Christopher Abularrage - Academia.edu (original) (raw)
Papers by Christopher Abularrage
Journal of the American College of Surgeons, 2015
The Journal of surgical research, Jan 2, 2015
Lower extremity bypass (LEB) for peripheral vascular disease is a common procedure in diabetics a... more Lower extremity bypass (LEB) for peripheral vascular disease is a common procedure in diabetics and is associated with readmission. Thus, we hypothesized that diabetes might be a predictor of 30-d unplanned readmission after LEB. Patients undergoing infrainguinal LEB in the 2011-12 American College of Surgeons National Surgery Quality Improvement Program database were divided into nondiabetics mellitus (NDM), non-insulin-dependent diabetics mellitus (NIDDM), and insulin-dependent diabetic mellitus (IDDM). Univariate and multivariate analyses were used to evaluate the influence of diabetes on 30-d readmission. A total of 9207 patients (5155 [56%] NDM, 1690 (18%) NIDDM, and 2362 (26%) IDDM) underwent LEB. Unplanned readmission was observed in 1448 patients (16%). IDDM had significantly higher crude postoperative complication (43% versus 30% NDM, 36% NIDDM; P < 0.001) and unplanned readmission rates (20% versus 14% NDM, 16% NIDDM; P < 0.001). Concomitant cardiac disease significa...
Journal of Vascular Surgery, 2015
Annals of vascular surgery, Jan 13, 2015
The safety and effectiveness of using veno-venous and cardiopulmonary bypass for resection of the... more The safety and effectiveness of using veno-venous and cardiopulmonary bypass for resection of the inferior vena cava (IVC) is not well studied. The goal of this study was to compare outcomes following IVC resection with and without bypass support. We analyzed all patients undergoing IVC resection at our institution (9/1999-6/2014) and compared the use of bypass support with cross-clamp alone using univariable and Kaplan-Meier analyses. Outcomes included perioperative complications and survival. Sixty-three patients underwent IVC resection (mean age 58±2 years, mean follow-up 21±3 months). Bypass patients (32%) were similar to non-bypass patients (68%) in age, gender; tumor size, type, and grade (P=NS). Bypass patients were more likely to undergo complete IVC reconstruction (55% vs. 24%; P=.01) at the suprarenal level (62% vs. 35%; P=.05), and had higher intraoperative blood loss (9.6±2.1 vs. 3.2±1.4 L; P=.01). Complete R0 resection was similar between groups (50% vs. 52%, P=NS). The...
JAMA surgery, Jan 24, 2015
Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ES... more Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale. To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System. The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ2 test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients re...
Journal of Vascular Surgery, 2015
Vascular reconstruction can facilitate pancreas tumor resection, but optimal methods of reconstru... more Vascular reconstruction can facilitate pancreas tumor resection, but optimal methods of reconstruction are not well studied. We report our results for portal vein reconstruction (PVR) for pancreatic resection and determinants of postoperative patency. We identified 173 patients with PVR in a prospective database of 6522 patients who underwent pancreatic resection at our hospital from 1970 to 2014. There were 128 patients who had &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 year of follow-up with computed tomography imaging. Preoperative, intraoperative, and postoperative factors were recorded. Patients with and without postoperative PVR thrombosis were compared by univariable, multivariable, and receiver operating characteristic curve analyses. The survival of patients was 100% at 1 month, 88% at 6 months, 66% at 1 year, and 39% on overall median follow-up of 310 days (interquartile range, 417 days). Median survival was 15.5 months (interquartile range, 25 months); 86% of resections were for cancer. Four types of PVR techniques were used: 83% of PVRs were performed by primary repair, 8.7% with interposition vein graft, 4.7% with interposition prosthetic graft, and 4.7% with patch. PVR patency was 100% at 1 day, 98% at 1 month, 91% at 6 months, and 83% at 1 year. Patients with PVR thrombosis were not significantly different from patients with patent PVR in age, survival, preoperative comorbidities, tumor characteristics, perioperative blood loss or transfusion, or postoperative complications. They were more likely to have had preoperative chemotherapy (53% vs 9%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), radiation therapy (35% vs 2%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), and prolonged operative time (618 ± 57 vs 424 ± 20 minutes; P = .002) and to develop postoperative ascites (76% vs 22%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Among patients who developed ascites, 38% of those with PVR thrombosis did so in the setting of tumor recurrence at the porta detected on imaging, whereas among patients with patent PVR, 50% did so (P = .73). Patients with PVR thrombosis were more likely to have had prosthetic graft placement compared with patients with patent PVRs (18% vs 2.7%; P = .03; odds ratio [OR], 7.7; 95% confidence interval [CI], 1.4-42). PVR patency overall was significantly worse for patients who had an interposition prosthetic graft reconstruction (log-rank, P = .04). On multivariable analysis, operative time (OR, 1.01; 95% CI, 1.01-1.02) and prosthetic graft placement (OR, 8.12; 95% CI, 1.1-74) were independent predictors of PVR thrombosis (C statistic = 0.88). Long operative times and use of prosthetic grafts for reconstruction are risk factors for postoperative portal vein thrombosis. Primary repair, patch, or vein interposition should be preferentially used for PVR in the setting of pancreatic resection.
JAMA Surgery, 2015
IMPORTANCE Superior outcomes have been established with the use of an arteriovenous fistula (AVF)... more IMPORTANCE Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation.
Journal of vascular surgery, 2014
Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femora... more Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femoral artery aneurysms (FAAs) to achieve adequate numbers for analysis and have recommended repair of asymptomatic FAAs with diameters ≥2.5 cm and all symptomatic FAAs. This study evaluated the contemporary management of isolated FAAs. Patients with FAAs were evaluated using a standardized, prospectively maintained database by a research consortium. From 2002 to 2012, 236 FAAs were identified in 182 patients (mean age, 72 years; male-to-female ratio, 16:1) at eight institutions. The mean nonoperative mean diameter was 2.8 ± 0.7 cm, and the operative diameter was 3.3 ± 1.5 cm. FAA location was the common femoral artery in 191, superficial femoral artery (SFA) in 34, and profunda femoris artery in 11. Synchronous aneurysms (mean, 1.7 per patient) occurred in the aorta (n = 113), in the iliac (n = 109), popliteal (n = 86), and hypogastric (n = 56) arteries, and in the contralateral common femor...
Annals of vascular surgery, 2006
Brachial artery vasoactivity (BAVA) is a reliable, noninvasive method of assessing endothelium-de... more Brachial artery vasoactivity (BAVA) is a reliable, noninvasive method of assessing endothelium-dependent vasodilatation (EDV) in vivo. Acute hyperglycemia, impaired glucose tolerance (IGT), and diabetes mellitus impair EDV, a precursor to atherosclerosis. Thiamine is a coenzyme important in intracellular glucose metabolism. The purpose of this study was to evaluate the effect of thiamine on BAVA in the presence of hyperglycemia. Ten healthy subjects (group H, mean age 27 years), 10 patients with impaired glucose tolerance by World Health Organization criteria (group IGT, mean age 65 years), and 10 patients with non-insulin-dependent diabetes mellitus (group NIDDM, mean age 50 years) were studied. Duplex ultrasound was used to measure brachial artery flow changes in response to reactive hyperemia following brachial artery tourniquet occlusion for 5 min. This test was performed after a 10 hr fast and at 30, 60, and 120 min after a 75 g oral glucose challenge along with measurements of...
Perspectives in vascular surgery and endovascular therapy, 2005
Macrocirculatory endothelium-dependent and independent vasodilatation is integral to tissue-bed o... more Macrocirculatory endothelium-dependent and independent vasodilatation is integral to tissue-bed oxygen delivery and homeostasis. Dysfunction of macrocirculatory vasoreactivity is a precursor to atherosclerosis and occurs in a similar fashion in multiple tissue beds long before the onset of symptoms. Impaired macrocirculatory vasodilatation has been shown to occur in certain disease states including diabetes mellitus, hypercholesterolemia, chronic renal failure, peripheral arterial atherosclerosis, and abdominal aortic aneurysms, as well as secondary to smoking, advanced age, menopause, high-fat diet, and sedentary lifestyle. Brachial artery vasoreactivity is a noninvasive means of assessing macrocirculatory vasodilatory capacity that may help identify patients at increased risk for peripheral and cardiovascular disease and allow for objective assessment and monitoring of treatment. Endothelium-dependent vasoreactivity, or flow-mediated dilatation, is measured after brachial artery o...
Vascular and endovascular surgery
Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased... more Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 +/-0.13 vs 6.1 +/-0.17 c...
Annals of vascular surgery, 2010
To date, murine models of treadmill exercise have been used to study general exercise physiology ... more To date, murine models of treadmill exercise have been used to study general exercise physiology and angiogenesis in ischemic hindlimbs. The purpose of these experiments was to develop a murine model of demand ischemia in an ischemic limb to mimic claudication in humans. The primary goal was to determine whether treadmill exercise reflected a hemodynamic picture which might be consistent with the hyperemic response observed in humans. Aged hypercholesterolemic ApoE null mice (ApoE(-/-), n = 13) were subjected to femoral artery ligation (FAL) and allowed to recover from the acute ischemic response. Peripheral perfusion of the hindlimbs at rest was determined by serial evaluation using laser Doppler imaging (LDI) on days 0, 7, and 14 following FAL. During the experiments, mice were also assessed on an established five-point clinical ischemic score, which assessed the degree of digital amputation, necrosis, and cyanosis compared to the nonischemic contralateral limb. After stabilizatio...
Annales de Chirurgie Vasculaire, 2010
ABSTRACT Objectif A ce jour, les modèles murins d’exercice sur tapis roulant ont été utilisés pou... more ABSTRACT Objectif A ce jour, les modèles murins d’exercice sur tapis roulant ont été utilisés pour étudier la physiologie globale et l’angiogénèse au cours de l’ischémie des pattes arrières. Le but de nos expériences était de développer un modèle murin d’ischémie d’effort des membres afin de reproduire la claudication humaine. L’objectif primaire était de déterminer si l’exercice sur tapis roulant reflétait une réponse hémodynamique compatible avec la réponse hyperémique observée chez les humains. Méthodes Des souris âgées hypercholestérolémiques ApoE déficitaires (ApoE-/-, n = 13) ont été soumises à une ligature de l’artère fémorale (LAF) et étudiées après récupération de la phase ischémique aiguë. La perfusion périphérique des pattes arrières au repos a été déterminée par des évaluations successives en laser Doppler (LD) 0, 7 et 14 jours suivant la LAF. Durant les expérimentations, les souris ont également été testées pour un score ischémique pré établi en 5 points cliniques s’adressant aux degrés d’amputation digitale, de nécrose et de cyanose comparés avec le membre controlatéral non ischémique. Après stabilisation du ratio LD (flux dans le membre ischémique / flux dans le membre controlatéral non ischémique) et du score ischémique clinique, les souris ont été soumises à un exercice sur tapis roulant pendant deux jours (10 min à 10 m/min, inclinaison de 10°) suivi par un exercice quotidien sur tapis roulant de 60 minutes (13 m/min, inclinaison de 10°) jusqu’au 25ème jour. Une évaluation par LD de la perfusion avant et après exercice a été effectuée à deux reprises à la suite de la mise en route de l’exercice quotidien. Durant l’évaluation, après les premières 15 minutes d’exercice, un LD a été effectué en quatre exemplaires, afin d’identifier les ratios de pics de flux. L’analyse statistique a inclus des tests non appariés et une analyse de variance. Résultats Après LAF, le ratio de flux LD a atteint un nadir entre les 1er et 2ème jour, puis s’est stabilisé au 14ème jour et est resté stable jusqu’au 25ème jour. Le score ischémique clinique s’est stabilisé au 7ème jour et est resté stable durant toute la durée de l’expérimentation. En se basant sur la stabilisation du score clinique ischémique et du ratio LD, l’exercice a repris au 15ème jour. Le pic de ratio LD à 15 minutes de l’exercice s’est accru significativement comparé avec le ratio pré exercice à J17 (0,48 ± 0,04 vs. 0,34 ± 0,04, p < 0,05) et au 25ème jour (0,37 ± 0,03 vs. 0,27 ± 0,03, p < 0,01). Après deux heures d’exercice, le ratio LD a rejoint les niveaux pré exercices de J17 et J25. Conclusion Une stabilisation clinique et hémodynamique de perfusion du membre est évidente dans les 14 jours suivant la LAF. La LAF suivie par l’ischémie d’effort permet d’observer une réponse réversible hyperémique relative similaire à celle observée chez les claudicants humains à l’exercice. Un modèle murin de LAF associé à une ischémie d’effort pourrait être utile afin d’évaluer les variations métaboliques, inflammatoires et dépendantes du flux associées à la claudication chez les humains.
Journal of Vascular Surgery, 2014
Annals of vascular surgery, 2014
The adjunctive use of a preoperative cerebrospinal fluid (CSF) drain and/or left subclavian arter... more The adjunctive use of a preoperative cerebrospinal fluid (CSF) drain and/or left subclavian artery (LSA) bypass for thoracic endovascular aortic repair (TEVAR) to minimize neurologic complications remains controversial. A retrospective review was conducted of a prospective database of patients undergoing TEVAR from April 2005 through August 2012. CSF drainage was performed under local anesthesia in a staged fashion prior to TEVAR. When possible, LSA bypass was also performed prior to TEVAR. Adjunctive procedures were not performed for patients in emergent operations. Preoperative characteristics, operative variables, outcomes, neurologic complications, and survival status were recorded. Ninety patients underwent TEVAR at our institution during the study period with a mean follow-up of 23 months (IQR 7-50). Mean age was 67.3 years (SD 13.8) and 48 (53%) were male. One (1%) patient had a connective tissue disorder. Sixty-six (73%) patients presented with degenerative aneurysm, 13 (14%...
Annals of vascular surgery, 2005
Aortic angiosarcoma is a rare, malignant neoplasm of the vasculature, with 24 case reports in the... more Aortic angiosarcoma is a rare, malignant neoplasm of the vasculature, with 24 case reports in the literature. Patients usually present with either aneurysmal or occlusive disease. Treatment consists of en bloc resection of the vessel and contiguous structures with postoperative chemoradiation therapy. Despite surgery and adjunctive measures, prognosis remains dismal as a result of early metastasis and late diagnosis. We report a case of aortic angiosarcoma that presented with distal thromboembolic phenomenon.
Vascular and endovascular surgery
Hyperhomocysteinemia (HHcy) has been identified as an independent risk factor for atherosclerotic... more Hyperhomocysteinemia (HHcy) has been identified as an independent risk factor for atherosclerotic vascular disease. The effect of high-dose folic acid or combination vitamin therapy for the treatment of HHcy on the microcirculation is unknown. The purpose of this study was to evaluate the effect of a combination of folic acid, vitamin B6, and vitamin B12 on endothelium-dependent and endothelium-independent vasoreactivity in patientswith HHcy. Baseline cutaneous microvascular vasoreactivity was measured in 20 patients with HHcy and 18 patients with normohomocysteinemia (NHcy). Laser Doppler scan imaging before and after iontophoresis of 1% acetylcholine chloride (endothelium-dependent response) and 1% sodium nitroprusside (endothelium-independent response) was performed for the measurement of forearm skin vasodilatation. Patients were then treated with 10 mg folic acid, 100 mg vitamin B6, and 1 mg vitamin B12 orally once a day for 6 months. Follow-up fasting serum homocysteine and cu...
Journal of Vascular Surgery, 2014
A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) re... more A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) repair (FEVAR) was safe and effective in appropriately selected patients at experienced centers. As this new technology is disseminated to the community, it will be important to understand how this technology compares with standard endovascular AAA repair (EVAR). The goal of this study was to compare the outcomes of FEVAR vs EVAR of AAAs. The American College of Surgeons-National Surgical Quality Improvement Program database from 2005 to 2012 was queried for AAAs (International Classification of Diseases, Ninth Revision code 441.4). Patients were stratified according to procedure (FEVAR vs EVAR). A bivariate analysis was done to assess preoperative and intraoperative risk factors for postoperative outcomes. Thirty-day postoperative mortality and complication rates were described for each procedure type. Multivariable logistic regression was performed to assess the association between the type of procedure and the risk of postoperative complications. A total of 458 patients underwent FEVAR and 19,060 patients underwent EVAR for AAA. Patients undergoing FEVAR were older (P = .02) and less likely to have a bleeding disorder (P = .046). Otherwise, the incidence of comorbidities in both groups was similar. FEVAR was associated with increased median operative time (156 vs 137 minutes; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), and average postoperative length of stay (3.3 vs 2.8 days; P = .03). There was a statistically significant increase in overall complications (23.6% vs 14.3%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and postoperative transfusions (15.3% vs 6.1%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and trends toward increased cardiac complications (2.2% vs 1.3%; P = .09) and the need for dialysis (1.5% vs 0.8%; P = .08) in the FEVAR group. Mortality (2.4% vs 1.5%; P = .12) was not statistically different. On multivariable analysis, FEVAR remained independently associated with the need for postoperative transfusions when operative time was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;75th percentile (adjusted odds ratio, 1.72; 95% confidence interval, 1.09-2.72; P = .02) as well as when operative time was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;75th percentile for respective procedures (adjusted odds ratio, 5.33; 95% confidence interval, 3.55-8.00; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Patients undergoing FEVAR are more likely than patients undergoing EVAR to receive blood transfusions postoperatively and are more likely to sustain postoperative complications. Although mortality was similar, trends toward increased cardiac and renal complications may suggest the need for judicious dissemination of this new technology. Future research with larger number of FEVAR cases will be necessary to determine if these associations remain.
Journal of Surgical Research, 2014
Laparoscopic Smoking Wound complications a b s t r a c t Background: In the United States, approx... more Laparoscopic Smoking Wound complications a b s t r a c t Background: In the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates. Materials and methods: Using the National Surgical Quality Improvement Program database (2005e2011), patients aged !18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach. Results: Of 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean þ standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P ¼ 0.010) and LC (odds ratio 1.20; P ¼ 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2e4 d (P <0.001). Conclusions: Active smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications. ª
Seminars in Vascular Surgery, 2004
Venous hypertension is a significant problem for the patient on chronic hemodialysis. This condit... more Venous hypertension is a significant problem for the patient on chronic hemodialysis. This condition can result in impairment of arteriovenous access function, disabling upper extremity edema with bluish discoloration and pigmentation of the skin, and, in advanced cases, ulceration of the finger tips and neuralgias. Venous hypertension usually results from central vein stenosis or valvular incompetence in the arteriovenous access outflow vein. A high index of suspicion is required to identify patients at risk for venous hypertension. A history of ipsilateral central venous catheter placement, or physical signs such as visible distended shoulder venous collaterals, and upper extremity edema are suggestive. Diagnosis is confirmed with Duplex ultrasound or contrast venography. The primary goal of diagnosis and therapy of venous hypertension is symptomatic relief while maintaining the functionality of the access. Treatment includes percutaneous catheter-based and open surgical techniques. Open surgical techniques, while more invasive, remain the gold standard as long-term patency after angioplasty, with or without covered stents, remains unproven.
Journal of the American College of Surgeons, 2015
The Journal of surgical research, Jan 2, 2015
Lower extremity bypass (LEB) for peripheral vascular disease is a common procedure in diabetics a... more Lower extremity bypass (LEB) for peripheral vascular disease is a common procedure in diabetics and is associated with readmission. Thus, we hypothesized that diabetes might be a predictor of 30-d unplanned readmission after LEB. Patients undergoing infrainguinal LEB in the 2011-12 American College of Surgeons National Surgery Quality Improvement Program database were divided into nondiabetics mellitus (NDM), non-insulin-dependent diabetics mellitus (NIDDM), and insulin-dependent diabetic mellitus (IDDM). Univariate and multivariate analyses were used to evaluate the influence of diabetes on 30-d readmission. A total of 9207 patients (5155 [56%] NDM, 1690 (18%) NIDDM, and 2362 (26%) IDDM) underwent LEB. Unplanned readmission was observed in 1448 patients (16%). IDDM had significantly higher crude postoperative complication (43% versus 30% NDM, 36% NIDDM; P < 0.001) and unplanned readmission rates (20% versus 14% NDM, 16% NIDDM; P < 0.001). Concomitant cardiac disease significa...
Journal of Vascular Surgery, 2015
Annals of vascular surgery, Jan 13, 2015
The safety and effectiveness of using veno-venous and cardiopulmonary bypass for resection of the... more The safety and effectiveness of using veno-venous and cardiopulmonary bypass for resection of the inferior vena cava (IVC) is not well studied. The goal of this study was to compare outcomes following IVC resection with and without bypass support. We analyzed all patients undergoing IVC resection at our institution (9/1999-6/2014) and compared the use of bypass support with cross-clamp alone using univariable and Kaplan-Meier analyses. Outcomes included perioperative complications and survival. Sixty-three patients underwent IVC resection (mean age 58±2 years, mean follow-up 21±3 months). Bypass patients (32%) were similar to non-bypass patients (68%) in age, gender; tumor size, type, and grade (P=NS). Bypass patients were more likely to undergo complete IVC reconstruction (55% vs. 24%; P=.01) at the suprarenal level (62% vs. 35%; P=.05), and had higher intraoperative blood loss (9.6±2.1 vs. 3.2±1.4 L; P=.01). Complete R0 resection was similar between groups (50% vs. 52%, P=NS). The...
JAMA surgery, Jan 24, 2015
Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ES... more Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale. To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System. The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ2 test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients re...
Journal of Vascular Surgery, 2015
Vascular reconstruction can facilitate pancreas tumor resection, but optimal methods of reconstru... more Vascular reconstruction can facilitate pancreas tumor resection, but optimal methods of reconstruction are not well studied. We report our results for portal vein reconstruction (PVR) for pancreatic resection and determinants of postoperative patency. We identified 173 patients with PVR in a prospective database of 6522 patients who underwent pancreatic resection at our hospital from 1970 to 2014. There were 128 patients who had &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 year of follow-up with computed tomography imaging. Preoperative, intraoperative, and postoperative factors were recorded. Patients with and without postoperative PVR thrombosis were compared by univariable, multivariable, and receiver operating characteristic curve analyses. The survival of patients was 100% at 1 month, 88% at 6 months, 66% at 1 year, and 39% on overall median follow-up of 310 days (interquartile range, 417 days). Median survival was 15.5 months (interquartile range, 25 months); 86% of resections were for cancer. Four types of PVR techniques were used: 83% of PVRs were performed by primary repair, 8.7% with interposition vein graft, 4.7% with interposition prosthetic graft, and 4.7% with patch. PVR patency was 100% at 1 day, 98% at 1 month, 91% at 6 months, and 83% at 1 year. Patients with PVR thrombosis were not significantly different from patients with patent PVR in age, survival, preoperative comorbidities, tumor characteristics, perioperative blood loss or transfusion, or postoperative complications. They were more likely to have had preoperative chemotherapy (53% vs 9%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), radiation therapy (35% vs 2%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), and prolonged operative time (618 ± 57 vs 424 ± 20 minutes; P = .002) and to develop postoperative ascites (76% vs 22%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Among patients who developed ascites, 38% of those with PVR thrombosis did so in the setting of tumor recurrence at the porta detected on imaging, whereas among patients with patent PVR, 50% did so (P = .73). Patients with PVR thrombosis were more likely to have had prosthetic graft placement compared with patients with patent PVRs (18% vs 2.7%; P = .03; odds ratio [OR], 7.7; 95% confidence interval [CI], 1.4-42). PVR patency overall was significantly worse for patients who had an interposition prosthetic graft reconstruction (log-rank, P = .04). On multivariable analysis, operative time (OR, 1.01; 95% CI, 1.01-1.02) and prosthetic graft placement (OR, 8.12; 95% CI, 1.1-74) were independent predictors of PVR thrombosis (C statistic = 0.88). Long operative times and use of prosthetic grafts for reconstruction are risk factors for postoperative portal vein thrombosis. Primary repair, patch, or vein interposition should be preferentially used for PVR in the setting of pancreatic resection.
JAMA Surgery, 2015
IMPORTANCE Superior outcomes have been established with the use of an arteriovenous fistula (AVF)... more IMPORTANCE Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation.
Journal of vascular surgery, 2014
Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femora... more Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femoral artery aneurysms (FAAs) to achieve adequate numbers for analysis and have recommended repair of asymptomatic FAAs with diameters ≥2.5 cm and all symptomatic FAAs. This study evaluated the contemporary management of isolated FAAs. Patients with FAAs were evaluated using a standardized, prospectively maintained database by a research consortium. From 2002 to 2012, 236 FAAs were identified in 182 patients (mean age, 72 years; male-to-female ratio, 16:1) at eight institutions. The mean nonoperative mean diameter was 2.8 ± 0.7 cm, and the operative diameter was 3.3 ± 1.5 cm. FAA location was the common femoral artery in 191, superficial femoral artery (SFA) in 34, and profunda femoris artery in 11. Synchronous aneurysms (mean, 1.7 per patient) occurred in the aorta (n = 113), in the iliac (n = 109), popliteal (n = 86), and hypogastric (n = 56) arteries, and in the contralateral common femor...
Annals of vascular surgery, 2006
Brachial artery vasoactivity (BAVA) is a reliable, noninvasive method of assessing endothelium-de... more Brachial artery vasoactivity (BAVA) is a reliable, noninvasive method of assessing endothelium-dependent vasodilatation (EDV) in vivo. Acute hyperglycemia, impaired glucose tolerance (IGT), and diabetes mellitus impair EDV, a precursor to atherosclerosis. Thiamine is a coenzyme important in intracellular glucose metabolism. The purpose of this study was to evaluate the effect of thiamine on BAVA in the presence of hyperglycemia. Ten healthy subjects (group H, mean age 27 years), 10 patients with impaired glucose tolerance by World Health Organization criteria (group IGT, mean age 65 years), and 10 patients with non-insulin-dependent diabetes mellitus (group NIDDM, mean age 50 years) were studied. Duplex ultrasound was used to measure brachial artery flow changes in response to reactive hyperemia following brachial artery tourniquet occlusion for 5 min. This test was performed after a 10 hr fast and at 30, 60, and 120 min after a 75 g oral glucose challenge along with measurements of...
Perspectives in vascular surgery and endovascular therapy, 2005
Macrocirculatory endothelium-dependent and independent vasodilatation is integral to tissue-bed o... more Macrocirculatory endothelium-dependent and independent vasodilatation is integral to tissue-bed oxygen delivery and homeostasis. Dysfunction of macrocirculatory vasoreactivity is a precursor to atherosclerosis and occurs in a similar fashion in multiple tissue beds long before the onset of symptoms. Impaired macrocirculatory vasodilatation has been shown to occur in certain disease states including diabetes mellitus, hypercholesterolemia, chronic renal failure, peripheral arterial atherosclerosis, and abdominal aortic aneurysms, as well as secondary to smoking, advanced age, menopause, high-fat diet, and sedentary lifestyle. Brachial artery vasoreactivity is a noninvasive means of assessing macrocirculatory vasodilatory capacity that may help identify patients at increased risk for peripheral and cardiovascular disease and allow for objective assessment and monitoring of treatment. Endothelium-dependent vasoreactivity, or flow-mediated dilatation, is measured after brachial artery o...
Vascular and endovascular surgery
Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased... more Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 +/-0.13 vs 6.1 +/-0.17 c...
Annals of vascular surgery, 2010
To date, murine models of treadmill exercise have been used to study general exercise physiology ... more To date, murine models of treadmill exercise have been used to study general exercise physiology and angiogenesis in ischemic hindlimbs. The purpose of these experiments was to develop a murine model of demand ischemia in an ischemic limb to mimic claudication in humans. The primary goal was to determine whether treadmill exercise reflected a hemodynamic picture which might be consistent with the hyperemic response observed in humans. Aged hypercholesterolemic ApoE null mice (ApoE(-/-), n = 13) were subjected to femoral artery ligation (FAL) and allowed to recover from the acute ischemic response. Peripheral perfusion of the hindlimbs at rest was determined by serial evaluation using laser Doppler imaging (LDI) on days 0, 7, and 14 following FAL. During the experiments, mice were also assessed on an established five-point clinical ischemic score, which assessed the degree of digital amputation, necrosis, and cyanosis compared to the nonischemic contralateral limb. After stabilizatio...
Annales de Chirurgie Vasculaire, 2010
ABSTRACT Objectif A ce jour, les modèles murins d’exercice sur tapis roulant ont été utilisés pou... more ABSTRACT Objectif A ce jour, les modèles murins d’exercice sur tapis roulant ont été utilisés pour étudier la physiologie globale et l’angiogénèse au cours de l’ischémie des pattes arrières. Le but de nos expériences était de développer un modèle murin d’ischémie d’effort des membres afin de reproduire la claudication humaine. L’objectif primaire était de déterminer si l’exercice sur tapis roulant reflétait une réponse hémodynamique compatible avec la réponse hyperémique observée chez les humains. Méthodes Des souris âgées hypercholestérolémiques ApoE déficitaires (ApoE-/-, n = 13) ont été soumises à une ligature de l’artère fémorale (LAF) et étudiées après récupération de la phase ischémique aiguë. La perfusion périphérique des pattes arrières au repos a été déterminée par des évaluations successives en laser Doppler (LD) 0, 7 et 14 jours suivant la LAF. Durant les expérimentations, les souris ont également été testées pour un score ischémique pré établi en 5 points cliniques s’adressant aux degrés d’amputation digitale, de nécrose et de cyanose comparés avec le membre controlatéral non ischémique. Après stabilisation du ratio LD (flux dans le membre ischémique / flux dans le membre controlatéral non ischémique) et du score ischémique clinique, les souris ont été soumises à un exercice sur tapis roulant pendant deux jours (10 min à 10 m/min, inclinaison de 10°) suivi par un exercice quotidien sur tapis roulant de 60 minutes (13 m/min, inclinaison de 10°) jusqu’au 25ème jour. Une évaluation par LD de la perfusion avant et après exercice a été effectuée à deux reprises à la suite de la mise en route de l’exercice quotidien. Durant l’évaluation, après les premières 15 minutes d’exercice, un LD a été effectué en quatre exemplaires, afin d’identifier les ratios de pics de flux. L’analyse statistique a inclus des tests non appariés et une analyse de variance. Résultats Après LAF, le ratio de flux LD a atteint un nadir entre les 1er et 2ème jour, puis s’est stabilisé au 14ème jour et est resté stable jusqu’au 25ème jour. Le score ischémique clinique s’est stabilisé au 7ème jour et est resté stable durant toute la durée de l’expérimentation. En se basant sur la stabilisation du score clinique ischémique et du ratio LD, l’exercice a repris au 15ème jour. Le pic de ratio LD à 15 minutes de l’exercice s’est accru significativement comparé avec le ratio pré exercice à J17 (0,48 ± 0,04 vs. 0,34 ± 0,04, p < 0,05) et au 25ème jour (0,37 ± 0,03 vs. 0,27 ± 0,03, p < 0,01). Après deux heures d’exercice, le ratio LD a rejoint les niveaux pré exercices de J17 et J25. Conclusion Une stabilisation clinique et hémodynamique de perfusion du membre est évidente dans les 14 jours suivant la LAF. La LAF suivie par l’ischémie d’effort permet d’observer une réponse réversible hyperémique relative similaire à celle observée chez les claudicants humains à l’exercice. Un modèle murin de LAF associé à une ischémie d’effort pourrait être utile afin d’évaluer les variations métaboliques, inflammatoires et dépendantes du flux associées à la claudication chez les humains.
Journal of Vascular Surgery, 2014
Annals of vascular surgery, 2014
The adjunctive use of a preoperative cerebrospinal fluid (CSF) drain and/or left subclavian arter... more The adjunctive use of a preoperative cerebrospinal fluid (CSF) drain and/or left subclavian artery (LSA) bypass for thoracic endovascular aortic repair (TEVAR) to minimize neurologic complications remains controversial. A retrospective review was conducted of a prospective database of patients undergoing TEVAR from April 2005 through August 2012. CSF drainage was performed under local anesthesia in a staged fashion prior to TEVAR. When possible, LSA bypass was also performed prior to TEVAR. Adjunctive procedures were not performed for patients in emergent operations. Preoperative characteristics, operative variables, outcomes, neurologic complications, and survival status were recorded. Ninety patients underwent TEVAR at our institution during the study period with a mean follow-up of 23 months (IQR 7-50). Mean age was 67.3 years (SD 13.8) and 48 (53%) were male. One (1%) patient had a connective tissue disorder. Sixty-six (73%) patients presented with degenerative aneurysm, 13 (14%...
Annals of vascular surgery, 2005
Aortic angiosarcoma is a rare, malignant neoplasm of the vasculature, with 24 case reports in the... more Aortic angiosarcoma is a rare, malignant neoplasm of the vasculature, with 24 case reports in the literature. Patients usually present with either aneurysmal or occlusive disease. Treatment consists of en bloc resection of the vessel and contiguous structures with postoperative chemoradiation therapy. Despite surgery and adjunctive measures, prognosis remains dismal as a result of early metastasis and late diagnosis. We report a case of aortic angiosarcoma that presented with distal thromboembolic phenomenon.
Vascular and endovascular surgery
Hyperhomocysteinemia (HHcy) has been identified as an independent risk factor for atherosclerotic... more Hyperhomocysteinemia (HHcy) has been identified as an independent risk factor for atherosclerotic vascular disease. The effect of high-dose folic acid or combination vitamin therapy for the treatment of HHcy on the microcirculation is unknown. The purpose of this study was to evaluate the effect of a combination of folic acid, vitamin B6, and vitamin B12 on endothelium-dependent and endothelium-independent vasoreactivity in patientswith HHcy. Baseline cutaneous microvascular vasoreactivity was measured in 20 patients with HHcy and 18 patients with normohomocysteinemia (NHcy). Laser Doppler scan imaging before and after iontophoresis of 1% acetylcholine chloride (endothelium-dependent response) and 1% sodium nitroprusside (endothelium-independent response) was performed for the measurement of forearm skin vasodilatation. Patients were then treated with 10 mg folic acid, 100 mg vitamin B6, and 1 mg vitamin B12 orally once a day for 6 months. Follow-up fasting serum homocysteine and cu...
Journal of Vascular Surgery, 2014
A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) re... more A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) repair (FEVAR) was safe and effective in appropriately selected patients at experienced centers. As this new technology is disseminated to the community, it will be important to understand how this technology compares with standard endovascular AAA repair (EVAR). The goal of this study was to compare the outcomes of FEVAR vs EVAR of AAAs. The American College of Surgeons-National Surgical Quality Improvement Program database from 2005 to 2012 was queried for AAAs (International Classification of Diseases, Ninth Revision code 441.4). Patients were stratified according to procedure (FEVAR vs EVAR). A bivariate analysis was done to assess preoperative and intraoperative risk factors for postoperative outcomes. Thirty-day postoperative mortality and complication rates were described for each procedure type. Multivariable logistic regression was performed to assess the association between the type of procedure and the risk of postoperative complications. A total of 458 patients underwent FEVAR and 19,060 patients underwent EVAR for AAA. Patients undergoing FEVAR were older (P = .02) and less likely to have a bleeding disorder (P = .046). Otherwise, the incidence of comorbidities in both groups was similar. FEVAR was associated with increased median operative time (156 vs 137 minutes; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), and average postoperative length of stay (3.3 vs 2.8 days; P = .03). There was a statistically significant increase in overall complications (23.6% vs 14.3%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and postoperative transfusions (15.3% vs 6.1%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and trends toward increased cardiac complications (2.2% vs 1.3%; P = .09) and the need for dialysis (1.5% vs 0.8%; P = .08) in the FEVAR group. Mortality (2.4% vs 1.5%; P = .12) was not statistically different. On multivariable analysis, FEVAR remained independently associated with the need for postoperative transfusions when operative time was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;75th percentile (adjusted odds ratio, 1.72; 95% confidence interval, 1.09-2.72; P = .02) as well as when operative time was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;75th percentile for respective procedures (adjusted odds ratio, 5.33; 95% confidence interval, 3.55-8.00; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Patients undergoing FEVAR are more likely than patients undergoing EVAR to receive blood transfusions postoperatively and are more likely to sustain postoperative complications. Although mortality was similar, trends toward increased cardiac and renal complications may suggest the need for judicious dissemination of this new technology. Future research with larger number of FEVAR cases will be necessary to determine if these associations remain.
Journal of Surgical Research, 2014
Laparoscopic Smoking Wound complications a b s t r a c t Background: In the United States, approx... more Laparoscopic Smoking Wound complications a b s t r a c t Background: In the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates. Materials and methods: Using the National Surgical Quality Improvement Program database (2005e2011), patients aged !18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach. Results: Of 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean þ standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P ¼ 0.010) and LC (odds ratio 1.20; P ¼ 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2e4 d (P <0.001). Conclusions: Active smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications. ª
Seminars in Vascular Surgery, 2004
Venous hypertension is a significant problem for the patient on chronic hemodialysis. This condit... more Venous hypertension is a significant problem for the patient on chronic hemodialysis. This condition can result in impairment of arteriovenous access function, disabling upper extremity edema with bluish discoloration and pigmentation of the skin, and, in advanced cases, ulceration of the finger tips and neuralgias. Venous hypertension usually results from central vein stenosis or valvular incompetence in the arteriovenous access outflow vein. A high index of suspicion is required to identify patients at risk for venous hypertension. A history of ipsilateral central venous catheter placement, or physical signs such as visible distended shoulder venous collaterals, and upper extremity edema are suggestive. Diagnosis is confirmed with Duplex ultrasound or contrast venography. The primary goal of diagnosis and therapy of venous hypertension is symptomatic relief while maintaining the functionality of the access. Treatment includes percutaneous catheter-based and open surgical techniques. Open surgical techniques, while more invasive, remain the gold standard as long-term patency after angioplasty, with or without covered stents, remains unproven.