Publications by authors named "Nathan L Liang"

28 Publications

  • Page 1 of 1

New randomized controlled trials for abdominal aortic aneurysm treatment should focus on younger, good-risk patients.

J Vasc Surg 2021 Jun;73(6):2209

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

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http://dx.doi.org/10.1016/j.jvs.2020.11.053DOI Listing
June 2021

The Effect of Blood Transfusion during Air Medical Transport on Transport Times in Patients with Ruptured Abdominal Aortic Aneurysm.

Prehosp Emerg Care 2021 Feb 17:1-8. Epub 2021 Feb 17.

Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (NM, FXG); Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (ARP, NLL); College of General Studies, University of Pittsburgh, Pittsburgh, Pennsylvania (NC).

Patients presenting with a diagnosis of ruptured abdominal aortic aneurysm (RAAA) to community hospitals must be transported to tertiary care centers, where necessary resources are available. Unfortunately, guidelines for treatment of RAAA lack high-level evidence on the optimal resuscitation of RAAA patients during transport. We hypothesized that transfusion of packed red blood cells (PRBCs) during transport would not delay transport times in patients with RAAA. We performed a retrospective analysis of a prospective registry including prehospital data of patients with RAAA presenting to a single academic hospital in Western Pennsylvania between 2001 and 2019. Our primary outcomes were prehospital transport times: "transport interval" and "total interval." "Transport interval" is the duration from patient pickup at the outside hospital (OSH) to arrival at the receiving facility. "Total interval" is the duration from dispatch of the air medical transport to arrival of the patient to the receiving facility. We then compared two groups of patients, stratified by the receipt of PRBCs in transit, by reporting mean difference (95% confidence interval: CI) for continuous variables and percent difference (95% CI) for categorical variables. We performed two multivariate linear regression models to test if there was any effect of the receipt of PRBCs in transit on transport times. We included 271 patients with RAAA transported by our air ambulance system who underwent an operation at the receiving facility, 99 (37%) of whom received PRBCs in transit. Mean ± standard deviation (SD) of the total intervals were 67 ± 28 and 71 ± 42 minutes, among patients who received or did not receive PRBCs in transit respectively, with no significant difference ( = 0.437). Following adjusted analysis, the receipt of PRBCs during transport was not associated with increased transport times, after accounting for age, hypotension, endovascular aneurysm repair (EVAR), and PRBC transfusion at the OSH. PRBC transfusion during air medical transport in patients with RAAA did not delay transport times.
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http://dx.doi.org/10.1080/10903127.2020.1868636DOI Listing
February 2021

Systematic review of plasma/packed red blood cell ratio on survival in ruptured abdominal aortic aneurysms.

J Vasc Surg 2021 Apr 13;73(4):1438-1444. Epub 2020 Nov 13.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Background: The ideal perioperative fluid resuscitation for patients with ruptured abdominal aortic aneurysms (rAAAs) is unknown. It has been shown in trauma studies that a higher ratio of plasma and platelets to packed red blood cells confers a mortality benefit. Controversy remains whether this is true also in the rAAA population. The objective of the present study was to investigate the benefit of a greater ratio of plasma/packed red blood cells in patients with rAAAs.

Methods: A health sciences librarian searched four electronic databases, including PubMed, Embase, Cochrane, and ClinicalTrials.gov, using concepts for the terms "fluid resuscitation," "survival," and "ruptured abdominal aortic aneurysm." Two reviewers independently screened the studies that were identified through the search strategy and read in full any study that was potentially relevant. Studies were included if they had compared the mortality of patients with rAAAs who had received a greater ratio of plasma to other component therapy with that of patients who had received a lower ratio. The risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) validated tool, and evidence quality was rated using the GRADE (grades of recommendation assessment, development, and evaluation) profile. No data synthesis or meta-analysis was planned or performed, given the anticipated paucity of research on this topic and the high degree of heterogeneity of available studies.

Results: Our search identified seven observational studies for inclusion in the present review. Of these seven studies, three found an associated decrease in mortality with a greater ratio of plasma to packed red blood cells. The remaining four found no significant differences. The overall risk of bias was serious, and the evidence quality was very low.

Conclusions: Overall, the findings from the available studies would suggest that for patients who have undergone open surgery for a rAAA, mortality tends to be decreased when the amount of plasma transfused perioperatively is similar to the amount of packed red blood cells. However, the included studies reported very low-quality evidence based solely on highly heterogeneous observational studies, and further research is warranted.
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http://dx.doi.org/10.1016/j.jvs.2020.10.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005448PMC
April 2021

Improved outcomes of endovascular repair of thoracic aortic injuries at higher volume institutions.

J Vasc Surg 2021 Apr 1;73(4):1314-1319. Epub 2020 Sep 1.

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Background: The use of thoracic endovascular aortic repair (TEVAR) has significantly improved the ability to treat traumatic aortic injuries (tTEVAR). We sought to determine whether a greater center volume correlated with better outcomes.

Methods: Vascular Quality Initiative data of TEVAR (2011-2017) for trauma were used in the present analysis. Using the distribution of the annual case volume at the participating centers, the sample was stratified into three terciles. In-hospital mortality at high-volume centers (HVCs) and low-volume centers (LVCs) was compared after adjustment for risk factors established in our previous Vascular Quality Initiative-based risk model containing age, gender, renal impairment, left subclavian artery involvement, and select concomitant injuries.

Results: A total of 619 tTEVAR cases were studied across 74 centers. HVCs (n = 184 cases) had performed ≥4.9 cases annually and LVCs (n = 220 cases) had performed ≤2.4 cases annually. Both crude mortality (4.4% vs 8.6%; P = .22) and adjusted odds of mortality (odds ratio, 0.44; 95% confidence interval, 0.18-1.09; P = .08) showed a trend toward better outcomes for tTEVAR performed at HVCs than at LVCs. The addition of center volume to our previous multivariate model significantly improved its discriminative ability (C-statistic, 0.90 vs 0.88; P = .02). The overall TEVAR volume (for all indications) was not associated with increased odds of mortality for tTEVAR (odds ratio, 0.46; 95% confidence interval, 0.17-1.20; P = .11), nor did it improve the model's discriminative ability.

Conclusions: Higher volume centers showed improved perioperative mortality after tTEVAR. The thoracic aortic trauma volume was more predictive than the overall TEVAR volume, suggesting that technical expertise is not the driving factor. Stable patients might benefit from transfer to a higher volume center before repair.
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http://dx.doi.org/10.1016/j.jvs.2020.08.034DOI Listing
April 2021

Five-year results of the INSPIRATION study for the INCRAFT low-profile endovascular aortic stent graft system.

J Vasc Surg 2021 Mar 21;73(3):867-873.e2. Epub 2020 Jul 21.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Objective: We present the 5-year results of a prospective regulatory study of the INCRAFT device, a low-profile endovascular stent graft system for repair of abdominal aortic aneurysms.

Methods: This was an open-label prospective nonrandomized single-arm study enrolling in centers in the United States and Japan. The primary effectiveness outcome was successful aneurysm treatment and the primary safety outcome was the incidence of major adverse events at 30 days after the procedure. Major long-term outcomes were mortality, reintervention, adverse limb outcomes, and suprarenal stent fracture.

Results: One hundred and ninety patients (mean age, 73.8 ± 7.6 years; 90% male; 69% white and 30% Asian) were enrolled from 32 centers throughout the United States and Japan. Minimal access vessel size was less than 7 mm on both sides in 43.9% of the study cohort. Thirty-day major adverse events occurred in 3.2% of patients (6/190). Periprocedural technical success was 94.1% (176/187). Successful aneurysm treatment was 100% at 30 days and 87.9% at 1 year. Two patients required open conversion for thromboembolic complications, 3 developed new type I or III endoleaks, and 7 experienced graft or limb occlusion. Freedom from graft occlusion was 96 ± 2% at 1 year and 94 ± 2% at 5 years. Freedom from stent fracture was 97 ± 1% at 1 year and 87 ± 3% at 5 years. Freedom from aneurysm-related mortality was 99 ± 1% at 1 and 5 years.

Conclusions: This study demonstrates good efficacy and safety and a very low rate of aneurysm related deaths with the INCRAFT device in a population with a high proportion of challenging anatomy.
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http://dx.doi.org/10.1016/j.jvs.2020.06.128DOI Listing
March 2021

Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality.

Ann Vasc Surg 2021 Jan 27;70:109-115. Epub 2020 Jun 27.

Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA.

Background: Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options.

Methods: Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression.

Results: Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm (interquartile range, 1-6 cm). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47).

Conclusions: This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.
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http://dx.doi.org/10.1016/j.avsg.2020.06.051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744434PMC
January 2021

Acute Kidney Injury after Complex Endovascular Aneurysm Repair.

Curr Pharm Des 2019 ;25(44):4686-4694

Department of Vascular and Endovascular Surgery, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany.

Background: Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative morbidity than standard infrarenal endovascular repair.

Objective: This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms.

Methods: A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal, and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further analyzed by the level of anatomic complexity and method of repair.

Results: 52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017. The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19% (temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency did not demonstrate any associations with the outcome.

Conclusion: Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively associated factors other than increasing anatomic complexity and operative time. Further study is needed for the identification of predictors related to postoperative acute kidney injury.
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http://dx.doi.org/10.2174/1381612825666191129095829DOI Listing
June 2020

Inferior Mid-term Durability with Comparable Survival for Younger Patients Undergoing Elective Endovascular Infrarenal versus Open Abdominal Aortic Aneurysm Repair.

Ann Vasc Surg 2020 Apr 18;64:143-150.e1. Epub 2019 Oct 18.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, UPMC Presbyterian Hospital, Pittsburgh, PA; Vascular Surgery, Veterans Affairs Pittsburgh Health System, Pittsburgh, PA.

Background: The durability of endovascular aneurysm repair (EVAR) when compared to open surgical repair (OSR) in younger patients for elective, infrarenal abdominal aortic aneurysms (AAA) remains unclear due to limited follow-up.

Methods: We identified all patients <70 years of age who underwent elective, de novo EVAR or OSR for infrarenal AAA from 2003 to 2013 in a multihospital, single institution. Baseline patient clinical and aneurysmal characteristics were adjusted for using multivariable Cox proportional hazards models and negative binomial regression.

Results: We identified 253 patients: 204 underwent EVAR (80.6%) and 49 OSR (19.4%). Baseline demographics and comorbidities were similar across groups. There were no deaths in the immediate perioperative period. The rate of new arrhythmia (EVAR: 1.0%, OSR: 10.2%; P = 0.004), median hospital length of stay (EVAR: 1 day, OSR: 5 days; P < 0.001), and discharge to a facility (EVAR: 2.9%, OSR: 12.2%; P = 0.016) were significantly increased for OSR. In both groups, median follow-up time was 4.5 years, in which survival did not differ between groups. The hazard of composite of freedom from death and any reinterventions (hazard ratio [HR] 4.3, P = 0.009), freedom from any reintervention (relative risk [RR] 4.08, P = 0.030), and freedom from any endovascular reintervention (RR 4.83, P = 0.038) were each higher for OSR when compared to EVAR. EVAR of the standard instruction for use (IFU) for neck length was more likely to die or undergo a reintervention (HR 4.90, P = 0.001).

Conclusions: Our retrospective review of younger patients undergoing elective AAA repair demonstrated no significant differences in perioperative mortality or survival over time between EVAR and OSR. EVAR required more total reinterventions and endovascular reintervention when compared to OSR.
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http://dx.doi.org/10.1016/j.avsg.2019.10.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096248PMC
April 2020

Risk factors for mortality after endovascular repair for blunt thoracic aortic injury.

J Vasc Surg 2020 03 13;71(3):768-773. Epub 2019 Sep 13.

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Objective: Despite high use of endovascular repair, blunt thoracic aortic injury (BTAI) leads to significant mortality. We sought to identify risk factors and create a predictive model for mortality after thoracic endovascular aortic repair (TEVAR) based on available preoperative clinical data.

Methods: We queried the Vascular Quality Initiative TEVAR dataset from April 2011 to November 2017 to identify patients with BTAI as the indication for repair. Patient characteristics, injury grade, timing of repair, and technical aspects including left subclavian artery (LSCA) involvement and coverage were evaluated. Logistic regression was used to identify univariable predictors of the primary outcome of in-hospital mortality. A multivariable model was constructed to predict in-hospital mortality after TEVAR for traumatic aortic injury. The model was tested as a prediction tool, internally validated using 10-fold cross-validation approach, externally validated using early and late split samples, and finally simplified into a scoring system.

Results: We identified 633 TEVAR cases performed for blunt trauma. The majority of patients were male (73.9%) with median age of 39 years (interquartile range, 27-56 years). Although 18.6% documented zone 2 or proximal involvement, 28.1% documented involvement or treatment of the LSCA. 8.9% of repairs were performed for a grade 1 injury, with an increase from 6.4% in 2014 to 16.7% in 2017 (P = .04). The overall in-hospital mortality rate was 7.3%. Independent predictors of mortality were age 60 year or greater (odds ratio [OR], 11.33; 95% confidence interval [CI], 5.30-24.23; P < .001), creatinine 1.2 or greater (OR, 5.28; 95% CI, 2.46-11.34; P < .001), male gender (OR, 4.26; 95% CI, 1.53-11.84; P = .005), Injury Severity Score of greater than 30 (OR, 3.86; 95% CI, 1.74-8.57; P = .001), and LSCA involvement (OR, 2.25; 95% CI, 1.11-4.53; P = .02). The model predicted in-hospital mortality with a C-statistic of 0.86 (95% CI, 0.80-0.92), and a simplified model based on a point system had a similar C-statistic of 0.86 (95% CI, 0.80-0.92; P = .44).

Conclusions: TEVAR for BTAI is associated with a 7.3% in-hospital mortality in the Vascular Quality Initiative. Treatment of grade 1 injuries has increased significantly in recent years. Factors most strongly associated with mortality include age, male gender, renal impairment, LSCA involvement, and high ISS score. A simple point score model based on these variables robustly predicts in-hospital mortality and may assist in appropriate patient selection and risk stratification.
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http://dx.doi.org/10.1016/j.jvs.2019.07.059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082096PMC
March 2020

Persistently low inferior vena cava filter retrieval rates in a population-based cohort.

J Vasc Surg Venous Lymphat Disord 2019 01 12;7(1):38-44. Epub 2018 Nov 12.

Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Background: Practice patterns associated with inferior vena cava (IVC) filter placement have seen considerable variation in the last decade. We used a statewide administrative database to examine trends in IVC filter placement and retrieval in the general population.

Methods: We reviewed Florida state inpatient and ambulatory surgery databases from 2004 to 2014. International Classification of Diseases, Ninth Revision diagnosis and procedure codes and Current Procedural Terminology codes were searched for patients undergoing inpatient or outpatient IVC filter placement, and each patient was longitudinally tracked to the time of inpatient or outpatient filter retrieval. For inpatient filter placements, associated diagnoses were reviewed to identify indications for placement. Univariate and multivariate logistic regression models were constructed to identify factors associated with improved retrieval rates.

Results: During the 11-year period, 131,791 IVC filter placements were identified, with a 50% increase from 2004 to 2010 and a 24% decline from 2010 to 2014. Median age at filter placement was 71 years (interquartile range, 57-81 years). Mean follow-up after filter placement was 17.3 ± 25.5 months. Only 8637 filters (6.6%) were retrieved. The annual retrieval rate trended upward, from 3.4% in 2004 to 8.5% in 2013 (P < .001). Median filter dwell time was 96.5 days (interquartile range, 44-178 days). Diagnoses associated with filter placement included venous thromboembolism (75.9%), trauma (35.0%), hemorrhage (29.9%), malignant disease (29.4%), and stroke (5.1%). Retrieval rates were highest in younger patients (34.0% in patients younger than 20 years) and lowest in Medicare patients (2.5%). In a multivariate logistic regression model, Medicare was associated with decreased retrieval rates (odds ratio, 0.33; 95% confidence interval, 0.31-0.35; P < .001) after adjusting for age and associated diagnoses. Weaker risk factors included increased age, white race, and diagnoses of deep venous thrombosis, pulmonary embolism, and malignant disease. A trauma diagnosis was associated with improved retrieval. To further investigate the Medicare effect, a propensity score-matched model was created to better account for confounding effects. In this model, Medicare persisted as a risk factor for decreased filter retrieval (odds ratio, 0.43; 95% confidence interval, 0.40-0.46; P < .001).

Conclusions: IVC filter placements, after a substantial increase between 2004 and 2010, have been declining since 2010. Retrieval rates in the general population are steadily improving but continue to lag behind those described in center-specific literature. Increased age and Medicare as the primary payer are the strongest risk factors for lack of filter retrieval. Widespread improvements on a national scale are needed to improve the appropriateness of filter placements and to enhance filter retrieval rates.
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http://dx.doi.org/10.1016/j.jvsv.2018.08.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296863PMC
January 2019

Catheter-directed interventions compared with systemic thrombolysis achieve improved ventricular function recovery at a potentially lower complication rate for acute pulmonary embolism.

J Vasc Surg Venous Lymphat Disord 2018 07 31;6(4):425-432. Epub 2018 Mar 31.

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address:

Objective: Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis (ST) while decreasing the associated complications. The purpose of this study was to compare outcomes between CDI and ST.

Methods: Consecutive patients who underwent CDIs or ST for massive or submassive PE between 2006 and 2016 were identified. Clinical and echocardiographic parameters at baseline and after treatment were recorded. Clinical success was defined as decompensation resolution (or prevention) without major bleeding, stroke, other major treatment-related event, or in-hospital death. The χ test and t-test were used for between-groups comparisons.

Results: There were 213 patients who received CDIs (standard catheter thrombolysis in 56, ultrasound-assisted thrombolysis in 146, suction thrombectomies in 10, and pharmacomechanical thrombolysis in 1) and 104 patients who received ST (94 high dose [100 mg], 10 low dose [50 mg]). At baseline, CDI and ST groups had comparable echocardiographic parameters, demographics, and comorbidities, except for PE type (massive PE, 8.5% for CDIs vs 69.2% for ST; P < .001), age (60.2 ± 14.9 years for CDIs vs 55.9 ± 17.3 years for ST; P = .023), and renal function (glomerular filtration rate, 78.1 ± 33.7 mL/min/1.73 m for CDIs vs 64.1 ± 35.2 mL/min/1.73 m for ST; P = .001). Without stratifying per PE type, CDIs had a higher clinical success rate (87.8% vs 66.3%; P < .001) and a lower rate of major bleed (8.0% vs 19.2%; P = .003), stroke (1.4% vs 4.8%; P = .120), and death (1.4% vs 13.5%; P < .001). On stratifying by PE type, there was no difference in clinical success between groups. The mean reduction in right ventricular/left ventricular diameter ratio between baseline and the first post-treatment echocardiographic examination (within 30 days) was significantly higher for CDI (0.27 ± 0.20 vs 0.18 ± 0.15; P = .037). Beyond 30 days, there was no echocardiographic difference between groups. There was no significant difference in clinical outcomes and echocardiographic parameters between standard and ultrasound-assisted CDIs.

Conclusions: CDIs provide improved recovery of right ventricular function compared with ST. Major bleeding and stroke complications may be lower, but larger studies are needed to validate this. CDIs are complementary to ST, and their use should be individualized on the basis of the patients' clinical presentation, risk profile, and local resources.
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http://dx.doi.org/10.1016/j.jvsv.2017.12.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151647PMC
July 2018

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair.

J Vasc Surg 2018 05 31;67(5):1404-1409.e2. Epub 2017 Oct 31.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa; VA Pittsburgh Health System, Pittsburgh, Pa.

Background: Evidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set.

Methods: We identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years.

Results: We identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results.

Conclusions: In this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population.
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http://dx.doi.org/10.1016/j.jvs.2017.08.057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916017PMC
May 2018

Predictors of failure and complications of catheter-directed interventions for pulmonary embolism.

J Vasc Surg Venous Lymphat Disord 2017 05;5(3):303-310

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address:

Objective: Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis while decreasing the dose of thrombolytic required and the associated risks. This study aimed to identify factors associated with CDI failure and to describe anticipated complications.

Methods: Consecutive patients who underwent CDI for massive or submassive PE between 2009 and 2015 were identified; outcomes and complications were retrospectively collected. CDI clinical failure was defined as major bleeding, perioperative stroke or other major adverse procedure-related event, decompensation for submassive or persistent shock for massive PE, need for surgical thromboembolectomy, or in-hospital death. Univariate analysis was used to study the factors associated with CDI failure.

Results: There were 102 patients who received a CDI during the study period (36 standard catheter thrombolysis, 60 ultrasound assisted, 6 other; age, 59.2 ± 15.9 years; male, 50 [49.0%]; massive PE, 14 [13.7%]). Five patients (4.9%) had a major contraindication and 15 patients (14.7%) had a minor contraindication to systemic thrombolysis. The mean alteplase dose was 28.2 ± 18.8 mg (range, 0-123 mg; three patients had already received systemic lysis). CDI failure occurred in 15 patients (14.7%; 7 in massive PE, 8 in submassive PE). Of these patients, seven had major bleeding events, whereas eight patients decompensated. Ten (9.8%) patients had minor bleeding events (four access related). Factors associated with CDI failure and major bleeding included massive PE, age ≥70 years, and major contraindication to thrombolytics. Both failures and bleeding events were independent of lysis dose and CDI technique.

Conclusions: CDIs for acute PE are not risk-free procedures, and their use should be individualized on the basis of a risk-benefit ratio. Particularly for patients with major contraindications to systemic thrombolytics, CDIs should be used selectively. Lytic dose, within the low-volume range administered in CDI, and type of CDI seem to have no impact on adverse events.
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http://dx.doi.org/10.1016/j.jvsv.2016.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394221PMC
May 2017

Comparative effectiveness of anticoagulation on midterm infrainguinal bypass graft patency.

J Vasc Surg 2017 08 8;66(2):499-505.e2. Epub 2017 Apr 8.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Objective: Therapeutic anticoagulation (AC) is used clinically for prolongation of infrainguinal bypass patency, but evidence for the efficacy of this practice is conflicting. The objective of our study was to determine the association of AC with bypass graft primary patency.

Methods: Clinical and comorbid data of patients undergoing infrainguinal bypass grafts to a below-knee target with at least 1 year of follow-up performed from 2003 to 2015 were obtained from the Society for Vascular Surgery Vascular Quality Initiative. Inverse propensity of treatment-weighted Cox regression was used to assess the effect of AC on patency in the total cohort while adjusting for clinical, operative, and comorbid differences between treatment groups. Subgroup analyses of distal targets and conduit type were performed. Perioperative complications were analyzed using propensity-weighted logistic regression.

Results: We identified 7612 bypass grafts with intact 1-year follow-up information from 2003 to 2015. The mean age was 67.5 ± 11.2 years; 30.5% (n = 2320) were female, and 28.6% (n = 2165) were discharged on therapeutic AC. The anticoagulated group had a higher rate of tibial, ankle, and pedal targets (52.1% [n = 1127] vs 47.6% [n = 2269]; P < .001), had a greater use of non-single-segment vein conduits (44.3% [n = 951] vs 26.5% [n = 1426]; P < .001), and was more likely to have had a previous ipsilateral bypass (27.2% [n = 589] vs 14.7% [n = 794]; P < .001) or stent (25.4% [n = 550] vs 20.9% [n = 1130]; P < .001). Estimated unadjusted primary patency was 70.8% ± 0.6% at 1 year and lower for anticoagulated bypasses (66.9% ± 1.2% vs 72.4% ± 0.7%; P < .001). Propensity-weighted analysis showed no significant association of AC with primary patency in the overall cohort (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.86-1.11; P = .8) but demonstrated a trend toward improvement of primary patency in those with a non-single-segment vein conduit to a below-knee popliteal target (HR, 0.85; 95% CI, 0.80-1.02; P = .09). AC was associated with significantly improved secondary patency in those with prosthetic bypass grafts (HR, 0.77; 95% CI, 0.62-0.96; P = .02) or prosthetic bypasses to an infrapopliteal target (HR, 0.72; 95% CI, 0.54-0.97; P = .02). Odds of postoperative wound complications were significantly higher in those receiving AC (odds ratio, 1.33; 95% CI, 1.11-1.61; P = .002).

Conclusions: This study does not demonstrate a significant impact of therapeutic AC on primary patency for infrainguinal bypass grafts. Treatment with AC may benefit secondary patency in those with a prosthetic bypass, especially to an infrapopliteal target, but at an increased risk of postoperative wound complications.
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http://dx.doi.org/10.1016/j.jvs.2016.12.141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524600PMC
August 2017

High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease.

J Vasc Surg 2017 10 8;66(4):991-996. Epub 2017 Apr 8.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Background: Morbidity and mortality have improved with the evolution of endovascular techniques (thoracic endovascular aortic repair [TEVAR]) for thoracic aortic disease, but results after aortic intervention in patients with end-stage renal disease (ESRD) remain unclear. The objective of this study was to evaluate outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients.

Methods: We identified 352 patients with ESRD on dialysis undergoing open repair (n = 136) or TEVAR (n = 216) of the thoracic aorta from 2005 to 2008 using the United States Renal Data System database. Acute presentation was defined as ruptured aneurysm, dissection, or traumatic injury; all other interventions were considered elective. End points were 30-day mortality, overall survival, rates of perioperative complications, and procedural trends over time. Between-group comparisons and survival analysis used standard statistical methods. Logistic regression and Cox regression were performed using multivariate analysis.

Results: TEVAR subjects were older than those undergoing open repair (68.2 ± 11.5 vs 60.8 ± 13.2 years; P < .001); no other demographics differed. There were 303 patients who had thoracic or thoracoabdominal aneurysms; 47 (13.4%) were ruptured on presentation. There were 44 patients (12.5%) who had aortic dissection and 5 (1.4%) with aortic trauma. Overall 30-day mortality was 21.3% (n = 75), and it was greater for open repair (n = 41 [30.1%]) than for TEVAR (n = 34 [15.7%]; P = .002). Elective 30-day mortality for open repair (n = 27 [29.3%]) was also greater than for TEVAR (n = 24 [14.3%]; P = .005). Those with acute presentation trended toward higher mortality for open repair (n = 14 [31.8%] vs n = 10 [15.7%]; P = .17). Respiratory failure was higher for open repair (n = 69 [50.7%] vs n = 56 [25.9%]; P < .001); postoperative stroke was higher with TEVAR (n = 21 [9.7%] vs n < 10 [<7%]; P = .02). Estimated 1-year survival was 50% and did not differ between groups (44% for open repair, 53% for TEVAR). In multivariate analysis, TEVAR decreased odds of 30-day mortality compared with open repair (odds ratio, 0.41; 95% confidence interval, 0.24-0.71) but failed to demonstrate long-term survival advantage.

Conclusions: In ESRD patients, TEVAR provides short-term mortality benefits compared with open repair, but long-term mortality remains high regardless of treatment modality. Elective intervention for thoracic aortic disease in this population remains high risk and should be approached with caution.
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http://dx.doi.org/10.1016/j.jvs.2016.12.144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612851PMC
October 2017

Impact of Inferior Vena Cava Filter Placement on Short-Term Outcomes in Patients with Acute Pulmonary Embolism.

Ann Vasc Surg 2017 Jul 23;42:71-77. Epub 2017 Mar 23.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Inferior vena cava filters (IVCFs) have been associated with improved survival in patients with acute pulmonary embolism (PE) in some studies. However, without randomization, those with early mortality who did not receive an IVCF might have died prior to treatment decision about filter placement, falsely contributing a survival advantage to those receiving IVCF and biasing the results of previous observational studies. The objective of this study is to evaluate the impact of IVCF on in-hospital mortality after adjusting for this survivor treatment selection.

Methods: National Inpatient Sample data sets from 2009 to 2012 were analyzed to assess the impact of IVCF placement on in-hospital mortality in all patients with acute PE. Subgroup analyses were performed in those with high-risk PE (hemodynamic shock) and also for those with both shock and concomitant thrombolysis. Inverse propensity-score weighting was used to balance clinical and comorbid differences between filter and nonfilter groups. To account for survivor treatment selection bias, an extended Cox model was fitted with IVCF placement as a time-dependent covariate.

Results: We identified 263,955 patients with acute PE over this period; 36,702 (13.9%) received IVCF. Those receiving IVCF in the unadjusted cohort were older (IVCF: 66.3 ± 15.9 vs. non-IVCF: 62.4 ± 17.4; P < 0.001) with higher rates of shock (6.8% vs. 3.8%; P < 0.001), deep venous thrombosis (32.8% vs. 13.9%; P < 0.001), thrombolytic therapy (5.9% vs. 1.6%; P < 0.001), and lower crude mortality (6.0% vs. 6.7%; P < 0.001). Propensity weighted extended Cox analysis showed that IVCF placement did not significantly decrease mortality hazard compared to an untreated patient (hazard ratio [HR]: 0.93, 95% confidence interval [CI]: 0.89-1.01). Similar results were seen in the combined high-risk and thrombolysis (HR: 0.85, 95% CI: 0.60-1.21) subgroup and associated with worse outcomes in the high-risk (HR: 1.2, 95% CI 1.11-1.38) subgroup.

Conclusions: Placement of IVCF in all patients with acute PE, in high-risk patients, or in high-risk patients concurrently treated with thrombolysis is not significantly associated with improvement of in-hospital mortality when accounting for survivor treatment selection bias.
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http://dx.doi.org/10.1016/j.avsg.2016.11.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536973PMC
July 2017

Systemic thrombolysis increases hemorrhagic stroke risk without survival benefit compared with catheter-directed intervention for the treatment of acute pulmonary embolism.

J Vasc Surg Venous Lymphat Disord 2017 03 16;5(2):171-176.e1. Epub 2017 Jan 16.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Background: Systemic thrombolysis (ST) and catheter-directed intervention (CDI) are both used in the treatment of acute pulmonary embolism (PE), but the comparative outcomes of these two therapies remain unclear. The objective of this study was to compare short-term mortality and safety outcomes between the two treatments using a large national database.

Methods: Patients presenting with acute PE were identified in the National Inpatient Sample (NIS) from 2009 to 2012. Comorbidities, clinical characteristics, and invasive procedures were identified using International Classification of Diseases, Ninth Revision (ICD) codes and the Elixhauser comorbidity index. To adjust for anticipated baseline differences between the two treatment groups, propensity score matching was used to create a matched ST cohort with clinical and comorbid characteristics similar to those of the CDI cohort. Subgroups of patients with and without hemodynamic shock were analyzed separately. Primary outcomes were in-hospital mortality, overall bleeding risk, and hemorrhagic stroke risk.

Results: Of 263,955 subjects with acute PE, 1.63% (n = 4272) received ST and 0.55% (n = 1455) received CDI. ST subjects were older, had more chronic comorbidities, and had higher rates of respiratory failure (ST, 27.9% [n = 1192]; CDI, 21.2% [n = 308]; P < .001) and shock (ST, 18.2% [n = 779]; CDI, 12% [n = 174]; P < .001). CDI subjects had higher rates of concurrent deep venous thrombosis (ST, 35.8% [n = 1530]; CDI, 45.9% [n = 668]; P < .001) and vena cava filter placement (ST, 31.1% [n = 1328]; CDI, 57% [n = 830]; P < .001). In the unmatched cohort, ST subjects had higher in-hospital mortality (ST, 16.7% [n = 714]; CDI, 9.4% [n = 136]; P < .001) and hemorrhagic stroke rates (ST, 2.2% [n = 96]; CDI, 1.4% [n = 20]; P = .041). After propensity matching, 1430 patients remained in each cohort; baseline characteristics of the matched cohorts did not differ significantly using standardized difference comparisons. Analysis of the matched cohorts did not demonstrate a significant effect of CDI on in-hospital mortality or overall bleeding risk but did show a significant protective effect against hemorrhagic stroke compared with ST (odds ratio, 0.47; 95% confidence interval, 0.27-0.82; P = .01). Subgroup analysis showed decreased odds of hemorrhagic stroke for CDI in the nonshock subgroup and increased procedural bleeding for CDI but no difference in hemorrhagic stroke risk in the shock subgroup.

Conclusions: ST for acute PE may not improve in-hospital mortality compared with CDI but increases the overall risk of hemorrhagic stroke compared with CDI. Further prospective studies should examine the comparative effectiveness and safety of these two treatments.
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http://dx.doi.org/10.1016/j.jvsv.2016.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5324829PMC
March 2017

Comparative Outcomes of Ultrasound-Assisted Thrombolysis and Standard Catheter-Directed Thrombolysis in the Treatment of Acute Pulmonary Embolism.

Vasc Endovascular Surg 2016 Aug;50(6):405-10

Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objectives: The objective of this study was to compare the outcomes of patients undergoing ultrasound-accelerated thrombolysis (USAT) and standard catheter-directed thrombolysis (CDT) for the treatment of acute pulmonary embolism (PE).

Methods: The records of all patients in our institution having undergone CDT or USAT for massive or submassive PE from 2009 to 2014 were retrospectively reviewed. Standard statistical methods were used to compare characteristics and to assess for longitudinal change in outcomes.

Results: Sixty-three patients, 27 CDT and 36 USAT, were treated for massive (12.7%) or submassive (87.3%) PE. Of which, 96.8% were treated for bilateral PE. Baseline patient characteristics did not differ between the 2 treatment groups. There was no difference in total dose of lytic administered (CDT: 23.2 ± 13.7 mg; USAT: 27.5 ± 12.9 mg; P = .2). Two patients in the CDT and 1 in the USAT groups required conversion to surgical thrombectomy (CDT: 7.4%; USAT: 2.8%; P = .6). Rates of major and minor bleeding complications (CDT: 11.0%; USAT: 13.9%; P = .8) did not differ significantly between the CDT and USAT groups. Estimated survival at 90 days was 92% for CDT and 93% for USAT and 82% at 1 year for both groups (P = .8). All echocardiographic parameters improved significantly from baseline to 1-year follow-up, but quantitative improvement did not differ between groups.

Conclusion: This study suggests no statistical differences in clinical and hemodynamic outcomes or procedural complication rates between USAT and standard CDT for the treatment of acute PE. Prospective studies are needed to further evaluate comparative and cost-effectiveness of different interventions for acute massive and submassive PE.
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http://dx.doi.org/10.1177/1538574416666228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193277PMC
August 2016

Effects of Gender Differences on Short-term Outcomes in Patients with Type B Aortic Dissection.

Ann Vasc Surg 2017 Jan 10;38:78-83. Epub 2016 Aug 10.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Gender-related differences in type B aortic dissection (TBAD) presentation and outcomes are not well understood. The objective of this study is to assess the impact of gender on short-term outcomes in patients with TBAD.

Methods: Patients with TBAD were identified from the National Inpatient Sample datasets from 2009 to 2012 according to previously published methods. The primary outcomes of interest were in-hospital mortality and major complications (renal, cardiac, pulmonary, paraplegia, and stroke related) between men and women. An inverse propensity-weighted regression was used to balance comorbid and clinical presentation differences. Subgroup analyses were performed on those undergoing endovascular (thoracic endovascular aortic repair [TEVAR]) and open repair, and for elderly patients over the age of 70.

Results: We identified 9855 patients with TBAD; women were fewer (43.6%, n = 4293) and presented at a later age (69.8 ± 15.5 vs. 62.8 ± 15.6, P < 0.001). Women had more comorbidities (median Elixhauser 4 [interquartile range, IQR 2-5] vs. 3 [IQR 2-5], P < 0.001) and were more often managed nonoperatively (87.4% vs. 81.8%, P < 0.001) compared with men. For those undergoing intervention, 58% (n = 903) had open repair and TEVAR rates were higher in women compared with men (45.6% vs. 40.0%, P < 0.001). Unadjusted mortality rates did not differ significantly by gender (male: 11.6% vs. female: 10.7%). In an adjusted propensity-weighted regression, gender did not significantly affect in-hospital mortality or stroke rates, but women were less likely to have acute renal failure during their hospitalization and more likely to experience cardiac events when undergoing open repair. Elderly women were also less likely to experience acute renal failure but had higher odds of cardiac events regardless of intervention compared with elderly men.

Conclusions: In comparison with men, women with TBAD presented at a later age, were more likely to undergo TEVAR, sustain a perioperative cardiac event with open surgery, and were less likely to experience acute renal complications overall. Elderly women were additionally more likely to sustain a cardiac event regardless of operative status. Future studies should attempt to identify anatomic and epidemiologic reasons for these differences.
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http://dx.doi.org/10.1016/j.avsg.2016.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5164863PMC
January 2017

Contemporary outcomes of civilian lower extremity arterial trauma.

J Vasc Surg 2016 09 18;64(3):731-6. Epub 2016 Jul 18.

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Objective: Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation.

Methods: The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis.

Results: We identified 149 patients (86% male; mean age, 33 ± 14 years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1 ± 1.8 vs 4.3 ± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation.

Conclusions: Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.
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http://dx.doi.org/10.1016/j.jvs.2016.04.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5002387PMC
September 2016

Improved early right ventricular function recovery but increased complications with catheter-directed interventions compared with anticoagulation alone for submassive pulmonary embolism.

J Vasc Surg Venous Lymphat Disord 2016 07 7;4(3):268-75. Epub 2016 Jan 7.

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address:

Objective: The purpose of this study was to determine the short-term and midterm outcomes of catheter-directed intervention (CDI) compared with anticoagulation (AC) alone in patients with submassive pulmonary embolism (sPE).

Methods: This was a retrospective review of all patients treated for sPE between January 2009 and October 2014. Two groups were identified on the basis of the therapy: AC and CDI. End points included complications, mortality, and change in echocardiographic parameters. Standard statistical techniques were used.

Results: There were 64 patients who received AC and 64 patients who received CDI (five were initially treated with AC but did not improve or worsened; six received ≤8 mg of tissue plasminogen activator). Most baseline characteristics, including the Pulmonary Embolism Severity Index, were similar among the AC and CDI groups. There was no difference in PE-related death (one in each group) or major bleeding events (three in the AC group, four in the CDI group), but CDIs had two additional procedural complications that required open heart surgery. CDIs showed significantly more minor bleeding events (6 vs 0; P = .028) and significantly shorter intensive care unit stay (2.7 ± 2.1 vs 5.6 ± 7.5 days; P = .04). The mean difference in right ventricular/left ventricular ratio from baseline to the first subsequent echocardiogram (within 30 days) showed a trend for higher reduction in favor of CDI (AC, 0.17 ± 0.12; CDI, 0.27 ± 0.15; P = .076). Between 3 and 8 months, significant improvement was evident within groups in all assessed right-sided heart echocardiographic parameters, but there was no difference between groups. Pulmonary hypertension (pulmonary artery pressure >40 mm Hg) was present in 7 of 15 of the AC group vs 6 of 19 of the CDI group (P = .484). During the follow-up, dyspnea or oxygen dependence, not existing before the index PE event, was recorded in 5 of 49 (10.2%) of the AC patients and 8 of 52 (15.4%) of the CDI patients (P = .556).

Conclusions: CDI for sPE can result in faster restoration of right ventricular function and shorter intensive care unit stay, but at the cost of a higher complication rate, with similar midterm outcomes compared with AC alone. A potential effect of CDI on mortality and pulmonary hypertension needs further investigation through larger studies.
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http://dx.doi.org/10.1016/j.jvsv.2015.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151648PMC
July 2016

Midterm outcomes of catheter-directed interventions for the treatment of acute pulmonary embolism.

Vascular 2017 Apr 9;25(2):130-136. Epub 2016 Jul 9.

1 Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA.

Objective The hemodynamic benefits of catheter-directed thrombolysis for acute pulmonary embolism have not been clearly defined beyond the periprocedural period. The objective of this study is to report midterm outcomes of catheter-directed thrombolysis for treatment of acute pulmonary embolism. Methods Records of all patients undergoing catheter-directed thrombolysis for high- or intermediate-risk pulmonary embolism were retrospectively reviewed. Endpoints were clinical success, procedure-related complications, mortality, and longitudinal echocardiographic parameter improvement. Results A total of 69 patients underwent catheter-directed thrombolysis (mean age 59 ± 15 y, 56% male). Eleven had high-risk and 58 intermediate-risk pulmonary embolism. Baseline characteristics did not differ by pulmonary embolism subtype. Fifty-two percent of patients underwent ultrasound-assisted thrombolysis, 39% standard catheter-directed thrombolysis, and 9% other interventional therapy; 89.9% had bilateral treatment. Average treatment time was 17.7 ± 11.3 h with average t-Pa dose of 28.5 ± 19.6 mg. The rate of clinical success was 88%. There were two major (3%) and six minor (9%) periprocedural bleeding complications with no strokes. All echocardiographic parameters demonstrated significant improvement at one-year follow-up. Pulmonary embolism-related in-hospital mortality was 3.3%, and estimated survival was 81.2% at one year. Conclusions Catheter-directed thrombolysis is safe and effective for treatment of acute pulmonary embolism, with sustained hemodynamic improvement at one year. Further prospective large-scale studies are needed to determine comparative effectiveness of interventions for acute pulmonary embolism.
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http://dx.doi.org/10.1177/1708538116654638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193278PMC
April 2017

Endovascular Repair of an Iliac Ureteroarterial Fistula with Late Stent Thrombosis and Migration into the Bladder.

Ann Vasc Surg 2016 Aug 26;35:204.e5-7. Epub 2016 May 26.

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Ureteroarterial fistulas are rare. We describe a case of ureteral-arterial fistulas (UAF) repaired with an endovascular stent graft and examine late complications associated with the procedure.

Case Report: A 37-year-old woman with a history of complicated locally invasive cervical cancer treated with chemoradiation presented initially with right leg rest pain and chronic intermittent gross hematuria. She was found to have an ureteroarterial fistula and underwent successful endovascular exclusion with a covered stent with resolution of her symptoms. She returned 1 year later with stent-graft thrombosis manifesting as lower extremity rest pain, requiring a femoral-femoral bypass. She then returned 6 months later with imaging evidence of extravascular migration of the stent graft into the bladder. Because of a poor prognosis of recurrent gynecologic cancer, extraction was not attempted, and she underwent complete urinary diversion.

Conclusions: UAFs are a rare occurrence but may be treated successfully with endovascular stent grafting. Despite technical success, late complications such as stent thrombosis may occur even with anticoagulation. Extravascular stent migration may occur in the presence of a chronically dilated ureter.
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http://dx.doi.org/10.1016/j.avsg.2016.01.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039064PMC
August 2016

Catheter Interventions for Pulmonary Embolism: Are They Really that Safe?

Am J Cardiol 2016 07 24;118(2):307-8. Epub 2016 Mar 24.

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

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http://dx.doi.org/10.1016/j.amjcard.2016.03.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151646PMC
July 2016

Outcomes of interventions for carotid blowout syndrome in patients with head and neck cancer.

J Vasc Surg 2016 Jun 28;63(6):1525-30. Epub 2016 Feb 28.

Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa.

Background: The purpose of this study was to examine outcomes of a patient cohort undergoing intervention for carotid blowout syndrome associated with head and neck cancer.

Methods: Patients with head and neck cancer who presented with carotid distribution bleeding from 2000 to 2014 were identified in the medical record. Primary outcomes were short- and midterm mortality and recurrent bleeding. Standard statistical methods and survival analysis were used to analyze study population characteristics and outcomes.

Results: Thirty-seven patients were included in the study. The mean age was 60.1 ± 11.4 years (74% male). All malignancies were squamous cell type, stage IV, in a variety of primary locations: 32% oral cavity, 24% larynx, 16% superficial neck, with the remainder in the oropharynx, nasopharynx, and hypopharynx. Fifty-one percent of bleeds were of common carotid, 29% external carotid, and 19% internal carotid origin. Among the patients, 68% presented with acute hemorrhage, 24% with impending bleed, and 8% with threatened bleed. All patients underwent intervention: 38% received endovascular coil embolization, 30% stent grafts, 22% surgical ligation, and 10% primary vessel repair or bypass grafting. Although major complications were rare, 10.8% of patients had perioperative stroke. Sixteen recurrent bleeding episodes involving 12 arteries occurred in 11 patients (29.73%). Median rebleeding time was 7 days (interquartile range, 6-49). Estimated recurrent bleeding risk at 30 days and 6 months was 24% and 34%, respectively. Of the patients, 91.9% survived to hospital discharge. The 90-day and 1-year estimated survivals were 60.9% and 36.6%, respectively.

Conclusions: Carotid blowout syndrome associated with head and neck cancer carries poor mid- and long-term prognoses; however, mortality may be related more to the advanced stage of disease rather than carotid involvement or associated intervention. Both surgical and endovascular approaches may be efficacious in cases of acute hemorrhage but carry a significant risk of periprocedural stroke and recurrent bleeding.
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http://dx.doi.org/10.1016/j.jvs.2015.12.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884149PMC
June 2016

Catheter-Directed Interventions for Acute Pulmonary Embolism: The Jury Is Still Out.

Chest 2015 Sep;148(3):e93

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA. Electronic address:

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http://dx.doi.org/10.1378/chest.15-1011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589910PMC
September 2015

Dealing honestly with an honest mistake.

J Vasc Surg 2010 Feb;51(2):494-5

Texas A&M Health Science Center College of Medicine, College Station, TX 77843-1114, USA.

A 70-year-old woman was admitted for a symptomatic left iliofemoral deep vein thrombosis. She underwent percutaneous mechanical thrombectomy, followed by overnight thrombolysis. The next day her clot had resolved, and a culprit left iliac vein stenosis was identified. After stent placement, a heparin infusion was initiated and the patient was taken back to the ward. At 11 the evening after the procedure, the resident on call was contacted to verify the written order. The resident stated that the heparin dose was to be 250 U/h; however, the nurse documented 2500 U/h and changed the infusion pump at the patient's bedside. At 5:30 the next morning, the resident was notified that the patient's partial thromboplastin time was >300 seconds and promptly shut off the heparin infusion. No noticeable adverse events occurred because of the high heparin dosing. The charge nurse was notified, as was risk management. What should the patient be told?
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http://dx.doi.org/10.1016/j.jvs.2009.11.001DOI Listing
February 2010

Modular software platform for low-dose electron microscopy and tomography.

J Microsc 2007 Dec;228(Pt 3):384-9

Graduate Program in Structural and Computational Biology and Molecular Biophysics, and National Center for Macromolecular Imaging, #Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX 77030, USA.

Transmission electron microscopy imaging protocols required by structural scientists vary widely and can be laborious without tailor-made applications. We present here the jeol automated microscopy expert system (james) api integrator, a programming library for computer control of transmission electron microscopy operations and equipment. james has been implemented on JEOL microscopes with Gatan CCDs but is designed to be modular so it can be adapted to run on different microscopes and detectors. We have used the james api integrator to develop two applications for low-dose digital imaging: james imaging application and the mr t tomographic imaging application. Both applications have been widely used within our NCRR-supported Center for routine data collection and are now made available for public download.
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http://dx.doi.org/10.1111/j.1365-2818.2007.01856.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384816PMC
December 2007