Boulos Toursarkissian - Academia.edu (original) (raw)

Papers by Boulos Toursarkissian

Research paper thumbnail of Hot Topic: Complications and Intra-Procedural Adverse Events Due to Embolic Protection Devices During Protected Carotid Interventions

PURPOSE: Outflow embolic protection devices during carotid artery stenting (CAS) protect the cere... more PURPOSE: Outflow embolic protection devices during carotid artery stenting (CAS) protect the cerebral circulation by capturing clinically significant debris. However, use of these devices increases procedural time and carries the risk of intra-procedural adverse events and potential complications. The aim of this study was to evaluate and classify the adverse events of these embolic protection devices during carotid interventions. METHODS: 75 protected CAS procedures were analyzed for variables related to the embolic protection device. Technical success of embolic device deployment and retrieval, with or without adjunctive procedures was documented. Adjunctive procedures included use of buddy wires or angioplasty to facilitate filter deployment and neck maneuvers or catheter interventions to facilitate removal. The filter was assessed for visible debris in each case. Adverse events related to the filter device were classified into two categories (I) minor adverse events that resolve...

Research paper thumbnail of Diabetes Mellitus (DM) and Peripheral Vascular Disease (PAD): Imaging Evaluation and Interventions for Critical Limb Ischemia in the 21st Century Revisited

Research paper thumbnail of Endovascular treatment of innominate artery stenosis in a bovine aortic arch--a case report

Vascular and endovascular surgery

Recent reports have established the feasibility and safety of percutaneous transluminal angioplas... more Recent reports have established the feasibility and safety of percutaneous transluminal angioplasty and stent placement in the treatment of innominate artery occlusive disease. Although the long-term durability of these endovascular approaches has not been clearly established, they are particularly attractive in patients who are not considered good candidates for surgical reconstruction. The authors present a case involving a morbidly obese Hispanic woman who had undergone previous coronary artery bypass and complained of right visual symptoms, dizziness, and right upper extremity claudication. Because of her unusual bovine anatomy and the desire to avoid reoperating in her chest, a unique approach with a left subclavian-to-carotid bypass and innominate artery angioplasty and stenting was used.

Research paper thumbnail of Lower extremity bypass graft revision in diabetics

Vascular surgery

Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is f... more Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is frequently required in diabetic patients. The authors evaluated (1) the value of routine angiography before graft revision in diabetics, (2) factors that predict patients in whom angiography alters management, and (3) the incidence of recurrent stenosis and factors that might predict it. Forty-two infrainguinal primary vein bypasses undergoing primary revision were retrospectively studied. The initial graft stenosis was detected at a mean of 11.5 +/-3.6 months after the original bypass. Angiograms were obtained in 38 cases, revealing additional findings in 29 of 38 cases (76%), with a resultant alteration of the operative plan in 27 cases (71%). The most frequent additional angiographic finding was the identification or localization of a lesion in the inflow or outflow tracts (18 of 27 cases). Cases where the angiogram altered the management plan had a mean systolic velocity ratio across ...

Research paper thumbnail of Does lower limb revascularization result in an improvement in sensory perception thresholds?

Annals of vascular surgery, 2002

Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We ... more Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We wished to determine whether revascularization of chronically ischemic limbs results in any clinical changes in peripheral sensory thresholds. We prospectively measured quantitative vibration perception thresholds (VPT) using a Horwell neurothesiometer (in volts) in patients undergoing infrainguinal bypass, preoperatively and up to 6 month postoperatively. The bypassed limbs' preoperative VPT values were higher (lesser sensory perception) than the contralateral control limbs' preoperative values (mean score differences: 6 +/- 2 and 4 +/- 10 at toe and foot levels respectively; p ? 0.004). Preoperative VPT values were not different from the 6-month postoperative values for the revascularized legs at toe and foot levels for all 55 patients (mean score change of ?0.84 and ?1.32, p > 0.5). The contralateral limbs' VPT values did not change significantly over the 6-month period ...

Research paper thumbnail of Does the efficacy of dorsalis pedis artery bypasses vary among diabetic patients of different ethnic backgrounds?

Vascular and endovascular surgery

Hispanic patients suffer from a high rate of leg amputations, far beyond what would be expected f... more Hispanic patients suffer from a high rate of leg amputations, far beyond what would be expected from the high prevalence of diabetes in this population. This raises questions about the efficacy of bypass operations across ethnic lines. We focused this review on dorsalis pedis bypasses, as these are frequently performed in diabetic patients. We compared outcomes between Hispanics and non-Hispanics and sought to identify factors predictive of failure or complications. The authors conducted a retrospective review of 144 dorsalis pedis bypasses in 106 men and 29 women with a mean age of 62 years. Eighty-two percent were Hispanic; 96% of cases were done for tissue loss, and 4% for rest pain. Twenty-five percent of patients experienced perioperative complications; these were more frequent in non-Hispanics than Hispanics (40% vs 22%, p = 0.05). The most frequent complications were wound related (11%). The 30-day mortality was 1.5% and 30-day graft thrombosis was 5%. Follow-up ranged from 1...

Research paper thumbnail of Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution

The American surgeon, 2002

Our objective is to describe our current experience with major lower-extremity amputation seconda... more Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 +/- 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status (P > 0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics (P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level (P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA (P = 0.04). At an averag...

Research paper thumbnail of Early Duplex-derived Hemodynamic Parameters after Lower Extremity Bypass in Diabetics: Implications for Mid-term Outcomes

Annals of Vascular Surgery, 2002

Early postoperative changes in the hemodynamic parameters of infrainguinal bypass grafts in diabe... more Early postoperative changes in the hemodynamic parameters of infrainguinal bypass grafts in diabetics have not been well de®ned. We undertook this study to better de®ne such changes in duplex-derived velocities and waveforms, and correlate any observed changes with intermediate-term outcomes. A prospective study of 68 primary vein bypasses for limb salvage was carried out, with scans obtained intraoperatively, daily until discharge, and at 8-to 12-weeks intervals. During follow-up (12 6 months), 20 grafts developed stenoses, 17 occluded, and 8 limbs were amputated. Most grafts show a variant of a biphasic waveform intraoperatively at the mid-graft (MG) and distal graft (DG) levels (54% and 57%); 65% of waveforms remain unchanged during the ®rst week, and 54% remain unchanged at 3 months. No duplex-derived factors were predictive of the development of stenoses. A number of parameters were predictive of ultimate graft thrombosis. Intraoperative MG velocity was higher in grafts that eventually remained patent (83 36 vs. 60 29 cm/sec; p < 0.025). Grafts that remained patent also had a much lower decline in DG and distal native (DN) velocities from immediately postoperative to 8-12 weeks later, than grafts that eventually thrombosed ()3 35 vs. )44 43 cm/sec for DG, p < 0.001; and )17 66 vs. )76 53 cm/sec for DN, p < 0.04 respectively). In terms of limb salvage, when the MG or DG waveform worsened (from postoperation to 12 weeks later), amputation was more likely than when it remained unchanged or improved (MG 67% vs. 9% limb loss, p < 0.04; DG 43% vs. 8% limb loss, p < 0.04). We conclude that intensive graft duplex surveillance does not identify grafts likely to develop stenoses. However, a number of features allow the prediction of ultimate graft failure or limb loss.

Research paper thumbnail of Type 2 Endoleaks after Abdominal Aortic Aneurysm Stent Grafting with Systematic Mesenteric and Lumbar Coil Embolization

Annals of Vascular Surgery, 2006

We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric... more We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric artery (IMA) and/or lumbar arteries (LAs) prior to endovascular abdominal aortic aneurysm (AAA) repair (EVAR). We retrospectively reviewed all patients undergoing EVAR over a 4-year period at one hospital. Results were analyzed using uni- and multivariate analyses. Fifty-five male patients with an average age of 71 years were evaluated. Follow-up averaged 15 +/- 13 months. The IMA was either coiled or occluded in 30 cases. One or more LAs were coiled in 29 patients. An average of 1.3 LAs per patients were coiled (range 0-6). There were no immediate or late complications from coiling. At last follow-up, 14 AAAs showed no change in diameter, one increased by 2 mm, and the remainder (n = 40) decreased by 7.5 +/- 6 mm in maximal diameter. Only five (9%) type 2 endoleaks were detected during follow-up. Three were associated with AAA size increase. Four of the five were treated with additional coiling, with good results. By logistic regression, neither endoleak occurrence nor AAA shrinkage correlated with LA or IMA coiling. However, by multivariate analysis, completeness of lumbar coiling correlated negatively with aneurysm shrinkage (p = 0.04) and IMA coiling correlated positively with aneurysm shrinkage (p = 0.04). Coil embolization of the IMA and/or LAs prior to EVAR can be safely accomplished in a large number of cases and is associated with a low incidence of type 2 endoleaks. We cannot at present demonstrate a benefit to LA embolization in terms of endoleak prevention or AAA shrinkage. However, IMA embolization may be of benefit in terms of AAA shrinkage.

Research paper thumbnail of Mirizziʼs Syndrome

Southern Medical Journal, 1994

Research paper thumbnail of Bypass to the perigeniculate collateral vesselsA useful technique for limb salvage: Preliminary report on 22 patients

Journal of Vascular Surgery, 1998

Research paper thumbnail of Angiographic scoring of vascular occlusive disease in the diabetic foot: Relevance to bypass graft patency and limb salvage

Journal of Vascular Surgery, 2002

We graded the severity of occlusive disease in foot vessels of patients with diabetes and correla... more We graded the severity of occlusive disease in foot vessels of patients with diabetes and correlated the scoring obtained with graft patency and limb salvage. Methods: In this retrospective review of 199 limbs studied by means of angiography in 117 patients with diabetes mellitus, 124 limbs underwent bypass grafting. Each dorsalis pedis (DP), lateral plantar (LP), and medial plantar (MP) artery was assigned a score according to the reporting standards of the Joint Vascular Societies Council (0, no stenosis > 20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, < half the vessel length occluded; 3, > half the vessel length occluded.) A foot score (DP + MP + LP + 1) was calculated for each foot (1 to 10). The mean follow-up period was 14 months. Results: For all 199 limbs and for the 124 limbs that underwent bypass grafting, the mean scores were similar for the DP, MP, and LP (1.8 ± 1.0, 1.9 ± 1.0, 1.9 ± 1.0, respectively; P > .4). Only the MP and LP correlated with each other (r = 0.57; P < .0001). There were no scoring differences between limbs with symptoms and limbs that did not undergo bypass grafting. Bypass graft patency correlated with both the foot score and the MP score for tibial and inframalleolar grafts (P < .04). Patency correlated with the LP score only for inframalleolar bypass grafting procedures. The DP score alone did not differ between bypass grafts that remained patent and bypass grafts that failed. Bypass grafts in limbs with a foot score less than 7 and an MP score less than 2 had only a 2% failure rate. A foot score greater or equal to 7 was associated with a 30% failure rate for all bypass grafts (41% for inframalleolar grafts). Bypass grafts with low foot scores that failed did so much later than bypass grafts with high foot scores that failed (17 ± 11 months vs 6 ± 8 months; P < .02), possibly reflecting different etiologies for the failure. The limb salvage rate correlated with foot score (P < .05). The limbs that were saved had an average foot score of 6.4 ± 2.0, versus 7.2 ± 1.4 for limbs that required amputation. Conclusion: In patients with diabetes mellitus, the foot score is a useful tool for predicting the likelihood of graft patency and limb salvage for infrapopliteal revascularization. However, the relatively high bypass success rate (70%) in the presence of a high foot score (≥ 7) does not allow its use in identifying the subgroup of patients who are unlikely to benefit from bypass grafting surgery. It cannot be used as a means of selecting patients for primary amputation. (J Vasc Surg 2002;35:494-500.)

Research paper thumbnail of Target lesion characteristics in failing vein grafts predict the success of endovascular and open revision

Journal of Vascular Surgery, 2007

Methods: Consecutive open and endovascular revisions for graft threatening lesions were reviewed.... more Methods: Consecutive open and endovascular revisions for graft threatening lesions were reviewed. We evaluated graft durability and individual target lesion response to open and endovascular treatment to determine characteristics that may influence outcomes. Treatment failure was defined as target lesion restenosis or graft occlusion. Results: Eighty-four (58 endovascular, 26 open) infrainguinal vein graft revisions were performed in 67 failing, nonthrombosed infrainguinal vein grafts. Primary assisted graft patency at 5 years was 63% (95% confidence interval [CI], 46% to 77%). Follow-up was 29.5 ؎ 19.2 months. Grafts treated for early lesions (<6 months) failed (occlusion or need for additional interventions) more frequently than those with late occurring lesions (P ‫؍‬ .03). Overall target lesion revascularization patency was 45% (95% CI, 32% to 58%) at 3 years. Average time to target lesion revascularization failure was 7.5 months, with no significant difference noted between endovascular and open treatment groups. Overall target lesion revascularization patency at 3 years was also not significantly different between open and endovascular groups at 54% (95% CI, 30% to 73%) vs 41% (95% CI, 25% to 56%; P ‫؍‬ .15).

Research paper thumbnail of Endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta: Long-term outcome

Journal of Vascular Surgery, 2004

Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial in... more Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: The vitamin intervention for stroke prevention (VISP) randomized controlled trial Toole JF, Malinow MR, Chambless LE, et al. JAMA 2004; 291:565-75. Conclusion: Vitamin therapy resulting in moderate reductions of total homocysteine after a nondisabling cerebral event has no affect on vascular outcomes during a 2-year follow up period.

Research paper thumbnail of Aortic injury in a young go-cart enthusiast

Research paper thumbnail of The management of deep sternal wound infections using vacuum assisted closure? (V.A.C. � ) therapy

International Wound Journal, 2006

A group of international experts met in May 2006 to develop clinical guidelines on the practical ... more A group of international experts met in May 2006 to develop clinical guidelines on the practical application of vacuum assisted closure (V.A.C.)+ therapy in deep sternal wound infections. Group discussion and an anonymous interactive voting system were used to develop content. The recommendations are based on current evidence or, where this was not available, the majority consensus of the international group. The principles of treatment for deep sternal wound infections include early recognition and treatment of infection. V.A.C. therapy should be instigated early, following thorough wound irrigation and surgical debridement. V.A.C. therapy in deep sternal wound infections requires specialist surgical supervision and should only be undertaken by clinicians with adequate experience and training in the use of the technique.

Research paper thumbnail of Mediastinal epithelioid hemangioendothelioma

The Annals of Thoracic Surgery, 1990

An epithelioid hemangioendothelioma arising from the innominate vein in the anterior superior med... more An epithelioid hemangioendothelioma arising from the innominate vein in the anterior superior mediastinum of a 62-year-old man was treated by wide local excision followed by radiotherapy. This clinicopathologic entity is a rare cause of mediastinal mass and is characterized by an intermediate malignant potential. To our knowledge, very few cases have been reported in the mediastinum; those cases are listed in this report. Gross and microscopic distinguishing features of epithelioid hemangioendothelioma, as well as differential diagnosis, are reviewed from the literature. Finally, clinical behavior is discussed and treatment options are suggested.

Research paper thumbnail of Changing Pattern of Access Site Complications with the Use of Percutaneous Closure Devices

Vascular and Endovascular Surgery, 2001

ABSTRACT

Research paper thumbnail of Percutaneous Dilational Tracheostomy

The Journal of Trauma: Injury, Infection, and Critical Care, 1996

Research paper thumbnail of Surgical treatment of thoracic outlet compression syndromes: diagnostic considerations and transaxillary first rib resection

Annals of vascular surgery, 1997

Supraclavicular exploration has become a widely utilized, versatile, and effective approach in th... more Supraclavicular exploration has become a widely utilized, versatile, and effective approach in the treatment of thoracic outlet compression syndromes. It is applicable to neurogenic, arterial, and venous form of TOS. Although certain aspects of the surgical anatomy are quite familiar to most vascular surgeons, considerable attention must be given to the details of this procedure to avoid inadequate decompression, serious injury, or predictable causes of recurrent compression. Supraclavicular exploration and its variations provide an excellent approach to the entire spectrum of problems encountered in patients with TOS, and in many centers it has superceded the transaxillary approach previously popularized for these disorders. Because supraclavicular exploration for TOS involves a number of unique technical considerations and because it is typically applied to a difficult clinical problem outside the routine experience of most vascular surgeons, it should be undertaken only with appropriate training and interest in the comprehensive management of patients with TOS.

Research paper thumbnail of Hot Topic: Complications and Intra-Procedural Adverse Events Due to Embolic Protection Devices During Protected Carotid Interventions

PURPOSE: Outflow embolic protection devices during carotid artery stenting (CAS) protect the cere... more PURPOSE: Outflow embolic protection devices during carotid artery stenting (CAS) protect the cerebral circulation by capturing clinically significant debris. However, use of these devices increases procedural time and carries the risk of intra-procedural adverse events and potential complications. The aim of this study was to evaluate and classify the adverse events of these embolic protection devices during carotid interventions. METHODS: 75 protected CAS procedures were analyzed for variables related to the embolic protection device. Technical success of embolic device deployment and retrieval, with or without adjunctive procedures was documented. Adjunctive procedures included use of buddy wires or angioplasty to facilitate filter deployment and neck maneuvers or catheter interventions to facilitate removal. The filter was assessed for visible debris in each case. Adverse events related to the filter device were classified into two categories (I) minor adverse events that resolve...

Research paper thumbnail of Diabetes Mellitus (DM) and Peripheral Vascular Disease (PAD): Imaging Evaluation and Interventions for Critical Limb Ischemia in the 21st Century Revisited

Research paper thumbnail of Endovascular treatment of innominate artery stenosis in a bovine aortic arch--a case report

Vascular and endovascular surgery

Recent reports have established the feasibility and safety of percutaneous transluminal angioplas... more Recent reports have established the feasibility and safety of percutaneous transluminal angioplasty and stent placement in the treatment of innominate artery occlusive disease. Although the long-term durability of these endovascular approaches has not been clearly established, they are particularly attractive in patients who are not considered good candidates for surgical reconstruction. The authors present a case involving a morbidly obese Hispanic woman who had undergone previous coronary artery bypass and complained of right visual symptoms, dizziness, and right upper extremity claudication. Because of her unusual bovine anatomy and the desire to avoid reoperating in her chest, a unique approach with a left subclavian-to-carotid bypass and innominate artery angioplasty and stenting was used.

Research paper thumbnail of Lower extremity bypass graft revision in diabetics

Vascular surgery

Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is f... more Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is frequently required in diabetic patients. The authors evaluated (1) the value of routine angiography before graft revision in diabetics, (2) factors that predict patients in whom angiography alters management, and (3) the incidence of recurrent stenosis and factors that might predict it. Forty-two infrainguinal primary vein bypasses undergoing primary revision were retrospectively studied. The initial graft stenosis was detected at a mean of 11.5 +/-3.6 months after the original bypass. Angiograms were obtained in 38 cases, revealing additional findings in 29 of 38 cases (76%), with a resultant alteration of the operative plan in 27 cases (71%). The most frequent additional angiographic finding was the identification or localization of a lesion in the inflow or outflow tracts (18 of 27 cases). Cases where the angiogram altered the management plan had a mean systolic velocity ratio across ...

Research paper thumbnail of Does lower limb revascularization result in an improvement in sensory perception thresholds?

Annals of vascular surgery, 2002

Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We ... more Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We wished to determine whether revascularization of chronically ischemic limbs results in any clinical changes in peripheral sensory thresholds. We prospectively measured quantitative vibration perception thresholds (VPT) using a Horwell neurothesiometer (in volts) in patients undergoing infrainguinal bypass, preoperatively and up to 6 month postoperatively. The bypassed limbs' preoperative VPT values were higher (lesser sensory perception) than the contralateral control limbs' preoperative values (mean score differences: 6 +/- 2 and 4 +/- 10 at toe and foot levels respectively; p ? 0.004). Preoperative VPT values were not different from the 6-month postoperative values for the revascularized legs at toe and foot levels for all 55 patients (mean score change of ?0.84 and ?1.32, p > 0.5). The contralateral limbs' VPT values did not change significantly over the 6-month period ...

Research paper thumbnail of Does the efficacy of dorsalis pedis artery bypasses vary among diabetic patients of different ethnic backgrounds?

Vascular and endovascular surgery

Hispanic patients suffer from a high rate of leg amputations, far beyond what would be expected f... more Hispanic patients suffer from a high rate of leg amputations, far beyond what would be expected from the high prevalence of diabetes in this population. This raises questions about the efficacy of bypass operations across ethnic lines. We focused this review on dorsalis pedis bypasses, as these are frequently performed in diabetic patients. We compared outcomes between Hispanics and non-Hispanics and sought to identify factors predictive of failure or complications. The authors conducted a retrospective review of 144 dorsalis pedis bypasses in 106 men and 29 women with a mean age of 62 years. Eighty-two percent were Hispanic; 96% of cases were done for tissue loss, and 4% for rest pain. Twenty-five percent of patients experienced perioperative complications; these were more frequent in non-Hispanics than Hispanics (40% vs 22%, p = 0.05). The most frequent complications were wound related (11%). The 30-day mortality was 1.5% and 30-day graft thrombosis was 5%. Follow-up ranged from 1...

Research paper thumbnail of Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution

The American surgeon, 2002

Our objective is to describe our current experience with major lower-extremity amputation seconda... more Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 +/- 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status (P > 0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics (P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level (P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA (P = 0.04). At an averag...

Research paper thumbnail of Early Duplex-derived Hemodynamic Parameters after Lower Extremity Bypass in Diabetics: Implications for Mid-term Outcomes

Annals of Vascular Surgery, 2002

Early postoperative changes in the hemodynamic parameters of infrainguinal bypass grafts in diabe... more Early postoperative changes in the hemodynamic parameters of infrainguinal bypass grafts in diabetics have not been well de®ned. We undertook this study to better de®ne such changes in duplex-derived velocities and waveforms, and correlate any observed changes with intermediate-term outcomes. A prospective study of 68 primary vein bypasses for limb salvage was carried out, with scans obtained intraoperatively, daily until discharge, and at 8-to 12-weeks intervals. During follow-up (12 6 months), 20 grafts developed stenoses, 17 occluded, and 8 limbs were amputated. Most grafts show a variant of a biphasic waveform intraoperatively at the mid-graft (MG) and distal graft (DG) levels (54% and 57%); 65% of waveforms remain unchanged during the ®rst week, and 54% remain unchanged at 3 months. No duplex-derived factors were predictive of the development of stenoses. A number of parameters were predictive of ultimate graft thrombosis. Intraoperative MG velocity was higher in grafts that eventually remained patent (83 36 vs. 60 29 cm/sec; p < 0.025). Grafts that remained patent also had a much lower decline in DG and distal native (DN) velocities from immediately postoperative to 8-12 weeks later, than grafts that eventually thrombosed ()3 35 vs. )44 43 cm/sec for DG, p < 0.001; and )17 66 vs. )76 53 cm/sec for DN, p < 0.04 respectively). In terms of limb salvage, when the MG or DG waveform worsened (from postoperation to 12 weeks later), amputation was more likely than when it remained unchanged or improved (MG 67% vs. 9% limb loss, p < 0.04; DG 43% vs. 8% limb loss, p < 0.04). We conclude that intensive graft duplex surveillance does not identify grafts likely to develop stenoses. However, a number of features allow the prediction of ultimate graft failure or limb loss.

Research paper thumbnail of Type 2 Endoleaks after Abdominal Aortic Aneurysm Stent Grafting with Systematic Mesenteric and Lumbar Coil Embolization

Annals of Vascular Surgery, 2006

We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric... more We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric artery (IMA) and/or lumbar arteries (LAs) prior to endovascular abdominal aortic aneurysm (AAA) repair (EVAR). We retrospectively reviewed all patients undergoing EVAR over a 4-year period at one hospital. Results were analyzed using uni- and multivariate analyses. Fifty-five male patients with an average age of 71 years were evaluated. Follow-up averaged 15 +/- 13 months. The IMA was either coiled or occluded in 30 cases. One or more LAs were coiled in 29 patients. An average of 1.3 LAs per patients were coiled (range 0-6). There were no immediate or late complications from coiling. At last follow-up, 14 AAAs showed no change in diameter, one increased by 2 mm, and the remainder (n = 40) decreased by 7.5 +/- 6 mm in maximal diameter. Only five (9%) type 2 endoleaks were detected during follow-up. Three were associated with AAA size increase. Four of the five were treated with additional coiling, with good results. By logistic regression, neither endoleak occurrence nor AAA shrinkage correlated with LA or IMA coiling. However, by multivariate analysis, completeness of lumbar coiling correlated negatively with aneurysm shrinkage (p = 0.04) and IMA coiling correlated positively with aneurysm shrinkage (p = 0.04). Coil embolization of the IMA and/or LAs prior to EVAR can be safely accomplished in a large number of cases and is associated with a low incidence of type 2 endoleaks. We cannot at present demonstrate a benefit to LA embolization in terms of endoleak prevention or AAA shrinkage. However, IMA embolization may be of benefit in terms of AAA shrinkage.

Research paper thumbnail of Mirizziʼs Syndrome

Southern Medical Journal, 1994

Research paper thumbnail of Bypass to the perigeniculate collateral vesselsA useful technique for limb salvage: Preliminary report on 22 patients

Journal of Vascular Surgery, 1998

Research paper thumbnail of Angiographic scoring of vascular occlusive disease in the diabetic foot: Relevance to bypass graft patency and limb salvage

Journal of Vascular Surgery, 2002

We graded the severity of occlusive disease in foot vessels of patients with diabetes and correla... more We graded the severity of occlusive disease in foot vessels of patients with diabetes and correlated the scoring obtained with graft patency and limb salvage. Methods: In this retrospective review of 199 limbs studied by means of angiography in 117 patients with diabetes mellitus, 124 limbs underwent bypass grafting. Each dorsalis pedis (DP), lateral plantar (LP), and medial plantar (MP) artery was assigned a score according to the reporting standards of the Joint Vascular Societies Council (0, no stenosis > 20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, < half the vessel length occluded; 3, > half the vessel length occluded.) A foot score (DP + MP + LP + 1) was calculated for each foot (1 to 10). The mean follow-up period was 14 months. Results: For all 199 limbs and for the 124 limbs that underwent bypass grafting, the mean scores were similar for the DP, MP, and LP (1.8 ± 1.0, 1.9 ± 1.0, 1.9 ± 1.0, respectively; P > .4). Only the MP and LP correlated with each other (r = 0.57; P < .0001). There were no scoring differences between limbs with symptoms and limbs that did not undergo bypass grafting. Bypass graft patency correlated with both the foot score and the MP score for tibial and inframalleolar grafts (P < .04). Patency correlated with the LP score only for inframalleolar bypass grafting procedures. The DP score alone did not differ between bypass grafts that remained patent and bypass grafts that failed. Bypass grafts in limbs with a foot score less than 7 and an MP score less than 2 had only a 2% failure rate. A foot score greater or equal to 7 was associated with a 30% failure rate for all bypass grafts (41% for inframalleolar grafts). Bypass grafts with low foot scores that failed did so much later than bypass grafts with high foot scores that failed (17 ± 11 months vs 6 ± 8 months; P < .02), possibly reflecting different etiologies for the failure. The limb salvage rate correlated with foot score (P < .05). The limbs that were saved had an average foot score of 6.4 ± 2.0, versus 7.2 ± 1.4 for limbs that required amputation. Conclusion: In patients with diabetes mellitus, the foot score is a useful tool for predicting the likelihood of graft patency and limb salvage for infrapopliteal revascularization. However, the relatively high bypass success rate (70%) in the presence of a high foot score (≥ 7) does not allow its use in identifying the subgroup of patients who are unlikely to benefit from bypass grafting surgery. It cannot be used as a means of selecting patients for primary amputation. (J Vasc Surg 2002;35:494-500.)

Research paper thumbnail of Target lesion characteristics in failing vein grafts predict the success of endovascular and open revision

Journal of Vascular Surgery, 2007

Methods: Consecutive open and endovascular revisions for graft threatening lesions were reviewed.... more Methods: Consecutive open and endovascular revisions for graft threatening lesions were reviewed. We evaluated graft durability and individual target lesion response to open and endovascular treatment to determine characteristics that may influence outcomes. Treatment failure was defined as target lesion restenosis or graft occlusion. Results: Eighty-four (58 endovascular, 26 open) infrainguinal vein graft revisions were performed in 67 failing, nonthrombosed infrainguinal vein grafts. Primary assisted graft patency at 5 years was 63% (95% confidence interval [CI], 46% to 77%). Follow-up was 29.5 ؎ 19.2 months. Grafts treated for early lesions (<6 months) failed (occlusion or need for additional interventions) more frequently than those with late occurring lesions (P ‫؍‬ .03). Overall target lesion revascularization patency was 45% (95% CI, 32% to 58%) at 3 years. Average time to target lesion revascularization failure was 7.5 months, with no significant difference noted between endovascular and open treatment groups. Overall target lesion revascularization patency at 3 years was also not significantly different between open and endovascular groups at 54% (95% CI, 30% to 73%) vs 41% (95% CI, 25% to 56%; P ‫؍‬ .15).

Research paper thumbnail of Endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta: Long-term outcome

Journal of Vascular Surgery, 2004

Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial in... more Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: The vitamin intervention for stroke prevention (VISP) randomized controlled trial Toole JF, Malinow MR, Chambless LE, et al. JAMA 2004; 291:565-75. Conclusion: Vitamin therapy resulting in moderate reductions of total homocysteine after a nondisabling cerebral event has no affect on vascular outcomes during a 2-year follow up period.

Research paper thumbnail of Aortic injury in a young go-cart enthusiast

Research paper thumbnail of The management of deep sternal wound infections using vacuum assisted closure? (V.A.C. � ) therapy

International Wound Journal, 2006

A group of international experts met in May 2006 to develop clinical guidelines on the practical ... more A group of international experts met in May 2006 to develop clinical guidelines on the practical application of vacuum assisted closure (V.A.C.)+ therapy in deep sternal wound infections. Group discussion and an anonymous interactive voting system were used to develop content. The recommendations are based on current evidence or, where this was not available, the majority consensus of the international group. The principles of treatment for deep sternal wound infections include early recognition and treatment of infection. V.A.C. therapy should be instigated early, following thorough wound irrigation and surgical debridement. V.A.C. therapy in deep sternal wound infections requires specialist surgical supervision and should only be undertaken by clinicians with adequate experience and training in the use of the technique.

Research paper thumbnail of Mediastinal epithelioid hemangioendothelioma

The Annals of Thoracic Surgery, 1990

An epithelioid hemangioendothelioma arising from the innominate vein in the anterior superior med... more An epithelioid hemangioendothelioma arising from the innominate vein in the anterior superior mediastinum of a 62-year-old man was treated by wide local excision followed by radiotherapy. This clinicopathologic entity is a rare cause of mediastinal mass and is characterized by an intermediate malignant potential. To our knowledge, very few cases have been reported in the mediastinum; those cases are listed in this report. Gross and microscopic distinguishing features of epithelioid hemangioendothelioma, as well as differential diagnosis, are reviewed from the literature. Finally, clinical behavior is discussed and treatment options are suggested.

Research paper thumbnail of Changing Pattern of Access Site Complications with the Use of Percutaneous Closure Devices

Vascular and Endovascular Surgery, 2001

ABSTRACT

Research paper thumbnail of Percutaneous Dilational Tracheostomy

The Journal of Trauma: Injury, Infection, and Critical Care, 1996

Research paper thumbnail of Surgical treatment of thoracic outlet compression syndromes: diagnostic considerations and transaxillary first rib resection

Annals of vascular surgery, 1997

Supraclavicular exploration has become a widely utilized, versatile, and effective approach in th... more Supraclavicular exploration has become a widely utilized, versatile, and effective approach in the treatment of thoracic outlet compression syndromes. It is applicable to neurogenic, arterial, and venous form of TOS. Although certain aspects of the surgical anatomy are quite familiar to most vascular surgeons, considerable attention must be given to the details of this procedure to avoid inadequate decompression, serious injury, or predictable causes of recurrent compression. Supraclavicular exploration and its variations provide an excellent approach to the entire spectrum of problems encountered in patients with TOS, and in many centers it has superceded the transaxillary approach previously popularized for these disorders. Because supraclavicular exploration for TOS involves a number of unique technical considerations and because it is typically applied to a difficult clinical problem outside the routine experience of most vascular surgeons, it should be undertaken only with appropriate training and interest in the comprehensive management of patients with TOS.