Jerry Youkey | University of South Carolina (original) (raw)

Papers by Jerry Youkey

J Surg Res, 1996

Understanding and being able to manipulate intracellular signaling pathways which control VSMC ge... more Understanding and being able to manipulate intracellular signaling pathways which control VSMC gene expression and proliferation will be important in efforts to control neointimal hyperplastic vascular diseases. Activation of the protein kinase C (PKC) family of enzymes is a central event in growth factor-stimulated cells. PKC activation results in the activation of downstream protein kinases including mitogen activated protein kinase (MAPK). PKC isozymes alpha (α) and delta (δ) predominate in cultured rat aortic VSMC and both isozymes are completely downregulated upon prolonged (16–24 hr) stimulation with the PKC activator, phorbol 12,13 dibutyrate (PDBu). At these low levels of PKC, MAPK activation in response to PDBu is nearly abolished. To assess the role of specific PKC isozymes in regulating MAPK, isozyme-specific antisense oligodeoxynucleotides (ODNs) were used to inhibit reexpression of PKC in downregulated cells. ODNs were phosphorothioated to increase stability and contained C-5 propynyl modified pyrimidines which are reported to have increased binding affinity. ODNs were administered in low concentration (400 nM) with a cationic liposome carrier (Lipofectin; GibcoBRL). Optical imaging of cells treated with FITC-labeled ODNs confirmed that virtually all cells took up the ODNs within 2 hr. With this technique, PKCα-specific antisense ODNs selectively inhibited PKCα recovery compared to cells treated with an equal length nonsense ODN (76 ± 3.9,P< 0.001), with no effect on recovery of PKCδ. However, activation of MAPK by PDBu was not significantly inhibited in these PKCα downregulated cells. This suggests that only a small amount of the total PKCα is required for PDBu induced activation of MAPK and/or that PKCδ can mediate the response. Manipulation of PKC isozymes using this model system should allow assessment of the roles of specific isozymes in controlling diverse downstream effectors and events related to VSMC growth and proliferation.

Vascular and Endovascular Surgery, 1998

... Case Reports David A. Bigatel, MD David P. Franklin, MD Steven C. Meschter, MD James R.Elmore... more ... Case Reports David A. Bigatel, MD David P. Franklin, MD Steven C. Meschter, MD James R.Elmore, MD and Jerry R. Youkey, MD ... 8. Ayala AG, Ro JY, Fanning CV, et al: Core needle biopsy and fine-needle aspiration in the diagnosis of bone and soft-tissue lesions. ...

The American surgeon, 2008

Functional success after below-knee amputation (BKA) has been poorly studied. The purpose of this... more Functional success after below-knee amputation (BKA) has been poorly studied. The purpose of this study was to establish a consistent definition of "successful outcome" after BKA and to identify clinical variables influencing that definition. Three hundred nine consecutive patients undergoing BKA were evaluated postoperatively using the following definition for "successful outcome": 1) wound healing of the BKA without need for revision to a higher level; 2) maintenance of ambulation with a prosthesis for at least 1 year or until death; and 3) survival for at least 6 months. Independent clinical predictors influencing outcome were determined using bivariate and multivariable logistic regression analyses. For the cohort, median survival and maintenance of ambulation were 44 months and 60 months, respectively. Although 86.4 per cent of patients healed without the need for revision to a higher level, 63.4 per cent maintained ambulation with a prosthesis for 1 year an...

The American Journal of Surgery, 1986

local anesthetic injection of the carotid sinus nerve is routinely practiced by many surgeons per... more local anesthetic injection of the carotid sinus nerve is routinely practiced by many surgeons performing carotid endarterectomy today [l-8]. Others routinely divide the nerve at the time of endarterectomy (91, and some place small catheters at the carotid bifurcation for postoperative injection of local anesthetics .

Vascular and endovascular surgery

Renal artery stenosis is a consequence of generalized atherosclerosis and many specialists perfor... more Renal artery stenosis is a consequence of generalized atherosclerosis and many specialists perform routine selective renal angiography to detect and treat renal artery stenosis. The incidence of clinically important renal artery stenosis is not well defined in patients with symptomatic peripheral arterial disease. The purpose of this study was to better delineate the incidence of and the risk factors associated with renal artery stenosis, renovascular hypertension, and ischemic nephropathy incidentally discovered during angiography for symptomatic peripheral arterial disease. Two hundred consecutive patients undergoing angiographic evaluation of symptomatic lower extremity peripheral arterial disease were studied retrospectively. Angiograms were reviewed for the presence of renal artery stenosis (defined as >or= 25% diameter reduction in either renal artery) and findings were then correlated to the clinical diagnosis of renovascular hypertension (> 50% renal artery stenosis an...

The American surgeon, 2005

The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively m... more The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable. Little objective data, however, is available documenting that a better model exists. From September 2002 through August 2003, the trauma model at a 735-bed level I trauma teaching hospital was changed from the contemporary model to a new one where selected general surgeons with Advanced Trauma Life Support (ATLS) certification covered in-house trauma and emergency surgery call on a rotational basis. As well, each pursued elective practices, admitting all inpatients (trauma, emergent, elective) to a single teaching service (formerly the trauma service). Critical care was managed by a separate group of intensivists. The purpose of this study was to objectively compare the two models. Quantitative, financial, and qualitative data were derived from August 2001 to January 2002 (trauma/critical care model) and compared to August 200...

Annals of vascular surgery, 2000

Arteriovenous (AV) access graft infection results in disruption of dialysis and usually necessita... more Arteriovenous (AV) access graft infection results in disruption of dialysis and usually necessitates graft removal when the entire graft is involved. The management of an isolated infected segment of an otherwise noninfected AV access graft, however, remains controversial. To evaluate the utility of segmental bypass and partial graft excision for the treatment of an isolated infected AV access graft segment, 17 consecutive cases in 12 patients (7 females/5 males; 14 arm grafts/3 leg grafts; median age = 69 years) were analyzed on a vascular teaching service that performed 1244 total access procedures from January 1995 through February 1999. Infections presented as a draining sinus or a sinus with hemorrhage emanating from an area over the graft. At operation, the infected sinus was covered by a transparent occlusive dressing and the graft was explored through clean incisions proximal and distal to the infected segment. If the graft was incorporated and free of infection, a piece of ...

Annals of vascular surgery, 1999

This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in... more This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in predicting not only perioperative but also long-term cardiac events. One hundred fifty-nine patients who were evaluated for elective abdominal aortic surgery were screened preoperatively with DSE from January 1, 1992 to December 31, 1993. We concluded that DSE is useful for preoperative assessment of cardiac risk prior to elective aortic surgery to minimize the need for cardiac intervention and still maintain acceptable perioperative MI and death rates. A selective approach for coronary revascularization is justified by the higher mortality in the subgroup requiring sequential procedures. DSE also allowed us to identify those high-risk patients who are best excluded from aortic surgery. Patients with abnormal DSE results are at higher risk for late cardiac events, require cardiology follow-up, and may require late coronary intervention.

Annals of vascular surgery, 1998

Excellent correlation between carotid angiography and duplex scanning has made it possible to per... more Excellent correlation between carotid angiography and duplex scanning has made it possible to perform carotid endarterectomy without angiography. The accuracy of scans from practices without a dedicated vascular laboratory must be validated prior to their use for clinical decisions. Seventy six patients had a carotid duplex performed at an outside institution and were referred for vascular surgery. All patients underwent a repeat study at our dedicated vascular lab. The overall accuracy of our lab was 93.8% for all carotid categories as demonstrated by angiography. Outside carotid duplex reports correlated with repeat exams as follows: occlusions: 10/13 carotids (76.9%); 80%-99% stenoses: 15/39 carotids (38.5%); 50%-79% stenoses: 28/44 carotids (63.6%). If a surgeon's practice is to operate for asymptomatic 80%-99% stenoses by report, then unnecessary surgery might have been performed in 61.5% of these carotids and appropriate surgery denied in 3.6%. Outside duplex velocities co...

The American surgeon, 2005

The purpose of this study was to provide outcomes after intervention for critical limb ischemia (... more The purpose of this study was to provide outcomes after intervention for critical limb ischemia (CLI) in elderly patients (> or =80 years) according to medical and functional status at presentation. From January 1998 to September 2003, 140 limbs/122 patients (age range 80-97 years) were treated (57 patients/66 limbs, infrainguinal bypass; 65 patients/74 limbs, infrainguinal angioplasty) for CLI. At presentation, 71 (58.2%) patients were functionally ambulatory, 41 (33.6%) were homebound ambulators, and 10 (8.2%) were transfer-only ambulators. Overall end points after treatment as well as outcomes according to type of treatment and preoperative medical and functional status were determined. End points included reconstruction patency, limb salvage, survival, amputation-free survival, and maintenance of ambulatory and independent living status. Results for the 140 limbs/122 patients at 3 years (Kaplan-Meier curves) include primary patency, 55.3%; secondary patency, 73.2%; limb salva...

Principles and Practice, Third Edition, 2003

Annals of Vascular Surgery, 2004

The care of patients requiring lifelong intravenous access was revolutionized with the developmen... more The care of patients requiring lifelong intravenous access was revolutionized with the development of tunneled catheters and implantable ports. These devices are not without complications, however, and selected patients may benefit from alternative modalities to maintain access for such therapies as parenteral nutrition, phlebotomy, or chemotherapy. Use of surgically created arteriovenous (AV) fistulae as an alternative to central venous access has been described. This report reviews our experience using AV access for central venous access. An AV access database of more than 800 active patients was reviewed and all patients who had autogenous or synthetic AV fistulae created exclusively for central venous access between July 1, 2001, and December 31, 2003, were identified. Outcomes were assessed. A total of 853 new accesses were placed during the time period. Six fistulae in six patients (0.7%) were placed for central access. All patients (5 males, 1 female, mean age, 42.8 years) required access for intermittent parenteral nutrition or intravenous fluids secondary to short-gut syndrome (n = 5) or gastroparesis (n = 1). All patients had failed at least two prior catheter-based accesses before access placement was considered. Procedures were all brachial artery based and included autogenous brachiobasilic vein fistulae with elevation or transposition (n = 3), autogenous brachiocephalic fistula (n = 1), autogenous brachiobasilic graft with transposed greater saphenous vein (n = 1), and a prosthetic brachiobasilic graft with ePTFE (n = 1). There was one perioperative autogenous fistula thrombosis treated with thrombectomy and revision. A total of seven late revisions (thrombectomy, thrombectomy with venous outflow revision, fistula elevation, and 4 percutaneous angioplasties) in four patients were required. All fistulae were patent and functional at the end of the review period (mean follow-up, = 393 days; range, 35-757 days). Daily access was performed by family members (n = 2) or nurses (n = 4). One patient received small bowel transplantation and no longer required use of his patent fistula. One patient died of liver failure 382 days after fistula placement with a patent fistula. These results show that, while often forgotten and infrequently used, AV access can be a durable alternative to catheter-based venous access.

Annals of vascular surgery, 2002

Many patients are not considered candidates for radiocephalic fistula (RCF) or brachiocephalic fi... more Many patients are not considered candidates for radiocephalic fistula (RCF) or brachiocephalic fistula (BCF) creation or have fistulas that do not mature because the cephalic vein is too deep or tortuous to be accessed. Other patients have not been candidates for the basilic vein transposition (BVT) because limited length of adequate caliber vein precludes subcutaneous tunneling of the vein. In an effort to maximize arteriovenous fistula (AVF) utilization, we developed an adjunctive procedure designed to make the deep or tortuous fistula accessible to needle cannulation. The fistula elevation procedure (FEP) involves mobilization of the fistula, approximation of the subcutaneous tissue beneath the fistula, and subcuticular skin closure over the fistula. The procedure enhances the accessibility of the fistula by placing it in a more superficial position. The overlying cicatrix also acts as a guide for dialysis needle insertion. Between June 1998 and January 2001, 45 patients underwen...

The American surgeon, 2002

As the number of cardiac and interventional radiologic procedures has risen, the frequency with w... more As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventiona...

Annals of vascular surgery, 2003

The treatment of choice for renal artery occlusive disease has shifted from open repair to percut... more The treatment of choice for renal artery occlusive disease has shifted from open repair to percutaneous angioplasty and stenting in many institutions. Whether this change in treatment modality will lead to altered and, perhaps, relaxed indications for intervention is unclear. We reviewed our experience to determine if a shift from open surgery to percutaneous management of renal occlusive disease was associated with changes in either indications for intervention or patient outcomes. Over an 8-year period, 165 patients had intervention for renal artery stenosis by our vascular surgery teaching service. Over the period there was a dramatic increase in interventions per year (4 patients 1994 to 57 patients 2001). There was also a shift from open to endovascular management. Patient demographics and indications for intervention showed no difference between open and endovascular groups. Outcome analysis revealed similar technical success rates between groups but a significantly higher mor...

The American surgeon, 2003

While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected ... more While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. Th...

Annals of vascular surgery, 2004

With the emergence of endovascular surgery, there is a perception that open aortic procedures for... more With the emergence of endovascular surgery, there is a perception that open aortic procedures for aneurysmal and occlusive disease have become more difficult. To test this hypothesis, two consecutive groups of patients undergoing open aortic surgery for aneurysmal (AAA) and occlusive (AIOD) disease before and after the establishment of an endovascular program (EP) were analyzed. The pre-EP patient group (January 1996 through December 1997) consisted of 112 patients (52 with AAA, 60 with AIOD) and the post-EP patient group (January 2000 through December 2001) consisted of 142 patients (72 with AAA, 70 with AIOD). The pre-EP AAA group was compared with the post-EP AAA group and the pre-EP AIOD group was compared with the post-EP AIOD group. Factors analyzed included patient demographics, comorbidities, and operative outcomes. Statistical comparisons were carried out using Fisher's exact test for proportions and the Wilcoxon rank-sum test for medians. There were no statistical diff...

Annals of vascular surgery, 2004

The purpose of this report is to examine the contemporary indications for diagnostic carotid arte... more The purpose of this report is to examine the contemporary indications for diagnostic carotid arteriography and evaluate its utility and safety when performed by vascular surgeons. The records of all patients having selective carotid arteriography from September 2000 through March 2002 at our institution were reviewed. One hundred sixty-four consecutive patients had selective arteriography of the extracranial carotid arteries for the following indications: hemispheric symptoms with stenosis <80% by duplex ultrasound (20.6%), suspected brachiocephalic trunk stenosis (15.8%), unclear anatomy by duplex (10.3%), recurrent carotid stenosis (10.3%), symptomatic high-grade (>80% by duplex) internal carotid stenosis (9.8%), ipsilateral internal carotid artery occlusion (7.1%), bilateral high-grade internal carotid artery stenoses (7.1%), vertebral-basilar ischemia (7.0%), contralateral internal carotid occlusion (5.4%), duplex ultrasound from a nonaccredited vascular laboratory (3.3%),...

The American Journal of Surgery, 1984

in 1959, first reported embolization to the legs stemming from aortoiliac atherosclerosis. Virtua... more in 1959, first reported embolization to the legs stemming from aortoiliac atherosclerosis. Virtually all of the early reports of atheromatous embolization incriminated the aortoiliac segments without questioning the possibility that femoropopliteal-tibial disease might cause the same problem. Mehigan and Stoney [3] in 1976, were the first investigators to identify femoropopliteal disease as causing distal embolization. The pedal signs and symptoms associated with embolization from aortoiliac and femoropopliteal sources were termed the "blue toe" syndrome by Karmody et al . Despite many reports dealing with this problem, none has focused on the dilemma of determining the source of embolization when aortoiliac disease coexists with femoropopliteal disease. This report discusses this dilemma and the various treatment options available.

J Surg Res, 1996

Understanding and being able to manipulate intracellular signaling pathways which control VSMC ge... more Understanding and being able to manipulate intracellular signaling pathways which control VSMC gene expression and proliferation will be important in efforts to control neointimal hyperplastic vascular diseases. Activation of the protein kinase C (PKC) family of enzymes is a central event in growth factor-stimulated cells. PKC activation results in the activation of downstream protein kinases including mitogen activated protein kinase (MAPK). PKC isozymes alpha (α) and delta (δ) predominate in cultured rat aortic VSMC and both isozymes are completely downregulated upon prolonged (16–24 hr) stimulation with the PKC activator, phorbol 12,13 dibutyrate (PDBu). At these low levels of PKC, MAPK activation in response to PDBu is nearly abolished. To assess the role of specific PKC isozymes in regulating MAPK, isozyme-specific antisense oligodeoxynucleotides (ODNs) were used to inhibit reexpression of PKC in downregulated cells. ODNs were phosphorothioated to increase stability and contained C-5 propynyl modified pyrimidines which are reported to have increased binding affinity. ODNs were administered in low concentration (400 nM) with a cationic liposome carrier (Lipofectin; GibcoBRL). Optical imaging of cells treated with FITC-labeled ODNs confirmed that virtually all cells took up the ODNs within 2 hr. With this technique, PKCα-specific antisense ODNs selectively inhibited PKCα recovery compared to cells treated with an equal length nonsense ODN (76 ± 3.9,P< 0.001), with no effect on recovery of PKCδ. However, activation of MAPK by PDBu was not significantly inhibited in these PKCα downregulated cells. This suggests that only a small amount of the total PKCα is required for PDBu induced activation of MAPK and/or that PKCδ can mediate the response. Manipulation of PKC isozymes using this model system should allow assessment of the roles of specific isozymes in controlling diverse downstream effectors and events related to VSMC growth and proliferation.

Vascular and Endovascular Surgery, 1998

... Case Reports David A. Bigatel, MD David P. Franklin, MD Steven C. Meschter, MD James R.Elmore... more ... Case Reports David A. Bigatel, MD David P. Franklin, MD Steven C. Meschter, MD James R.Elmore, MD and Jerry R. Youkey, MD ... 8. Ayala AG, Ro JY, Fanning CV, et al: Core needle biopsy and fine-needle aspiration in the diagnosis of bone and soft-tissue lesions. ...

The American surgeon, 2008

Functional success after below-knee amputation (BKA) has been poorly studied. The purpose of this... more Functional success after below-knee amputation (BKA) has been poorly studied. The purpose of this study was to establish a consistent definition of "successful outcome" after BKA and to identify clinical variables influencing that definition. Three hundred nine consecutive patients undergoing BKA were evaluated postoperatively using the following definition for "successful outcome": 1) wound healing of the BKA without need for revision to a higher level; 2) maintenance of ambulation with a prosthesis for at least 1 year or until death; and 3) survival for at least 6 months. Independent clinical predictors influencing outcome were determined using bivariate and multivariable logistic regression analyses. For the cohort, median survival and maintenance of ambulation were 44 months and 60 months, respectively. Although 86.4 per cent of patients healed without the need for revision to a higher level, 63.4 per cent maintained ambulation with a prosthesis for 1 year an...

The American Journal of Surgery, 1986

local anesthetic injection of the carotid sinus nerve is routinely practiced by many surgeons per... more local anesthetic injection of the carotid sinus nerve is routinely practiced by many surgeons performing carotid endarterectomy today [l-8]. Others routinely divide the nerve at the time of endarterectomy (91, and some place small catheters at the carotid bifurcation for postoperative injection of local anesthetics .

Vascular and endovascular surgery

Renal artery stenosis is a consequence of generalized atherosclerosis and many specialists perfor... more Renal artery stenosis is a consequence of generalized atherosclerosis and many specialists perform routine selective renal angiography to detect and treat renal artery stenosis. The incidence of clinically important renal artery stenosis is not well defined in patients with symptomatic peripheral arterial disease. The purpose of this study was to better delineate the incidence of and the risk factors associated with renal artery stenosis, renovascular hypertension, and ischemic nephropathy incidentally discovered during angiography for symptomatic peripheral arterial disease. Two hundred consecutive patients undergoing angiographic evaluation of symptomatic lower extremity peripheral arterial disease were studied retrospectively. Angiograms were reviewed for the presence of renal artery stenosis (defined as >or= 25% diameter reduction in either renal artery) and findings were then correlated to the clinical diagnosis of renovascular hypertension (> 50% renal artery stenosis an...

The American surgeon, 2005

The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively m... more The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable. Little objective data, however, is available documenting that a better model exists. From September 2002 through August 2003, the trauma model at a 735-bed level I trauma teaching hospital was changed from the contemporary model to a new one where selected general surgeons with Advanced Trauma Life Support (ATLS) certification covered in-house trauma and emergency surgery call on a rotational basis. As well, each pursued elective practices, admitting all inpatients (trauma, emergent, elective) to a single teaching service (formerly the trauma service). Critical care was managed by a separate group of intensivists. The purpose of this study was to objectively compare the two models. Quantitative, financial, and qualitative data were derived from August 2001 to January 2002 (trauma/critical care model) and compared to August 200...

Annals of vascular surgery, 2000

Arteriovenous (AV) access graft infection results in disruption of dialysis and usually necessita... more Arteriovenous (AV) access graft infection results in disruption of dialysis and usually necessitates graft removal when the entire graft is involved. The management of an isolated infected segment of an otherwise noninfected AV access graft, however, remains controversial. To evaluate the utility of segmental bypass and partial graft excision for the treatment of an isolated infected AV access graft segment, 17 consecutive cases in 12 patients (7 females/5 males; 14 arm grafts/3 leg grafts; median age = 69 years) were analyzed on a vascular teaching service that performed 1244 total access procedures from January 1995 through February 1999. Infections presented as a draining sinus or a sinus with hemorrhage emanating from an area over the graft. At operation, the infected sinus was covered by a transparent occlusive dressing and the graft was explored through clean incisions proximal and distal to the infected segment. If the graft was incorporated and free of infection, a piece of ...

Annals of vascular surgery, 1999

This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in... more This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in predicting not only perioperative but also long-term cardiac events. One hundred fifty-nine patients who were evaluated for elective abdominal aortic surgery were screened preoperatively with DSE from January 1, 1992 to December 31, 1993. We concluded that DSE is useful for preoperative assessment of cardiac risk prior to elective aortic surgery to minimize the need for cardiac intervention and still maintain acceptable perioperative MI and death rates. A selective approach for coronary revascularization is justified by the higher mortality in the subgroup requiring sequential procedures. DSE also allowed us to identify those high-risk patients who are best excluded from aortic surgery. Patients with abnormal DSE results are at higher risk for late cardiac events, require cardiology follow-up, and may require late coronary intervention.

Annals of vascular surgery, 1998

Excellent correlation between carotid angiography and duplex scanning has made it possible to per... more Excellent correlation between carotid angiography and duplex scanning has made it possible to perform carotid endarterectomy without angiography. The accuracy of scans from practices without a dedicated vascular laboratory must be validated prior to their use for clinical decisions. Seventy six patients had a carotid duplex performed at an outside institution and were referred for vascular surgery. All patients underwent a repeat study at our dedicated vascular lab. The overall accuracy of our lab was 93.8% for all carotid categories as demonstrated by angiography. Outside carotid duplex reports correlated with repeat exams as follows: occlusions: 10/13 carotids (76.9%); 80%-99% stenoses: 15/39 carotids (38.5%); 50%-79% stenoses: 28/44 carotids (63.6%). If a surgeon's practice is to operate for asymptomatic 80%-99% stenoses by report, then unnecessary surgery might have been performed in 61.5% of these carotids and appropriate surgery denied in 3.6%. Outside duplex velocities co...

The American surgeon, 2005

The purpose of this study was to provide outcomes after intervention for critical limb ischemia (... more The purpose of this study was to provide outcomes after intervention for critical limb ischemia (CLI) in elderly patients (> or =80 years) according to medical and functional status at presentation. From January 1998 to September 2003, 140 limbs/122 patients (age range 80-97 years) were treated (57 patients/66 limbs, infrainguinal bypass; 65 patients/74 limbs, infrainguinal angioplasty) for CLI. At presentation, 71 (58.2%) patients were functionally ambulatory, 41 (33.6%) were homebound ambulators, and 10 (8.2%) were transfer-only ambulators. Overall end points after treatment as well as outcomes according to type of treatment and preoperative medical and functional status were determined. End points included reconstruction patency, limb salvage, survival, amputation-free survival, and maintenance of ambulatory and independent living status. Results for the 140 limbs/122 patients at 3 years (Kaplan-Meier curves) include primary patency, 55.3%; secondary patency, 73.2%; limb salva...

Principles and Practice, Third Edition, 2003

Annals of Vascular Surgery, 2004

The care of patients requiring lifelong intravenous access was revolutionized with the developmen... more The care of patients requiring lifelong intravenous access was revolutionized with the development of tunneled catheters and implantable ports. These devices are not without complications, however, and selected patients may benefit from alternative modalities to maintain access for such therapies as parenteral nutrition, phlebotomy, or chemotherapy. Use of surgically created arteriovenous (AV) fistulae as an alternative to central venous access has been described. This report reviews our experience using AV access for central venous access. An AV access database of more than 800 active patients was reviewed and all patients who had autogenous or synthetic AV fistulae created exclusively for central venous access between July 1, 2001, and December 31, 2003, were identified. Outcomes were assessed. A total of 853 new accesses were placed during the time period. Six fistulae in six patients (0.7%) were placed for central access. All patients (5 males, 1 female, mean age, 42.8 years) required access for intermittent parenteral nutrition or intravenous fluids secondary to short-gut syndrome (n = 5) or gastroparesis (n = 1). All patients had failed at least two prior catheter-based accesses before access placement was considered. Procedures were all brachial artery based and included autogenous brachiobasilic vein fistulae with elevation or transposition (n = 3), autogenous brachiocephalic fistula (n = 1), autogenous brachiobasilic graft with transposed greater saphenous vein (n = 1), and a prosthetic brachiobasilic graft with ePTFE (n = 1). There was one perioperative autogenous fistula thrombosis treated with thrombectomy and revision. A total of seven late revisions (thrombectomy, thrombectomy with venous outflow revision, fistula elevation, and 4 percutaneous angioplasties) in four patients were required. All fistulae were patent and functional at the end of the review period (mean follow-up, = 393 days; range, 35-757 days). Daily access was performed by family members (n = 2) or nurses (n = 4). One patient received small bowel transplantation and no longer required use of his patent fistula. One patient died of liver failure 382 days after fistula placement with a patent fistula. These results show that, while often forgotten and infrequently used, AV access can be a durable alternative to catheter-based venous access.

Annals of vascular surgery, 2002

Many patients are not considered candidates for radiocephalic fistula (RCF) or brachiocephalic fi... more Many patients are not considered candidates for radiocephalic fistula (RCF) or brachiocephalic fistula (BCF) creation or have fistulas that do not mature because the cephalic vein is too deep or tortuous to be accessed. Other patients have not been candidates for the basilic vein transposition (BVT) because limited length of adequate caliber vein precludes subcutaneous tunneling of the vein. In an effort to maximize arteriovenous fistula (AVF) utilization, we developed an adjunctive procedure designed to make the deep or tortuous fistula accessible to needle cannulation. The fistula elevation procedure (FEP) involves mobilization of the fistula, approximation of the subcutaneous tissue beneath the fistula, and subcuticular skin closure over the fistula. The procedure enhances the accessibility of the fistula by placing it in a more superficial position. The overlying cicatrix also acts as a guide for dialysis needle insertion. Between June 1998 and January 2001, 45 patients underwen...

The American surgeon, 2002

As the number of cardiac and interventional radiologic procedures has risen, the frequency with w... more As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventiona...

Annals of vascular surgery, 2003

The treatment of choice for renal artery occlusive disease has shifted from open repair to percut... more The treatment of choice for renal artery occlusive disease has shifted from open repair to percutaneous angioplasty and stenting in many institutions. Whether this change in treatment modality will lead to altered and, perhaps, relaxed indications for intervention is unclear. We reviewed our experience to determine if a shift from open surgery to percutaneous management of renal occlusive disease was associated with changes in either indications for intervention or patient outcomes. Over an 8-year period, 165 patients had intervention for renal artery stenosis by our vascular surgery teaching service. Over the period there was a dramatic increase in interventions per year (4 patients 1994 to 57 patients 2001). There was also a shift from open to endovascular management. Patient demographics and indications for intervention showed no difference between open and endovascular groups. Outcome analysis revealed similar technical success rates between groups but a significantly higher mor...

The American surgeon, 2003

While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected ... more While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. Th...

Annals of vascular surgery, 2004

With the emergence of endovascular surgery, there is a perception that open aortic procedures for... more With the emergence of endovascular surgery, there is a perception that open aortic procedures for aneurysmal and occlusive disease have become more difficult. To test this hypothesis, two consecutive groups of patients undergoing open aortic surgery for aneurysmal (AAA) and occlusive (AIOD) disease before and after the establishment of an endovascular program (EP) were analyzed. The pre-EP patient group (January 1996 through December 1997) consisted of 112 patients (52 with AAA, 60 with AIOD) and the post-EP patient group (January 2000 through December 2001) consisted of 142 patients (72 with AAA, 70 with AIOD). The pre-EP AAA group was compared with the post-EP AAA group and the pre-EP AIOD group was compared with the post-EP AIOD group. Factors analyzed included patient demographics, comorbidities, and operative outcomes. Statistical comparisons were carried out using Fisher's exact test for proportions and the Wilcoxon rank-sum test for medians. There were no statistical diff...

Annals of vascular surgery, 2004

The purpose of this report is to examine the contemporary indications for diagnostic carotid arte... more The purpose of this report is to examine the contemporary indications for diagnostic carotid arteriography and evaluate its utility and safety when performed by vascular surgeons. The records of all patients having selective carotid arteriography from September 2000 through March 2002 at our institution were reviewed. One hundred sixty-four consecutive patients had selective arteriography of the extracranial carotid arteries for the following indications: hemispheric symptoms with stenosis <80% by duplex ultrasound (20.6%), suspected brachiocephalic trunk stenosis (15.8%), unclear anatomy by duplex (10.3%), recurrent carotid stenosis (10.3%), symptomatic high-grade (>80% by duplex) internal carotid stenosis (9.8%), ipsilateral internal carotid artery occlusion (7.1%), bilateral high-grade internal carotid artery stenoses (7.1%), vertebral-basilar ischemia (7.0%), contralateral internal carotid occlusion (5.4%), duplex ultrasound from a nonaccredited vascular laboratory (3.3%),...

The American Journal of Surgery, 1984

in 1959, first reported embolization to the legs stemming from aortoiliac atherosclerosis. Virtua... more in 1959, first reported embolization to the legs stemming from aortoiliac atherosclerosis. Virtually all of the early reports of atheromatous embolization incriminated the aortoiliac segments without questioning the possibility that femoropopliteal-tibial disease might cause the same problem. Mehigan and Stoney [3] in 1976, were the first investigators to identify femoropopliteal disease as causing distal embolization. The pedal signs and symptoms associated with embolization from aortoiliac and femoropopliteal sources were termed the "blue toe" syndrome by Karmody et al . Despite many reports dealing with this problem, none has focused on the dilemma of determining the source of embolization when aortoiliac disease coexists with femoropopliteal disease. This report discusses this dilemma and the various treatment options available.