54 results on '"Fleischman F"'
Search Results
2. Restoration prioritization must be informed by marginalized people
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Fleischman F, Coleman E, Fischer H, Kashwan P, Pfeifer M, Ramprasad V, Rodriguez Solorzano C, Veldman JW
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- 2022
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3. Surgical Aortic Arch Intervention at the time of Extended Ascending Aortic Replacement is Associated with Increased Mortality
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Cohen R, Fleischman F, Elsayed R, Starnes, Logsdon D, Abt B, Mack W, Kazerouni K, and Bowdish M
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Aortic arch ,medicine.medical_specialty ,Text mining ,business.industry ,medicine.artery ,Intervention (counseling) ,medicine ,business ,Surgery - Abstract
Objective: To compare outcomes of hemiarch versus total arch repair during extended ascending aortic replacement. Methods: Between 2004 and 2017, 261 patients underwent hemiarch (n=149, 57%) or total arch repair (aortic debranching or Carrell patch technique, n=112, 43%) in the setting of extended replacement of the ascending aorta. Median follow-up was 17.2 (IQR 4.2–39.1) months. Multivariable models considering preoperative and intraoperative factors associated with mortality and aortic reintervention were constructed. Results: Survival was 89.0, 81.3, and 73.5% vs. 76.4, 69.5, and 61.7% at 1, 3, and 5 years in the hemiarch versus total arch groups, respectively (log-rank p=0.010). After adjustment for preoperative and intraoperative factors, the presence of a total arch repair (adjusted HR 2.53, 95% CI 1.39 – 4.62, p=0.003), and increasing age (adjusted HR per 10 years of age, 1.76, 95% CI 1.37 – 2.28, p
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- 2021
4. Comparing forest decentralization and local institutional change in Bolivia, Kenya, Mexico and Uganda
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Coleman, E., Fleischman, F., Bauer, J., and Sustainable Agriculture and Natural Resource Management (SANREM) Knowledgebase
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Bolivia ,Governance ,Forest management ,Decentralization ,Uganda ,Community institutions ,Kenya ,Mexico - Abstract
In this paper we assess the institutional and environmental impacts of forest decentralization policies in Bolivia, Kenya, Mexico, and Uganda. Although decentralization is often described as if it were a single policy intervention, many different types of reforms have been described as decentralization. We develop theories of institutional impacts based upon the specific decentralization reforms in the specific context of each country and then argue that decentralization impacts are moderated by a set of control variables. Using data from the International Forestry Resources and Institutions Program, we estimated the effects of forest decentralization on local forest investments, rulemaking, wealth inequality, and forest conditions. LTRA-1 (Decentralization Reforms and Property Rights)
- Published
- 2009
5. THE CLEANING OF GLASS PIPING IN DAIRY PLANTS*
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Fleischman, F. F., primary and Holland, R. F., additional
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- 1953
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6. Spinal cord ischemia and reinterventions following thoracic endovascular repair for acute type B aortic dissections.
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Potter HA, Ding L, Han SM, Fleischman F, Weaver FA, and Magee GA
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- Aged, Female, Humans, Male, Middle Aged, Acute Disease, Databases, Factual, Registries, Reoperation, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Aortic Aneurysm, Thoracic surgery, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic physiopathology, Aortic Dissection surgery, Aortic Dissection diagnostic imaging, Aortic Dissection physiopathology, Endovascular Aneurysm Repair adverse effects, Endovascular Aneurysm Repair instrumentation, Spinal Cord Ischemia etiology, Spinal Cord Ischemia prevention & control, Spinal Cord Ischemia physiopathology
- Abstract
Objective: The technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear., Methods: The Vascular Quality Initiative was queried for TEVARs performed for acute TBAD with zone 3 entry tear, zone 3 proximal zone of disease, treated with TEVAR extending between zone 2 and zone 5. The primary outcomes were SCI and related reintervention. Secondary outcomes were stroke, arm ischemia, and retrograde type A dissection (RTAD). The exposure variables were PSZ 2 vs 3, DSZ 4 vs 5, prophylactic lumbar drain, and LSA revascularization. Univariate analyses were conducted with χ
2 analysis, and multivariable logistic regression was used to evaluate association with outcomes., Results: Of 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain, and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs 39 [9.2%]; P = .01) and multivariable (odds ratio, 7.384; 95% confidence interval, 2.193-24.867; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (odds ratio, 2.966; 95% confidence interval, 1.016-8.656; P = .05)., Conclusions: This study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible., Competing Interests: Disclosures G.A.M. is a consultant for W.L. Gore and Cook. S.M.H. is a consultant for WL Gore, Cook, and Terumo. L.D. is supported by grants UL1TR001855 and UL1TR000130 from the National Center for Advancing Translational Science (NCATS) of the United States National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)- Published
- 2024
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7. A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the PERSEVERE trial.
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Szeto WY, Fukuhara S, Fleischman F, Sultan I, Brinkman W, Arnaoutakis G, Takayama H, Eudailey K, Brinster D, Jassar A, DeRose J, Brown C, Farrington W, and Moon MC
- Abstract
Background: Outcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion., Methods: PERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling., Results: Clinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment., Conclusions: Early results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)
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- 2024
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8. Branch-first aortic arch replacement strategy decreases perioperative mortality.
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Abt BG, Bojko M, Elsayed RS, Han S, Wang A, Vu I, Wishart D, and Fleischman F
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- Humans, Male, Female, Retrospective Studies, Aged, Middle Aged, Risk Factors, Postoperative Complications mortality, Postoperative Complications prevention & control, Treatment Outcome, Time Factors, Cerebrovascular Circulation, Risk Assessment, Aorta, Thoracic surgery, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation mortality, Blood Vessel Prosthesis Implantation methods
- Abstract
Objective: Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement., Methods: We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality., Results: A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007)., Conclusions: We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2024
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9. The Initial Results of Physician-Modified Fenestrated-Branched Endovascular Repairs of the Aortic Arch and Lessons Learned From the First 21 Cases.
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DiBartolomeo AD, Kazerounim K, Fleischman F, and Han SM
- Abstract
Introduction: Physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for the aortic arch provides a minimally invasive treatment option for patients who are too high-risk for open repair. Improvements in technique are gained with ongoing experience with these complex repairs. This study aims to describe outcomes of arch PM-FBEVAR and technical lessons., Materials and Methods: A retrospective review of consecutive patients who underwent PM-FBEVAR with zone 0 proximal sealing at a single institution between January 2019 and July 2023 was performed. Cases completed using initial techniques (early technique) were compared with cases using the current techniques (current technique). Modification technique changed to include a self-orienting spine trigger wire and anatomically specific fenestrations or inner branches in the current group. The primary outcome was in-hospital mortality. Secondary outcomes included technical success and 30 day stroke., Results: A total of 21 patients underwent arch PM-FBEVAR, with 7 in the early group and 14 in the current group. Severe comorbidities were present in both groups including chronic obstructive pulmonary disease (COPD) (43% vs 36%), prior open ascending aortic repair (57% vs 43%), and prior stroke (86% vs 21%), respectively. Technical success was the same (86% vs 86%, p=1.0). Fluoroscopy time (56 vs 24 min, p=0.012) and in-hospital death (43% vs 0%, p=0.026) were significantly lower in the current group. A 30 day stroke rate (29% vs 7%, p=0.247) was non-significantly decreased in the current group. All-cause mortality was 100% vs 7% during median follow-up of 8 and 6 months (p<0.001). Three deaths in the early group were related to their aortic arch repair including aortic rupture during endograft advancement and 2 postoperative strokes., Conclusion: There is a significant learning curve associated with aortic arch PM-FBEVAR. This study suggests that gained experience, use of the spine trigger wire technique, and precise creation of fenestrations or inner branches can lead to a shorter procedure time and lower complications., Clinical Impact: Physician modified fenestrated branched endografting is feasible for the aortic arch. The high rate of stroke and perioperative mortality was reduced with incorporation of self-orienting spine trigger wire and anatomically specific inner branch creation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: S.M.H. is a consultant for consultant for W. L. Gore & Associates, Cook Medical, Terumo Aortic, and Vestek and is on the scientific advisory board for W. L. Gore & Associates and Vestek. F.F. is a consultant for W. L. Gore & Associates, Cook Medical, Terumo, and Artivion.
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- 2024
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10. Use of Iliac Branch Endoprosthesis to Rescue Inadvertent False Lumen Deployment of the Innominate Branch Stent During Physician-Modified Fenestrated-Branched Aortic Arch Repair.
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Han SM, DiBartolomeo AD, Pyun AJ, Maithel S, Patel S, and Fleischman F
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- Male, Humans, Aged, Aorta, Thoracic diagnostic imaging, Aorta, Thoracic surgery, Blood Vessel Prosthesis, Treatment Outcome, Prosthesis Design, Stents, Blood Vessel Prosthesis Implantation adverse effects, Aneurysm, False diagnostic imaging, Aneurysm, False etiology, Aneurysm, False surgery, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic surgery, Aortic Dissection diagnostic imaging, Aortic Dissection surgery, Endovascular Procedures adverse effects
- Abstract
A 70-year-old male with a history of 3 prior median sternotomies and on anticoagulation presented with acute chest and back pain associated with a pseudoaneurysm of the ascending and aortic arch in the setting of residual dissection involving the innominate, proximal right carotid, and subclavian arteries. A physician-modified triple vessel fenestrated-branched arch endograft was deployed. The innominate branch stent was deployed from the right carotid cut down, while the left carotid and left subclavian branch stents were placed from a femoral approach. Postoperatively, the innominate branch was found to be deployed in the false lumen of the dissected native innominate artery, leading to continued pressurization of the pseudoaneurysm. This was rescued by placing a Gore Iliac Branch Endoprosthesis (IBE) into the innominate branch through a temporary conduit sewn to the right carotid artery with a right subclavian branch placed via a brachial artery cut down into the internal iliac gate. The use of IBE allowed branch stent extension past the dissected native vessels. The patient had an uneventful recovery without neurologic complications. At 3-month follow-up, the patient remains well with an excluded pseudoaneurysm, and patent bifurcated innominate, bilateral carotid, and subclavian artery branches. A Gore IBE can be utilized in a dissected innominate artery to create an innominate branch device during fenestrated-branched endovascular arch repair., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sukgu M. Han is a consultant for W. L. Gore and Associates, Cook Medical, Terumo, and Vestek, and is on the scientific advisory board for W. L. Gore and Associates and Vestek. Fernando Fleischman is a consultant for W. L. Gore and Associates, Cook Medical, Terumo, and Artivion.
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- 2024
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11. Emergency and Compassionate Use of a Novel Ascending Endograft for Ascending and Arch Aortic Pathology.
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Patel HJ, Preventza O, Roselli EE, Atkins MD, Brinkman W, Coselli J, Desai N, Estrera A, Fleischman F, Taylor BS, and Reardon MJ
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Purpose: Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta., Materials and Methods: This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta., Results: Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%)., Conclusions: Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies., Clinical Impact: This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: W.L. Gore is the co-patent holder for different device and consultant.
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- 2023
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12. Aortic rupture during STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique.
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Hsu AC, DiBartolomeo AD, Han SM, Fleischman F, and Magee GA
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The STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique has shown promising results for treating type B aortic dissections, but the potential exists for fatal adverse effects. We present a case of infrarenal aortic rupture while using a compliant balloon to balloon mold the true lumen inside previously placed bare metal stents during the STABILISE technique. Caution is advised for providers who wish to perform the STABILISE technique, and we recommend using a semi-compliant balloon sized to the smallest total aortic diameter to mitigate the risk of rupture., Competing Interests: None., (© 2023 The Author(s).)
- Published
- 2023
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13. Sandwich thoracic branch endoprosthesis technique for endovascular repair of thoracic aortic aneurysm with aberrant right subclavian artery.
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Dhindsa Y, DiBartolomeo A, Magee GA, Fleischman F, and Han SM
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Subclavian artery coverage is frequently required to achieve an adequate proximal seal during thoracic endovascular aortic repair. The thoracic branch endoprosthesis (TBE; W.L. Gore & Associates) is the first U.S. Food and Drug Administration-approved branched device for thoracic endovascular aortic repair, designed for left subclavian artery incorporation. However, anatomic suitability of the TBE has been shown to be limited. In the present report, we describe a novel technique using the TBE in a sandwich periscope configuration to allow for emergent repair of a ruptured thoracic aortic aneurysm with a highly angulated proximal seal zone and aberrant right subclavian artery., (© 2023 The Author(s).)
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- 2023
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14. ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection.
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Roselli EE, Atkins MD, Brinkman W, Coselli J, Desai N, Estrera A, Johnston DR, Patel H, Preventza O, Vargo PR, Fleischman F, Taylor BS, and Reardon MJ
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- Humans, Female, Middle Aged, Aged, Aged, 80 and over, Male, Blood Vessel Prosthesis, Prospective Studies, Treatment Outcome, Prosthesis Design, Stents, Postoperative Complications etiology, Dissection, Ascending Aorta, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis Implantation, Endovascular Procedures
- Abstract
Background: Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ)., Objective: The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection., Methods: This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months., Results: Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%)., Conclusion: Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.
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- 2023
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15. Making the Gestalt More Rigorous-Is Less Still More?
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Fleischman F and Abt BG
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- 2023
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16. Social considerations are crucial to success in implementing the 30×30 global conservation target.
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Sandbrook C, Albury-Smith S, Allan JR, Bhola N, Bingham HC, Brockington D, Byaruhanga AB, Fajardo J, Fitzsimons J, Franks P, Fleischman F, Frechette A, Kakuyo K, Kaptoyo E, Kuemmerle T, Kalunda PN, Nuvunga M, O'Donnell B, Onyai F, Pfeifer M, Pritchard R, Ramos A, Rao M, Ryan CM, Shyamsundar P, Tauli J, Tumusiime DM, Vilaça M, Watmough GR, Worsdell T, and Zaehringer JG
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- Conservation of Natural Resources
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- 2023
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17. Readmission after early thoracic endovascular aortic repair versus medical management of acute type B aortic dissection.
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Yi JA, Gupta R, Tat Q, Potter HA, Han SM, Fleischman F, Jacobs D, Nehler M, and Magee GA
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- Humans, Endovascular Aneurysm Repair, Patient Readmission, Treatment Outcome, Risk Factors, Retrospective Studies, Blood Vessel Prosthesis Implantation adverse effects, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic surgery, Endovascular Procedures, Aortic Dissection diagnostic imaging, Aortic Dissection surgery
- Abstract
Background: The use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population., Methods: We performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management., Results: A total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones., Conclusions: In the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR., (Published by Elsevier Inc.)
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- 2023
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18. ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up.
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Contrella BN, Khaja MS, Majdalany BS, Kim CY, Kalva SP, Beck AW, Browne WF, Clough RE, Ferencik M, Fleischman F, Gunn AJ, Hickey SM, Kandathil A, Kim KM, Monroe EJ, Ochoa Chaar CI, Scheidt MJ, Smolock AR, Steenburg SD, Waite K, Pinchot JW, and Steigner ML
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- Humans, United States, Follow-Up Studies, Societies, Medical, Evidence-Based Medicine, Angiography, Aortic Aneurysm, Thoracoabdominal
- Abstract
As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)
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- 2023
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19. Combining socioeconomic and biophysical data to identify people-centric restoration opportunities.
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Choksi P, Agrawal A, Bialy I, Chaturvedi R, Davis KF, Dhyani S, Fleischman F, Lechner J, Nagendra H, Srininvasan V, and DeFries R
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- 2023
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20. Use of retrograde left subclavian branch portal of Gore TAG thoracic branch endoprosthesis for physician-modified fenestrated branched endovascular repair of thoracoabdominal aortic aneurysm.
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DiBartolomeo AD, Miranda E, Pyun AJ, Fleischman F, Magee GA, and Han SM
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A 75-year-old man who had undergone zone 2 thoracic endovascular repair of a symptomatic penetrating aortic ulcer using a Gore TAG thoracic branch endoprosthesis (TBE) device (W.L. Gore & Associates) 5 years before had presented with an enlarging extent I thoracoabdominal aortic aneurysm. A physician-modified five-vessel fenestrated-branched endograft repair was performed using preloaded wires. The visceral renal vessels were sequentially catheterized from the left brachial access via the TBE portal, and the endograft was deployed in staggered fashion. At 1 year of follow-up, imaging studies demonstrated a stable aneurysm sac, patent visceral renal branches, and no endoleak. The retrograde portal of Gore TAG TBE can facilitate fenestrated-branched endovascular repair of thoracoabdominal aortic aneurysms., (© 2023 The Author(s).)
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- 2023
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21. How Social Considerations Improve the Equity and Effectiveness of Ecosystem Restoration.
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Löfqvist S, Kleinschroth F, Bey A, de Bremond A, DeFries R, Dong J, Fleischman F, Lele S, Martin DA, Messerli P, Meyfroidt P, Pfeifer M, Rakotonarivo SO, Ramankutty N, Ramprasad V, Rana P, Rhemtulla JM, Ryan CM, Vieira ICG, Wells GJ, and Garrett RD
- Abstract
Ecosystem restoration is an important means to address global sustainability challenges. However, scientific and policy discourse often overlooks the social processes that influence the equity and effectiveness of restoration interventions. In the present article, we outline how social processes that are critical to restoration equity and effectiveness can be better incorporated in restoration science and policy. Drawing from existing case studies, we show how projects that align with local people's preferences and are implemented through inclusive governance are more likely to lead to improved social, ecological, and environmental outcomes. To underscore the importance of social considerations in restoration, we overlay existing global restoration priority maps, population, and the Human Development Index (HDI) to show that approximately 1.4 billion people, disproportionately belonging to groups with low HDI, live in areas identified by previous studies as being of high restoration priority. We conclude with five action points for science and policy to promote equity-centered restoration., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Institute of Biological Sciences.)
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- 2022
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22. Restoration prioritization must be informed by marginalized people.
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Fleischman F, Coleman E, Fischer H, Kashwan P, Pfeifer M, Ramprasad V, Rodriguez Solorzano C, and Veldman JW
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- Humans, Social Marginalization
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- 2022
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23. Management strategy for lower extremity malperfusion due to acute aortic dissection.
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Plotkin A, Vares-Lum D, Magee GA, Han SM, Fleischman F, and Rowe VL
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- Acute Disease, Adult, Aged, Amputation, Surgical, Aortic Dissection diagnosis, Aortic Dissection mortality, Aortic Dissection physiopathology, Aortic Aneurysm diagnostic imaging, Aortic Aneurysm mortality, Aortic Aneurysm physiopathology, Databases, Factual, Female, Hospital Mortality, Humans, Ischemia diagnostic imaging, Ischemia mortality, Ischemia physiopathology, Limb Salvage, Male, Middle Aged, Regional Blood Flow, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Time-to-Treatment, Treatment Outcome, Aortic Dissection surgery, Aortic Aneurysm surgery, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation mortality, Endovascular Procedures adverse effects, Endovascular Procedures mortality, Ischemia surgery, Lower Extremity blood supply
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Objective: Aortic dissection can result in devastating cerebral, visceral, renal, spinal, and extremity ischemia. We describe the management and outcomes of patients presenting with aortic dissection and lower extremity malperfusion (LEM)., Methods: A single-center institutional aortic database was queried for patients with aortic dissection and LEM from 2011 to 2019. The primary end point was resolution of LEM after aortic repair. Secondary end points were amputation, in-hospital mortality, time to intervention, and postoperative complications., Results: Of 769 patients with aortic dissection, 42 (5.5%) presented acutely with LEM: 16 with Stanford type A and 26 Stanford type B aortic dissection (age 55 ± 13 years; 90% men). Most presented as Rutherford IIB symptoms, but patients with type A had Rutherford III more often, compared with those with type B. Aortic repair was performed before limb interventions in 36 patients (86%; 19 TEVAR, 16 open arch and ascending repair, and 1 open descending aortic repair with fenestration). Seven (19%) had immediate failure with persistent malperfusion recognized in the operating room and underwent additional limb intervention, including extra-anatomic revascularization (n = 4), iliac stenting (n = 2), and femoral patch with septal fenestration or tacking (n = 2). Three patients (8%) had early delayed failure requiring extra-anatomic bypass in two and amputation in one. In contrast, six patients had limb-first intervention with extra-anatomic revascularization. None had immediate failure, but one-half had early delayed failure requiring proximal aortic intervention: two TEVAR and one open aortic fenestration. Limb-first patients were more likely to have early delayed failure compared with aortic dissection treated first patients (50% vs 8%; P = .029). The amputation rate was 2%, occurring in one type A patient. The overall in-hospital mortality was 7% (n = 3), with no difference between type A and type B aortic dissection. There was no difference in surgical site infection, postoperative dialysis need, stroke, and myocardial infarction., Conclusions: In patients presenting with acute aortic dissection with limb ischemia, resolution of the malperfusion occurs in the majority of cases after primary aortic dissection intervention, emphasizing the usefulness of urgent TEVAR for complicated type B and open repair of type A before lower extremity intervention. Limb-first interventions have a higher early delayed failure rate and thus require more frequent reoperation. However, the overall amputation rate in LEM owing to aortic dissection remains low., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2021
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24. Complications associated with lumbar drain placement for endovascular aortic repair.
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Plotkin A, Han SM, Weaver FA, Rowe VL, Ziegler KR, Fleischman F, Mack WJ, Hendrix JA, and Magee GA
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- Aged, Aorta, Thoracic diagnostic imaging, Aortic Diseases diagnostic imaging, Body Mass Index, Databases, Factual, Drainage instrumentation, Female, Humans, Lumbar Vertebrae, Male, Middle Aged, Obesity complications, Obesity diagnosis, Postoperative Complications diagnostic imaging, Postoperative Complications therapy, Retrospective Studies, Risk Assessment, Risk Factors, Treatment Outcome, Aorta, Thoracic surgery, Aortic Diseases surgery, Blood Vessel Prosthesis Implantation adverse effects, Drainage adverse effects, Endovascular Procedures adverse effects, Postoperative Complications etiology
- Abstract
Objective: We reviewed the complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair., Methods: Patients who had undergone perioperative LD placement for endovascular repair of thoracic and thoracoabdominal aortic pathologies from 2010 to 2019 were reviewed. The primary endpoints were major and minor LD-associated complications. Complications that had resulted in neurological sequelae or had required an intervention or a delay in operation were defined as major. These included intracranial hemorrhage, symptomatic spinal hematoma, cerebrospinal fluid (CSF) leak requiring intervention, meningitis, retained catheter tip, arachnoiditis, and traumatic (or bloody) tap resulting in delayed operation. Minor complications were defined as a bloody tap without a delay in surgery, asymptomatic epidural hematoma, and CSF leak with no intervention required. Isolated headaches were recorded separately owing to the minimal clinical impact., Results: A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs (EVARs; fenestrated branched EVAR/parallel grafting), and 2 EVARs (age, 65 ± 13 years; 71% male) for aortic pathology, including aneurysm (47%), dissection (49%), penetrating aortic ulcer (3%), and traumatic injury (0.6%). A dedicated neurosurgical team performed all LD procedures; most were performed by the same individual, with a technical success rate of 98%. Radiologic guidance was required in 3%. The reasons for unsuccessful placement were body habitus (n = 2) and severe spinal disease (n = 3). Most were placed prophylactically (96%). The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal hematoma with paraplegia in 1 patient, intracranial hemorrhage in 2, meningitis in 2, arachnoiditis in 3, CSF leak requiring a blood patch in 3, bloody tap delaying the operation in 1, and a retained catheter tip in 1 patient. Patients who had undergone previous LD placement had experienced significantly more major LD-related complications (12.2% vs 3%; P = .019). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00) nor between major or minor complications. On multivariate analysis, previous LD placement and an overweight body mass index were the only independent predictors of major LD-related complications., Conclusions: The complications associated with LD placement can be severe even when performed by a dedicated team. Previous LD placement and overweight body mass index were associated with a significantly greater risk of complications; however, emergent therapeutic placement was not. Although these risks are justified for therapeutic LD placement, the benefit of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2021
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25. Dark and bright spots in the shadow of the pandemic: Rural livelihoods, social vulnerability, and local governance in India and Nepal.
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Gupta D, Fischer H, Shrestha S, Shoaib Ali S, Chhatre A, Devkota K, Fleischman F, Khatri DB, and Rana P
- Abstract
The global COVID-19 pandemic has brought unprecedented disruption to lives and livelihoods around the world. These disruptions have brought into sharp focus experiences of vulnerability but also, at times, evidence of resilience as people and institutions gear up to respond to the crisis. Drawing on intensive qualitative enquiry in 16 villages of Himalayan India and Nepal, this paper documents both dark and bright spots from the early days of the pandemic. We find intense experiences of fear and uncertainty, heightened food insecurity, and drastic reductions in livelihood opportunities. However, we also find a wide range of individual and collective responses as well as a patchwork of policy support mechanisms that have provided at least some measure of basic security. Local elected governments have played a critical role in coordinating responses and delivering social support, however the nature of their actions varies as a result of different institutional arrangements and state support systems in the two countries. Our findings highlight the changing nature of vulnerability in the present era, as demographic shifts, growing off-farm employment and dependence on remittances, and increasing market integration have all brought about new kinds of exposure to risk for rural populations in the context of the present disruption and beyond. Most importantly, our research shows the critical importance of strong systems of state support for protecting basic well-being in times of crises. Based on these findings, we argue that there is a need for greater knowledge of how local institutions work in tandem with a broader set of state support mechanisms to generate responses for urgent challenges; such knowledge holds the potential to develop governance systems that are better able to confront diverse shocks that households face, both now and in the future., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Author(s).)
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- 2021
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26. Commentary: Flow delivery to the left subclavian artery using a novel branched graft in total arch replacement.
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Fleischman F and Elsayed RS
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- 2021
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27. Periscope sandwich stenting as an alternative to open cervical revascularization of left subclavian artery during zone 2 thoracic endovascular aortic repair.
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Johnson CE, Zhang L, Magee GA, Ham SW, Ziegler KR, Weaver FA, Fleischman F, and Han SM
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- Aged, Aortic Dissection diagnostic imaging, Aortic Dissection mortality, Aortic Dissection physiopathology, Aorta, Thoracic diagnostic imaging, Aorta, Thoracic physiopathology, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic mortality, Aortic Aneurysm, Thoracic physiopathology, Blood Vessel Prosthesis, Endoleak etiology, Female, Graft Occlusion, Vascular etiology, Humans, Male, Middle Aged, Retrospective Studies, Stents, Subclavian Artery diagnostic imaging, Subclavian Artery physiopathology, Time Factors, Treatment Outcome, Ulcer diagnostic imaging, Ulcer mortality, Ulcer physiopathology, Vascular Patency, Aortic Dissection surgery, Aorta, Thoracic surgery, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation instrumentation, Blood Vessel Prosthesis Implantation mortality, Endovascular Procedures adverse effects, Endovascular Procedures instrumentation, Endovascular Procedures mortality, Subclavian Artery surgery, Ulcer surgery
- Abstract
Objective: Revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications, including stroke, spinal cord ischemia, and upper extremity ischemia. Both open surgical and endovascular LSA revascularization techniques have been described, each with unique risks and benefits. We describe our "periscope sandwich" technique for the LSA during zone 2 TEVAR, which maintains antegrade access to the distal abdominal aorta if subsequent interventions are necessary. Technical results and short-term outcomes are compared with LSA open surgical debranching., Methods: A single-institution retrospective review was performed for patients requiring zone 2 TEVAR with LSA revascularization by periscope sandwich technique or open surgical debranching with subclavian to carotid transposition (SCT) or carotid-subclavian bypass (CSB). The presenting aortic disease and perioperative details were recorded. Intraoperative angiography and postoperative computed tomography images were reviewed for occurrence of endoleak and branch patency., Results: Between January 2013 and December 2018, the LSA was revascularized by periscope sandwich in 18 patients, SCT in 22 patients, and CSB in 13 patients. Compared with open surgical debranching, periscope sandwich had a lower median estimated blood loss (100 mL vs 200 mL for pooled SCT and CSB; P = .03) and lower median case duration (133.5 minutes vs 226 minutes; P < .001). Contrast material volume (120 mL vs 120 mL; P = .98) and fluoroscopy time (13.1 minutes vs 13.3 minutes; P = .92) did not differ significantly between the groups. There was no difference in aorta-related mortality (P = .14), and LSA patency was 100%. Median follow-up for the periscope sandwich group was 11 months, with an overall estimated 91% freedom from gutter leak at 6 months., Conclusions: LSA periscope sandwich technique provides safe and effective LSA revascularization during zone 2 TEVAR. LSA periscope sandwich can be used emergently with off-the-shelf endovascular components and facilitates future branched-fenestrated endovascular repair of thoracoabdominal aortic diseases., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2021
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28. Intercostal artery incorporation to prevent spinal cord ischemia during total endovascular thoracoabdominal aortic repair.
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Plotkin A, Han SM, Manzur MF, Cunningham MJ, Fleischman F, and Magee GA
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- 2021
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29. Triage and management of aortic emergencies during the coronavirus disease 2019 (COVID-19) pandemic: A consensus document supported by the American Association for Thoracic Surgery (AATS) and Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS).
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Mehta CK, Malaisrie SC, Budd AN, Okita Y, Matsuda H, Fleischman F, Ueda Y, Bavaria JE, and Moon MR
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- 2020
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30. En Bloc AngioVac Removal of Thoracic Aortic Mass.
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Kang J, Fleischman F, Saremi F, and Shavelle DM
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- Aortic Diseases diagnosis, Computed Tomography Angiography, Echocardiography, Transesophageal, Equipment Design, Female, Humans, Middle Aged, Thrombosis diagnosis, Aorta, Thoracic surgery, Aortic Diseases surgery, Thrombosis surgery, Vascular Surgical Procedures instrumentation
- Abstract
The AngioVac system, designed for suction during extracorporeal bypass, is used to aspirate masses, thrombi, and other undesirable material from the cardiovascular system. To date, it has been used extensively in the venous system and right side of the heart; however, its use in the arterial system has been limited because of smaller vessel sizes and the requirement for a 26F sheath. We report the case of a 45-year-old woman with a history of angiosarcoma who presented with acute embolic events that affected her spleen and lower extremities. We removed a large mobile mass en bloc from her distal thoracic aorta by using the AngioVac system as an alternative to surgical resection. The patient recovered with no recurrence. We discuss the benefits and challenges of using the AngioVac within small vessels of the arterial system., (© 2020 by the Texas Heart® Institute, Houston.)
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- 2020
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31. The Disparity Between Public Utilization and Surgeon Awareness of the STS Patient Education Website.
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Cohen RG, Kumar SR, Lin J, Reddy RM, Kane L, Bagley J, Juarez A, Fleischman F, Farkas EA, Hackmann AE, Grubb KJ, Reddy S, Erhunmwunsee L, Villamizar NR, Masood MF, Griffin M, and Boden N
- Subjects
- Facilities and Services Utilization, Humans, Patient Acceptance of Health Care, Societies, Medical, Surgeons, Surveys and Questionnaires, Education, Distance statistics & numerical data, Internet, Patient Education as Topic statistics & numerical data, Thoracic Surgery education
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Background: Many online resources currently provide healthcare information to the public. In 2015, the Society of Thoracic Surgeons (STS) created a multimedia web portal (ctsurgerypatients.org) to educate the public regarding cardiothoracic surgery and provide an informative tool to which cardiothoracic surgeons could refer patients., Methods: A patient education task force was created, and disease-specific content was created for 25 pathological conditions. After launching the website online, a marketing campaign was initiated to make STS members aware of its availability. Website visits were monitored, and an online survey for public users was created. An email survey was sent to STS members to evaluate awareness and content. Surveys were analyzed for effectiveness and utilization by both public users and STS member surgeons., Results: From 2016 to 2018, the website had more than 1 million visits, with visits increasing yearly. Surveyed user ratings of the website were positive regarding quality and utility of the information provided. STS member response was poor (379 responses of 6347 emails), and 78.3% of responders were unaware of the website. Surgeon responders were positive about the content, though many still refrain from referring patients., Conclusions: Online education for cardiothoracic surgery is seeing increased public use, with high ratings for content and utility. Despite aggressive marketing to STS members, most remain unaware of this website's existence. Those who are aware approve of its content, but adoption of referring patients to it has been slow. Improved strategies are necessary to make surgeons aware of this STS-provided service and increase patient referrals to it., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)
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- 2020
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32. In-Situ Fenestration of a PTFE Thoracic Aortic Stent Graft for Delayed Left Subclavian Artery Revascularization Following Frozen Elephant Trunk Repair of Type A Aortic Dissection.
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Veranyan N, Dunn J, Bowdish M, Magee GA, Weaver FA, Fleischman F, and Han SM
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- Aged, Aortic Dissection diagnostic imaging, Aortic Dissection physiopathology, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic physiopathology, Blood Vessel Prosthesis Implantation adverse effects, Endovascular Procedures adverse effects, Humans, Male, Prosthesis Design, Subclavian Artery diagnostic imaging, Subclavian Artery physiopathology, Subclavian Steal Syndrome diagnostic imaging, Subclavian Steal Syndrome etiology, Subclavian Steal Syndrome physiopathology, Thrombectomy, Thrombosis diagnostic imaging, Thrombosis etiology, Thrombosis physiopathology, Time Factors, Treatment Outcome, Aortic Dissection surgery, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation instrumentation, Endovascular Procedures instrumentation, Stents, Subclavian Artery surgery, Subclavian Steal Syndrome surgery, Thrombosis surgery
- Abstract
Left subclavian artery revascularization during endovascular repair of aortic dissection is often accomplished by left carotid-subclavian artery bypass or transposition. In situ fenestration of thoracic stent grafts provides an alternative method of revascularization without manipulation of the left carotid artery. We describe a case whereby in situ laser fenestration, combined with catheter-directed thrombectomy, was utilized to revascularize a thrombosed left subclavian artery following a frozen elephant trunk repair of type A aortic dissection. A 75-year-old male presented with pericardial tamponade and aortic insufficiency, secondary to type A aortic dissection. Patient underwent an emergent replacement of the aortic root, valve, arch, and ascending aorta in the frozen elephant trunk configuration. The innominate and left carotid arteries were revascularized with a bifurcated bypass graft from the ascending aortic graft. The left subclavian artery (LSCA) was covered with an antegrade deployment of a cTAG stent graft. During the immediate postoperative period, the patient was found to have a dissection of the left common carotid artery (LCCA) and pseudoaneurysm of the bypass graft anastomosis. The left carotid artery was replaced up to the proximal internal carotid. During rehabilitation, the patient developed left subclavian steal syndrome, with a CT angiography demonstrating thrombosis of the subclavian origin, and duplex ultrasound showing a reversal of the left vertebral flow. In order to revascularize the left subclavian artery without using the left carotid as the inflow, the in situ laser fenestration technique was planned. The vertebral artery origin was protected with a neuroclip through a supraclavicular incision. Through a brachial artery cutdown, a 9Fr flex sheath was positioned at the origin of the subclavian artery. A suction thrombectomy catheter was used to create a central channel in the thrombus. A 0.035″ 3.2 mm over-the-wire laser atherectomy catheter was used to create a fenestration through the cTAG stent graft. The subclavian branch stent was stented with an iCast balloon-expandable covered stent, excluding the mural thrombus. The patient recovered well with resolution of symptoms and was discharged home. Postoperative CT scan showed patent left subclavian branch stent and no endoleak across the fenestration of the aortic stent graft. Delayed laser in situ fenestration of a PTFE stent graft can be performed safely. The vertebral artery protection and catheter-directed thrombectomy are important adjuncts to reduce the risk of posterior stroke., (Copyright © 2019 Elsevier Inc. All rights reserved.)
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- 2020
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33. Anatomic suitability for "off-the-shelf" thoracic single side-branched endograft in patients with type B aortic dissection.
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Magee GA, Veranyan N, Kuo EC, Ham SW, Ziegler KR, Weaver FA, Fleischman F, Bowdish ME, and Han SM
- Subjects
- Aged, Aortic Dissection classification, Aorta, Thoracic anatomy & histology, Aortic Aneurysm, Thoracic classification, Female, Humans, Male, Middle Aged, Prosthesis Design, Retrospective Studies, Aortic Dissection surgery, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis, Endovascular Procedures
- Abstract
Objective: Treatment of type B aortic dissections with thoracic endovascular aortic repair (TEVAR) has been adopted in many centers with the goal of covering the proximal entry tear. Coverage of the left subclavian artery (LSCA) is commonly required to achieve a dissection-free proximal seal zone. A novel thoracic single side-branched (TSSB) endograft device offers a potential off-the-shelf option to achieve total endovascular incorporation of LSCA during zone 2 TEVAR. The aim of this study was to determine what percentage of patients with type B aortic dissection who require zone 2 TEVAR meet the anatomical requirements for this device., Methods: All consecutive patients undergoing TEVAR for type B aortic dissections at a single institution from 2006 to 2016 were evaluated. Three-dimensional centerline reconstruction of preoperative computed tomography angiography was performed to identify the diameter of the aorta, distances between branch vessels, diameter of the target branch vessel, and location of the primary entry tear. Only patients who met criteria for zone 2 TEVAR were included in the analysis. The primary outcome was percentage of patients that meet all anatomical requirements for TSSB. Individual criteria were evaluated independently, and results were stratified by dissection chronicity., Results: Eighty-seven patients who underwent TEVAR for Stanford type B aortic dissections were reviewed. Fifty-seven (66%) would have required zone 2 TEVAR. Indications for TEVAR were malperfusion (12), aneurysm (15), persistent pain (22), rupture (3), uncontrolled hypertension (5), and other (3). Mean follow-up was 19 months (range, 1-72 months). Only 16 of the 57 patients (28%) met all the requirements for anatomic suitability. The primary contributor was that only 49% of patients had sufficient length between arch branches to prevent coverage of a proximal branch., Conclusions: Although the new TSSB device can allow for a more proximal seal zone and eliminate the need for open aortic arch debranching, only 28% of patients with type B dissection who required zone 2 TEVAR met all the anatomic requirements for this device. Future devices will need to account for the short distance between the left carotid and LSCA to be more broadly applicable., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2019
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34. Endovascular septal fenestration using a radiofrequency wire to salvage inadvertent false lumen deployment of a frozen elephant trunk stent graft.
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Plotkin A, Hanks SE, Han SM, Fleischman F, Weaver FA, and Magee GA
- Abstract
We report a case of a frozen elephant trunk arch repair, where the stent graft was unintentionally placed into the false lumen. Postoperative imaging demonstrated an enlarged false lumen with no thoracic aorta fenestrations that could be traversed to place another thoracic endovascular aortic repair endograft into the true lumen. An atraumatic radiofrequency wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) was used to create a new septal fenestration, enabling thoracic endovascular aortic repair endograft extension into the thoracic true lumen. This novel use of a radiofrequency wire can enable safe and controlled endovascular septal fenestration even in chronic dissections to redirect flow into the true lumen., (© 2019 The Authors.)
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- 2019
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35. Comment on "The global tree restoration potential".
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Veldman JW, Aleman JC, Alvarado ST, Anderson TM, Archibald S, Bond WJ, Boutton TW, Buchmann N, Buisson E, Canadell JG, Dechoum MS, Diaz-Toribio MH, Durigan G, Ewel JJ, Fernandes GW, Fidelis A, Fleischman F, Good SP, Griffith DM, Hermann JM, Hoffmann WA, Le Stradic S, Lehmann CER, Mahy G, Nerlekar AN, Nippert JB, Noss RF, Osborne CP, Overbeck GE, Parr CL, Pausas JG, Pennington RT, Perring MP, Putz FE, Ratnam J, Sankaran M, Schmidt IB, Schmitt CB, Silveira FAO, Staver AC, Stevens N, Still CJ, Strömberg CAE, Temperton VM, Varner JM, and Zaloumis NP
- Subjects
- Carbon, Carbon Sequestration, Climate Change, Soil, Trees
- Abstract
Bastin et al 's estimate (Reports, 5 July 2019, p. 76) that tree planting for climate change mitigation could sequester 205 gigatonnes of carbon is approximately five times too large. Their analysis inflated soil organic carbon gains, failed to safeguard against warming from trees at high latitudes and elevations, and considered afforestation of savannas, grasslands, and shrublands to be restoration., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)
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- 2019
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36. Lift Sandwich Grafting Enables Transfemoral Abdominal Aortic Branch Incorporation during Endovascular Aortic Repair for Chronic Type B Aortic Dissection.
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Johnson CE, Ham SW, Ziegler KR, Magee GA, Weaver FA, Fleischman F, and Han SM
- Subjects
- Aortic Dissection diagnostic imaging, Aorta, Abdominal diagnostic imaging, Aorta, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic diagnostic imaging, Aortography methods, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation instrumentation, Chronic Disease, Computed Tomography Angiography, Endovascular Procedures instrumentation, Humans, Male, Middle Aged, Prosthesis Design, Stents, Treatment Outcome, Aortic Dissection surgery, Aorta, Abdominal surgery, Aorta, Thoracic surgery, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis Implantation methods, Endovascular Procedures methods
- Abstract
Chronic type B aortic dissections with continued aneurysmal expansion of the thoracoabdominal aorta after the initial thoracic endovascular aortic repair represent a subset of aortic pathology in which staged distal extension to seal additional septal tears can be advantageous. This approach may require incorporation of visceral or renal branches into the distal seal zone, while maintaining the possibility of further distal extension in the future. We describe a novel technique for incorporation of the celiac axis, with a branch stent graft delivered from a transfemoral approach, then lifted cranially to create an antegrade sandwich graft configuration in a 59-year-old male who presented with a complicated type B aortic dissection requiring coverage of the celiac artery. Utilizing the previous thoracic endograft as a platform for sandwich grafting, a self-expanding stent graft was deployed into the celiac artery from a femoral approach. A steerable sheath with an anchoring balloon was used to lift the stent into an up-facing snorkel position, which was subsequently sandwiched with another thoracic stent graft terminating proximal to the superior mesenteric artery. When single visceral or renal branch incorporation is desired, sandwich grafting via a "lift" technique limits the extent of aortic coverage and reduces the number of branch components, without increasing the complexity of additional visceral and renal branch incorporation during future endovascular aortic repair., (Copyright © 2019 Elsevier Inc. All rights reserved.)
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- 2019
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37. Impact of proximal seal zone length and intramural hematoma on clinical outcomes and aortic remodeling after thoracic endovascular aortic repair for aortic dissections.
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Kuo EC, Veranyan N, Johnson CE, Weaver FA, Ham SW, Rowe VL, Fleischman F, Bowdish M, and Han SM
- Subjects
- Adult, Aged, Aortic Dissection diagnostic imaging, Aortic Dissection mortality, Aortic Dissection physiopathology, Aorta, Thoracic diagnostic imaging, Aorta, Thoracic physiopathology, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic mortality, Aortic Aneurysm, Thoracic physiopathology, Blood Vessel Prosthesis Implantation adverse effects, Blood Vessel Prosthesis Implantation mortality, Endovascular Procedures adverse effects, Endovascular Procedures mortality, Female, Hematoma diagnostic imaging, Humans, Male, Middle Aged, Prosthesis Design, Retrospective Studies, Risk Factors, Time Factors, Treatment Outcome, Aortic Dissection surgery, Aorta, Thoracic surgery, Aortic Aneurysm, Thoracic surgery, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation instrumentation, Endovascular Procedures instrumentation, Hematoma etiology, Stents, Vascular Remodeling
- Abstract
Objective: Thoracic endovascular aortic repair (TEVAR) has become standard treatment of complicated type B aortic dissections (TBADs). Whereas adequate proximal seal is a fundamental requisite for TEVAR, what constitutes "adequate" in dissections and its impact on outcomes remain unclear. The goal of this study was to describe the proximal seal zone achieved with associated clinical outcomes and aortic remodeling., Methods: A retrospective review was performed of TEVARs for TBAD at a single institution from 2006 to 2016. Three-dimensional centerline analysis of preoperative computed tomography was used to identify the primary entry tear, dissection extent, distances between arch branches, and intramural hematoma (IMH) involvement of the proximal seal zone. Patients were categorized into group A, those with proximal extent of seal zone in IMH/dissection-free aorta, and group B, those with landing zone entirely within IMH. Clinical outcomes including retrograde type A dissection (RTAD), death, and aortic reinterventions were recorded. Postoperative computed tomography scans were analyzed for remodeling of the true and false lumen volumes of the thoracic aorta., Results: Seventy-one patients who underwent TEVAR for TBAD were reviewed. Indications for TEVAR included malperfusion, aneurysm, persistent pain, rupture, uncontrolled hypertension, and other. Mean follow-up was 14 months. In 26 (37%) patients, the proximal extent of the seal zone was without IMH, whereas 45 (63%) patients had proximal seal zone entirely in IMH. Proximal seal zone of 2-cm IMH-free aorta was achieved in only six (8.5%) patients. Review of arch anatomy revealed that to create a 2-cm landing zone of IMH-free aorta, 31 (43.7%) patients would have required coverage of all three arch branch vessels. Postoperatively, two patients developed image-proven RTADs requiring open repair, and one patient had sudden death. All three of these patients had TEVAR with the proximal seal zone entirely in IMH. No RTADs occurred in patients whose proximal seal zone involved healthy aortic segment. At 24 months, overall survival was 93% and freedom from aorta-related mortality was 97.4%. Complete thoracic false lumen thrombosis was seen in 46% of patients. Aortic remodeling, such as true lumen expansion, false lumen regression, and false lumen thrombosis, was similar in both groups of patients., Conclusions: Whereas achieving 2 cm of IMH-free proximal seal zone during TEVAR for TBAD would often require extensive arch branch coverage, failure to achieve any IMH-free proximal seal zone may be associated with higher incidence of RTAD. The length and quality of the proximal seal zone did not affect the subsequent aortic remodeling after TEVAR., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2019
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38. Image Predictors of Treatment Outcome after Thoracic Aortic Dissection Repair.
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Saremi F, Hassani C, Lin LM, Lee C, Wilcox AG, Fleischman F, and Cunningham MJ
- Subjects
- Aortic Dissection classification, Aortic Aneurysm, Thoracic classification, Humans, Treatment Outcome, Aortic Dissection diagnostic imaging, Aortic Dissection surgery, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic surgery, Endovascular Procedures
- Abstract
Treatment of thoracic aortic dissection remains highly challenging and is rapidly evolving. Common classifications of thoracic aortic dissection include the Stanford classification (types A and B) and the DeBakey classification (types I to III), as well as a new supplementary classification geared toward endovascular decision making. By using various imaging techniques, the extent of the dissection, the location of the primary intimal tear, the shape of the aortic arch, and the zonal involvement of the aortic arch-factors that affect the treatment strategy-can easily be identified. Thoracic endovascular aortic repair (TEVAR) is generally performed in two groups of patients: (a) those with a surgically repaired type A dissection, and (b) those with a complicated type B dissection. Several imaging findings can help predict the course of remodeling of the dissected aorta after a repaired type A dissection and TEVAR. A spectrum of imaging findings exist with regard to favorable (positive) or failing (negative) remodeling. A schematic model with imaging support allows the classification of important causes of failing remodeling into proximal and distal groups, on the basis of the origin of the refilling of the false lumen and the underlying pathophysiology of pressurization. Refilling of the false lumen of the aorta after repair of a type A dissection is usually secondary to a persistent intimal tear at the aortic arch, a leak of the distal graft anastomosis, or refilling from the false lumen of a dissected aortic arch vessel. After TEVAR, false lumen refilling is most commonly due to an incomplete seal of the proximal landing related to the aortic tortuosity, an arch branch stump, a supra-arch chimney stent, or the TEVAR technique. Online supplemental material is available for this article.
© RSNA, 2018.- Published
- 2018
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39. Optimal Approach for Repair of Left Atrial-Esophageal Fistula Complicating Radiofrequency Ablation.
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Gray WH, Fleischman F, Cunningham MJ, Kim AW, Baker CJ, Starnes VA, and McFadden PM
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- Esophageal Fistula diagnosis, Esophageal Fistula etiology, Humans, Vascular Fistula diagnosis, Vascular Fistula etiology, Atrial Fibrillation surgery, Catheter Ablation adverse effects, Esophageal Fistula surgery, Heart Atria, Vascular Fistula surgery
- Abstract
Left atrial-esophageal fistula after endovascular radiofrequency ablation for cardiac arrhythmias is a life-threatening complication. Immediate surgical repair offers the best chance for survival. The optimal surgical technique is unknown. We describe our recommended surgical approach., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)
- Published
- 2018
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40. Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection.
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Fleischman F, Elsayed RS, Cohen RG, Tatum JM, Kumar SR, Kazerouni K, Mack WJ, Barr ML, Cunningham MJ, Hackmann AE, Baker CJ, Starnes VA, and Bowdish ME
- Subjects
- Acute Disease, Aortic Dissection diagnosis, Aortic Dissection mortality, Aorta, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic diagnosis, Aortic Aneurysm, Thoracic mortality, California epidemiology, Female, Follow-Up Studies, Humans, Male, Middle Aged, Retrospective Studies, Survival Rate trends, Treatment Outcome, Aortic Dissection surgery, Aorta, Thoracic surgery, Aortic Aneurysm, Thoracic surgery, Vascular Surgical Procedures methods
- Abstract
Background: Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair., Methods: Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality., Results: Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01)., Conclusions: A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)
- Published
- 2018
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41. Comparison of intravascular ultrasound- and centerline computed tomography-determined aortic diameters during thoracic endovascular aortic repair.
- Author
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Han SM, Elsayed RS, Ham SW, Mahajan A, Fleischman F, Rowe VL, Cunningham MJ, and Weaver FA
- Subjects
- Blood Vessel Prosthesis, Humans, Imaging, Three-Dimensional, Linear Models, Observer Variation, Predictive Value of Tests, Prosthesis Design, Radiographic Image Interpretation, Computer-Assisted, Reproducibility of Results, Retrospective Studies, Stents, Treatment Outcome, Aorta, Thoracic diagnostic imaging, Aorta, Thoracic surgery, Aortography methods, Blood Vessel Prosthesis Implantation instrumentation, Computed Tomography Angiography, Ultrasonography, Interventional
- Abstract
Background: Accurate sizing of stent grafts during thoracic endovascular aortic repair (TEVAR) is critical for a successful outcome. Centerline measurements using three-dimensional reconstruction of preoperative computed tomography angiography (CTA) is the current standard for stent graft sizing. However, this technique is predicated on an idealized straightened aorta and does not account for the variability in the aortic diameter during the cardiac cycle or the overall status of the patient's volume. Intravascular ultrasound (IVUS) offers real-time cross-sectional imaging of the aorta orthogonal to the support wire, thereby providing an adjunctive method for aortic diameter determination at the time of TEVAR., Methods: A retrospective review was performed on all patients who underwent TEVAR for nontraumatic aortic pathology from July 2015 to December 2015. Preoperative CTA images were reconstructed on a dedicated three-dimensional workstation. CTA centerline aortic diameter measurements were performed in major and minor axes at 1-cm intervals from the left subclavian origin to 20 cm distally. The IVUS images were acquired intraoperatively through 1-cm stepwise pullback along the aorta from the left subclavian origin to 20 cm. IVUS aortic diameters were measured at the maximum phase during the cardiac cycle. The average values of major and minor axes diameters from both modalities were calculated at each location for comparison. Linear regression analysis was performed to evaluate correlation, and Bland-Altman plots assessed agreement between different imaging modalities., Results: During the study period, 26 patients underwent TEVAR. Of these, 20 patients had adequate CTA and IVUS images, providing 355 paired measurements. There was a high correlation between CTA- and IVUS-determined aortic diameters (R = 0.62; P < .001). However, Bland-Altman analysis showed that, compared with CT, IVUS resulted in larger aortic diameters, with the mean difference of 3.09 mm. There was a significant variability between IVUS and CTA with the standard deviation of difference (SD diff) of 4.56 mm. When stratified by the aortic position, a high degree of agreement was observed at the base of the left subclavian (position 0), with a mean difference of -2.69 mm and an SD diff of 4 mm. The agreement was the lowest at the angulated aortic segments (2 cm to 7 cm distal to the subclavian origin) with a mean difference up to 7.96 mm and an SD diff up to 8.27 mm., Conclusions: IVUS imaging and centerline CTA may provide significantly different aortic diameter measurements, particularly in angulated aortic segments. Caution must be taken when sizing a stent graft using CTA alone, particularly in an angulated proximal landing zone., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
- Published
- 2017
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42. Acute Type A Aortic Dissection.
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Elsayed RS, Cohen RG, Fleischman F, and Bowdish ME
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- Acute Disease, Aortic Dissection etiology, Aortic Dissection mortality, Aorta, Aortic Aneurysm, Thoracic etiology, Aortic Aneurysm, Thoracic mortality, Humans, Aortic Dissection surgery, Aortic Aneurysm, Thoracic surgery
- Abstract
Type A aortic dissection is a surgical emergency occurring when an intimal tear in the aorta creates a false lumen in the ascending aorta. Prompt diagnosis and surgical treatment are imperative to optimize outcomes. Surgical repair requires replacement of the ascending aorta with or without aortic root or aortic arch replacement. Surgical outcomes for this highly lethal diagnosis have improved, with contemporary survival to discharge at Centers of Excellence of 85% to 90%. Survival is related to prompt treatment, preexisting medical comorbidities, presence or absence of end organ malperfusion, extent of aortic repair required, and the development of postoperative complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)
- Published
- 2017
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43. Diagnostic and Treatment Dilemmas of the Aortic Arch.
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Hui DS and Fleischman F
- Subjects
- Aorta, Thoracic abnormalities, Aorta, Thoracic anatomy & histology, Endovascular Procedures, Hospitals, High-Volume, Humans, Stents, Treatment Outcome, Aorta, Thoracic surgery, Blood Vessel Prosthesis Implantation
- Abstract
Endovascular approaches to the aortic arch are challenged by unique anatomy and physiology of this area. Simple application of conventional endovascular technology and technique for abdominal or descending thoracic aortic disease to the aortic arch is insufficient to achieve effective and durable repairs. Appreciation of these challenges has led to developments in endovascular technology as well as complex strategies to deal with individual patient anatomy that hold the potential for continued improved outcomes in both the short and the long term., (Copyright © 2017 Elsevier Inc. All rights reserved.)
- Published
- 2017
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44. Symptomatic Intragraft Thrombus following Endovascular Repair of Blunt Thoracic Aortic Injury.
- Author
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Abdoli S, Ham SW, Wilcox AG, Fleischman F, and Lam L
- Subjects
- Accidents, Traffic, Adult, Aorta, Thoracic diagnostic imaging, Aorta, Thoracic injuries, Aortography methods, Blood Vessel Prosthesis Implantation adverse effects, Computed Tomography Angiography, Endovascular Procedures adverse effects, Graft Occlusion, Vascular diagnostic imaging, Graft Occlusion, Vascular surgery, Humans, Ischemia diagnostic imaging, Ischemia surgery, Male, Pedestrians, Prosthesis Design, Thrombosis diagnostic imaging, Thrombosis surgery, Treatment Outcome, Vascular System Injuries diagnostic imaging, Vascular System Injuries etiology, Wounds, Nonpenetrating diagnostic imaging, Wounds, Nonpenetrating etiology, Aorta, Thoracic surgery, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation instrumentation, Endovascular Procedures instrumentation, Graft Occlusion, Vascular etiology, Ischemia etiology, Stents, Thrombosis etiology, Vascular System Injuries surgery, Wounds, Nonpenetrating surgery
- Abstract
Thoracic endovascular aortic repair (TEVAR) can be complicated by graft collapse, endoleaks, and stent migration. The incidence of these complications and other outcomes is poorly understood in young trauma victims who receive endovascular aortic repair of blunt thoracic aortic injury (BTAI). A 29-year-old pedestrian was struck by a vehicle resulting in polytrauma including BTAI with transection distal to the left subclavian artery origin. The patient underwent successful TEVAR. Nine months later, the patient developed transient paresthesia below the waist that progressed to bilateral lower extremity paralysis and malperfusion syndrome below the diaphragm including nonpalpable pulses in the lower extremities, acute renal failure, and ischemic colitis. Imaging demonstrated near occlusive thrombosis of the distal end of the thoracic endograft. An emergent axillobifemoral bypass resolved the organ malperfusion and acute limb ischemia. Patients who have undergone TEVAR for BTAI may develop asymptomatic or symptomatic intragraft thrombosis. In patients presenting with malperfusion syndrome below the diaphragm, extra-anatomic bypass can expeditiously resolve symptoms until definitive treatment can be performed. Oversizing of thoracic stents in trauma patient may lead to intragraft thrombosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)
- Published
- 2017
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45. A correlative study of aortic valve rotation angle and thoracic aortic sizes using ECG gated CT angiography.
- Author
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Saremi F, Cen S, Tayari N, Alizadeh H, Emami A, Lin L, and Fleischman F
- Subjects
- Adult, Aged, Aged, 80 and over, Female, Humans, Male, Middle Aged, Young Adult, Aortic Diseases diagnostic imaging, Aortic Valve abnormalities, Aortic Valve diagnostic imaging, Computed Tomography Angiography, Electrocardiography, Rotation
- Abstract
Objective: Various degrees of aortic valve rotation may be seen in individuals with no history of congenital cardiovascular malformations, but its association with aortic sizes has not been studied., Methods: Gated computed tomographic (CT angiograms in 217 patients were studied (66.7±15; 22-97 years old)). Aortic diameters were determined at 5 anatomic locations. The length of the aorta from sinus to left subclavian artery was measured. The angle of valve rotation was recorded by measuring the angle between a line connecting the midpoint of the non-coronary sinus to the anterior commissure and another line along the interatrial septum. Rotation angles were correlated with aortic measurements. Patients were separated into two groups based on aortic sizes and into three groups based on age. The threshold for aortic dilatation was set at maximum ascending aorta diameter ≥40mm (≥21mm body surface area [BSA] indexed)., Results: No significant difference in rotation angles was seen between the three age groups or between genders. Rotation angles were significantly correlated with maximal, average, and BSA adjustment of the aortic root and ascending aortic measurements. The aortic root angles were significantly different between the dilated versus nondilated aortas. There was no significant association between the rotation angles and age, length of ascending aorta, or diameters of descending aorta. Multivariate adaptive regression splines showed 25° of aortic root rotation as the diagnostic cut off for ascending aorta dilation. Above the 25° rotation, every 10° of increasing rotation was associated with a 3.78±0.87mm increase in aortic diameter (p<0.01) and a 1.73±0.25 times increased risk for having a dilated aorta (p<0.01)., Conclusion: Rotation angles of the aortic valve may be an independent non-invasive imaging marker for dilatation of the ascending aorta. Patients with increased rotation angle of the aortic valve may have higher risk for development or acceleration of an ascending aortic dilatation., (Published by Elsevier B.V.)
- Published
- 2017
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46. Type A Aortic Dissection Repair: How I Teach It.
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Cohen RG, Hackmann AE, Fleischman F, Baker CJ, Cunningham MJ, Starnes VA, and Bowdish ME
- Subjects
- Humans, Aortic Dissection surgery, Aortic Aneurysm, Thoracic surgery, Education, Medical, Graduate methods, Thoracic Surgery education, Vascular Surgical Procedures education
- Published
- 2017
- Full Text
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47. Management of patients with acute aortic syndrome through a regional rapid transport system.
- Author
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Manzur M, Han SM, Dunn J, Elsayed RS, Fleischman F, Casagrande Y, and Weaver FA
- Subjects
- APACHE, Acute Disease, Adult, Aged, Aged, 80 and over, Aortic Dissection diagnosis, Aortic Dissection mortality, Aortic Dissection physiopathology, Aortic Aneurysm diagnosis, Aortic Aneurysm mortality, Aortic Aneurysm physiopathology, Aortic Rupture diagnosis, Aortic Rupture mortality, Aortic Rupture physiopathology, Catchment Area, Health, Chi-Square Distribution, Emergencies, Female, Hemodynamics, Hospital Mortality, Humans, Linear Models, Logistic Models, Los Angeles, Male, Middle Aged, Multivariate Analysis, Odds Ratio, Program Evaluation, Retrospective Studies, Risk Assessment, Risk Factors, Syndrome, Time Factors, Treatment Outcome, Aortic Dissection surgery, Aortic Aneurysm surgery, Aortic Rupture surgery, Centralized Hospital Services organization & administration, Delivery of Health Care organization & administration, Patient Transfer organization & administration, Regional Medical Programs organization & administration, Time-to-Treatment organization & administration
- Abstract
Objective: The objective of this study was to describe the outcomes of patients with acute aortic syndrome (AAS) during and after transfer to a regional aortic center by a rapid transport system., Methods: Review of patients with AAS who were transferred by a rapid transport system to a regional aortic center was performed. Data regarding demographics, diagnosis, comorbidities, transportation, and hospital course were acquired. Severity of existing comorbidities was determined by the Society for Vascular Surgery Comorbidity Severity Score (SVSCSS). The Acute Physiology and Chronic Health Evaluation II (APACHE II) score assessed physiologic instability on admission. Risk factors associated with system-related (transfer and hospital) mortality were identified by univariate and multivariate linear regression analysis., Results: During a recent 18-month period (December 2013-July 2015), 183 patients were transferred by a rapid transport system; 148 (81%) patients were transported by ground and 35 (19%) by air. Median distance traveled was 24 miles (range, 3.6-316 miles); median transport time was 42 minutes (range, 10-144 minutes). Two patients died during transport, one with a type A dissection, the other of a ruptured abdominal aortic aneurysm. There were 118 (66%) patients who received operative intervention. Median time to operation was 6 hours. Type B dissections had the longest median time to operation, 45 hours, with system-related mortality of 1.9%; type A dissections had the shortest median time, 3 hours, and a system-related mortality of 16%. Overall, system-related mortality was 15%. On univariate analysis, factors associated with system-related mortality were age ≥65 years (P = .026), coronary artery disease (P = .030), prior myocardial infarction (P = .049), prior coronary revascularization (P = .002), SVSCSS of >8 (P < .001), abdominal pain (P = .002), systolic blood pressure <90 mm Hg at sending hospital (P = .001), diagnosis of aortic aneurysm (P = .013), systolic blood pressure <90 mm Hg in the intensive care unit (P < .001), and APACHE II score >10 (P = .004). Distance traveled and transport mode and duration were not associated with increased risk of system-related mortality. Only SVSCSS of >8 (odds ratio, 7.73; 95% confidence interval, 2.32-25.8; P = .001) was independently associated with an increase in system-related mortality on multivariate analysis., Conclusions: Implementation of a rapid transport system, regardless of mode or distance, can facilitate effective transfer of patients with AAS to a regional aortic center. An SVSCSS of >8 predicted an increased system-related mortality and may be a useful metric to assess the appropriateness of patient transfer., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
- Published
- 2017
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48. Thromboembolism-in-Transit and Patent Foramen Ovale: Should Screening Echocardiogram Be Routine for Thromboembolic Disease?
- Author
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Hui DS, Fleischman F, and McFadden PM
- Abstract
Background: Thromboembolism-in-transit straddling a patent foramen ovale (PFO) is a rare condition that requires urgent surgical intervention to prevent arterial emboli., Case Report: We present the case of a 42-year-old female who presented with a symptomatic pulmonary embolism. Echocardiography identified a PFO, with a bridging thrombus-in-transit and evidence of right ventricular strain. Urgent surgery was performed because of the risk of systemic embolism. A large thrombus was identified during biatrial exploration. Pulmonary embolectomy and primary PFO closure were performed., Conclusion: Because of the 20%-30% incidence of PFOs in the general population, we suggest that echocardiography should be considered for routine surveillance in thromboembolism because of the risk of systemic sequelae.
- Published
- 2016
49. Anomalous coronary arteries: cardiovascular computed tomographic angiography for surgical decisions and planning.
- Author
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Shinbane JS, Shriki J, Fleischman F, Hindoyan A, Withey J, Lee C, Wilcox A, Cunningham M, Baker C, Matthews RV, and Starnes V
- Subjects
- Cardiovascular Surgical Procedures, Humans, Coronary Angiography methods, Coronary Vessel Anomalies diagnostic imaging, Coronary Vessels diagnostic imaging, Imaging, Three-Dimensional methods, Tomography, X-Ray Computed methods
- Abstract
Cardiovascular computed tomographic angiography (CCTA) provides an understanding of the three-dimensional (3D) coronary artery anatomy in relation to cardiovascular thoracic structures important to the surgical management of anomalous coronary arteries (ACAs). Although some ACA variants are not clinically significant, others can lead to ischemia/infarction, related acute ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death. The CCTA is important to surgical decision making, as it provides noninvasive visualization of the coronary arteries with (1) assessment of origin, course, and termination of coronary artery anomalies in the context of 3D thoracic anatomy, (2) characterization of anatomy helpful for differentiation of benign versus hemodynamically significant variants, (3) identification of other cardiothoracic anomalies, and (4) detection of coronary artery disease. High-risk ACA anatomy in the appropriate clinical setting can require surgical intervention with decisions including minimally invasive versus open sternotomy approach, correction via reimplantation of a coronary artery, alteration of the ACA course without reimplantation, or bypass of an ACA. Given the rarity of ACA, there is limited data in the literature, and significant controversy related to the management issues. The management of ACA requires comprehensive clinical history, thorough assessment of cardiac function, and detailed anatomic imaging. Future studies will need to address the long-term outcome based on detailed assessment of original anatomy and surgical approach.
- Published
- 2013
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50. Successful extraction of cardiac-extending intravenous leiomyomatosis through gonadal vein.
- Author
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Matsuo K, Fleischman F, Ghattas CS, Gabrielyan AS, Ballard CA, Roman LD, and Morrow CP
- Subjects
- Adult, Echocardiography, Transesophageal, Female, Heart Atria pathology, Heart Atria surgery, Humans, Hysterectomy, Incidental Findings, Leiomyomatosis diagnosis, Leiomyomatosis pathology, Ovariectomy, Salpingectomy, Tomography, X-Ray Computed, Treatment Outcome, Uterine Neoplasms diagnosis, Uterine Neoplasms pathology, Veins pathology, Veins surgery, Leiomyomatosis surgery, Ovary blood supply, Uterine Neoplasms surgery, Vascular Surgical Procedures
- Abstract
Objective: To report a conservative surgical management of cardiac-extending intravenous (IV) leiomyomatosis., Design: Case report., Setting: Tertiary care center., Patient(s): A 40-year-old nulligravid with incidentally identified IV leiomyomatosis arising from the right gonadal vein and extending into the right atrium., Intervention(s): First, intraoperative transesophageal echocardiogram was performed that demonstrated the IV leiomyomatosis stalk to be 1.1 cm in diameter without an enlarged tip or adherence to the vessel lumen. Next, the 20-week-size uterus was gently pulled caudally under live visualization of the IV leiomyomatosis tip with transesophageal echocardiogram. As the uterus was pulled caudally, the IV leiomyomatosis tip obviously protruded from the right atrium and down into inferior vena cava. Lastly, the gonadal vein was incised longitudinally and the stalk of the tumor was grasped and extracted through the incision., Main Outcome Measure(s): One-step abdominal surgery for complete tumor resection without sternotomy or cardiac bypass surgery., Result(s): To our knowledge, this is the first reported case of a cardiac-extending IV leiomyomatosis successfully extracted through the gonadal vein., Conclusion(s): In a selected case with logistic step-by-step approach, conservative surgical treatment via gonadal vein extraction could be a feasible option in the management of cardiac-extending IV leiomyomatosis. Systematic literature review highlights important clinical characteristics and management options for IV leiomyomatosis., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)
- Published
- 2012
- Full Text
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