Section of Vascular Surgery

Indianapolis, IN, United States

Section of Vascular Surgery

Indianapolis, IN, United States
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Thomas B.G.,Section of Vascular Surgery | Sanchez L.A.,Section of Vascular Surgery | Geraghty P.J.,Section of Vascular Surgery | Rubin B.G.,Section of Vascular Surgery | And 2 more authors.
Journal of Vascular Surgery | Year: 2010

Objective: Proximal attachment failure, often leading to graft migration, is a severe complication of endovascular aneurysm repair (EVAR). Aortic cuffs have been used to treat proximal attachment failure with mixed results. The Zenith Renu AAA Ancillary Graft (Cook Inc, Bloomington, Ind) is available in two configurations: converter and main body extension. Both provide proximal extension with active fixation for the treatment of pre-existing endovascular grafts with failed or failing proximal fixation or seal in patients who are not surgical candidates. We prospectively compared the outcomes of patient treatment with these two device configurations. Methods: From September 2005 to May 2008, a prospective, nonrandomized, postmarket registry was conducted to collect data from 151 patients treated at 95 institutions for proximal aortic endovascular graft failure using the Renu graft. Treatment indications included inadequate proximal fixation or seal, for example, migration, and type I and III endoleak. A total of 136 patients (90%) had migration, 111 (74%) had endoleak, and 94 (62%) had endoleaks and graft migration. AneuRx grafts were present in 126 patients (83%), of which 89 (59%) were treated with a converter and 62 (41%) with a main body extension. Outcomes using converters vs main body extensions for endoleak rates, changes in aneurysm size, and ruptures were compared. Results: Preprocedural demographics between the two groups did not differ significantly. Procedural success rates were 98% for the converter group and 100% for the main body extension group. At a mean follow-up of 12.8 ± 7.5 months, no type III endoleaks (0%)were identified in the converter group, and five (8%) were identified in the main body extension group. There were no aneurysm ruptures in patients treated with converters (0%) and three ruptures (5%) in patients treated with main body extensions. Each patient with aneurysm rupture had been treated with a Renu main body extension, developed a type III endoleak, and underwent surgical conversion. Two of the three patients died postoperatively. Conclusions: Proximal attachment failure and graft migration are potentially lethal complications of EVAR. Proximal graft extension using an aortic cuff is the easiest technique for salvaging an endovascular graft. Unfortunately, it has a predictable failure mode (development of a type III endoleak due to component separation) and is associated with a significantly higher failure rate than with the use of a converter. EVAR salvage with a converter and a femorofemoral bypass is a more complex but superior option for endovascular graft salvage. © 2010 Society for Vascular Surgery.


Bekelis K.,Dartmouth Hitchcock Medical Center | Missios S.,Cleveland Clinic | Labropoulos N.,Section of Vascular Surgery
Journal of NeuroInterventional Surgery | Year: 2014

Background: The Institute of Medicine called attention to the pervasive differences in treatments and outcomes between ethnic groups. We sought to highlight the geographic and racial disparities in access to treatment for unruptured cerebral aneurysms. Methods: We performed a retrospective cohort study involving patients with unruptured cerebral aneurysms from 2000 to 2010, registered in the National Inpatient Sample (NIS) database. Primary outcomes were those patients receiving treatment and the ratio of untreated to treated aneurysms per state. The purpose of this study was to determine if there were geographic and racial disparities in access to treatment of unruptured cerebral aneurysms based on the NIS. Logistic regression and analysis of variance (ANOVA) techniques were used. Results: There were 57 418 patients diagnosed with unruptured aneurysms (mean age 61.4 years, 70.5% females), with 18 231 undergoing treatment. Males (OR 0.67, 95% CI 0.64 to 0.71, p<0.0001), Asian (OR 0.88, 95% CI 0.81 to 0.96, p=0.003), Hispanic (OR 0.76, 95% CI 0.65 to 0.90, p=0.001), African American (OR 0.57, 95% CI 0.53 to 0.62, p<0.0001), and patients without insurance (OR 0.76, 95% CI 0.67 to 0.87, p<0.0001) were associated with decreased chance of treatment. The opposite was true for lower Charlson Comorbidity Index (OR 3.03, 95% CI 2.71 to 3.39, p<0.0001), coverage by Medicaid (OR 1.12, 95% CI 1.03 to 1.23, p=0.012), or private insurance (OR 1.92, 95% CI 1.80 to 2.04, p<0.0001), and lower income (OR 1.22, 95% CI 1.15 to 1.31, p<0.0001). Significant regional variability was observed among the different states ( p=0.006, ANOVA), with Maryland being an outlier. Conclusions: Based on the NIS database, the rate of treatment of unruptured cerebral aneurysms varies according to sex, race, and region.


Pannucci C.J.,Section of Plastic Surgery | Laird S.,Michigan Surgical Quality Collaborative | Campbell D.A.,University of Michigan | Henke P.K.,Section of Vascular Surgery | Henke P.K.,University of Michigan
Chest | Year: 2014

Background: VTE is the proximate cause of 100,000 deaths in the United States each year. Perioperative VTE risk among surgical patients varies by 20-fold, which highlights the importance of risk stratification to identify high-risk patients, in whom chemoprophylaxis can decrease VTE risk, and low-risk patients, for whom the risk-benefi t relationship of prophylaxis may be unfavorable. Methods: We used data from a statewide surgical quality collaborative for surgical procedures performed between 2010 and 2012. Regression-based techniques identifi ed predictors of 90-day VTE while adjusting for procedural complexity and comorbid conditions. A weighted risk index was created and was validated subsequently in a separate, independent dataset. Results: Data were available for 10,344 patients, who were allocated randomly to a derivation or validation cohort. The 90-day VTE rate was 1.4%; 66.2% of the derivation cohort and 65.5% of the validation cohort received chemoprophylaxis. Seven risk factors were incorporated into a weighted risk index: personal history of VTE, current cancer, sepsis/septic shock/systemic infl ammatory response syndrome, age ≥ 60 years, BMI ≥40 kg/m 2 , male sex, and family history of VTE. Prediction for 90-day VTE was similar in the derivation and validation cohorts (areas under the receiver operator curve, 0.72 and 0.70, respectively). An 18-fold variation in 90-day VTE rate was identified. Conclusions: A weighted risk index quantifi es 90-day VTE risk among surgical patients and identifies an 18-fold variation in VTE risk among the overall surgical population. © 2014 American College of Chest Physicians.


Bekelis K.,Section of Neurosurgery | Missios S.,Portsmouth Hospital | Desai A.,Section of Neurosurgery | Labropoulos N.,Section of Vascular Surgery | And 2 more authors.
Journal of Neurosurgery | Year: 2014

Object. Precise delineation of individualized risks of morbidity and mortality is crucial in decision making in cerebrovascular neurosurgery. The authors attempted to create a predictive model of complications in patients undergoing cerebral aneurysm clipping (CAC). Methods. The authors performed a retrospective cohort study of patients who had undergone CAC in the period from 2005 to 2009 and were registered in the Nationwide Inpatient Sample (NIS) database. A model for outcome prediction based on preoperative individual patient characteristics was developed. Results. Of the 7651 patients in the NIS who underwent CAC, 3682 (48.1%) had presented with unruptured aneurysms and 3969 (51.9%) with subarachnoid hemorrhage. The respective inpatient postoperative risks for death, unfavorable discharge, stroke, treated hydrocephalus, cardiac complications, deep vein thrombosis, pulmonary embolism, and acute renal failure were 0.7%, 15.3%, 5.3%, 1.5%, 1.3%, 0.6%, 2.0%, and 0.1% for those with unruptured aneurysms and 11.5%, 52.8%, 5.5%, 39.2%, 1.7%, 2.8%, 2.7%, and 0.8% for those with ruptured aneurysms. Multivariate analysis identified risk factors independently associated with the above outcomes. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated using the area under the receiver operating characteristic curve, and it was found to have good discrimination. Conclusions. The featured model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and can potentially be used as an adjunct in decision making in cerebrovascular neurosurgery. ©AANS, 2014.


Thompson A.M.,Section of Vascular Surgery | Martin K.A.,Yale University | Rzucidlo E.M.,Section of Vascular Surgery
PLoS ONE | Year: 2014

Phenotypic plasticity in vascular smooth muscle cells (VSMC) is necessary for vessel maintenance, repair and adaptation to vascular changes associated with aging. De-differentiated VSMC contribute to pathologies including atherosclerosis and intimal hyperplasia. As resveratrol has been reported to have cardio- protective effects, we investigated its role in VSMC phenotypic modulation. We demonstrated the novel finding that resveratrol promoted VSMC differentiation as measured by contractile protein expression, contractile morphology and contraction in collagen gels. Resveratrol induced VSMC differentiation through stimulation of SirT1 and AMPK. We made the novel finding that low or high dose resveratrol had an initially different mechanism on induction of differentiation. We found that low dose resveratrol stimulated differentiation through SirT1-mediated activation of AKT, whereas high dose resveratrol stimulated differentiation through AMPK-mediated inhibition of the mTORC1 pathway, allowing activation of AKT. The health effects of resveratrol in cardiovascular diseases, cancer and longevity are an area of active research. We have demonstrated a supplemental avenue where-by resveratrol may promote health by maintaining and enhancing plasticity of the vasculature. © 2014 Thompson et al.


Suckow B.D.,University of Utah | Kraiss L.W.,University of Utah | Schanzer A.,University of Massachusetts Medical School | Stone D.H.,Section of Vascular Surgery | And 4 more authors.
Journal of Vascular Surgery | Year: 2015

Objective Although statin therapy has been linked to fewer short-term complications after infrainguinal bypass, its effect on long-term survival remains unclear. We therefore examined associations between statin use and long-term mortality, graft occlusion, and amputation after infrainguinal bypass. Methods We used the Vascular Study Group of New England registry to study 2067 patients (71% male; mean age, 67 ± 11 years; 67% with critical limb ischemia [CLI]) who underwent infrainguinal bypass from 2003 to 2011. Of these, 1537 (74%) were on statins perioperatively and at 1-year follow-up, and 530 received no statin. We examined crude, adjusted, and propensity-matched rates of 5-year surviva1, 1-year amputation, graft occlusion, and perioperative myocardial infarction. Results Patients taking statins at the time of surgery and at the 1-year follow-up were more likely to have coronary disease (38% vs 22%; P <.001), diabetes (51% vs 36%; P <.001), hypertension (89% vs 77%; P <.001), and prior revascularization procedures (50% vs 38%; P <.001). Despite higher comorbidity burdens, long-term survival was better for patients taking statins in crude (risk ratio [RR], 0.7; P <.001), adjusted (hazard ratio, 0.7; P =.001), and propensity-matched analyses (hazard ratio, 0.7; P =.03). In subgroup analysis, a survival advantage was evident in patients on statins with CLI (5-year survival rate, 63% vs 54%; log-rank, P =.01) but not claudication (5-year survival rate, 84% vs 80%; log-rank, P =.59). Statin therapy was not associated with 1-year rates of major amputation (12% vs 11%; P =.84) or graft occlusion (20% vs 18%; P =.58) in CLI patients. Perioperative myocardial infarction occurred more frequently in patients on a statin in crude analysis (RR, 2.2; P =.01) but not in the matched cohort (RR, 1.9; P =.17). Conclusions Statin therapy is associated with a 5-year survival benefit after infrainguinal bypass in patients with CLI. However, 1-year limb-related outcomes were not influenced by statin use in our large observational cohort of patients undergoing revascularization in New England. © 2015 Society for Vascular Surgery.


Wagner R.J.,Section of Vascular Surgery | Martin K.A.,Section of Vascular Surgery | Martin K.A.,Yale University | Powell R.J.,Section of Vascular Surgery | Rzucidlo E.M.,Section of Vascular Surgery
American Journal of Physiology - Cell Physiology | Year: 2010

It is becoming increasingly clear that cholesterol-independent effects of statins also contribute to the cardioprotective effects, but these mechanisms remain poorly understood. We investigated the effects of lovastatin on vascular smooth muscle phenotype. We have previously shown that mammalian target of rapamycin complex 1 (mTORC1) inhibition with rapamycin induces vascular smooth muscle cell (VSMC) differentiation. We found that lovastatin also inhibits mTORC1 signaling and that this inhibition is required for VSMC differentiation. Lovastatin inhibition of mTORC1 was farnesylation dependent, suggesting the farnesylated G protein Rheb (Ras homologue enriched in brain), a known upstream activator of mTORC1. Rheb overexpression induced mTORC1 activity and repressed contractile protein expression, but a farnesylation-deficient mutant (C18S) elicited the opposite effect. Rheb knockdown with small interfering RNA was also sufficient to inhibit mTORC1 and induce contractile protein expression, and it prevented statin-induced VSMC differentiation. Notably, mTORC1 activity was elevated in VSMC isolated from an intimal hyperplastic patient lesion compared with normal media, and lovastatin treatment inhibited mTORC1 activity in these cultures. Furthermore, lovastatin inhibited mTORC1 activity and prevented the downregulation of contractile protein expression in an ex vivo angioplasty model. In conclusion, these findings illustrate a mechanism for the cardioprotective effects of lovastatin through inhibition of Rheb and mTORC1 and promotion of a differentiated VSMC phenotype. Copyright © 2010 the American Physiological Society.


Hogendoorn W.,Section of Vascular Surgery | Schlosser F.J.V.,Section of Vascular Surgery | Muhs B.E.,Section of Vascular Surgery | Popescu W.M.,Yale University
Current Opinion in Anaesthesiology | Year: 2014

PURPOSE OF REVIEW: Ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening disease. In the last decade, thoracic endovascular aortic repair (TEVAR) has evolved as a viable option and is now considered the preferred treatment for rDTAAs. New opportunities as well as new challenges are faced by both the surgeon and the anesthesiologist. This review describes the impact of current developments and new modalities for the surgical and anesthetic management of rDTAAs. RECENT FINDINGS: A collaborative approach between the anesthesiologist and surgeon during critical moments such as induction, moment of aortic occlusion and placement of the aortic stent-graft is mandatory. Important issues to consider on preoperative imaging evaluation are correct sizing of the aortic stent-graft and localization of the artery of Adamkiewicz. Emergency TEVAR should preferentially be started under local anesthesia and could be switched to general anesthesia after stent placement. Patients should be kept in permissive hypotension preoperatively and during the intervention before stent-graft deployment and relative hypertension after deployment. The use of a proactive spinal cord protection protocol could decrease the risk of spinal cord ischemia and/or paraplegia and consists of permissive hypertension after stent deployment, cerebrospinal fluid drainage to maintain adequate spinal cord perfusion, relative hypothermia and possibly use of mannitol. SUMMARY: In order to improve outcomes of TEVAR for rDTAA, a close communication between the anesthesiologist and the surgeon and a thorough understanding of the events during the procedure is mandatory. The use of a proactive spinal cord protection protocol may decrease the rates of devastating spinal cord ischemia. © 2014 Lippincott Williams and Wilkins.


Thompson A.M.,Section of Vascular Surgery | Wagner R.,Section of Vascular Surgery | Rzucidlo E.M.,Section of Vascular Surgery
American Journal of Physiology - Heart and Circulatory Physiology | Year: 2014

Loss of vascular smooth muscle cell (VSMC) function is a hallmark of vascular disease. VSMCs become increasingly dysregulated, apoptotic, and senescent as we age. Sirtuin 1 (SirT1) is a deactylase that regulates substrates associated with stress mitigation, metabolism, and aging. Our aim was to examine the role of SirT1 in vascular aging and the function this protein plays in the context of cellular response to stress and senescence. We compared endogenous SirT1 expression in young and old human donors. Human VSMC (HuVSMC) from donors ranging in age from 12 to 88 (n = 14) were isolated and cultured. In cultured HuVSMC the levels of endogenous SirT1 were examined by Western blot analysis. We found that endogenous SirT1 protein expression inversely correlated with donor age. Additionally, we demonstrated that age-related loss of SirT1 correlated in functional deficits, diminished stress response, reduced capacity for migration, and proliferation and increased senescence. Manipulation of SirT1 levels in young cells confirmed the role of SirT1 in cellular migration and proliferation capability. Furthermore, we demonstrated that age-related loss of SirT1 was associated with the induction of VSMC senescence. With correlation to symptomatic disease, we demonstrated a significant difference in SirT1 levels from HuVSMC isolated from aged arteries that were occluded with atherosclerotic lesions (n = 7), compared with patent sections of the same artery. Having demonstrated that endogenous SirT1 is lost with age, which correlates with a loss of capacity for vascular repair, our data explain one of the molecular changes that occurs in the aged vasculature. © 2014 the American Physiological Society.


Krishnamurthy V.N.,Section of Vascular and Interventional Radiology | Eliason J.L.,Section of Vascular Surgery | Henke P.K.,Section of Vascular Surgery | Rectenwald J.E.,Section of Vascular Surgery
Annals of Vascular Surgery | Year: 2010

Background: Endovascular revascularization of chronic total occlusion (CTO) of the iliac arteries is rapidly becoming first-line treatment, with surgical aortofemoral bypass procedures reserved for failure of endovascular treatment. Percutaneous subintimal recanalization is the most common endovascular revascularization technique for CTO of the iliac arteries. The primary reason for failure of the subintimal recanalization technique is failure to reenter the true lumen. This report describes the benefits of using true lumen reentry devices to improve the success and safety of conventional subintimal recanalization for revascularization of CTO of the iliac arteries. Methods: This is a retrospective review of 11 patients with CTO of the iliac arteries in whom true lumen reentry was not successful using conventional subintimal recanalization. An intravascular ultrasound (IVUS)-guided true lumen reentry device was used in all patients to assist true lumen reentry. Clinical records, procedural records, angiographic imaging, and follow-up data were analyzed. Indications for intervention, length and location of the lesion treated, access site(s), location of true lumen reentry, stent use, procedural times, technical success, and complications were analyzed in all patients. Results: The technical success of true lumen reentry at the desired point was 100%. Total procedure time from the start of reentry device manipulation to achieve reentry was <10 min (routinely <5 min). Mean patient follow-up was 10.5 months. At follow-up, all patients had palpable femoral pulses. The ankle-brachial index normalized (>0.9) in six patients and improved significantly in the remaining five patients. Rest pain resolved and claudication improved in all patients. Out of seven patients who had foot ulcers, the ulcers healed completely in five and demonstrated improved healing in two, with the clinical manifestation of osteomyelitis resolved in two. No procedure-related complications were noted. The amputation-free survival was 100%. Conclusion: True lumen reentry devices greatly improve the technical success and safety of percutaneous recanalization procedures in CTO of the iliac arteries. There are significant reductions in procedure time and complication rates associated with the use of these devices.

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