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12
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Liu IH, Wu B, El Khoury R, Ferraresi R, Reyzelman AM, Gasper WJ, Hiramoto JS, Schneider PA, Conte MS, Vartanian SM. Pedal Arterial Calcification Is Associated With Progression From Transmetatarsal Amputation To Major Amputation Following Infrainguinal Revascularization For Chronic Limb-threatening Ischemia. Ann Vasc Surg 2023. [DOI: 10.1016/j.avsg.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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13
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El Khoury R, Wu B, Kupiec-Weglinski SA, Liu IH, Edwards CT, Lancaster EM, Hiramoto JS, Vartanian SM, Schneider PA, Conte MS. Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia. J Vasc Surg 2022; 76:997-1005.e2. [PMID: 35697305 DOI: 10.1016/j.jvs.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway (TAP) following intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events following infrainguinal revascularization for CLTI. METHODS Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aorto-iliac disease, prior infrainguinal stents or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System (GLASS) scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of re-intervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. Major adverse limb events (MALE) included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation. RESULTS 184 unique limbs in 163 patients were analyzed. This cohort was composed of 66.9% male patients with a mean age of 72. Baseline characteristics included diabetes (66%), tissue loss (91%) and advanced WIfI stages (30% stage 3, 51% stage 4). GLASS stage 3 anatomic patterns were common (n=119; 65%). 60 limbs were treated with open bypass (65% involving tibial targets) while 124 underwent endovascular intervention (70% including infrapopliteal targets). 12-month freedom from MALE and loss of LBP were 74.0%±3.7% and 48.6%±4.2%, respectively. Diabetes (HR=2.56 [1.13-5.83]; p=.025) and loss of LBP (4.12 [1.96-8.64]; p<.001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR=4.97 [1.89-13.09]; p=.001). Loss of LBP impacted both intermediate-risk limbs (HR=2.85 [1.02-7.97]; p=.047 in WIfI stages 1-3) and high-risk limbs (HR=3.99 [1.32-12.11]; p=.014 in WIfI stage 4). However, loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs. 8% major limb amputation at 12-months in limbs without vs. with maintained LBP). CONCLUSIONS Anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Bian Wu
- Department of Surgery, Division of Vascular Surgery, Kaiser Permanente San Francisco Medical Center, CA
| | | | - Iris H Liu
- School of Medicine, University of California San Francisco, CA
| | - Ceazon T Edwards
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Elizabeth M Lancaster
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Shant M Vartanian
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA.
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Wang KK, El Khoury R, Joob A, Jacobs CE, White JV, Schwartz LB. Thoracobifemoral bypass for infrarenal aortic occlusion caused by retroperitoneal fibrosis. J Vasc Surg Cases Innov Tech 2022; 8:132-135. [PMID: 35330901 PMCID: PMC8938248 DOI: 10.1016/j.jvscit.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
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15
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Liu IH, El Khoury R, Wu B, Gasper WJ, Schneider PA, Hiramoto JS, Vartanian SM, Conte MS. WIfI Staging and Long-term Outcomes After Infrainguinal Revascularization for Chronic Limb-threatening Ischemia. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Kulangara R, Bystrom P, El Khoury R, Piel M, Chaney M, Jacobs C, White J, Schwartz L. Extravascular Access Artery Closure After Percutaneous Peripheral Intervention. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.438] [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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17
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El Khoury R, Tammana V, Patton J, Jacobs CE, White JV, Schwartz LB. Small popliteal aneurysm thrombosis after SARS-CoV-2 vaccination. J Vasc Surg Cases Innov Tech 2022; 8:298-299. [PMID: 35578624 PMCID: PMC9095077 DOI: 10.1016/j.jvscit.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Rym El Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Vikram Tammana
- College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jill Patton
- Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
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Chaney M, Martinez-Zavala V, El Khoury R, Joshi G, Jacobs CE, White JV, Schwartz LB. Transposition of left subclavian artery with reimplantation of isolated left vertebral artery before thoracic endovascular aneurysm repair for type B aortic dissection. J Vasc Surg Cases Innov Tech 2022; 8:222-226. [PMID: 35493343 PMCID: PMC9046120 DOI: 10.1016/j.jvscit.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/04/2022] [Indexed: 11/28/2022] Open
Abstract
Understanding and recognizing anatomic anomalies of the aortic arch is important when planning extra-anatomic debranching before thoracic endovascular aortic repair. A rare anomaly is the left vertebral artery aberrantly arising from the aortic arch; found in ∼5% of adults. When present, the artery courses through the carotid sheath at a variable length before entering the third or fourth cervical transverse foramen. In the present report, we have described the case of a 49-year-old man with a symptomatic, enlarging type B aortic dissection with an aberrant left vertebral artery and the novel methods used to surgically correct his pathology.
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Affiliation(s)
- Michael Chaney
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
- Correspondence: Michael Chaney, BS, Department of Surgery, Advocate Lutheran General Hospital, 1775 Dempster St, Park Ridge, IL 60068
| | | | - Rym El Khoury
- Division of Vascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E. Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V. White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B. Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
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Fiore DM, El Khoury R. Isolated idiopathic radial artery aneurysm in an infant. Journal of Pediatric Surgery Case Reports 2022. [DOI: 10.1016/j.epsc.2021.102156] [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: 10/19/2022] Open
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20
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El Khoury R, Tzvetanov I, Estrada EA, McCarroll E, Michal E, Blumeyer J, Guy LG, Laflamme M, Schwartz LB. Intravascular treatment of long segments of experimental peripheral arteries with multiple, serial, balloon-expandable, resorbable scaffolds. JVS Vasc Sci 2022; 3:205-210. [PMID: 35517990 PMCID: PMC9065303 DOI: 10.1016/j.jvssci.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/04/2022] [Indexed: 11/24/2022] Open
Abstract
Symptomatic femoropopliteal occlusive disease has been increasingly treated using endovascular methods. However, restenosis, especially after implantation of permanent metallic stents, has remained common. To date, resorbable scaffolds have failed to achieve sufficient radial strength to enable the successful treatment of long, mobile, peripheral arteries. In the present nonsurvival, large animal experiment, a novel device consisting of multiple, short, serial, balloon-expandable, bioresorbable scaffolds was deployed in arteries subjected to supraphysiologic deformation. Compared with native vessels, the scaffolded arteries continued to bend (113° ± 19° vs 110° ± 20°; P = .10) and shorten (15% ± 15% vs 20% ± 14%; P = .16), unencumbered by the placement of the investigational device. The mean luminal diameter of the scaffolded arteries was preserved without kinks or occlusions in exaggerated flexion (4.7 ± 0.7 vs 4.7 ± 0.5 mm in extension vs flexion; P = .80). Arterial deformation was borne by shortening of the interscaffold spaces (2.2 ± 0.8 mm vs 1.9 ± 0.7 mm in extension vs flexion; P < .01) and the scaffolds themselves (10.7 ± 1.4 mm vs 9.9 ± 1.1 mm in extension vs flexion; P < .01). The results from the present study challenge the perceived limitations of balloon-expandable devices implanted in peripheral mobile arteries. We have presented a bioresorbable scaffold that combines sufficient radial strength to preserve the mean luminal diameter with movement and the flexibility to accommodate femoropopliteal deformation. In the present study, we have described a novel treatment paradigm for femoropopliteal arterial occlusive disease using bioresorbable scaffolds. The balloon-expandable nature and material properties of the polylactide-based scaffolds combined with the short and segmented configuration provided the radial force to resist the physiologic mechanical deformation of the lower extremity artery while accompanying its natural motion. In the present study an acute animal model was tested, and the experimental device is now undergoing a first-in-human clinical trial (ClinicalTrials.gov identifier, NCT04584632).
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Joshi G, Zhang S, Wang K, El Khoury R, Jacobs C, White J, Schwartz L. Predictors of Amputation-free Survival After Endovascular Intervention for Chronic Limb-threatening Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.140] [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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22
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El Khoury R, Woodford C, Ramirez JL, Lancaster EM, Nacari J, Hiramoto JS, Eichler CM, Reilly LM, Iannuzzi JC, Conte MS. Capturing the Complexity of Open Abdominal Aortic Surgery in the Endovascular Era. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.187] [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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23
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El Khoury R, Wu B, Kupiec-Weglinski SA, Eyler LE, Lancaster EM, Hiramoto JS, Vartanian SM, Schneider PA, Simons JP, Conte MS. The Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model Underestimates Mortality After Infrainguinal Revascularization. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.203] [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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24
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Liu IH, Wu B, Krepkiy V, El Khoury R, Ferraresi R, Reyzelman AM, Hiramoto JS, Schneider PA, Conte MS, Vartanian SM. Pedal Arterial Calcification Score Is Associated With Hemodynamic Change and Major Amputation After Revascularization in Chronic Limb-Threatening Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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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25
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El Khoury R, Tzvetanov I, Estrada E, McCarroll E, Blumeyer J, Laflamme M, Guy LG, Schwartz LB. A New Paradigm for Endovascular Treatment of Long Peripheral Arteries. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.151] [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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26
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El Khoury R, Brodmann M, Schneider PA. Progress on developing an effective below-the-knee drug-coated balloon. Rev Cardiovasc Med 2021; 22:585-595. [PMID: 34565062 DOI: 10.31083/j.rcm2203070] [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: 08/02/2021] [Revised: 08/18/2021] [Accepted: 08/25/2021] [Indexed: 11/06/2022] Open
Abstract
Infrapopliteal atherosclerotic disease continues to present the greatest conundrum for effective endovascular therapies. To date, conventional angioplasty has been fraught with early restenosis and recoil in these complex, long, calcified, and occlusive lesions. The success of metallic drug-eluting stents in coronary arteries has not carried over to below-the-knee arteries. Initial promise in paclitaxel-coated balloons has not been demonstrated in large randomized clinical trials. Furthermore, the potential association between paclitaxel and mortality continues to generate tremendous controversy. The goal of this review article is to discuss the evolution and challenges of drug-coated balloon (DCB) science, present the clinical results of currently available tibial DCBs, and introduce new horizons in DCB technology.
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Affiliation(s)
- Rym El Khoury
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA 94143, USA
| | | | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA 94143, USA
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27
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Joshi G, Zhang SM, Wang KK, El Khoury R, Jacobs C, White J, Schwartz L. Predictors of Amputation-free Survival After Endovascular Intervention for Chronic Limb-threatening Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.115] [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: 11/30/2022]
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28
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El Khoury R, Wu B, Kupiec-Weglinski S, Liu IH, Edwards C, Lancaster E, Hiramoto J, Vartanian SM, Schneider PA, Conte MS. Limb-Based Patency Defines Effective Revascularization for Chronic Limb-Threatening Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.369] [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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29
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El Khoury R, Wu B, Kupiec-Weglinski S, Eyler L, Edwards C, Lancaster E, Hiramoto J, Vartanian SM, Schneider PA, Simons JP, Conte MS. The Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model Underestimates Mortality After Infrainguinal Revascularization. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.260] [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: 11/28/2022]
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30
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Liu IH, Wu B, Krepkiy V, El Khoury R, Ferraresi R, Reyzelman A, Hiramoto J, Schneider PA, Conte MS, Vartanian SM. Pedal Arterial Calcification Score Is Associated With Lack of Hemodynamic Improvement and Major Amputation After Revascularization in Chronic Limb-Threatening Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.261] [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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31
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El Khoury R, Wu B, Edwards CT, Lancaster EM, Hiramoto JS, Vartanian SM, Schneider PA, Conte MS. The Global Limb Anatomic Staging System is associated with outcomes of infrainguinal revascularization in chronic limb threatening ischemia. J Vasc Surg 2021; 73:2009-2020.e4. [PMID: 33548444 DOI: 10.1016/j.jvs.2020.12.094] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 09/28/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The Global Limb Anatomic Staging System (GLASS) has been proposed to facilitate clinical decision-making regarding revascularization for chronic limb threatening ischemia (CLTI). The purpose of the present study was to define its relationship to the treatment outcomes in CLTI. METHODS Consecutive patients who had undergone peripheral angiography for rest pain or tissue loss from January 2017 to July 2019 at a tertiary referral center with a dedicated limb preservation program were reviewed. Subjects with significant aortoiliac disease, previous infrainguinal stenting or functioning bypass grafts, or GLASS stage 0 were excluded. The GLASS score was assigned from the preintervention angiography findings, and the treating surgeon determined the primary infrapopliteal target artery pathway for the limb at risk. The demographic data, procedural details, and clinical outcomes were analyzed. RESULTS The study cohort included 167 patients and 194 limbs, of which 175 of 194 limbs (90%) had presented with tissue loss and 149 of 182 limbs (83%) with WIfI (Wound, Ischemia and foot Infection) stage 3 or 4. The GLASS stage was GLASS 1 in 14%, GLASS 2 in 18%, and GLASS 3 in 68%. GLASS 3 anatomy was present in 85% of 52 limbs treated by bypass and 55% of 108 limbs treated by endovascular intervention (EVI; P < .001). Revascularization was not performed in 34 limbs, most of which were GLASS 3 (85%). Immediate technical failure for EVI (ie, failure to establish target artery pathway) occurred exclusively in the setting of GLASS 3 anatomy (n = 13; 22%). After a median follow-up of 10 months, limb-based patency after EVI was significantly lower in GLASS 3 than in GLASS 1 or 2 limbs (42% vs 59%; P = .018). GLASS 3 was associated with reduced major adverse limb events-free survival in both the EVI group (P = .002) and the overall revascularized cohort (P = .001). GLASS 3 was also associated with significantly reduced overall survival, amputation-free survival, and reintervention-free survival. In a Cox proportional hazards model, GLASS 3 (hazard ratio, 2.35; 95% confidence interval, 1.30-4.24; P = .005) and WIfI wound grade 3 (hazard ratio, 2.64; 95% confidence interval, 1.26-5.53; P = .010) were independent predictors of reduced major adverse limb events-free survival after revascularization. CONCLUSIONS GLASS stage 3 was strongly associated with major adverse clinical outcomes after revascularization in patients with CLTI.
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Affiliation(s)
- Rym El Khoury
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Bian Wu
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Ceazon T Edwards
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Elizabeth M Lancaster
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Jade S Hiramoto
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Shant M Vartanian
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Peter A Schneider
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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Joshi G, Ogbudinkpa C, Stecher J, Khoury RE, Resnick DJ, Jacobs CE, White JV, Schwartz LB. Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision. Vasc Endovascular Surg 2020; 55:282-285. [PMID: 33047669 DOI: 10.1177/1538574420966455] [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] [Indexed: 01/17/2023]
Abstract
An 80 year-old gentleman presented with aortoduodenal fistula 2 months after uncomplicated endovascular aneurysm repair (EVAR). Upon laparotomy and fistula takedown, there was no active hemorrhage from the excluded aneurysm. It was theorized the fistula had originated from an occult type II endoleak which had since thrombosed. The duodenum was repaired primarily; the anterior defect in the aneurysm sac was packed and covered with omentum. The patient recovered uneventfully and remains well after 9 months. This is the first case, to our knowledge, of a post-EVAR aortoduodenal fistula successfully treated without endograft excision.
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Affiliation(s)
- Gaurang Joshi
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Chinelo Ogbudinkpa
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Johanna Stecher
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Rym El Khoury
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Daniel J Resnick
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Chad E Jacobs
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - John V White
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Lewis B Schwartz
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
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El Khoury R, Wu B, Edwards CT, Lancaster EM, Hiramoto JS, Vartanian SS, Schneider PA, Conte MS. The Global Limb Anatomic Staging System Predicts Clinical Outcomes in Chronic Limb Threatening Ischemia. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.07.029] [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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El Khoury R, Cataneo JL, Paredes JA, Schwartz AM, Jacobs CE, White JV, Schwartz LB. "Failure-to-Cross" in Patients Undergoing Percutaneous Peripheral Intervention: The Nonreimbursed Procedure. Ann Vasc Surg 2020; 70:349-354. [PMID: 32603846 DOI: 10.1016/j.avsg.2020.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/04/2020] [Accepted: 06/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Percutaneous peripheral intervention (PPI) is often the first mode of therapy for patients with symptomatic arterial occlusive disease. Technical success generally remains high although "failure-to-cross" still complicates 5-20% of cases. Extended efforts to cross long, occlusive lesions can utilize significant hospital and practitioner resources. The hospital is typically reimbursed for this effort as facility fees are charged by the hour and materials are charged per use. However, given the lack of a CPT® code for "failure-to-cross," practitioners are rarely appropriately compensated. The purpose of this study is to analyze the predictors, technical details, outcomes, and costs of "failure-to-cross" during PPI. METHODS All PPI procedures over a 2-year period at a single institution were retrospectively reviewed. Clinical characteristics, results, costs, and reimbursements obtained from hospital cost accounting were compared among successful therapeutic interventions, crossing failures, and diagnostic angiograms without attempted intervention. RESULTS A total of 146 consecutive PPIs were identified; the rate of "failure-to-cross" was 11.6% (17 patients). The majority of patients with "failure-to-cross" were male (82%) with single-vessel runoff (53%). Compared to successful interventions, the incidences of chronic limb-threatening ischemia (82% vs. 70%, P = 0.34) and infrapopliteal occlusive disease were similar (47% vs. 31%, P = 0.20). "Failure-to-cross" procedures were just as long as successful procedures; there were no significant differences in fluoroscopy time (27 ± 10 vs. 24 ± 14 min, P = 0.52), in-room time (106 ± 98 vs. 103 ± 44 min, P = 0.84), or contrast dye volume utilization (73 ± 37 vs. 96 ± 54 mL, P = 0.12). As expected, "failure-to-cross" procedures incurred far higher hospital charges and costs compared to noninterventional diagnostic angiograms (charges $13,311 ± 6,067 vs. $7,690 ± 1,942, P < 0.01; costs $5,289 ± 2,099 vs. $2,826 ± 1,198, P < 0.01). Despite the additional time and effort spent attempting to cross difficult lesions, the operators were reimbursed at the same low rate as a purely diagnostic procedure (average fee charge $7,360; average reimbursement $992). After 1 year, the 17 patients in whom lesions could not be crossed were treated with advanced interventional procedures with success (n = 2), surgical bypass grafting (n = 5), extremity amputation (n = 4), or no additional intervention in their salvaged limb (n = 6). CONCLUSIONS Patients whose lesions cannot be crossed during PPI fare worse than patients undergoing successful interventions. Hospital costs and charges appropriately reflect the high technical difficulty and resource utilization of extended attempts at endovascular therapy. For practitioners, crossing lesions during PPI is truly a "pay-for-performance" procedure in that only successful procedures are reasonably reimbursed.
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Advocate Lutheran General Hospital, University of Illinois at Chicago, Park Ridge, IL
| | - Jose L Cataneo
- Department of Surgery, Advocate Lutheran General Hospital, University of Illinois at Chicago, Park Ridge, IL
| | - Juan A Paredes
- Department of Surgery, Advocate Lutheran General Hospital, University of Illinois at Chicago, Park Ridge, IL
| | | | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, University of Illinois at Chicago, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, University of Illinois at Chicago, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, University of Illinois at Chicago, Park Ridge, IL.
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El Khoury R, Schwartz LB. Reduced patency in left-sided arteriovenous grafts. J Vasc Surg 2020; 72:318. [PMID: 32553402 DOI: 10.1016/j.jvs.2019.08.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Rym El Khoury
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, Ill
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, Ill
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El Khoury R, Schwartz LB. Comparison of Percutaneous Peripheral Intervention Performed in a Dedicated Hybrid Operating Theater vs Cardiac Catheterization Laboratory. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1307] [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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El Khoury R, Greenspahn BR, Jacobs CE, White JV, Schwartz LB. Minimally Invasive Repair of Left Subclavian Artery Aneurysm. Cardiovasc Revasc Med 2019; 21:165-167. [PMID: 31208838 DOI: 10.1016/j.carrev.2019.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/22/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Abstract
A 79 year-old gentleman with a history of trauma resulting in paraplegia was being evaluated for vascular access for hemodialysis. Cardiac catheterization revealed a large, asymptomatic left subclavian artery aneurysm. The patient was taken to the hybrid vascular intervention suite. A small incision was made in the left arm to gain access to the left brachial artery into which a sheath was inserted. The aneurysm was crossed with a wire through which two, overlapping covered stents were deployed completely excluding the aneurysm. The patient was discharged to home the following day. Endovascular exclusion has become the treatment of choice for aneurysms of the subclavian artery.
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, United States of America
| | - Bruce R Greenspahn
- Division of Cardiology, Advocate Lutheran General Hospital, Park Ridge, IL, United States of America
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, United States of America
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, United States of America
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, United States of America.
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El Khoury R, Nikanorov A, McCarroll E, LeClerc G, Guy LG, Laflamme M, Mailloux A, Schwartz LB. An Animal Model of Human Peripheral Arterial Bending and Deformation. J Surg Res 2019; 241:240-246. [PMID: 31035138 DOI: 10.1016/j.jss.2019.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/02/2019] [Accepted: 04/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Designing peripheral arterial stents has proved challenging, as implanted devices will repetitively and unpredictably deform and fatigue during movement. Preclinical testing is often inadequate, given the lack of relevant animal models. The purpose of this study was to test the hypothesis that deformation of the human peripheral vasculature could be qualitatively and quantitatively modeled using an experimental animal. METHODS Anteroposterior contrast angiography was performed in domestic Landrace-Yorkshire farm pigs. Images were obtained with the hind limbs naturally extended then repeated, (1) flexed approximately 90° at the hip and knee, (2) overflexed in a nonphysiological fashion. Quantitative vascular angiographic analysis was utilized to measure arterial diameter, length, and deformation. Percent axial arterial compression and bending were assessed. RESULTS Eight iliofemoral arteries in four animals were imaged. Mean luminal diameters of the iliac and femoral segments in the neutral position were 5.4 ± 0.5 mm and 4.6 ± 0.5 mm. Hind limb physiologic flexion induced profound arterial compression, 17 ± 8% and 29 ± 6% and bending, 36°±10° and 76° ± 13° within the iliac and femoral segments, respectively. With extreme flexion, the femoral artery could be reliably bent >90°. The observed findings exceeded the deformation observed historically within the human superficial femoral (∼5% compression and 10° bending) and popliteal artery (∼10% compression and 70° bending). CONCLUSIONS Significant nonradial deformation of the porcine iliofemoral arteries was observed during manual hind limb flexion and exceeded that typically observed in humans. This model constitutes a "worst case" scenario for testing deformation and fatigue of intravascular devices indicated for the human peripheral vasculature.
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | | | | | | | | | | | | | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois; Efemoral Medical, L.L.C, Los Altos, California.
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El Khoury R, Kunda NM, Keldahl ML. Endovascular treatment of a penetrating injury of the suprarenal inferior vena cava. J Vasc Surg Venous Lymphat Disord 2019; 7:247-250. [DOI: 10.1016/j.jvsv.2018.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 10/03/2018] [Indexed: 01/10/2023]
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40
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El Khoury R, Cataneo JL, Paredes JA, Schwartz AM, Jacobs CE, White JV, Schwartz LB. CRT-200.11 “Failure-to-Cross” in Patients Undergoing Percutaneous Peripheral Intervention: The Non-Reimbursed Procedure. JACC Cardiovasc Interv 2019. [DOI: 10.1016/j.jcin.2019.01.100] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Khoury RE, Kabir C, Maker VK, Banulescu M, Wasserman M, Maker AV. What is the Incidence of Malignancy in Resected Intraductal Papillary Mucinous Neoplasms? An Analysis of Over 100 US Institutions in a Single Year. Ann Surg Oncol 2018; 25:1746-1751. [PMID: 29560572 DOI: 10.1245/s10434-018-6425-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND A subset of intraductal papillary mucinous neoplasms (IPMNs) will progress to invasive adenocarcinoma, however identifying invasive from non-invasive disease preoperatively remains challenging. The rate of malignancy in resected IPMNs in the US remains unclear. OBJECTIVE We aimed to determine the rate of malignancy and factors associated with high-risk pathology in resected IPMNs. METHODS The most recent annual cohort of patients undergoing pancreatectomy included in the American College of Surgeons National Surgical Quality Improvement Program were assessed, and contributions of demographics, preoperative laboratory values, and outcome data to level of IPMN dysplasia were analyzed. The main outcomes were incidence of invasive carcinoma or high-grade dysplasia. RESULTS Of 5025 pancreatectomies in 1 year, 478 patients underwent pancreatectomy for IPMN. Invasive carcinoma/high-grade dysplasia was identified in 23% of resected lesions, and there was no difference in patient characteristics or type of resection performed in patients with invasive versus non-invasive pathology. Patients with invasive IPMNs presented significantly more often with high liver function tests, >10% weight loss, clinical jaundice and stent placement, and were more likely to undergo an open operation (p = 0.03). There were no differences in perioperative outcomes. Adjusted logistic regression identified an association between invasive disease and non-soft pancreatic gland texture (odds ratio 0.19, 95% confidence interval 0.05-0.68, p < 0.01). CONCLUSIONS Approximately 10% of all pancreatectomies in the US are for IPMNs. In these patients, treated after the revised international consensus guidelines, only 23% of IPMNs contained invasive or high-grade histology. Resections carried similar morbidity regardless of pathology. Improved biomarkers are needed to aid in surgical selection.
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Affiliation(s)
- Rym El Khoury
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Christopher Kabir
- Advocate Research Institute, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Margaret Wasserman
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA. .,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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El Khoury R, Nikanorov A, Biondi-Zoccai G, Schwartz LB. The application of biobased polymers to peripheral intravascular stent development. Ital J Vasc Endovasc Surg 2018. [DOI: 10.23736/s1824-4777.17.01314-6] [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: 02/05/2023]
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Sternbach JM, Wang K, El Khoury R, Teitelbaum EN, Meyerson SL. Measuring Error Identification and Recovery Skills in Surgical Residents. Ann Thorac Surg 2017; 103:663-669. [DOI: 10.1016/j.athoracsur.2016.06.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 11/16/2022]
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Bourguignon T, Lhommet P, El Khoury R, Candolfi P, Loardi C, Mirza A, Boulanger-Lothion J, Bouquiaux-Stablo-Duncan AL, Marchand M, Aupart M. Very long-term outcomes of the Carpentier-Edwards Perimount aortic valve in patients aged 50-65 years. Eur J Cardiothorac Surg 2015; 49:1462-8. [PMID: 26530269 DOI: 10.1093/ejcts/ezv384] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 09/30/2015] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Aortic valve replacement (AVR) using a bioprosthesis remains controversial for patients aged 50-65 years. This cohort study reports the very long-term outcomes of AVR using Carpentier-Edwards Perimount pericardial bioprosthesis in this age group. METHODS From 1984 to 2008, 522 Carpentier-Edwards Perimount pericardial aortic bioprostheses were implanted in 516 patients aged 50-65 years (mean age, 60 ± 4 years; 19% female). Multiple valve replacements were excluded fro m our cohort. Baseline demographic, perioperative and follow-up data were recorded prospectively. Mean follow-up was 9 ± 6 years, for a total of 4428 valve-years. Follow-up was complete for 97% of patients included. RESULTS Operative mortality rate was 2%. One hundred and forty-six late deaths occurred for a linearized rate of 3%/valve-year. Actuarial survival rates averaged 73 ± 2, 59 ± 3 and 35 ± 5% after 10, 15 and 20 years of follow-up, respectively. Mortality rate associated with reoperation was 2%. Actuarial freedom from reoperation rates due to structural valve deterioration (SVD) at 10, 15 and 20 years was respectively of 91 ± 2, 76 ± 3 and 50 ± 6%. Competing risk analysis demonstrated an actual risk of explantation secondary to SVD at 20 years of 30 ± 3%. Expected valve durability was 19 years for this age group. Age was not a significant risk factor for SVD in this middle-aged population. CONCLUSIONS In patients aged 50-65 years undergoing AVR with the Carpentier-Edwards Perimount bioprosthesis, the expected valve durability was 19 years. Age was not a significant risk factor for SVD within this age group. Patient selection and attention to timing of reintervention may be determinants of long-term outcomes.
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Affiliation(s)
| | - Pierre Lhommet
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
| | - Rym El Khoury
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
| | - Pascal Candolfi
- Department of Biostatistics, Edwards Lifesciences, Nyon, Switzerland
| | - Claudia Loardi
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
| | - Alain Mirza
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
| | | | | | - Michel Marchand
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
| | - Michel Aupart
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
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El Khoury R, Ramirez M, Hungness ES, Soper NJ, Patti MG. Symptom Relief After Laparoscopic Paraesophageal Hernia Repair Without Mesh. J Gastrointest Surg 2015; 19:1938-42. [PMID: 26242885 DOI: 10.1007/s11605-015-2904-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic repair of paraesophageal hernia (LPEHR) is considered today the standard of care for this condition. While attention has been mostly focused on the incidence of postoperative radiologic recurrence of a hiatal hernia, few data are available about the effect of the operation on symptoms. AIMS In this study, we aim to determine the effect of primary LPEHR on postoperative symptoms. PATIENTS AND METHODS One hundred and sixty-two patients underwent LPEH repair in two academic tertiary care centers. Preoperative evaluation included barium swallow (100 %), endoscopy (80 %), manometry (81 %), and pH monitoring (25 %). Type III PEH was the most common (94 %), and it was associated with a gastric volvulus in 27 % of patients. RESULTS A fundoplication was performed in all patients: Nissen in 57 %, Dor in 36 %, and Toupet in 6 %. A Collis gastroplasty was added in 6 % of patients. There were no perioperative deaths. The intraoperative complication rate was 7 %. The operation was completed laparoscopically in 98 % of patients. Postoperative complications occurred in four patients, and three needed a second operation. Average follow-up was 24 months. Heartburn, regurgitation, chest pain, dysphagia, respiratory symptoms, and hoarseness improved as a result of the operation. Anemia fully resolved in all patients. CONCLUSIONS LPEH repair is safe and effective, and the need for reoperation is rare. Few patients experience postoperative symptoms, and these are easily controlled with acid-reducing medications.
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Northwestern University, 676 North Saint Clair, Suite 650, Chicago, IL, 60611, USA.
| | | | - Eric S Hungness
- Department of Surgery, Northwestern University, 676 North Saint Clair, Suite 650, Chicago, IL, 60611, USA
| | - Nathaniel J Soper
- Department of Surgery, Northwestern University, 676 North Saint Clair, Suite 650, Chicago, IL, 60611, USA
| | - Marco G Patti
- Department of Surgery, University of Chicago, Chicago, IL, USA
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Khoury RE, Sternbach JM, Teitelbaum EN, Soper NJ, Hungness ES. Esophagogastric junction distensibility measured by a functional lumen imaging probe with incremental gastric myotomy lengths in achalasia. Surg Endosc 2015. [PMID: 26201416 DOI: 10.1007/s00464-015-4437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rym El Khoury
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA.
| | - Joel M Sternbach
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - Nathaniel J Soper
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - Eric S Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
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Sternbach JM, El Khoury R, Teitelbaum EN, Soper NJ, Pandolfino JE, Hungness ES. Early esophagram in per-oral endoscopic myotomy (POEM) for achalasia does not predict long-term outcomes. Surgery 2015; 158:1128-35; discussion 1135-6. [PMID: 26189954 DOI: 10.1016/j.surg.2015.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/26/2015] [Accepted: 05/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the recently reported international survey of centers performing per-oral endoscopic myotomy (POEM), 88% of operators reported obtaining routinely an early postoperative contrast esophagram. To date, there have been no studies to assess the prognostic value of early esophagram in POEM. METHODS A retrospective review of a prospectively maintained, single-institution database of patients who underwent POEM for treatment of achalasia was conducted. Patients were evaluated with a routine contrast esophagram on the first postoperative day (POD#1) to assess for perforation. The finding of delayed esophageal emptying, as determined by an attending radiologist, was compared with the patients' symptomatic outcomes and functional parameters at one year follow-up. RESULTS Contrast esophagram was obtained on POD#1 for 72 patients undergoing POEM; 26 patients (36%) were observed to have a delay in esophageal emptying. Both groups of patients, those with a delay and those without a delay in esophageal emptying on POD#1, had similar preoperative Eckardt scores (7 ± 2 vs 7 ± 2, P = ns) and column height at 5 minutes on preoperative timed barium esophagram (12.1 ± 8 cm vs 14.1 ± 8 cm, P = ns). At a mean follow-up of 1 year, there was no difference in Eckardt scores between patients with and those without a delay in emptying on POD#1 esophagram (1 ± 2 vs 1 ± 1, P = ns), nor was there a difference between the 2 groups in column height at 5 minutes on TBE (5.5 ± 5 cm for delay vs 4.2 ± 4 cm for no delay; P = ns). Rates of treatment failure, as measured by Eckardt score >3 or need for subsequent treatment, also did not differ between the 2 groups (3 patients with delay vs 4 patients without delay in emptying, P = ns). CONCLUSION Delay in passage of contrast on POD#1 esophagram did not predict symptomatic or physiologic outcomes at 1-year follow-up in patients undergoing POEM for treatment of achalasia.
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Affiliation(s)
- Joel M Sternbach
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rym El Khoury
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Eric S Hungness
- Northwestern University Feinberg School of Medicine, Chicago, IL.
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