87 results on '"Dodson TF"'
Search Results
2. Shoulder Harness Traction for Roentgenographic Assessment of the Cervical Spine
- Author
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Norris Cs, Dodson Tf, Silva We, and Darrow J
- Subjects
Adult ,Male ,Shoulder ,medicine.medical_specialty ,Radiography ,medicine.medical_treatment ,Random Allocation ,Traction ,medicine ,Humans ,Prospective Studies ,Cervical fracture ,business.industry ,Glasgow Coma Scale ,Traction (orthopedics) ,medicine.disease ,Standard technique ,Cervical spine ,Surgery ,medicine.anatomical_structure ,Accidents ,Cervical Vertebrae ,Manual traction ,Female ,Emergencies ,business ,Cervical vertebrae - Abstract
We evaluated the clinical usefulness of a new shoulder traction device to facilitate a rapid complete cervical spine examination in an uncooperative patient population with multiple trauma. Forty-eight patients were randomly designated to receive the shoulder traction device or the standard technique (manual traction on the patient's upper extremities). Patient groups were equivalent in mean coma scale scores, trauma scores, age, and incidence of cervical fracture. Male-female ratios differed between groups, yet were biased against the harness technique. Fewer roentgenograms (lateral view) were required to visualize adequately all cervical vertebrae when the harness device was utilized (mean roentgenograms per patient, 1.2 vs 2.6; P less than .01). Shoulder harness traction during roentgenographic evaluation of the cervical spine may be a useful method to promote visibility of the lower cervical vertebrae.
- Published
- 1986
3. From the Base of the Cecum to the Throne of England: King Edward VII's Appendix.
- Author
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Lovasik BP, Dodson TF, and Srinivasan JK
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- Humans, Retrospective Studies, England, Appendectomy, Cecum, Appendix, Appendicitis diagnosis, Appendicitis surgery
- Abstract
This historical retrospective explores the case of King Edward VII's appendicitis at the time of his planned coronation in 1902, as well as the contributions of the king's surgeons Frederick Treves and Joseph Lister, towards his medical care. The history of appendicitis, as well as a view of the king's medical management in the lens of modern surgical and sociopolitical contexts, is also examined.
- Published
- 2023
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4. Heineke, Mikulicz, Jaboulay, and Finney: Innovators of Surgical Pyloroplasty.
- Author
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Lovasik BP, Dodson TF, and Srinivasan JK
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- Digestive System Surgical Procedures methods, Europe, History, 19th Century, History, 20th Century, Humans, Pyloric Stenosis surgery, United States, Digestive System Surgical Procedures history, Pyloric Stenosis history, Pylorus surgery
- Abstract
This historical retrospective explores the history of the gastric pyloroplasty through the lives of the 4 surgeons whose eponymous procedures have defined the operative management of pyloric strictures: Heineke, Mikulicz, Jaboulay, and Finney. Today's gastrointestinal surgeons employ a combination of techniques that highlight the rich and colorful history of their field.
- Published
- 2021
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5. Residents Behaving Badly: Pioneering Operations and the Surgical Trainees Who Performed Them.
- Author
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Lovasik BP, Dodson TF, Delman KA, and Srinivasan JK
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- Clinical Competence, Education, Medical, Graduate, Internship and Residency
- Published
- 2020
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6. Value of Dedicated Research Time for IMGs in Obtaining Surgical Residency Training Positions: A 10-Year Review of Applicants from a Medical College in Pakistan.
- Author
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Jajja MR, Tariq M, Hashmi SS, Dodson TF, and Ahmed R
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- Female, Humans, Male, Pakistan, Time Factors, United States, Biomedical Research statistics & numerical data, Foreign Medical Graduates, General Surgery education, Internship and Residency statistics & numerical data, Job Application, Schools, Medical
- Abstract
Objective: International Medical Graduates (IMGs) secured greater than 10% of all general surgery (GS) residency positions in the US during the past decade. The Match process remains competitive, with a significant number of IMGs performing dedicated research before residency application. The impact of such research remains largely unknown. We aimed to provide an objective analysis of the impact of dedicated research time on obtaining a categorical GS residency position., Design: Data for National Resident Matching Program Match results from 2008-2017 was compiled from annual Match lists of the Aga Khan University, Medical College (Karachi, Pakistan). Medical graduates provided this information voluntarily each year. Data was exported to Microsoft Excel and used for descriptive and statistical analysis using SPSS. Candidates were divided into quasi-experimental groups based on their preference for direct application (no-research group, n = 64) or research prior to Match (research group, n = 20)., Results: A total of 84 IMG applicants matched into GS residency positions in the US within the past decade. Amongst these, 18 matched directly into categorical positions while 66 applicants secured preliminary spots. A total of 37 (56%) preliminary candidates eventually secured categorical GS residency positions. Research group applicants had an overall 85% (n = 17) success rate of obtaining a categorical position, while no-research group had a 59% (n = 39) success rate (chi-square test, p = 0.04). Success rate was 69% (n = 38) for male applicants and 57% (n = 17) for female applicants. Median time to a categorical position was 4 years (2-6) for the research group and 3 years (1-6) for the no-research group., Conclusions: Our quasi-experimental study demonstrated a higher success rate for Aga Khan University, Medical College applicants with significant research background in the US, compared to those who did not. Better social integration, enhanced mentorship available during research, overcoming of cultural and linguistic barriers and a perception as better qualified candidate can be some factors contributing to higher success rates., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
- Published
- 2019
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7. Deterrents to Organ Donation: A Multivariate Analysis of 766 Survey Respondents.
- Author
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Sellers MT, McGinnis HS, Alperin M, Sweeney JF, and Dodson TF
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- Adult, Black or African American statistics & numerical data, Female, Humans, Male, Middle Aged, Multivariate Analysis, Socioeconomic Factors, Surveys and Questionnaires, Tissue Donors statistics & numerical data, White People statistics & numerical data, Black or African American psychology, Health Knowledge, Attitudes, Practice, Organ Transplantation, Tissue Donors psychology, Tissue and Organ Procurement, White People psychology
- Abstract
Background: Although successful on many fronts, solid organ transplantation fails patients who die on waitlists. Too few organ donors beget this failure. Dispelling misperceptions associated with donation and transplantation would expectedly increase donation and decrease waitlist mortality; recipients would also receive transplants earlier in their disease process, leading to better post-transplantation outcomes., Study Design: Survey responses to 7 questions pertaining to organ donation and transplantation were analyzed to determine their association with willingness to donate. Subgroup analyses according to race, residence status (rural vs nonrural), and education level were performed., Results: There were 766 respondents; 84.6% were willing to be a donor, 76.2% were female, 79.7% were Caucasian, and 16.5% were African-American. Having concerns about getting inadequate medical care if registered as a donor was the strongest independent predictor of willingness to donate overall (odds ratio 0.21; 95% CI 0.13 to 0.36) and in each subgroup; African Americans were more likely than Caucasians to have this concern (20.2% vs 9.5%; p < 0.001). Race (odds ratio 0.41; 95% CI 0.22 to 0.75 for African Americans) and age were also predictive overall, but less so. Willingness to donate a family member's organs depended on whether a discussion about donation had hypothetically occurred: 61.0% would donate if there had been no discussion; 95.2% would donate if the family member had said "yes" to donation; and 11.0% would donate if the family member had said "no" (p < 0.001). If there was no prior discussion, having concerns about getting less-aggressive medical care predicted willingness to donate a family member's organs (odds ratio 0.40; 95% CI 0.25 to 0.65)., Conclusions: The strongest deterrent of willingness to donate one's own or a family member's organs is a misperception that should be correctable. Race and age are less predictive. Efforts to dispel misperceptions and increase donation remain desperately needed to improve waitlist mortality and post-transplantation outcomes., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
- Published
- 2018
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8. Longer Patient Travel Times Associated with Decreased Follow-Up after Endovascular Aortic Aneurysm Repair (EVAR).
- Author
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Morris AD, Preiss JE, Ogbuchi S, Arya S, Duwayri Y, Dodson TF, Jordan WD, and Brewster LP
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- Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal diagnostic imaging, Aortic Aneurysm, Abdominal mortality, Blood Vessel Prosthesis Implantation mortality, Cohort Studies, Continuity of Patient Care, Female, Follow-Up Studies, Hospitals, University, Humans, Male, Prognosis, Retrospective Studies, Risk Assessment, Survival Rate, Time Factors, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis Implantation methods, Endovascular Procedures methods, Patient Compliance statistics & numerical data, Transportation of Patients trends
- Published
- 2017
9. The Readmission Event after Vascular Surgery: Causes and Costs.
- Author
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Duwayri Y, Goss J, Knechtle W, Veeraswamy RK, Arya S, Rajani RR, Brewster LP, Dodson TF, and Sweeney JF
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- Angioplasty adverse effects, Angioplasty economics, Aortic Aneurysm, Abdominal economics, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis economics, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation economics, Carotid Artery Diseases economics, Carotid Artery Diseases surgery, Chi-Square Distribution, Costs and Cost Analysis, Endarterectomy, Carotid adverse effects, Endarterectomy, Carotid economics, Endovascular Procedures instrumentation, Georgia, Humans, Length of Stay economics, Postoperative Complications therapy, Retrospective Studies, Risk Factors, Stents economics, Time Factors, Treatment Outcome, Vascular Surgical Procedures instrumentation, Endovascular Procedures adverse effects, Endovascular Procedures economics, Hospital Costs, Patient Readmission economics, Postoperative Complications economics, Postoperative Complications etiology, Vascular Surgical Procedures adverse effects, Vascular Surgical Procedures economics
- Abstract
Background: The study evaluates the readmission diagnoses after vascular surgical interventions and the associated hospital costs., Methods: Patients readmitted after undergoing carotid artery stenting (CAS), carotid endarterectomy (CEA), infrarenal endovascular abdominal aortic aneurysm repair (EVAR), open abdominal aortic aneurysm repair (OAAA), suprainguinal revascularization (SUPRA), or infrainguinal revascularization (INFRA) between January 1, 2008 and October 20, 2013 at a single academic institution were retrospectively identified. Demographic, preoperative, and postoperative event variables were obtained by chart review. The diagnoses and the costs of the readmission event were obtained by chart review and from hospital financial data. Readmission indications were grouped as unrelated or planned readmissions, procedure-specific complications, wound complications, cardiac causes, and other. Univariate analyses of categorical variables were performed with χ
2 or Fisher exact test where appropriate. Continuous variables were analyzed using the Wilcoxon rank-sum test., Results: A total of 1,170 patient records were identified. Thirty-day readmission occurred in 112 patients (9.6%). The readmission rate was significantly different between groups: 4.5% in CAS (n = 8/177), 8.5% in CEA (21/246), 5.8% in EVAR (18/312), 11.4% in OAAA (4/35), 15.6% in INFRA (33/212), 13.5% in SUPRA (24/178), and 40% in combined SUPRA and INFRA (4/10) (P < 0.0001). Readmissions were unrelated or planned in 19.6% of patients. Wound complications were the most common readmission diagnoses (36.6%, 41/112).There was a difference in the distribution of readmission indications among procedure groups, with wound complications being predominant in INFRA and SUPRA groups (60.6% and 58.3%, respectively), and cardiac events predominantly in EVAR patients (42%) (P < 0.001). In univariable analysis of predictors of readmission, significant preoperative factors were chronic obstructive pulmonary disease, renal insufficiency, and lower hematocrit. Significant postoperative predictors included any postoperative complication, number of complications, increased length of stay, wound complications, postoperative infections, blood transfusion, and reoperation. The median hospital cost for readmission for wound complications was 29,723 USD (interquartile range 23,841-36,878), and for cardiac complications was 39,784 USD (26,305-46,918). The median cost of readmission for bypass graft occlusion was 33,366 USD (20,530-43,170). The median length of stay also differed depending on the readmission diagnosis and was highest for bypass graft occlusion (8.5 days)., Conclusions: Readmissions after vascular procedures are associated with high cost and hospital bed utilization. Wound complications continue to be the dominant readmission etiology. The characterization of these costs and risk factors in this study can allow for resource allocation to minimize preventable related readmissions. A significant proportion of readmissions after vascular interventions are planned or unrelated, which should be taken into consideration in metric benchmarking and performance comparisons., (Copyright © 2016 Elsevier Inc. All rights reserved.)- Published
- 2016
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10. Gender and frailty predict poor outcomes in infrainguinal vascular surgery.
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Brahmbhatt R, Brewster LP, Shafii S, Rajani RR, Veeraswamy R, Salam A, Dodson TF, and Arya S
- Subjects
- Aged, Aged, 80 and over, Canada epidemiology, Female, Humans, Lower Extremity surgery, Male, Middle Aged, Retrospective Studies, Sex Factors, United States epidemiology, Frail Elderly statistics & numerical data, Lower Extremity blood supply, Postoperative Complications epidemiology, Vascular Surgical Procedures mortality
- Abstract
Background: Women have poorer outcomes after vascular surgery as compared to men as shown by studies recently. Frailty is also an independent risk factor for postoperative morbidity and mortality. This study examines the interplay of gender and frailty on outcomes after infrainguinal vascular procedures., Materials and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent infrainguinal vascular procedures from 2005-2012. Frailty was measured using a modified frailty index (mFI; derived from the Canadian Study of Health and Aging). Univariate and multivariate analysis were performed to investigate the association of preoperative frailty and gender, on postoperative outcomes., Results: Of 24,645 patients (92% open, 8% endovascular), there were 533 deaths (2.2%) and 6198 (25.1%) major complications within 30 d postoperatively. Women were more frail (mean mFI = 0.269) than men (mean mFI = 0.259; P < 0.001). Women and frail patients (mFI>0.25) were more likely to have a major morbidity (P < 0.001) or mortality (P < 0.001) with the highest risk in frail women. On multivariate logistic regression analysis, female gender and increasing mFI were independently significantly associated with mortality (P < 0.05) as well as major complications. The interaction of gender and frailty in multivariate analysis showed the highest adjusted 30-d mortality and morbidity in frail females at 2.8% and 30.1%, respectively and that was significantly higher (P < 0.001) than nonfrail males, nonfrail females and frail males., Conclusions: Female gender and frailty are both associated with increased risk of complications and death following infrainguinal vascular procedures with the highest risk in frail females. Further studies are needed to explore the mechanisms of interaction of gender and frailty and its effect on long-term outcomes for peripheral vascular disease., (Published by Elsevier Inc.)
- Published
- 2016
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11. Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm repair.
- Author
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Brahmbhatt R, Gander J, Duwayri Y, Rajani RR, Veeraswamy R, Salam A, Dodson TF, and Arya S
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- Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal diagnosis, Aortic Aneurysm, Abdominal mortality, Aortic Rupture diagnosis, Aortic Rupture mortality, Canada, Chi-Square Distribution, Databases, Factual, Emergencies, Endovascular Procedures adverse effects, Endovascular Procedures mortality, Female, Hospital Mortality trends, Humans, Logistic Models, Male, Middle Aged, Multivariate Analysis, Odds Ratio, Postoperative Complications mortality, Retrospective Studies, Risk Factors, Time Factors, Treatment Outcome, United States, Vascular Surgical Procedures adverse effects, Vascular Surgical Procedures mortality, Aortic Aneurysm, Abdominal surgery, Aortic Rupture surgery, Endovascular Procedures trends, Process Assessment, Health Care trends, Vascular Surgical Procedures trends
- Abstract
Background: Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm (AAA) repair. Emergency AAA repair carries a high risk of morbidity and mortality. This study seeks to examine morbidity and mortality trends from the National Surgical Quality Improvement Program (NSQIP) database, and identify potential risk factors., Methods: All emergency AAA repairs were identified using the NSQIP database from 2005 to 2011. Univariate analysis (using the Student t, χ(2), and Fisher's exact tests) and multivariate logistic regression was performed to examine trends in mortality and morbidity., Results: Out of 2761 patients who underwent emergency AAA repair, 321 (11.6%) died within 24 hours of surgery. Of the remaining 2440 patients, 1133 (46.4%) experienced major complications and 459 (18.8%) died during the postoperative period. From 2005 to 2011, there was a significant decrease in patient mortality, particularly in patients who survived the perioperative period (P = .002). Total complications increased overall (P < .0001); however, major complications decreased from 58.7% in 2005 to 42.6% in 2011 (P < .0001) among patients who survived beyond 24 hours. The use of endovascular aortic repair (EVAR) increased over the study period (P < .0001). On multivariate analysis of patients who survived past the initial 24-hour period, advancing age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.7-4.1), dependent functional status (OR, 2.0; 95% CI, 1.2-3.2), and presence of a major complication (OR, 3.1; 95% CI, 2.0-5.0) were significantly associated with death, whereas presence of a senior resident (OR, 0.4; 95% CI, 0.3-0.6) or fellow (OR 0.3; 95% CI, 0.2-0.6) was inversely associated with death. EVAR was not associated with death, but was associated with 30-day complications (OR, 0.5; 95% CI, 0.3-0.6)., Conclusions: Patient survival has increased from 2005 to 2011 after emergency AAA repair, with a significant improvement particularly in patients who survive past the first 24 hours. EVAR was not associated with mortality, but was protective of 30-day complications. Although the total number of complications increased, the number of major complications decreased over the study period, suggesting that newer techniques and patient care protocols may be improving outcomes., (Published by Elsevier Inc.)
- Published
- 2016
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12. Posttraumatic Resuscitation Affects Stent Graft Sizing in Patients with Blunt Thoracic Aortic Injury.
- Author
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Hoffman JR, Chowdhury R, Johnson LS, Brewster LP, Duwayri Y, Reeves JG, Veeraswamy RK, Dodson TF, and Rajani RR
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- Adult, Aorta, Thoracic injuries, Aortography methods, Blood Vessel Prosthesis Implantation methods, Cardiopulmonary Resuscitation adverse effects, Cohort Studies, Endovascular Procedures methods, Female, Hospital Mortality, Humans, Male, Middle Aged, Prognosis, Retrospective Studies, Risk Assessment, Survival Analysis, Thoracic Injuries diagnostic imaging, Thoracic Injuries mortality, Tomography, X-Ray Computed methods, Trauma Centers, Treatment Outcome, Wounds, Nonpenetrating diagnostic imaging, Wounds, Nonpenetrating mortality, Aorta, Thoracic diagnostic imaging, Cardiopulmonary Resuscitation methods, Stents, Thoracic Injuries surgery, Wounds, Nonpenetrating surgery
- Abstract
Patients with blunt aortic injury often present to the emergency department in a relatively hypovolemic state. These patients undergo extensive inhospital resuscitation. The effect of posttraumatic resuscitation on aortic diameter has implications for stent graft sizing. The potential utility of repeat aortic imaging after resuscitation remains unclear. A retrospective chart review of all adult patients presenting to a Level I trauma center between the years 2007 and 2013 was performed. Fifty-three patients were identified with a diagnosis of traumatic aortic injury. Of those, 10 had 2 CT scans before aortic repair and were selected as the study population for analysis. After resuscitation, there was a significant increase in aortic diameter both proximal and distal to the aortic injury: proximal aortic diameter increase of 1.97 mm and distal aortic diameter increase of 1.48 mm. This retrospective study shows that after resuscitation, there is a significant increase in proximal and distal aortic diameter. Interval reimaging of the thoracic aorta may be beneficial after adequate stabilization of the patient's other injuries. In certain cases, more appropriate sizing may prevent a device-related complication.
- Published
- 2016
13. Late mortality in females after endovascular aneurysm repair.
- Author
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Preiss JE, Arya S, Duwayri Y, Shafii SM, Veeraswamy RK, Rajani RR, Dodson TF, and Brewster LP
- Subjects
- Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal mortality, Female, Georgia epidemiology, Humans, Reoperation statistics & numerical data, Retrospective Studies, Aortic Aneurysm, Abdominal surgery, Endovascular Procedures mortality
- Abstract
Background: Abdominal aortic aneurysm (AAA) rupture is an adverse arterial remodeling event with high mortality risk. Because females have increased rupture risk with smaller AAAs (<5.5 cm), many recommend elective repair before the AAA reaches 5.5 cm. Elective repair improves survival for large AAAs, but long-term benefits of endovascular aneurysm repair (EVAR) for small AAAs in females remain less understood. The objective of this study was to identify if differences in late mortality exist between females undergoing elective EVAR at our institution for small and/or slow-growing AAAs compared with those who meet standard criteria., Methods: We retrospectively analyzed all patients that underwent EVAR for infrarenal AAA from June, 2009-June, 2013. We excluded patients that were male, treated emergently or for iliac artery aneurysm, and that received renal and/or mesenteric artery stenting. Patients did not meet anatomic criteria if preoperative AAA diameter was <5.5 cm or enlarged <0.5 cm over 6 mo. Late mortality was assessed from the social security death index., Results: Thirty-six of 162 elective EVAR patients (22.2%) were female (mean follow-up, 37.2 mo). Twenty patients (55.6%) met AAA size and/or growth criteria, whereas 16 (44.4%) did not meet criteria. Despite comparable demographics, comorbidities, and complications, patients that did not meet criteria had higher late mortality (37.5% versus 5%; P = 0.03) with a trend toward increased reoperation rate (25% versus. 5%; P = 0.48). Meeting size and/or growth criteria decreased odds of late death (odds ratio, 0.09; 95% confidence intervals, 0.01-0.83)., Conclusions: There is increased late mortality in females receiving elective EVAR at our institution for small and/or slow-growing AAAs. This late mortality may limit the benefits of EVAR for this population., (Copyright © 2015 Elsevier Inc. All rights reserved.)
- Published
- 2015
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14. Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.
- Author
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Arya S, Kim SI, Duwayri Y, Brewster LP, Veeraswamy R, Salam A, and Dodson TF
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- Age Factors, Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal diagnosis, Aortic Aneurysm, Abdominal mortality, Canada epidemiology, Chi-Square Distribution, Comorbidity, Databases, Factual, Elective Surgical Procedures, Female, Health Status Indicators, Humans, Logistic Models, Male, Middle Aged, Multivariate Analysis, Odds Ratio, Postoperative Complications diagnosis, Postoperative Complications mortality, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, United States epidemiology, Vascular Surgical Procedures mortality, Aortic Aneurysm, Abdominal surgery, Health Status, Postoperative Complications etiology, Vascular Surgical Procedures adverse effects
- Abstract
Background: Frailty, defined as a biologic syndrome of decreased reserve and resistance to stressors, has been linked to adverse outcomes after surgery. We evaluated the effect of frailty on 30-day mortality, morbidity, and failure to rescue (FTR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair., Methods: Patients undergoing elective endovascular AAA repair (EVAR) or open AAA repair (OAR) were identified in the National Surgical Quality Improvement Program database for the years 2005 to 2012. Frailty was assessed using the modified frailty index (mFI) derived from the Canadian Study of Health and Aging (CSHA). The primary outcome was 30-day mortality, and secondary outcomes included 30-day morbidity and FTR. The effect of frailty on outcomes was assessed by multivariate regression analysis, adjusted for age, American Society of Anesthesiology (ASA) class, and significant comorbidities., Results: Of 23,207 patients, 339 (1.5% overall; 1.0% EVAR and 3.0% OAR) died ≤30 days of repair. One or more complications occurred in 2567 patients (11.2% overall; 7.8% EVAR and 22.1% OAR). Odds ratios (ORs) for mortality adjusted for age, ASA class, and other comorbidities in the group with the highest frailty score were 1.9 (95% confidence interval [CI], 1.2-3.0) after EVAR and 2.3 (95% CI, 1.4-3.7) after OAR. Similarly, compared with the least frail, the most frail patients were significantly more likely to experience severe (Clavien-Dindo class IV) complications after EVAR (OR, 1.7; 95% CI, 1.3-2.1) and OAR (OR, 1.8; 95%, CI, 1.5-2.1). There was also a higher FTR rate among frail patients, with 1.7-fold higher risk odds of mortality (95% CI, 1.2-2.5) in the highest tertile of frailty compared with the lowest when postoperative complications occurred., Conclusions: Higher mFI, independent of other risk factors, is associated with higher mortality and morbidity in patients undergoing elective EVAR and OAR. The mortality in frail patients is further driven by FTR from postoperative complications. Preoperative recognition of frailty may serve as a useful adjunct for risk assessment., (Published by Elsevier Inc.)
- Published
- 2015
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15. Carotid artery stenting has increased risk of external carotid artery occlusion compared with carotid endarterectomy.
- Author
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Brown K, Itum DS, Preiss J, Duwayri Y, Veeraswamy RK, Salam A, Dodson TF, and Brewster LP
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- Aged, Carotid Artery, Internal physiopathology, Carotid Stenosis diagnosis, Carotid Stenosis physiopathology, Carotid Stenosis surgery, Cerebrovascular Circulation, Databases, Factual, Georgia, Humans, Recurrence, Regional Blood Flow, Retrospective Studies, Risk Factors, Time Factors, Angioplasty adverse effects, Angioplasty instrumentation, Carotid Artery, External physiopathology, Carotid Artery, Internal surgery, Carotid Stenosis therapy, Endarterectomy, Carotid adverse effects, Stents
- Abstract
Objective: The external carotid artery (ECA) can be an important source of cerebral blood flow in cases of high-grade internal carotid artery stenosis or occlusion. However, the treatment of the ECA is fundamentally different between carotid endarterectomy (CEA) and carotid artery stenting (CAS). CEA is routinely associated with endarterectomy of the ECA, whereas CAS excludes the ECA from direct flow. We hypothesize that these differences make ECA occlusion more common after CAS. Further, the impact of CAS on blood flow into the ECA is interesting because the flow from the stent into the ECA is altered in a way that may promote local inflammation and may influence in-stent restenosis (ISR). Thus, our objective was to use our institutional database to identify whether CAS increased the rate of ECA occlusion and, if it did, whether ECA occlusion was associated with ISR., Methods: Patients undergoing CAS or CEA from February 2007 to February 2012 were identified from our institutional carotid therapy database. Preoperative and postoperative images of patients who followed up in our institution were included in the analysis of ECA occlusion and rates of ISR., Results: There were 210 (67%) CAS patients and 207 (60%) CEA patients included in this analysis. Despite CAS patients being younger (68 vs 70 years), having shorter follow-up (12.5 vs 56.2 months), and being more likely to take clopidogrel (97% vs 35%), they had an increased rate of ECA occlusion (3.8%) compared with CEA patients (0.4%). CAS patients who went on to ECA occlusion had an increased incidence of prior neck irradiation (50% vs 15%; P = .03), but we did not identify an association of ECA occlusion with ISR >50%., Conclusions: Whereas prior publications have identified increased rates of external carotid stenosis, this is the first demonstration of increased ECA occlusion after CAS. However, ECA occlusion is uncommon (∼4%) and did not have an association with ISR >50%. Future work modeling ECA flow patterns before and after CAS will be used to further test this interaction., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
- Published
- 2015
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16. Influence of the hostile neck on restenosis after carotid stenting.
- Author
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Brown KA, Itum DS, Duwayri Y, Reeves JG, Rajani R, Veeraswamy RK, Arya S, Salam A, Dodson TF, and Brewster LP
- Subjects
- Aged, Aged, 80 and over, Angioplasty adverse effects, Angioplasty mortality, Cardiovascular Diseases etiology, Carotid Stenosis diagnosis, Carotid Stenosis mortality, Comorbidity, Female, Georgia, Humans, Male, Middle Aged, Prosthesis Failure, Radiotherapy adverse effects, Recurrence, Retreatment, Retrospective Studies, Risk Factors, Time Factors, Treatment Outcome, Angioplasty instrumentation, Carotid Stenosis therapy, Stents
- Abstract
Background: Carotid artery stenting (CAS) for carotid stenosis is favored over carotid endarterectomy (CEA) in patients with a hostile neck from prior CEA or cervical irradiation (XRT). However, the restenosis rate after CAS in patients with hostile necks is variable in the literature. The objective of this study was to quantify differences in the in-stent restenosis (ISR)/occlusion and reintervention rates after CAS in patients with and without a hostile neck. Here we hypothesize that patients with hostile necks have an increased ISR, and that this increase may add morbidity to these patients., Materials and Methods: All patients undergoing CAS from 2007 to 2013 for carotid artery stenosis with follow-up imaging at our institution were queried from our carotid database (n = 236). Patients with hostile necks, including both CAS after prior CEA (n = 65) and prior XRT (n = 37), were compared with patients who underwent CAS for other reasons including both anatomical (n = 46) and medical comorbidities (n = 88). The primary end points were ISR, repeat intervention, and stent occlusion. Secondary end points of the study were stroke/myocardial infarction (MI)/death at 30 days, perioperative cardiovascular accident, transient ischemic attack, MI, groin access complications, hyperperfusion syndrome, and periprocedural hypotension or bradycardia., Results: Despite the hostile neck cohort being younger and having lower incidence of chronic obstructive pulmonary disease, coronary artery disease, and renal insufficiency, they had a greater incidence of ISR (11% vs. 4%; P = .03) and required more reinterventions (8% vs. 2%; P = .04). Stent occlusion and periprocedural morbidity/mortality were not different between groups., Conclusions: Patients with hostile necks have increased risk of restenosis and need for reinterventions after CAS compared with patients without a hostile neck. However, they do not appear to have higher rates of stent occlusion or per-procedural events., (Published by Elsevier Inc.)
- Published
- 2015
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17. Smoking cessation is the least successful outcome of risk factor modification in uninsured patients with symptomatic peripheral arterial disease.
- Author
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Huen KH, Chowdhury R, Shafii SM, Brewster LP, Arya S, Duwayri Y, Veeraswamy RK, Dodson TF, and Rajani RR
- Subjects
- Adult, Black or African American, Age Factors, Aged, Aged, 80 and over, Antihypertensive Agents therapeutic use, Comorbidity, Female, Humans, Hypoglycemic Agents therapeutic use, Hypolipidemic Agents therapeutic use, Male, Medicaid, Medicare, Middle Aged, Peripheral Arterial Disease diagnosis, Peripheral Arterial Disease ethnology, Registries, Retrospective Studies, Risk Factors, Smoking adverse effects, Smoking ethnology, Treatment Outcome, United States epidemiology, Health Services Accessibility, Healthcare Disparities ethnology, Medically Uninsured ethnology, Peripheral Arterial Disease therapy, Risk Reduction Behavior, Smoking Cessation, Smoking Prevention
- Abstract
Background: Patients with peripheral arterial disease (PAD) have multiple atherosclerotic risk factors. Risk factor modification can reduce severity of disease at presentation and improve treatment outcomes. The Trans-Atlantic Inter-Society Consensus II (TASC II) has issued several recommendations that are widely adopted by specialists. However, the ability to provide proper services to patients may depend on the specific patient's access to care, which is primarily determined by the presence of health insurance. The purpose of our study was to determine whether insurance status impairs the ability of patients with symptomatic PAD to meet select TASC II recommendations., Methods: A retrospective review of patients with symptomatic PAD from August 2011 to May 2013 was conducted; demographic, preoperative, procedural, and standard outcome variables were collected. Patients were divided into the insured group (private insurance, Medicare, Medicaid) or the uninsured group (self-pay). Insurance status was analyzed for its association to select TASC II recommendations: smoking cessation, referral to smoking cessation program, low-density lipoprotein cholesterol <2.59 mmol/L (<100 mg/dL), low-density lipoprotein cholesterol <1.81 mmol/L (<70 mg/dL), patients with coexisting hyperlipidemia and diabetes, glycated hemoglobin <7%, systolic blood pressure <140 mm Hg, prescription of aspirin, and prescription of a statin., Results: One hundred and forty-four patients with symptomatic PAD were identified. Insured patients were more likely to be African American, older at presentation, or have a diagnosis of congestive heart failure. There was no significant difference between insured and uninsured patients in success rates of low-density lipoprotein cholesterol targets (65.1% vs. 51.1% for <2.59 mmol/L; 24.3% vs. 19.1% for <1.81 mmol/L), glycated hemoglobin targets (61.9% vs. 61.1% for <7%), blood pressure control (51.1% vs. 50.0% for systolic blood pressure <140), aspirin use (72.8% vs. 59.6%), or statin use (77.2% vs. 63.5%). However, insured patients were more likely to quit smoking than uninsured patients (35.1% vs. 17.7%, P = 0.023). Furthermore, there was no difference in patterns of referral to a multidisciplinary smoking cessation program between the 2 groups (31.5% vs. 38.5%)., Conclusions: Insurance status does not impair patients' ability to meet most TASC II guidelines to modify cardiovascular risk factors in patients who have access to health care. Uninsured patients are, however, less likely to cease smoking compared with insured patients, despite no significant difference in referral patterns between the 2 groups for multidisciplinary smoking cessation counseling. Future efforts to assist patients with symptomatic PAD with atherosclerotic risk factor modification should focus on aiding uninsured patients in smoking cessation efforts., (Copyright © 2015 Elsevier Inc. All rights reserved.)
- Published
- 2015
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18. Carotid duplex criteria for patients with contralateral occlusion.
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Preiss JE, Itum DS, Reeves JG, Duwaryi Y, Rajani R, Veeraswamy R, Salam A, Dodson TF, and Brewster LP
- Subjects
- Aged, Angiography, Carotid Artery, Common physiology, Carotid Artery, Internal physiology, Carotid Stenosis epidemiology, Carotid Stenosis physiopathology, Databases, Factual, Female, Humans, Magnetic Resonance Angiography, Male, Middle Aged, Predictive Value of Tests, Prospective Studies, Reproducibility of Results, Risk Factors, Sensitivity and Specificity, Tomography, X-Ray Computed, Carotid Artery, Common diagnostic imaging, Carotid Artery, Internal diagnostic imaging, Carotid Stenosis diagnostic imaging, Ultrasonography, Doppler, Duplex methods, Ultrasonography, Doppler, Duplex standards
- Abstract
Background: Contralateral occlusion (CLO) occurs in approximately 8% of patients undergoing intervention for carotid artery stenosis. Patients with CLO have increased stroke risk compared with patients without CLO, but standard carotid duplex ultrasonography (CDUS) criteria are not a reliable manner to screen or follow patients with CLO. Because appropriate duplex criteria for these patients are not well understood, this article defines CDUS parameters that accurately predict carotid artery stenosis at our institution., Methods: Sixty-five patients with ipsilateral carotid stenosis and CLO were identified from our institutional database. Fifteen of sixty-five patients had arteriography, computed tomography angiography, or magnetic resonance angiography within 6 mo of CDUS. We determined accuracy of our laboratory's criteria for determining stenosis category compared with three-dimensional imaging. Receiver operating characteristic curves were used to determine optimal peak systolic velocity (PSV), end diastolic velocity (EDV), and systolic ratio (SR) cutoff values for diagnosing ≥50% stenosis in this pilot cohort. Finally, the revised criteria were prospectively applied to a validation cohort (n = 8) from the same institution., Results: Categorization of stenosis by standard PSV, EDV, and SR criteria saw similar accuracy trends in both pilot (46.7, 53.3, and 66.7%) and validation (25, 25, and 62.5%) cohorts. Receiver operating characteristic curve analysis in the pilot cohort identified optimized PSV, EDV, and SR cutoffs (≥250, ≥90, and ≥2.3 cm/s, respectively) for diagnosing ≥50% stenosis. In the pilot cohort, new PSV criteria increased specificity (60%-100%) with minimal decreased sensitivity (90%-80%), whereas new EDV criteria increased specificity (40%-71.4%) and maintained 100% sensitivity. New SR criteria failed to improve sensitivity or specificity above 80%. Similar trends for the new CDUS velocity criteria were observed in the validation cohort., Conclusions: Increasingly stringent ultrasound parameters can provide reliable criteria for determining ≥50% carotid stenosis in patients with CLO. Further prospective validation that includes more patients with high-grade ipsilateral stenosis will help identify the role of SR in segregating high-grade versus moderate stenosis in CLO patients., (Published by Elsevier Inc.)
- Published
- 2015
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19. Invited commentary on Clostridium difficile increases the risk for venous thromboembolism.
- Author
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Dodson TF
- Subjects
- Female, Humans, Male, Clostridioides difficile, Clostridium Infections complications, Venous Thromboembolism etiology
- Published
- 2014
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20. Open repair of superior mesenteric artery mycotic aneurysm in an adolescent girl.
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Ruddy JM, Dodson TF, and Duwayri Y
- Subjects
- Adolescent, Aneurysm, Infected diagnosis, Aneurysm, Infected microbiology, Anti-Bacterial Agents therapeutic use, Female, Humans, Ligation, Mesenteric Artery, Superior diagnostic imaging, Mesenteric Artery, Superior microbiology, Tomography, X-Ray Computed, Treatment Outcome, Aneurysm, Infected surgery, Mesenteric Artery, Superior surgery, Saphenous Vein transplantation
- Abstract
Aneurysmal degeneration of the superior mesenteric artery (SMA) is rare, particularly in the pediatric population. We report the case of a 16-year-old female who presented with abdominal discomfort, back pain, fever, and vomiting. Extensive work-up revealed a 3-cm SMA aneurysm (SMAA) with surrounding inflammation. No bacterial growth was identified on current cultures, but a mycotic etiology was suspected due to recent episodes of suppurative hidradenitis. In addition to broad-spectrum antibiotics, she underwent transabdominal surgical intervention, including proximal and distal aneurysm ligation with aortomesenteric bypass, utilizing the reversed saphenous vein. Although endovascular intervention in the mesenteric arterial system has increased in utilization, patient-specific considerations, such as age and potential for infectious etiology, must drive therapeutic decision-making, with open surgical bypass being liberally employed., (Copyright © 2014 Elsevier Inc. All rights reserved.)
- Published
- 2014
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21. Anatomic characteristics of aortic transection: centerline analysis to facilitate graft selection.
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Rajani RR, Johnson LS, Brewer BL, Brewster LP, Duwayri Y, Reeves JG, Veeraswamy RK, and Dodson TF
- Subjects
- Adult, Aorta, Thoracic injuries, Female, Humans, Injury Severity Score, Male, Patient Selection, Predictive Value of Tests, Prosthesis Design, Radiographic Image Interpretation, Computer-Assisted, Registries, Trauma Centers, Aorta, Thoracic diagnostic imaging, Aorta, Thoracic surgery, Aortography methods, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation instrumentation, Stents, Tomography, X-Ray Computed, Vascular System Injuries diagnostic imaging, Vascular System Injuries surgery, Wounds, Nonpenetrating diagnostic imaging, Wounds, Nonpenetrating surgery
- Abstract
Background: Traumatic transection of the thoracic aorta is a life-threatening complication that most commonly occurs after high-speed motor vehicle collisions. Although such injuries were previously treated with open surgical reconstruction, they are now more commonly being treated with endovascularly placed stent grafts. Unfortunately, most stent grafts are designed for treating aortic aneurysmal disease instead of traumatic injury. Further refinements in stent graft technology depend on a thorough anatomic understanding of the transection injury process., Methods: All patients with computed tomography (CT) evidence of blunt aortic injury (BAI) between 2006 and 2012 at a Level 1 trauma center were queried. Their initial CT scans were imported into the Intuition (Terarecon, Inc.) viewing program, and off-line centerline reconstruction was performed. Standard demographic data were collected in addition to anatomic characteristics, including aortic diameters and the relationship of the injury to the arch vessels., Results: Thirty-five patients were identified. Three patients were injured proximal to the left subclavian artery. The average length from the left subclavian artery to the proximal site of injury was 16.2 mm (range 2-31 mm). Most patients had >15 mm of landing zone beyond the left subclavian artery. The range of proximal diameters ranged from 17 to 32 mm, with an average aortic diameter of 23.9 mm. The average length of injured aortic segment was 27 mm., Conclusions: In this contemporary series from a large trauma center, 91% of patients are anatomically able to be treated with a stent graft that does not require coverage of the left common carotid artery. Most patients have an aortic diameter that falls between 21 and 26 mm in diameter, as well as a short segment of injured artery. Centers interested in emergently treating aortic transections are able to do so while maintaining a limited stock of stent grafts that can be used to treat the majority of the population., (Copyright © 2014 Elsevier Inc. All rights reserved.)
- Published
- 2014
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22. Contralateral occlusion is not a clinically important reason for choosing carotid artery stenting for patients with significant carotid artery stenosis.
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Brewster LP, Beaulieu R, Kasirajan K, Corriere MA, Ricotta JJ 2nd, Patel S, and Dodson TF
- Subjects
- Aged, Aged, 80 and over, Carotid Stenosis pathology, Female, Humans, Male, Retrospective Studies, Severity of Illness Index, Carotid Stenosis surgery, Stents
- Abstract
Objective: Contralateral carotid artery occlusion by itself carries an increased risk of stroke. Carotid endarterectomy (CEA) in the presence of contralateral carotid artery occlusion has high reported rates of perioperative morbidity and mortality. Our objective was to determine if there is a clinical benefit to patients who receive carotid artery stenting (CAS) compared to CEA in the presence of contralateral carotid artery occlusion., Methods: We conducted a retrospective medical chart review over a 4.5-year institutional experience of persons with contralateral carotid artery occlusion and ipsilateral carotid artery stenosis who underwent CAS or CEA. The main outcome measures were 30-day cardiac, stroke, and mortality rate, and midterm mortality., Results: Of a total of 713 patients treated for carotid artery stenosis during this time period, 57 had contralateral occlusion (~8%). Thirty-nine of these patients were treated with CAS, and 18 with CEA. The most common indications for CAS were prior neck surgery (18), contralateral internal carotid occlusion (nine), and prior neck radiation (seven). The average age was 70 ± 8.5 for CEA and 66.7 ± 9.3 for CAS (P = .20). Both groups were predominantly men (CEA 12 of 18; CAS 28 of 39; P = .76), with similar prevalence of symptomatic lesions (CEA 8 of 18, CAS 20 of 39; P = .77). Two patients died within 30 days in the CAS group (5%). No deaths occurred within 30 days in the CEA group (P = .50); the mortality rate for CAS and CEA combined was 3.5%. No perioperative strokes or myocardial infarction occurred in either group. Two transient ischemic attacks occurred after CAS. At mean follow-up of 29.4 ± 16 months (CEA) and 28 ± 14.4 months (CAS; range, 1.5-48.5 months), seven deaths occurred in the CAS group and one in the CEA group (17.9% vs 5.5%; P = .40). There were two reinterventions in the CAS group for in-stent restenosis and there were no reoperations in the CEA group., Conclusions: Although CEA and CAS can both be performed with good perioperative results and acceptable midterm mortality, the observed outcomes do not support use of contralateral carotid artery occlusion as a selection criterion for CAS over CEA in the absence of other indications., (Copyright © 2012 Society for Vascular Surgery. All rights reserved.)
- Published
- 2012
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23. Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes.
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Reeves JG, Kasirajan K, Veeraswamy RK, Ricotta JJ 2nd, Salam AA, Dodson TF, McClusky DA 3rd, and Corriere MA
- Subjects
- Aged, Aged, 80 and over, Carotid Artery Diseases mortality, Chi-Square Distribution, Clinical Competence, Databases as Topic, Female, Heart Diseases etiology, Humans, Logistic Models, Male, Middle Aged, Odds Ratio, Perioperative Period, Risk Assessment, Risk Factors, Societies, Medical, Stroke etiology, Time Factors, Treatment Outcome, United States epidemiology, Carotid Artery Diseases surgery, Endarterectomy, Carotid adverse effects, Endarterectomy, Carotid mortality, Internship and Residency statistics & numerical data
- Abstract
Introduction: The impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events., Methods: CEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ(2) or Fisher's exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors., Results: A total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21)., Conclusions: Resident surgeon participation during CEA is not associated with risk of adverse perioperative events., (Published by Mosby, Inc.)
- Published
- 2012
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24. Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death.
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Chung J, Kasirajan K, Veeraswamy RK, Dodson TF, Salam AA, Chaikof EL, and Corriere MA
- Subjects
- Aged, Aged, 80 and over, Aortic Diseases mortality, Chi-Square Distribution, Databases as Topic, Female, Humans, Logistic Models, Male, Odds Ratio, Risk Assessment, Risk Factors, Stroke mortality, Time Factors, Treatment Outcome, United States epidemiology, Aorta, Thoracic surgery, Aortic Diseases surgery, Endovascular Procedures adverse effects, Endovascular Procedures mortality, Stroke etiology, Subclavian Artery surgery, Vascular Surgical Procedures adverse effects, Vascular Surgical Procedures mortality
- Abstract
Introduction: Left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) is often necessary due to anatomic factors and is performed in to up to 40% of procedures. Despite the frequency of LSA coverage during TEVAR, reported associations with risk of periprocedural stroke or death are inconsistent in reported literature. We examined the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data file to determine associations between LSA coverage during TEVAR and risk of perioperative stroke or death., Methods: Current procedural terminology (CPT) codes were used to identify patients undergoing TEVAR, LSA coverage, and subclavian revascularization. Patients undergoing coronary bypass, ascending aortic repair, abdominal aortic aneurysm repair, or nonvascular intra-abdominal procedures during the same operation were excluded. Perioperative stroke and mortality associations with LSA coverage were examined using logistic regression models for each outcome. Significance was assessed at α = 0.05, with univariable P < .05 required for multivariable model entry., Results: Eight hundred forty-five TEVAR procedures were identified, of which 52 patients were excluded due to additional major procedures performed with TEVAR. Seven hundred thirty-three of the remaining 793 procedures included CPT codes indicating primary placement of an initial thoracic endograft and form the basis of this analysis. LSA coverage occurred in 279 procedures (38%). Thirty-day stroke and mortality rates were 5.7% and 7.0%, respectively. LSA coverage was associated with increased 30-day risk of stroke in multivariable modeling (odds ratio [OR], 2.17 95% confidence interval [CI], 1.13-4.14; P = .019). Other significant multivariable risk factors for stroke included proximal aortic cuff placement during TEVAR (OR, 2.58; 95% CI, 1.30-5.16; P = .007) and emergency procedure status (OR, 3.60; 95% CI, 1.87-6.94; P < .001). No significant association between LSA coverage and perioperative mortality was identified (univariable OR, 1.70; 95% CI, 0.98-2.93; P = .0578)., Conclusion: LSA coverage during thoracic endovascular repair is associated with increased risk of perioperative stroke following TEVAR. Further evidence is needed to determine whether procedural modifications, including LSA revascularization, reduce the incidence of stroke associated with TEVAR., (Published by Mosby, Inc.)
- Published
- 2011
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25. Carotid revascularization outcomes comparing distal filters, flow reversal, and endarterectomy.
- Author
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Brewster LP, Beaulieu R, Corriere MA, Veeraswamy R, Niazi KA, Robertson G, Dodson TF, and Kasirajan K
- Subjects
- Aged, Aged, 80 and over, Angioplasty adverse effects, Angioplasty mortality, Asymptomatic Diseases, Carotid Stenosis complications, Carotid Stenosis mortality, Carotid Stenosis surgery, Chi-Square Distribution, Female, Georgia, Humans, Male, Middle Aged, Myocardial Infarction etiology, Patient Selection, Retrospective Studies, Risk Assessment, Risk Factors, Stroke etiology, Time Factors, Treatment Outcome, Angioplasty instrumentation, Carotid Stenosis therapy, Embolic Protection Devices, Endarterectomy, Carotid adverse effects, Endarterectomy, Carotid mortality, Stents
- Abstract
Introduction: Contradictory outcomes exist for different methods of carotid artery revascularization. Here we provide the comparative rates of adverse events in patients after carotid endarterectomy (CEA), carotid artery stenting (CAS) with a distal embolic protection device (EPD), and CAS with a proximal flow reversal system (FRS) from a single institution by various specialists treating carotid artery disease., Methods: Procedural billing codes and the electronic medical records of patients undergoing revascularization for carotid artery stenosis from February 2007 through March 2010 were used for data collection. Primary outcome was the incidence of cerebrovascular accident (CVA), myocardial infarction (MI), or death after CEA and CAS. Each practitioner determined the choice of therapy, with five of the 14 specialists providing both CAS and CEA. Baseline characteristics were examined for effect on outcome. Planned comparisons between and within groups were analyzed using χ(2), t tests, and analysis of variance, as appropriate., Results: A total of 495 procedures were documented, comprising 226 CEA, 216 CAS with EPD, and 53 CAS with FRS. Preoperative comparisons of patient comorbidities were similar among the cohorts. The carotid artery stenosis was symptomatic in 42% of these patients. Prior CEA was an indication for CAS rather than another CEA (P < .001). Significantly fewer patients undergoing CEA were receiving preoperative antiplatelet therapy (P < .001). The groups did not differ significantly in the overall composite end point of death, CVA, and MI (4%, 5.1%, 0%; P = .1) or any individual major adverse event. Overall, patients undergoing CAS with EPD had a statistically significant greater incidence of minor CVAs than CEA patients (P = .031), which was driven by the increased CVA risk for asymptomatic patients. Secondary end points occurred rarely (<2%). There have been no reoperations or interventions in these patients to date within this institution., Conclusions: We have established a similar and low incidence of MI, CVA, and death among patients undergoing CEA and CAS, of whom approximately 40% were symptomatic. FRS provided superior results in this series; however, its use was limited to 20% of the CAS procedures. Still, zero adverse events in this cohort make FRS an exciting technology that warrants a large-scale prospective comparative study., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)
- Published
- 2011
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26. The incidence of microemboli to the brain is less with endarterectomy than with percutaneous revascularization with distal filters or flow reversal.
- Author
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Gupta N, Corriere MA, Dodson TF, Chaikof EL, Beaulieu RJ, Reeves JG, Salam AA, and Kasirajan K
- Subjects
- Academic Medical Centers, Aged, Aged, 80 and over, Angioplasty adverse effects, Carotid Artery Diseases diagnostic imaging, Carotid Artery Diseases physiopathology, Carotid Artery Diseases surgery, Female, Georgia, Humans, Intracranial Embolism diagnostic imaging, Intracranial Embolism etiology, Intracranial Embolism physiopathology, Male, Middle Aged, Middle Cerebral Artery diagnostic imaging, Monitoring, Intraoperative methods, Retrospective Studies, Time Factors, Treatment Outcome, Ultrasonography, Doppler, Transcranial, Angioplasty instrumentation, Carotid Artery Diseases therapy, Cerebrovascular Circulation, Embolic Protection Devices, Endarterectomy, Carotid adverse effects, Intracranial Embolism prevention & control, Middle Cerebral Artery physiopathology, Stents
- Abstract
Background: Current data suggest microembolization to the brain may result in long-term cognitive dysfunction despite the absence of immediate clinically obvious cerebrovascular events. We reviewed a series of patients treated electively with carotid endarterectomy (CEA), carotid artery stenting (CAS) with distal filters, and carotid stenting with flow reversal (FRS) monitored continuously with transcranial Doppler scan (TCD) during the procedure to detect microembolization rates., Methods: TCD insonation of the M1 segment of the middle cerebral artery was conducted during 42 procedures (15 CEA, 20 CAS, and 7 FRS) in 41 patients seen at an academic center. One patient had staged bilateral CEA. Ipsilateral microembolic signals (MESs) were divided into three phases: preprotection phase (until internal carotid artery [ICA] cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection phase (until clamp/shunt was removed, filter removed, or antegrade flow re-established), and postprotection phase (after clamp/shunt was removed, filter removed, or antegrade flow re-established). Descriptive statistics are reported as mean ± SE for continuous variables and N (%) for categorical variables. Differences in ipsilateral emboli counts based on cerebral protection strategy were assessed using nonparametric methods., Results: TCD insonation and procedural success were obtained in 33 procedures (79%; 14 CEA, 14 CAS, and 5 FRS). Highest ipsilateral MESs were observed for CAS (319.3 ± 110.3), followed by FRS (184.2 ± 110.5), and CEA (15.3 ± 22.0). Pairwise comparisons revealed significantly higher ipsilateral MESs with both FRS and CAS when compared to CEA (P = .007 for FRS and P < .001 for CAS vs CEA, respectively), whereas the difference in MESs between FRS and CAS was not significant (P = .053). Periods of maximum embolization were postprotection phase for CEA, protection phase for CAS, and preprotection phase for FRS. Preprotection MESs were frequently observed during both CAS and FRS (20.4% and 63.3% of total MESs across all phases, respectively), and the primary difference between these two methods seemed to be related to lower MESs during the protection phase with FRS., Conclusion: CEA is associated with lower rates of microembolization compared with carotid stenting. Flow reversal may represent a procedural modification with potential to reduce microembolization during carotid stenting; further investigation is warranted to determine the relationship between cerebral protection strategies and outcomes associated with carotid stenting., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)
- Published
- 2011
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27. Midterm results of adjunctive neck therapies performed during elective infrarenal aortic aneurysm repair.
- Author
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Chung J, Corriere MA, Milner R, Kasirajan K, Salam A, Dodson TF, Chaikof EL, and Veeraswamy RK
- Subjects
- Aged, Aorta, Abdominal diagnostic imaging, Aorta, Abdominal pathology, Aortic Aneurysm, Abdominal diagnostic imaging, Aortic Aneurysm, Abdominal pathology, Aortic Rupture etiology, Elective Surgical Procedures, Endoleak etiology, Endoleak therapy, Female, Graft Survival, Humans, Intraoperative Complications, Kaplan-Meier Estimate, Male, Stents, Tomography, X-Ray Computed, Aorta, Abdominal surgery, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis Implantation adverse effects, Endovascular Procedures
- Abstract
Objective: This study evaluated the durability of adjunctive endovascular neck procedures, including aortic cuffs, Palmaz stents (Cordis, Miami Lakes, Fla), and high-pressure balloon angioplasty, at managing intraoperative proximal neck complications during endovascular aortic aneurysm repair (EVAR)., Methods: This was a single-center retrospective review of EVARs. The primary outcome variable studied was survival free of a graft-related event (GRE). GRE was defined by the occurrence of one of the following: type I endoleak, sac enlargement, aneurysm rupture, death, or procedure related to the aortic neck. These outcome variables were assessed relative to the preoperative anatomic neck variables (neck length, diameter, degree of angulation, degree of circumferential thrombus, and presence of conicity), procedural variables (manufacturing type of graft, use of a Palmaz stent), and patient characteristics (age and presence of medical comorbidities). Outcomes were assessed by t tests, Pearson χ(2), and Kaplan-Meier analysis, when appropriate., Results: A total of 174 EVARs performed between January 2005 and December 2007 were evaluated. Fifty-six adjunctive procedures were performed, with a 97% primary-assisted exclusion rate. Patients who received an adjunctive therapy had similar freedom from a GRE compared with EVARs that did not require adjunctive therapy (35.5 ± 2.6 vs 34.8 ± 1.5 months, P = .31, log-rank test). Subset analysis identified a significant association between Palmaz stent placement at the time of EVAR and decreased freedom from GREs (hazard ratio, 2.87; 95% confidence interval, 1.21-6.77; P = .02)., Conclusions: Midterm results suggest that adjunctive therapies to manage intraoperative proximal neck complications do not compromise durability. The subset of patients requiring aortic neck Palmaz stent placement at the time of EVAR are among those at highest risk for subsequent GRE., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)
- Published
- 2010
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28. Risk factors for late mortality after endovascular repair of the thoracic aorta.
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Chung J, Corriere MA, Veeraswamy RK, Kasirajan K, Milner R, Dodson TF, Salam AA, and Chaikof EL
- Subjects
- Aged, Aged, 80 and over, Aortic Dissection mortality, Aortic Dissection surgery, Aneurysm, False mortality, Aneurysm, False surgery, Aneurysm, Infected mortality, Aneurysm, Infected surgery, Aorta, Thoracic injuries, Aorta, Thoracic pathology, Aortic Aneurysm, Thoracic mortality, Aortic Aneurysm, Thoracic surgery, Aortic Diseases blood, Aortic Diseases pathology, Blood Vessel Prosthesis Implantation adverse effects, Comorbidity, Female, Georgia epidemiology, Hematoma mortality, Hematoma surgery, Hospital Mortality, Humans, Kaplan-Meier Estimate, Leukocyte Count, Leukocytosis blood, Leukocytosis mortality, Male, Middle Aged, Proportional Hazards Models, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Ulcer mortality, Ulcer surgery, Aorta, Thoracic surgery, Aortic Diseases mortality, Aortic Diseases surgery, Blood Vessel Prosthesis Implantation mortality
- Abstract
Objective: This study was conducted to identify risk factors for late mortality after thoracic endovascular aortic repair (TEVAR)., Methods: A retrospective analysis of consecutive TEVAR was conducted. Medical record review, telephone contact, or query of the Social Security Death Index was used to determine 30-day and late survival. Late mortality was assessed with respect to patient characteristics at the time of the initial treatment, preoperative laboratory values, pathology, clinical presentation, and treatment adjuncts. Significant univariate predictors of death were entered into a multivariate Cox proportional hazards model., Results: From 1998 to 2009, 252 patients (149 men; mean age, 68 years) underwent TEVAR for degenerative thoracic aortic aneurysm (TAA, n = 143), type B dissection (n = 62), mycotic aneurysm (n = 13), traumatic disruption (n = 12), penetrating ulcer or intramural hematoma (n = 10), anastomotic pseudoaneurysm (n = 4), or other pathology (n = 8). The 30-day mortality was 9.5%, with stroke or spinal cord injury in 5.6%. Mean follow-up was 22 +/- 22 months. Kaplan-Meier mean survival was 53 months. Predictors of late mortality by univariate analysis included age (P < .01), cardiac arrhythmia (P = .03), chronic obstructive pulmonary disease (P = .05), aneurysm diameter (P < .01), rupture (P < .01), debranching (P = .02), leukocytosis (white blood cell count > 10.0 x 10(3)/microL; P < .01), albumin, (P < .01), and creatinine > 1.7 mg/dL (P = .01). Multivariate predictors of mortality included rupture (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.02-9.44; P = .03), debranching (HR, 2.20; 95% CI, 1.09-4.24; P = .03), preoperative leukocytosis (HR, 1.23; 95% CI, 1.09-1.39; P = .001), and aneurysm diameter (HR, 1.02; 95% CI, 1.01-1.03; P = .04). Subgroup analysis of patients undergoing TEVAR for asymptomatic, nonruptured TAA demonstrated that debranching (HR, 2.47; 95% CI, 1.13-5.39; P = .02), White blood cell count (HR, 1.19; 95% CI, 1.01-1.40; P < .04), and aneurysm diameter (HR, 1.03; 95% CI, 1.01-1.05, P < .01) remain independently predictive of late mortality., Conclusions: Preoperative leukocytosis, aneurysm diameter, and concurrent debranching independently predict late mortality irrespective of clinical presentation and may assist in risk stratification.
- Published
- 2010
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29. Endovascular repair for diverse pathologies of the thoracic aorta: an initial decade of experience.
- Author
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Chaikof EL, Mutrie C, Kasirajan K, Milner R, Chen EP, Veeraswamy RK, Dodson TF, and Salam AA
- Subjects
- Aged, Aged, 80 and over, Aortic Dissection surgery, Aortic Aneurysm, Thoracic mortality, Aortic Aneurysm, Thoracic pathology, Blood Vessel Prosthesis, Cause of Death, Creatinine blood, Female, Humans, Kaplan-Meier Estimate, Male, Middle Aged, Postoperative Complications epidemiology, Prosthesis Failure, Risk Assessment, Stroke epidemiology, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis Implantation adverse effects
- Abstract
Background: Endovascular grafts have rapidly evolved as a minimally invasive treatment for a variety of acute and chronic disorders of the thoracic aorta. Application of this technology at a single center is reported., Study Design: Between 1998 and 2007, 197 patients underwent thoracic endovascular aortic repair. Primary indications included degenerative aneurysms (n = 121), type B aortic dissection (n = 44), mycotic aneurysms (n = 9), traumatic disruptions (n = 9), intramural hematoma (n = 5), pseudoaneurysm (n = 4), and miscellaneous pathology (n = 5). An analysis of patient demographics, periprocedural records, complications, reinterventions, and survival was conducted., Results: Thirty-day mortality was 6%, which was lowest among patients undergoing treatment for a degenerative thoracic aortic aneurysm (2.4%, 3 of 121). Major adverse events included stroke in 3%, spinal cord ischemia in 2%, peripheral vascular repair in 4.5%, renal failure in 4.5%, and open conversion in one patient (0.5%). Both preoperative serum creatinine (odds ratio 1.44, 95% CI 1.02 to 2.04, p = 0.039) and number of endograft components (odds ratio 1.43, 95% CI 1.01 to 2.01, p = 0.043) were predictors of major adverse events. Kaplan-Meier analysis revealed a reduction in late survival among patients with preoperative creatinine >or=1.8 mg/dL (p < 0.001). One- and 5-year intervention-free survivals were 77%+/-3% and 41%+/-6%, respectively., Conclusions: Thoracic endovascular aortic repair represents an effective treatment for a variety of pathologic states. But the risk-benefit analysis for thoracic endovascular aortic repair should carefully consider the extent of disease, pathologic condition, and renal function.
- Published
- 2009
- Full Text
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30. Julian K Quattlebaum, MD: American pioneer of hepatic surgery.
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Sarmiento JM and Dodson TF
- Subjects
- Aged, Biliary Tract Diseases surgery, Female, History, 20th Century, Humans, Liver Diseases surgery, Male, Hepatectomy history, Liver surgery
- Published
- 2008
- Full Text
- View/download PDF
31. A single-institution experience with the AneuRx Stent Graft for endovascular repair of abdominal aortic aneurysm.
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Smith S, Mountcastle S, Burridge A, Dodson TF, Salam AA, Kasirajan K, Milner R, Veeraswamy R, and Chaikof EL
- Subjects
- Aged, Aortic Aneurysm, Abdominal mortality, Female, Humans, Intraoperative Complications, Male, Postoperative Complications, Survival Rate, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation adverse effects, Stents adverse effects
- Abstract
We report our experience of endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) using the modular AneuRx Stent Graft System. We retrospectively reviewed the outcomes of 113 patients who underwent EVAR with the AneuRx system performed at our institution between October 1999 and August 2003. The mean age of this group was 72.5 years, with 71% (n = 80) over the age of 70 years and 95% (n = 107) males. Aneurysm diameter ranged 4.0-9.0 cm, with 33% (n = 37) >6.0 cm. The average duration of late follow-up was 32.6 +/- 24.8 months (median = 37). Successful deployment of the modular AneuRx system was noted in all patients. There were no immediate operative conversions, deaths within 24 hr of operation, or type I or III endoleaks observed at the completion of the procedure. Thirty-day mortality was 3.5% (n = 4). Acute deployment-related complications occurred in 10% (n = 13) of patients and included misdeployment, operative bleeding, arterial perforation/dissection, and access site complications. Acute systemic complications were present in nine patients, predominantly renal and cardiac complications. An endoleak noted at any time occurred in 25% of patients, with 40% of those requiring a secondary intervention. Two patients suffered late aneurysm rupture due to a type I endoleak and graft infection. Kaplan-Meier analysis revealed 5-year freedom from secondary intervention of 72.4%; freedom from aneurysm-related death of 93.9%; and probability of survival based on all-cause mortality of 60.1%. Endovascular treatment with the modular AneuRx Stent Graft System is safe and effective, producing acceptable rates of disease-free survival and mid-term clinical outcome.
- Published
- 2008
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32. SIR 2006 annual meeting film panel case: polyarteritis nodosa in upper extremity arteries.
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Chamsuddin AA, Dodson TF, Nazzal L, and Page A
- Subjects
- Adult, Anastomosis, Surgical methods, Female, Humans, Radiography, Treatment Outcome, Upper Extremity surgery, Polyarteritis Nodosa diagnostic imaging, Polyarteritis Nodosa surgery, Upper Extremity blood supply, Upper Extremity diagnostic imaging, Vascular Surgical Procedures methods
- Published
- 2007
- Full Text
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33. New opportunities for reducing risk of surgical site infection. Roundtable discussion.
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Malangoni MA, Cheadle WG, Dodson TF, Dohmen PM, Jones D, Katariya K, Kolvekar S, and Urban JA
- Subjects
- Humans, Risk, Surgical Wound Infection microbiology, Surgical Wound Infection prevention & control
- Published
- 2006
- Full Text
- View/download PDF
34. Secondary conversion of the Gore Excluder to operative abdominal aortic aneurysm repair.
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Kong LS, MacMillan D, Kasirajan K, Milner R, Dodson TF, Salam AA, Smith RB 3rd, and Chaikof EL
- Subjects
- Age Factors, Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal diagnostic imaging, Aortography, Balloon Occlusion methods, Clinical Trials, Phase I as Topic, Clinical Trials, Phase II as Topic, Female, Follow-Up Studies, Humans, Male, Middle Aged, Prosthesis Design, Prosthesis Failure, Reoperation, Risk Assessment, Severity of Illness Index, Sex Factors, Survival Analysis, Treatment Outcome, United States, Vascular Surgical Procedures adverse effects, Aortic Aneurysm, Abdominal mortality, Aortic Aneurysm, Abdominal therapy, Balloon Occlusion instrumentation, Blood Vessel Prosthesis adverse effects, Vascular Surgical Procedures methods
- Abstract
Objective: Reports continue to document the occurrence of major adverse events after endovascular aortic aneurysm repair. Although many of these problems can be successfully managed through endovascular salvage, operative conversion with explantation of the endoprosthesis remains necessary in some patients. We report herein a review of all patients initially enrolled in multicenter US clinical trials of the Excluder endograft who underwent secondary conversion to open surgical repair., Methods: Clinical data and relevant medical records of patients enrolled in phase I and II multicenter US clinical trials of the Excluder endograft were retrospectively reviewed for adverse events and further narrowed to those patients who underwent secondary operative conversion. Hospital records, operative and anesthesia reports, and all imaging studies were analyzed at initial implantation and at the time of subsequent open surgical repair., Results: Late open conversion was performed in 16 (2.7%) of the 594 patients enrolled in the Excluder clinical trials. Presumed endotension accounted for 8 of 16 of secondary conversions. In two of these patients, however, an endoleak was identified at the time of open surgical repair. Of the remaining eight patients, two underwent conversion for device infection, five for persistent endoleak, and one for aneurysm rupture. The overall 30-day mortality was 6.25% (1/16), with one death occurring in a patient with a ruptured aneurysm. Of patients who underwent conversion because of endotension, the maximal abdominal aortic aneurysm diameter (mean +/- SD) at the time of initial implantation and subsequent graft removal was 61 +/- 11 mm and 70 +/- 10 mm, respectively. The mean time to open conversion for treatment of endotension was 37 +/- 12 months (range, 20-50 months; median, 42 months). Freedom from conversion was 98.6% and 96.7% at 24 and 48 months, respectively., Conclusions: Endotension in the absence of a demonstrable endoleak has been a major indication for late surgical conversion in patients treated with the Excluder endograft. Given the potential presence of an undetected endoleak and the possible effects of progressive sac enlargement on long-term device stability, continued close surveillance of patients with assumed endotension is required. Should changes in device design eliminate endotension, a further reduction in the already low incidence of late open conversion of the Excluder endograft can be anticipated.
- Published
- 2005
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35. Why do residents leave general surgery? The hidden problem in today's programs.
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Dodson TF and Webb AL
- Subjects
- Attitude of Health Personnel, Clinical Competence, Female, Georgia, Humans, Life Style, Male, Sex Factors, Specialties, Surgical education, Specialties, Surgical statistics & numerical data, Student Dropouts statistics & numerical data, Career Choice, General Surgery education, Internship and Residency statistics & numerical data
- Abstract
Objective: Much has been written and discussed about the reasons for reduced interest in surgery, but few institutions have chosen to examine the loss or attrition of general surgery residents from their own programs. In preparation for an upcoming Residency Review Committee analysis of our program, we took the opportunity to examine the reasons for attrition in our own institution., Design, Setting, and Participants: During the years 1990 to 2003, 120 categorical residents were admitted into our general surgery residency program. Residents who matched into preliminary positions or non-5-year categorical positions were not included in this study. During this period of time, 20 residents (9 female and 11 male) left the program for a variety of reasons. The folders of those 20 residents along with all of the correspondence pertaining to each resident were reviewed in detail., Results: Our overall attrition rate during this 13-year period of time was 20 of 120 residents or 17%. This is comparable with the often-quoted figure of approximately 20% attrition in other general surgery programs. The reasons for leaving could be divided into 4 categories: (1) lifestyle, (2) opportunity for early specialization, (3) asked to leave the program because of emotional or performance difficulties, or (4) decided to leave medicine entirely. The largest group was related to lifestyle issues and comprised 13 of the total of 20 residents who left the program. Of this group of 13, 3 went into plastic surgery, 4 went into anesthesiology, 2 went into radiology, and the remaining 4 went into public health, internal medicine, pathology, and emergency medicine. Seven of these 13 individuals were women. Two individuals entered residency with the goal of specializing in plastic surgery. They both left their 5-year categorical general surgery positions after the third year when they were offered the opportunity to enter three-year plastic surgery fellowship positions. The third category was composed of 4 individuals who were asked to leave the program during this 13-year period because of performance or emotional problems, with 3 of these 4 being men. Only 1 person left medicine entirely, and he is now the vice-president of a successful software company. Of the total of 20 residents who left our program, 9 (45%) were female. Given that there were 33 females in our program during the subject period of time, these 9 females represent an attrition rate of 27%. The 11 males who left during this period represent, however, an attrition rate of only 13%., Conclusions: Although much concern has been expressed over the declining numbers of medical students interested in surgery, loss of residents after matching in general surgery is an equally significant problem. In our program over a 13-year period, 20 out 120 residents, or 17% dropped out or were released. The attrition rate for females (27%) was approximately twice that of males (13%), with 7 out of 9 females (78%) leaving for lifestyle reasons.
- Published
- 2005
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36. Endovascular abdominal aortic aneurysm repair in the octogenarian.
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Brinkman WT, Terramani TT, Najibi S, Weiss VJ, Salam AA, Dodson TF, Smith RB, and Chaikof EL
- Subjects
- Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal mortality, Female, Follow-Up Studies, Humans, Life Expectancy, Male, Morbidity, Postoperative Complications epidemiology, Radiology, Interventional, Risk Assessment, Time Factors, Treatment Outcome, Aortic Aneurysm, Abdominal surgery
- Abstract
The aim of this study was to analyze patient outcomes following endovascular repair of infrarenal abdominal aortic aneurysms (EAR) among patients 80 years of age or older. In this study, reporting standards of the Ad Hoc Committee for Standardized Reporting Practices for Endovascular Aortic Aneurysm Repair of the Society of Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) were followed. Between August 8, 1996 and February 12, 2001 EAR was performed in 31 patients (29 male and 2 female) with an average age of 83 +/- 3 years and an average maximum aneurysm diameter of 59 +/- 7 mm. Overall technical success was 90% (28/31) with a single acute conversion and a 6% (2/32) incidence of major morbidity. There were no in-hospital deaths, but two patients (6%) died within 30 days of intervention. Four endoleaks, two type I and two type II, were observed within the first 30 days after endograft implantation and three new type II endoleaks were noted after implant periods that exceeded 1 month. Average follow-up was 16 months, with a single aneurysm-related death that occurred after late conversion to open repair, 2 years following initial endovascular treatment. Kaplan-Meier analysis revealed 3-, 12-, and 24-month estimated survivals of 93% (+/-5), 75% (+/-8), and 68% (+/-10), respectively. Clinical success rates were 90% (+/-5), 90% (+/-5), and 72% (+/-17) at 12, 24, and 36 months, respectively. We conclude that, in the octogenarian with mild to moderate medical comorbidities, endovascular aneurysm repair provides an alternative to open AAA repair with low operative morbidity and good clinical success rates. Elevated SVS/AAVS medical comorbidity scores were not associated with increased operative mortality rates, but they did show a trend toward decreased mid-term survival. Careful consideration of life expectancy and the probability of rupture, as with traditional AAA repair, should dictate necessity for intervention.
- Published
- 2004
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37. Brachial artery pseudoaneurysm in a 6-week-old infant.
- Author
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Gow KW, Mykytenko J, Patrick EL, and Dodson TF
- Subjects
- Aneurysm, False diagnosis, Aneurysm, False etiology, Arm blood supply, Brachial Artery surgery, Female, Humans, Infant, Aneurysm, False surgery, Brachial Artery injuries, Catheterization adverse effects
- Abstract
Trauma to the wall of an artery may lead to the development of a pseudoaneurysm. There are infrequent case reports of children who have developed pseudoaneurysms after vascular access attempts. The options for management are limited in children and even more so in neonates. We describe the presentation and management of a 6-week-old infant who had attempts at insertion of an intravenous catheter as a newborn. She presented with an enlarging mass of the right upper extremity with no palpable radial pulse on examination. Workup included radiographs, Doppler ultrasound, and magnetic resonance imaging that established the diagnosis of pseudoaneurysm of the brachial artery. She underwent a repair of the right brachial artery by identifying the site of the arterial injury and oversewing the defect in the wall. Intraoperatively, she had good arterial flow with a return of the radial pulse. The patient did well immediately postoperatively and has been followed for more than a year with normal pulses and growth of the upper extremity. Patients that have had previous attempts at vascular access and subsequently develop a mass in the area of puncture should be worked up for the potential of a pseudoaneurysm. Doppler ultrasound and magnetic resonance imaging may help with diagnosis. Primary repair is advocated in this injury to ensure adequate growth of the limb.
- Published
- 2004
38. Pediatric blunt trauma resulting in major arterial injuries.
- Author
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Milas ZL, Dodson TF, and Ricketts RR
- Subjects
- Accidental Falls statistics & numerical data, Accidents, Traffic statistics & numerical data, Adolescent, Age Distribution, Angiography, Bicycling injuries, Bicycling statistics & numerical data, Biomechanical Phenomena, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation methods, Blood Vessel Prosthesis Implantation statistics & numerical data, Child, Child, Preschool, Female, Follow-Up Studies, Georgia epidemiology, Hospitals, Pediatric, Humans, Iliac Artery transplantation, Injury Severity Score, Male, Physical Examination, Polytetrafluoroethylene, Saphenous Vein transplantation, Tomography, X-Ray Computed, Treatment Outcome, Wounds, Nonpenetrating diagnosis, Wounds, Nonpenetrating epidemiology, Wounds, Nonpenetrating etiology, Arteries injuries, Wounds, Nonpenetrating surgery
- Abstract
Ten children, aged 4 to 14 years, sustaining blunt arterial trauma from motor vehicle collisions (6), bicycle accidents (2), and falls (2) were identified over a 10-year period. The arteries injured included the common iliac (3), abdominal aorta (2), carotid (2), brachial (2), and the subclavian, renal, and femoral artery (1 each). One patient had three arterial injuries. Six patients had associated injuries including a pelvic and lumbar spine fracture, Horner's syndrome, liver laceration, skull fracture, open humerus fracture, small bowel serosal tear, and a brachial plexus injury. Definitive diagnosis was made using arteriography (6), computed tomography (CT) scan (2), and physical examination (2). The types of arterial injuries found included incomplete transection, complete transection with pseudo-aneurysm formation, traumatic arteriovenous (AV) fistulas, complete occlusion, and dissection. Repair was accomplished by hypogastric artery interposition or bypass grafting, synthetic grafting with polytetrafluoroethylene (PTFE), reverse saphenous vein grafting, or primary repair, depending on the circumstances. An AV fistula between the carotid artery and cavernous sinus was embolized. All grafts remained patent with exception of the aorto-renal bypass graft at follow-up ranging from 1 month to 3 years. The principles for repairing vascular injuries in children are slightly different than those in adults. Every effort should be made to use autogenous tissue such as the hypogastric artery or saphenous vein for repair if possible. If not, PTFE grafts can be used, although the long-term patency of these grafts in growing children is not known.
- Published
- 2004
39. Secondary conversion due to failed endovascular abdominal aortic aneurysm repair.
- Author
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Terramani TT, Chaikof EL, Rayan SS, Lin PH, Najibi S, Bush RL, Lumsden AB, Salam A, Smith RB 3rd, and Dodson TF
- Subjects
- Aged, Aged, 80 and over, Angiography methods, Aortic Aneurysm, Abdominal diagnostic imaging, Blood Vessel Prosthesis Implantation methods, Female, Follow-Up Studies, Humans, Male, Middle Aged, Postoperative Complications mortality, Prosthesis Failure, Reoperation, Retrospective Studies, Risk Assessment, Severity of Illness Index, Survival Rate, Treatment Outcome, Aortic Aneurysm, Abdominal mortality, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation adverse effects, Cause of Death
- Published
- 2003
- Full Text
- View/download PDF
40. Impact of an endovascular program on the operative experience of abdominal aortic aneurysm in vascular fellowship and general surgery residency.
- Author
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Lin PH, Bush RL, Milas M, Terramani TT, Dodson TF, Chen C, Chaikof EL, and Lumsden AB
- Subjects
- Clinical Competence, Humans, Retrospective Studies, Stents, Vascular Surgical Procedures statistics & numerical data, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis Implantation education, Endoscopy education, General Surgery education, Internship and Residency
- Abstract
Background: This study was performed to determine the impact of an endovascular program (EVP) on open and endovascular abdominal aortic aneurysm (AAA) operations in a residency training institution., Methods: Over an 8-year period ending in September 2001, hospital records of all patients undergoing open or endovascular AAA repair were retrospectively reviewed. Data were analyzed to determine the changing patterns of case volume, type of operative repair, and complexity of open repair with regards to the training of both general surgical chief residents and vascular fellows., Results: A total of 849 AAA operations were performed during the study period. The initiation of the EVP in 1997 resulted in a steady increase in the total annual AAA cases (P < 0.05), due in part to an increase in endovascular AAA operations despite a decrease in the annual open AAA volume. EVP had a positive impact on the overall operative experience of vascular fellows owing to the large increase in their endovascular AAA experience (annual mean pre-EVP 3 +/- 0.8 versus post-EVP 47 +/- 9.6, P < 0.01). A significant reduction occurred in the vascular fellows' open AAA experience (annual mean pre-EVP 40 +/- 12.7 versus post-EVP 19 +/- 9.4, P < 0.05). EVP did not affect the endovascular AAA experience of general surgery chief residents (annual mean pre-EVP 1 +/- 0.8 versus post-EVP 3 +/- 1.5, not significant). A significant reduction occurred in chief residents' open AAA experience (annual mean pre-EVP 39 +/- 9.7 versus post-EVP 18 +/- 7.4, P < 0.05). EVP did not affect the operative experience of complex open AAA operations in either vascular fellows or general surgery residents., Conclusions: An endovascular program has a positive impact on the aortic aneurysm practice in an academic institution, as evidenced by the significant increase in annual endovascular AAA cases despite a decrease in open AAA operations. Although vascular fellows continued to maintain sufficient experience in both open and endovascular AAA operations, general surgery chief residents suffered a significant decrease in their open AAA experience. Further evaluation of the residency system is warranted to better optimize the training paradigm of both vascular fellowship and general surgery residency.
- Published
- 2003
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41. Calciphylaxis and nonhealing wounds: the role of the vascular surgeon in a multidisciplinary treatment.
- Author
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Milas M, Bush RL, Lin P, Brown K, Mackay G, Lumsden A, Weber C, and Dodson TF
- Subjects
- Adult, Angiography, Arterial Occlusive Diseases complications, Arterial Occlusive Diseases diagnostic imaging, Arterial Occlusive Diseases surgery, Calciphylaxis physiopathology, Female, Humans, Hyperparathyroidism, Secondary complications, Hyperparathyroidism, Secondary surgery, Kidney Failure, Chronic complications, Kidney Failure, Chronic therapy, Leg blood supply, Leg Ulcer complications, Leg Ulcer diagnostic imaging, Leg Ulcer therapy, Middle Aged, Necrosis, Renal Dialysis, Vascular Surgical Procedures, Calciphylaxis complications, Leg Ulcer pathology, Wound Healing
- Abstract
Objective: Calciphylaxis, a disorder of calcium-phosphate metabolism that can result in arterial calcification, skin and solid organ calcium deposits, and nonhealing ulcerations, is associated with significant morbidity and mortality. Although its most common cause is secondary hyperparathyroidism in patients with renal failure, vascular surgeons are frequently called on to evaluate these nonhealing extremity wounds. We reviewed our experience of a multidisciplinary approach in treating patients with calciphylaxis and nonhealing ulcers., Patients and Methods: Over a 14-month period at a tertiary center, five patients were seen with calciphylaxis and nonhealing leg wounds. Demographics, disease characteristics, surgical treatment, and outcomes were analyzed., Results: All five patients were black women aged 40 +/- 8.9 years with hypertensive renal failure undergoing long-term hemodialysis (80 +/- 43 months). They had large, painful lower extremity wounds or necrotic ulcers (mean size, 135 cm(2)) that had developed over 2 to 4 months. Three patients had palpable pedal pulses, one patient had Doppler pedal signals, and one patient had absent pedal flow. Arteriogram was performed in the latter two patients, and one patient underwent lower extremity revascularization because of superficial femoral artery stenosis with symptomatic improvement. Four patients underwent aggressive debridement by the vascular surgical service, and two needed plastic surgeon-performed skin grafting. All patients had elevated parathyroid hormone levels (mean, 1735 pg/mL; > 25 x normal level); mean preoperative calcium levels were normal (10 mg/dL). After either subtotal (n = 4) or total (n = 1) parathyroidectomy by an experienced endocrine surgeon, a significant reduction in parathyroid hormone and calcium levels was seen (122 pg/mL and 7.9 mg/dL, respectively; P <.05). There were no postoperative complications or amputations; one patient died 12 months after parathyroidectomy of severe preexisting cardiopulmonary disease. Complete wound healing was observed by 4.8 +/- 2 months. During a mean follow-up period of 9 months (range, 1 to 18 months), all wounds remained healed without ulcer recurrence., Conclusion: The diagnosis of calciphylaxis should be considered in patients with end-stage renal disease with atypical tissue necrosis or subcutaneous nodules. Early recognition of calciphylaxis and multidisciplinary treatment, including diligent wound care, frequent debridement, parathyroidectomy, and appropriate skin grafting or revascularization, can result in improved wound healing and limb salvage.
- Published
- 2003
- Full Text
- View/download PDF
42. Image of the month. Hepatic artery aneurysm.
- Author
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Najibi S, Terramani TT, Thourani VH, Brinkman WT, Lumsden AB, and Dodson TF
- Subjects
- Aged, Aged, 80 and over, Aneurysm surgery, Humans, Male, Tomography, X-Ray Computed, Aneurysm diagnostic imaging, Hepatic Artery
- Published
- 2002
- Full Text
- View/download PDF
43. Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting.
- Author
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Pruitt A, Dodson TF, Najibi S, Thourani V, Sherman A, Cloft H, Caliendo A, and Smith RB 3rd
- Subjects
- Aged, Aneurysm, False diagnostic imaging, Aneurysm, Infected diagnostic imaging, Angioplasty adverse effects, Brachiocephalic Trunk diagnostic imaging, Embolism diagnostic imaging, Fatal Outcome, Female, Humans, Prosthesis-Related Infections diagnostic imaging, Radiography, Sepsis diagnostic imaging, Aneurysm, False etiology, Aneurysm, Infected etiology, Blood Vessel Prosthesis Implantation adverse effects, Brachiocephalic Trunk microbiology, Embolism etiology, Prosthesis-Related Infections complications, Sepsis etiology, Stents adverse effects
- Abstract
The use of percutaneous angioplasty with subsequent intravascular metallic stent placement has gained increasing acceptance over the past decade. Infections of these stents appear to be uncommon; however, the rarity of this complication may in part be the result of a lack of availability of long-term follow-up data. A number of examples of infected cardiac and peripheral vascular stents have been reported, often with fatal consequences. Herein, we report a 74-year-old woman who underwent subclavian and brachiocephalic artery angioplasty and stent placement for symptomatic stenoses. Six months after the initial intervention, the patient returned with restenosis of the stents and underwent repeat angioplasty to restore full patency. Two weeks later, the patient was readmitted with generalized malaise and multiple erythematous, macular lesions on the right forearm and hand. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan of the chest showed a large brachiocephalic artery pseudoaneurysm with surrounding hematoma. Despite prompt surgical intervention, this complication proved ultimately fatal. Infections of metallic endovascular stents are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention.
- Published
- 2002
- Full Text
- View/download PDF
44. Endovascular repair of abdominal aortic aneurysms: risk stratified outcomes.
- Author
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Chaikof EL, Lin PH, Brinkman WT, Dodson TF, Weiss VJ, Lumsden AB, Terramani TT, Najibi S, Bush RL, Salam AA, and Smith RB 3rd
- Subjects
- Aged, Angioplasty adverse effects, Blood Vessel Prosthesis Implantation adverse effects, Follow-Up Studies, Humans, Middle Aged, Postoperative Complications, Retrospective Studies, Risk Factors, Survival Analysis, Time Factors, Treatment Outcome, Vascular Surgical Procedures adverse effects, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis, Stents, Vascular Surgical Procedures methods
- Abstract
Objective: The impact of co-morbid conditions on early and late clinical outcomes after endovascular treatment of abdominal aortic aneurysm (AAA) was assessed in concurrent cohorts of patients stratified with respect to risk for intervention., Summary Background Data: As a minimally invasive strategy for the treatment of AAA, endovascular repair has been embraced with enthusiasm for all prospective patients who are suitable anatomical candidates because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality., Methods: From April 1994 to March 2001, endovascular AAA repair was performed in 236 patients using commercially available systems. A subset of patients considered at increased risk for intervention (n = 123) were categorized, as such, based on a preexisting history of ischemic coronary artery disease, with documentation of myocardial infarction (60%) or congestive heart failure (35%), or due to the presence of chronic obstructive disease (21%), liver disease, or malignancy., Results: Perioperative mortality (30-day) was 6.5% in the increased-risk patients as compared to 1.8% among those classified as low risk (P = NS). There was no difference between groups in age (74 +/- 9 years vs. 72 +/- 6 years; mean +/- SD), surgical time (235 +/- 95 minutes vs. 219 +/- 84 minutes), blood loss (457 +/- 432 mL vs. 351 +/- 273 mL), postoperative hospital stay (4.8 +/- 3.4 days vs. 4.0 +/- 3.9 days), or days in the ICU (1.3 +/- 1.8 days vs. 0.5 +/- 1.6 days). Patients at increased risk of intervention had larger aneurysms than low-risk patients (59 +/- 13 mm vs. 51 +/- 14 mm; P <.05). Stent grafts were successfully implanted in 116 (95%) increased-risk versus 107 (95%) low-risk patients (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3% and 5%, respectively. The initial endoleak rate was 22% versus 20%, based on the first CT performed (either at discharge or 1 month; P = NS). To date, increased-risk patients have been followed for 17.4 +/- 15 months and low-risk patients for 16.3 +/- 14 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P <.05, Mantel-Cox test). Both cohorts had similar two-year primary and secondary clinical success rates of approximately 75% and 80%, respectively., Conclusions: Early and late clinical outcomes are comparable after endovascular repair of AAA, regardless of risk-stratification. Notably, 2 years after endovascular repair, at least one in five patients was classified as a clinical failure. Given the need for close life-long surveillance and the continued uncertainty associated with clinical outcome, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.
- Published
- 2002
- Full Text
- View/download PDF
45. Endovascular aortic aneurysm operations.
- Author
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Najibi S, Terramani TT, Weiss VJ, Smith RB, Salam AA, Dodson TF, Chaikof EL, and Lumsden AB
- Subjects
- Humans, Stents, Aortic Aneurysm surgery, Blood Vessel Prosthesis Implantation methods
- Abstract
Options for the treatment of abdominal and thoracic aortic aneurysms are in a state of evolutionary change. The development and continued refinement of the endoluminal approaches has decreased the need for open aortic aneurysm surgery. Endovascular stent graft technology is an area of active research in which both the delivery systems and the endografts are undergoing continued improvement so that patients with what was previously thought to be unfavorable anatomy may be treated by these means. The design and deployment techniques of the currently available endografts, as well as those in clinical trials, are presented.
- Published
- 2002
- Full Text
- View/download PDF
46. Conservatism and new technology: the impact on abdominal aortic aneurysm repair.
- Author
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Bush RL, Najibi S, Lin PH, Lumsden AB, Dodson TF, Salam AA, Smith RB 3rd, Chaikof EL, and Weiss VL
- Subjects
- Aortic Aneurysm, Abdominal economics, Clinical Competence, Georgia, Humans, Retrospective Studies, Surgery Department, Hospital economics, Surgery Department, Hospital statistics & numerical data, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis Implantation economics, Practice Patterns, Physicians' economics, Practice Patterns, Physicians' trends
- Abstract
The last decade has represented a time of fundamental change in the treatment of abdominal aortic aneurysms (AAAs). Potentially, vascular surgeons will either acquire catheter-based skills or relinquish the care for many patients with infrarenal AAA. We investigated AAA referral patterns and method of AAA repair after the establishment of an endovascular AAA program at our institution. We conducted a retrospective review of elective AAA repairs after the initiation of an endovascular AAA program in April 1994. Six vascular surgeons performed all procedures with a clear distinction between the surgeons (n=3) who performed traditional AAA repair only and those (n=3) who managed AAAs by means of either endovascular or traditional treatment. From April 1994 through December 2000, 740 elective AAA repairs were performed. During this time the mean number of AAA repairs has been 106/year ranging from 75 to 155/year. More notable however is the steady increase in the percentage of endovascular AAA repairs from 6 per cent of all AAA repairs in 1994 to 61 per cent in 2000. During this time traditional surgeons have experienced a plateau in total AAA repairs performed per year with their number of open repairs decreasing by 36 per cent. At the same time endovascular surgeons have seen a progressive rise in total AAA cases including an increase of 200 per cent in open repairs and of 1367 per cent in endovascular repairs. Our vascular surgeons who repair AAA utilizing both endovascular and open techniques have experienced an increase in aneurysm referrals since the advent of an endovascular AAA program. Those who have not adopted endovascular skills have seen a decline in their aneurysm practice. The larger question about whether or not to embrace new technology before the availability of long-term follow-up remains unanswered.
- Published
- 2002
47. Surgical intervention for complications caused by femoral artery catheterization in pediatric patients.
- Author
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Lin PH, Dodson TF, Bush RL, Weiss VJ, Conklin BS, Chen C, Chaikof EL, and Lumsden AB
- Subjects
- Acute Disease, Adolescent, Age Factors, Aneurysm, False diagnosis, Angioplasty instrumentation, Arteriovenous Fistula diagnosis, Blood Vessel Prosthesis Implantation instrumentation, Child, Child, Preschool, Chronic Disease, Hematoma diagnosis, Hemorrhage diagnosis, Humans, Infant, Infant, Newborn, Ischemia diagnosis, Prospective Studies, Risk Factors, Thrombectomy instrumentation, Treatment Outcome, Aneurysm, False etiology, Aneurysm, False surgery, Angioplasty methods, Arteriovenous Fistula etiology, Arteriovenous Fistula surgery, Blood Vessel Prosthesis Implantation methods, Catheterization, Peripheral adverse effects, Femoral Artery injuries, Femoral Artery surgery, Hematoma etiology, Hematoma surgery, Hemorrhage etiology, Hemorrhage surgery, Iatrogenic Disease, Ischemia etiology, Ischemia surgery, Thrombectomy methods
- Abstract
Purpose: This study evaluated the risk factors and surgical management of complications caused by femoral artery catheterization in pediatric patients., Methods: From January 1986 to March 2001, the hospital records of all children who underwent operative repairs for complications caused by femoral artery catheterization were reviewed. A prospective cardiac data bank containing 1674 catheterization procedures during the study period was used as a means of determining risk factors associated with iatrogenic femoral artery injury., Results: Thirty-six operations were performed in 34 patients (age range, 1 week-17.4 years) in whom iatrogenic complications developed after either diagnostic or therapeutic femoral artery catheterizations during the study period. Non-ischemic complications included femoral artery pseudoaneurysms (n = 4), arteriovenous fistulae (n = 5), uncontrollable bleeding, and expanding hematoma (n = 4). Operative repairs were performed successfully in all patients with non-ischemic iatrogenic femoral artery injuries. In contrast, ischemic complications occurred in 21 patients. Among them, 14 patients had acute femoral ischemia and underwent surgical interventions including femoral artery thrombectomy with primary closure (n = 6), saphenous vein patch angioplasty (n = 6), and resection with primary anastomosis (n = 2). Chronic femoral artery occlusion (> 30 days) occurred in seven patients, with symptoms including either severe claudication (n = 4) or gait disturbance or limb growth impairment (n = 3). Operative treatments in these patients included ileofemoral bypass grafting (n = 5), femorofemoral bypass grafting (n = 1), and femoral artery patch angioplasty (n = 1). During a mean follow-up period of 38 months, no instances of limb loss occurred, and 84% of children with ischemic complications eventually gained normal circulation. Factors that correlated with an increased risk of iatrogenic groin complications that necessitated surgical intervention included age younger than 3 years, therapeutic intervention, number of catheterizations (>or= 3), and use of 6F or larger guiding catheter., Conclusion: Although excellent operative results can be achieved in cases of non-ischemic complications, acute femoral occlusion in children younger than 2 years often leads to less satisfactory outcomes. Operative intervention can provide successful outcome in children with claudication caused by chronic limb ischemia. Variables that correlated with significant iatrogenic groin complications included a young age, therapeutic intervention, earlier catheterization, and the use of a large guiding catheter.
- Published
- 2001
- Full Text
- View/download PDF
48. Age versus comorbidities as risk factors for complications after elective abdominal aortic reconstructive surgery.
- Author
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Berry AJ, Smith RB 3rd, Weintraub WS, Chaikof EL, Dodson TF, Lumsden AB, Salam AA, Weiss V, and Konigsberg S
- Subjects
- Age Factors, Aged, Aged, 80 and over, Aortic Diseases mortality, Comorbidity, Confounding Factors, Epidemiologic, Elective Surgical Procedures, Female, Humans, Logistic Models, Male, Middle Aged, Multivariate Analysis, Odds Ratio, Retrospective Studies, Risk Factors, Survival Rate, Vascular Surgical Procedures mortality, Aorta, Abdominal surgery, Aortic Diseases complications, Aortic Diseases surgery, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation mortality, Postoperative Complications
- Abstract
Purpose: This study estimated the association between age and in-hospital postoperative complications, controlling for known or suspected risk factors, in a series of patients undergoing elective abdominal aortic reconstructive surgery (AAR)., Methods: This retrospective cohort study of outcome data with multivariate logistic regression analysis was conducted at Emory University Hospital, a tertiary care, university-affiliated hospital. All patients undergoing elective AAR between Jan 1, 1986, and Aug 1, 1996, were included (n = 856). An estimate of the odds ratio (OR) and 95% CI for the association between patient age and in-hospital major morbidity or mortality after elective AAR was made, controlling for significant risk factors., Results: Among the 856 patients, 170 had a nonfatal complication (136 with major and 34 with minor complications), and 11 patients (1.3%) died. The final logistic regression model demonstrated a mild association between increasing age and rate of major postoperative complications, including death (for each increase in age of 10 years: OR, 1.23; 95% CI, 1.00-1.52; P =.052). Other significant covariates in the final model included cardiac disease (OR, 2.84; 95% CI, 1.18-6.86; P =.020), pulmonary disease (OR, 1.96; 95% CI, 1.35-2.84; P =.0004), and renal disease (OR, 2.57; 95% CI, 1.66-3.99; P =.0001). Increasing age was associated with a moderate increase in the rate of death (for each increase in age of 10 years: OR, 2.74; 95% CI, 1.22-6.16; P =.015) in a model with cardiac disease as the only significant covariate (OR, 14.67; 95% CI, 3.46-62.16; P =.0003)., Conclusion: For patients undergoing elective AAR, increasing patient age is associated with a small increase in risk for in-hospital morbidity or mortality. However, significant cardiac, pulmonary, or renal disease is associated with a much greater risk of postoperative complications, and, therefore, advanced age should not be the sole basis of exclusion for otherwise suitable candidates for elective AAR.
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- 2001
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49. Endoluminal stent placement and coil embolization for the management of carotid artery pseudoaneurysms.
- Author
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Bush RL, Lin PH, Dodson TF, Dion JE, and Lumsden AB
- Subjects
- Adult, Aged, Aneurysm, False diagnostic imaging, Aneurysm, False physiopathology, Carotid Artery Diseases diagnostic imaging, Carotid Artery Diseases physiopathology, Carotid Artery, Common diagnostic imaging, Catheterization, Cerebral Angiography, Female, Humans, Male, Middle Aged, Postoperative Period, Vascular Patency, Aneurysm, False surgery, Carotid Artery Diseases therapy, Embolization, Therapeutic methods, Stents
- Abstract
Purpose: To present a series of carotid artery pseudoaneurysms treated successfully using an endovascular approach., Methods: From April 1995 to November 1999, 5 patients with neurological symptoms not explained by computed tomography of the head were identified by carotid angiography as having internal carotid artery (ICA) pseudoaneurysms. Three patients had sustained blunt trauma, and 2 had previous elective carotid endarterectomies for atherosclerotic disease. The time between injury and treatment ranged from 3 days to 10 years. The patients were treated with endovascular stent placement for exclusion of the pseudoaneurysm, followed by filling of the cavity with multiple detachable coils. Patients were maintained on oral antiplatelet agents or anticoagulant therapy after the procedure., Results: Primary technical success was 100%. No patient suffered permanent neurological sequelae. Postprocedure angiography demonstrated a patent ICA in all cases, with complete obliteration of the pseudoaneurysm. At a mean 8.4-month follow-up (range 2-21), all patients remained symptom free; angiograms in 3 patients at a mean 11.7 months demonstrated continued ICA patency. One patient had a 60% focal narrowing of the distal common carotid artery, which was treated successfully with balloon dilation and stenting., Conclusions: Endovascular treatment of carotid artery pseudoaneurysms is a useful alternative to standard surgical repair. This modality avoids the necessity for surgical exposure at the skull base with its inherent morbidity.
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- 2001
- Full Text
- View/download PDF
50. Mid-term results after endovascular repair of the abdominal aortic aneurysm.
- Author
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Bush RL, Lumsden AB, Dodson TF, Salam AA, Weiss VJ, Smith RB 3rd, and Chaikof EL
- Subjects
- Aftercare, Aged, Angioplasty instrumentation, Angioplasty mortality, Aortic Aneurysm, Abdominal diagnostic imaging, Aortic Aneurysm, Abdominal mortality, Blood Vessel Prosthesis Implantation instrumentation, Blood Vessel Prosthesis Implantation mortality, Comorbidity, Humans, Morbidity, Patient Selection, Proportional Hazards Models, Prosthesis Failure, Retrospective Studies, Risk Factors, Stents, Survival Analysis, Tomography, X-Ray Computed, Treatment Outcome, Angioplasty adverse effects, Angioplasty methods, Aortic Aneurysm, Abdominal surgery, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation methods
- Abstract
Purpose: As a minimally invasive strategy for the treatment of patients with abdominal aortic aneurysm (AAA), endovascular repair has been embraced with enthusiasm because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. Our mid-term experience with endovascular AAA repair was assessed by examining early and late clinical outcome in concurrent cohorts of patients stratified either as low-risk or as at increased-risk for intervention., Methods: From April 1994 to December 1999, endovascular AAA repair was performed in 104 patients with commercially available systems. A subset of patients considered at increased risk for intervention (n = 51) were categorized as such based on a pre-existing history of ischemic coronary artery disease (73%), with documentation of myocardial infarction (57%) or congestive heart failure (29%), or because of the presence of chronic obstructive pulmonary disease, liver disease, or malignancy., Results: The perioperative mortality rate (30-day) was 7.8% for patients at increased risk compared with 1.9% among those classified as low-risk (P = NS). There was no difference between groups in age (72 +/- 7 years vs 74 +/- 7 years; mean +/- SD), surgical time (221 +/- 90 minutes vs 192 +/- 68 minutes), blood loss (437 +/- 402 mL vs 331 +/- 238 mL), postoperative hospital stay (4.4 +/- 2.7 days vs 4.2 +/- 2.5 days), or days in the intensive care unit (1.2 +/- 1.6 days vs 0.6 +/- 1.3 days). Patients at increased risk of intervention had larger aneurysms than patients at low risk (58 +/- 11 mm vs 52 +/- 12 mm; P < .05). Stent grafts were successfully implanted in 47 (92%) patients at increased risk versus 50 (94%) patients at low risk (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3.9% and 5.7%, respectively. The initial endoleak rate was 21% versus 18% based on the first computed tomography performed (either at discharge or 1 month; P = NS). To date, patients at increased risk have been monitored for 14.6 +/- 12.4 months, and patients at low risk have been monitored for 17.7 +/- 15.0 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P < .05, Mantel-Cox test). Both cohorts had similar 2-year clinical success rates of approximately 75%., Conclusion: Despite the use of an endovascular approach for aneurysm treatment, the risk of perioperative death and morbidity remains present for all patients including those who have no significant medical comorbidity. Moreover, although clinical success rates are comparable in both patient groups, 2 years after endovascular repair was performed, at least one in four patients was classified as a clinical failure. Given the continued uncertainty associated with clinical outcome and the need for close life-long surveillance, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.
- Published
- 2001
- Full Text
- View/download PDF
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