Publications by authors named "Nii-Kabu Kabutey"

54 Publications

Kidney allograft infarction associated with transplant renal artery stenosis in a COVID-19 kidney transplant recipient.

Clin Nephrol Case Stud 2021 26;9:93-104. Epub 2021 Jul 26.

Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange.

Kidney allograft infarction is rare, but an urgent condition that requires prompt intervention to avoid allograft loss. Renal artery thrombosis is the leading cause of infarction. Apart from traditional risk factors for thrombosis, emerging SARS-CoV-2 predisposes patients to thrombotic diseases both in arterial and venous vasculatures. We report a case of kidney transplant recipient with known transplant renal artery stenosis (TRAS) status post angioplasty with severe COVID-19, complicated by oliguric acute kidney injury requiring continuous renal replacement therapy (CRRT). She did not have a history of thromboembolic disease. The hospital course was complicated by new-onset atrial and ventricular fibrillation and cardiac arrest requiring multiple rounds of cardiopulmonary resuscitation. She had no signs of renal recovery, and an abdominal CT scan showed evidence of allograft infarcts. She underwent an allograft nephrectomy. Pathology revealed diffuse thrombotic microangiopathy involving glomeruli, arterioles, and arteries associated with diffuse cortical infarction with negative SARS-CoV-2 immunostain and in situ hybridization. This is the first case of kidney allograft infarct with a history of TRAS in a COVID-19 patient. Underlying TRAS and COVID-19-associated thrombosis in this patient are unique and likely play a key role in allograft infarction from arterial thrombosis. Recognizing risk factors and early therapy for allograft infarction may improve transplant outcomes.
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http://dx.doi.org/10.5414/CNCS110462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387732PMC
July 2021

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature.

Ann Vasc Surg 2021 Apr 17;72:666.e13-666.e21. Epub 2020 Dec 17.

Division of Vascular and Endovascular Surgery, Department of Surgery, Irvine Medical Center, University of California, Orange, CA. Electronic address:

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.
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http://dx.doi.org/10.1016/j.avsg.2020.10.034DOI Listing
April 2021

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures.

Am Surg 2021 May 10;87(5):747-752. Epub 2020 Nov 10.

Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, CA, USA.

Background: A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed.

Results: From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, = .029) and BPI (18.2% vs. .4%, < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, < .001).

Conclusion: The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.
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http://dx.doi.org/10.1177/0003134820952832DOI Listing
May 2021

Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury.

Ann Vasc Surg 2021 Apr 16;72:440-444. Epub 2020 Sep 16.

Department of General Surgery, University of California, Irvine Medical Center, Orange, CA. Electronic address:

Background: Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected.

Methods: The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality.

Results: A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95).

Conclusions: The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.
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http://dx.doi.org/10.1016/j.avsg.2020.08.149DOI Listing
April 2021

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time.

Ann Vasc Surg 2021 Feb 2;71:428-436. Epub 2020 Sep 2.

University of California, Irvine, Department of Surgery, Orange, CA.

Background: Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time.

Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs.

Results: Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067).

Conclusions: The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.
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http://dx.doi.org/10.1016/j.avsg.2020.08.103DOI Listing
February 2021

Penetrating Abdominal Aortic Injury: Comparison of ACS-Verified Level-I and II Trauma Centers.

Vasc Endovascular Surg 2020 Nov 13;54(8):692-696. Epub 2020 Aug 13.

Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA.

Objectives: Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI.

Methods: We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers.

Results: PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99).

Conclusion: Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.
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http://dx.doi.org/10.1177/1538574420947234DOI Listing
November 2020

Analysis of Endovascular Aneurysm Repair for Small Abdominal Aortic Aneurysms in Males.

J Surg Res 2020 12 21;256:163-170. Epub 2020 Jul 21.

Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California. Electronic address:

Background: Current guidelines recommend repair of abdominal aortic aneurysms (AAAs) when ≥5.5 cm. This study sought to evaluate the incidence of male patients undergoing endovascular aneurysm repair (EVAR) for AAAs of various diameters (small <4 cm; intermediate 4-5.4 cm; standard ≥5.5 cm). We analyzed predictors of mortality, hypothesizing that smaller AAAs (<5.5 cm) have no differences in associated risk of mortality compared to standard AAAs (≥5.5 cm).

Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for male patients undergoing elective EVAR. Patients were stratified by aneurysm diameter. A multivariable logistic regression analysis for clinical outcomes, adjusting for age, clinical characteristics, and comorbidities, was performed.

Results: A total of 8037 male patients underwent EVAR with 3926 (48.9%) performed for AAAs <5.5 cm. There was no difference in mortality, readmission, major complications, myocardial infarction, stroke, or ischemic complications among the 3 groups (P > 0.05). In AAAs <5.5 cm, predictors of mortality included prior abdominal surgery (odds ratio [OR], 5.77; confidence interval [CI], 1.38-24.13; P = 0.016), weight loss (OR, 43.4; CI, 3.78-498.7; P = 0.002), disseminated cancer (OR, 17.9; CI, 1.30-245.97; P = 0.031), and diabetes (OR, 6.09; CI, 1.52-24.36; P = 0.011).

Conclusions: Nearly 50% of male patients undergoing elective EVAR were treated for AAAs <5.5 cm. There was no difference in associated risk of mortality for smaller AAAs compared to standard AAAs. The strongest predictors of mortality for patients with smaller AAAs were prior abdominal surgery, weight loss, disseminated cancer, and diabetes.
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http://dx.doi.org/10.1016/j.jss.2020.06.030DOI Listing
December 2020

Access Type for Endovascular Repair in Ruptured Abdominal Aortic Aneurysms Does Not Affect Major Morbidity or Mortality.

Ann Vasc Surg 2021 Jan 10;70:181-189. Epub 2020 Jul 10.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Background: There are limited data on access type when treating ruptured abdominal aortic aneurysms (AAAs) with endovascular aneurysm repair (EVAR). Our study's objective was to evaluate if the type of access in ruptured AAAs affected outcomes.

Methods: The Vascular Quality Initiative was queried from 2009 to 2018 for all ruptured AAAs treated with an index EVAR. Procedures were grouped by access type: percutaneous, open, and failed percutaneous that converted to open access. Patients with iliac access, both percutaneous and open access, and concurrent bypass were excluded. Baseline characteristics, procedure details, and outcomes were collected. Univariable and multivariable analyses were performed.

Results: There were 1,206 ruptured AAAs identified-739 (61.3%) was performed by percutaneous access, 416 (34.5%) by open access, and 51 (4.2%) by failed percutaneous that converted to open access. Percutaneous access, compared with open access and failed percutaneous access, respectively, had the shortest operative time (min, median) (111 vs. 138 vs. 180, P < 0.001) and was most often performed under local anesthesia (16.7% vs. 5% vs. 9.8%, P < 0.001). The amount of contrast used was similar between the approaches. Univariable analysis comparing percutaneous access, open access, and failed percutaneous access showed differences in 30-day mortality (19.9% vs. 24.8% vs. 39.2%, P = 0.002), postoperative complications (33.7% vs. 40.2% vs. 54%, P = 0.003), and cardiac complications (18.2% vs. 19.8% vs. 34.7%, P = 0.018). However, multivariable analysis did not show access type to have a significant effect on cardiac complications, pulmonary complications, any complications, return to the operating room, or perioperative mortality. Open access was independently associated with a prolonged length of stay (means ratio 1.17, 95% confidence interval (CI) 1.04-1.33, P = 0.012). Factors independently associated with failed percutaneous were prior bypass (odds ratio (OR) 9.77, 95% CI 2.44-39.16, P = 0.001) and altered mental status (OR 2.45, 95% CI 1.17-5.15, P = 0.018).

Conclusions: Access type for ruptured AAAs was not independently associated with major morbidity or mortality but did have a differential effect on length of stay. Access during these emergent procedures should be based on surgeon preference and experience.
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http://dx.doi.org/10.1016/j.avsg.2020.07.004DOI Listing
January 2021

Unique Case of Recurrent Pelvic Congestion Syndrome Treated with Median Sacral Vein Embolization.

Ann Vasc Surg 2020 Oct 10;68:569.e1-569.e7. Epub 2020 Apr 10.

Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA. Electronic address:

Background: Pelvic congestion syndrome (PCS) is defined as noncyclical pelvic pain or discomfort caused by dilated parauterine, paraovarian, and vaginal veins. PCS is typically characterized by ovarian venous incompetence that may be due to pelvic venous valvular insufficiency, hormonal factors, or mechanical venous obstruction.

Methods: We describe a case of a 38-year-old multiparous female with a history of pelvic pressure, vulvar varices, and dyspareunia. She underwent left gonadal vein coil embolization in 2014 for PCS that lead to symptomatic relief of her pain. Four years later, the patient returned for recurrent symptoms. Magnetic resonance venogram demonstrated dilated pelvic varices. The previously embolized left gonadal vein remained thrombosed, and there was no evidence of right gonadal vein insufficiency. However, catheter-based venography revealed a large, dilated, and incompetent median sacral vein.

Results: Pelvic venography demonstrated left gonadal vein embolization without any evidence of reflux. The right gonadal vein was also nondilated without reflux. Internal iliac venography showed large cross-pelvic collaterals and retrograde flow via a large, dilated median sacral vein. Coil embolization of the median sacral vein resulted in a dramatic reduction of pelvic venous reflux and resolution of symptoms.

Conclusions: Recurrence of PCS can occur after ovarian vein embolization through other tributaries in the venous network. The median sacral vein is a rare cause of PCS. We present an interesting case of a successfully treated recurrent PCS with coil embolization of an incompetent median sacral vein.
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http://dx.doi.org/10.1016/j.avsg.2020.04.008DOI Listing
October 2020

Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma.

Ann Vasc Surg 2020 Jul 21;66:242-249. Epub 2020 Jan 21.

Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA.

Background: Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population.

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI.

Results: From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001).

Conclusions: A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
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http://dx.doi.org/10.1016/j.avsg.2020.01.079DOI Listing
July 2020

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis.

Ann Vasc Surg 2020 May 8;65:10-16. Epub 2019 Nov 8.

Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA. Electronic address:

Background: Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO digital subtraction angiography (CO-DSA) and balloon angioplasty to manage failing renal transplants.

Methods: Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities.

Results: Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence.

Conclusions: CO-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.
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http://dx.doi.org/10.1016/j.avsg.2019.11.009DOI Listing
May 2020

Racial Disparities in Limb Amputations After Traumatic Vascular Injury.

J Clin Orthop Trauma 2019 Oct 14;10(Suppl 1):S100-S105. Epub 2019 May 14.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

Objectives: The influence of race or ethnicity on limb loss after traumatic vascular injury is unclear. We sought to determine whether there were racial differences in rates of amputation between American Indians, blacks, Asians, and Hispanics compared to white patients following arterial axillosubclavian vessel injury (ASVI), femoral artery injury (FAI), or popliteal artery injury (PAI). As black race has been identified as an independent prognostic factor for postsurgical complication in trauma-associated lower extremity amputation, we further hypothesized that black race would be associated with a higher risk for limb loss after arterial ASVI, FAI, and PAI injury in a large national database.

Methods: The National Trauma Data Bank was queried for patients ≥16-years-old with arterial ASVI, FAI, or PAI to determine the risk of arm, above knee amputation (AKA), and below knee amputation (BKA), respectively. Covariates were included in separate multivariable logistic regression models for analysis. The reference group included white trauma patients.

Results: From 5,683,057 patients, 21,843 were identified with arterial ASVI, FAI, or PAI (<0.4%). For arterial ASVI, American Indian race was associated with higher risk for upper-extremity amputation as compared to white race (OR = 5.10, CI = 1.62-16.06, p < 0.05). For FAI, black race was associated with (OR = 0.66, CI = 0.49-0.89, p < 0.05) a lower risk of AKA, compared to white race. For PAI, race was not associated with risk for BKA.

Conclusion: Black race is associated with a lower risk of AKA after FAI, compared to whites. Race was not associated with a risk for limb loss after PAI. Future prospective studies examining socioeconomic factors and access to healthcare within this patient population is warranted to identify barriers and areas of improvement.
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http://dx.doi.org/10.1016/j.jcot.2019.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823806PMC
October 2019

Predictors of blunt abdominal aortic injury in trauma patients and mortality analysis.

J Vasc Surg 2020 06 4;71(6):1858-1866. Epub 2019 Nov 4.

Department of Surgery, University of California, Irvine, Orange, Calif.

Objective: Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI.

Results: From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001).

Conclusions: In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.
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http://dx.doi.org/10.1016/j.jvs.2019.07.095DOI Listing
June 2020

Novel Utility of Amplatzer Septal Occlusion Device to Treat Persistent Aortocaval Fistula following Ruptured Endovascular Aortic Aneurysm Repair (rEVAR).

Ann Vasc Surg 2020 May 31;65:283.e7-283.e11. Epub 2019 Oct 31.

Division of Vascular Surgery, Department of Surgery, University of California Irvine School of Medicine, Irvine, CA.

Aortocaval fistulas following endovascular repair of ruptured abdominal aortic aneurysms (rAAA) are rare. We herein describe repair using an Amplatzer Septal Occluder in a 68-year-old male who presented to the emergency department 6 months after ruptured endovascular aneurysm repair (rEVAR) with right heart failure. With the assistance of diagnostic angiography and intravascular ultrasound, the patient was found to have a 1.2 cm diameter aortocaval fistula and a type-II endoleak. His aortocaval fistula was successfully closed using an Amplatzer septal occluder device after failure of attempted closure with an Amplatzer plug and coiling of the aneurysm sac. His symptoms of heart failure improved, and he was discharged to an acute rehabilitation unit. Follow-up at 3 months demonstrated continued improvement in heart failure symptoms, and a small persistent type II endoleak. Aortocaval fistulae are a potentially fatal complication of rAAA. We discuss the sequelae and treatment strategies of aortocaval fistulas following rEVAR including the use of the Amplatzer Septal Occluder.
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http://dx.doi.org/10.1016/j.avsg.2019.10.079DOI Listing
May 2020

Analysis of blunt cerebrovascular injury in pediatric trauma.

J Trauma Acute Care Surg 2019 12;87(6):1354-1359

From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, (A.G., M.D., M.L., R.M.F., N.-K.K., R.B., J.N.), University of California, Irvine, Orange; and Department of Anesthesia (C.M.K.), University of Southern California, Los Angeles, California.

Background: Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two principal screening criteria for BCVI in children are the Utah and McGovern Score with motor vehicle accident (MVA) considered to be a predictor for BCVI. We sought to confirm previously reported risk factors and identify novel associations with BCVI in pediatric patients.

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years presenting after blunt trauma. A multivariable logistic regression was used to determine risk of BCVI.

Results: From 69,149 pediatric patients, 109 (<0.2%) had BCVI. The median age was 13 years, and the median Injury Severity Score was 25. More than half the patients were involved in MVAs (53.2%) and had a skull base fracture (53.2%). Factors independently associated with BCVI include skull base fracture (odds ratio [OR], 3.84; 95% confidence interval [CI], 2.40-6.14; p < 0.001), cervical spine fracture (OR, 3.15; 95% CI, 1.91-5.18; p < 0.001), intracranial hemorrhage (OR, 3.11; 95% CI, 1.89-5.14; p < 0.001), Glasgow Coma Scale score of 8 or less (OR, 2.11; 95% CI, 1.33-3.54; p = 0.003), and mandible fracture (OR, 1.99; 95% CI, 1.05-3.84; p = 0.04). Motor vehicle accident was not an independent predictor for BCVI (p = 0.07).

Conclusion: In the largest analysis of pediatric BCVI to date, skull base fracture had the strongest association with BCVI. Other associations to pediatric BCVI included cervical spine and mandible fracture. Motor vehicle accident, previously identified to be associated with BCVI, was not an independent risk factor in our analysis. A future multicenter study incorporating newly identified variables in a scoring system to screen for BCVI is warranted.

Level Of Evidence: Level IV (Prognostic/Epidemiologic).
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http://dx.doi.org/10.1097/TA.0000000000002511DOI Listing
December 2019

Hepatoportal Venous Trauma: Analysis of Incidence, Morbidity, and Mortality.

Vasc Endovascular Surg 2020 Jan 30;54(1):36-41. Epub 2019 Sep 30.

University of California, Irvine Medical Center, Orange, CA, USA.

Objectives: Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients.

Methods: The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis.

Results: From 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries ( > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, = .002).

Conclusion: Traumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.
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http://dx.doi.org/10.1177/1538574419878577DOI Listing
January 2020

Locoregional Anesthesia Offers Improved Outcomes after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

Ann Vasc Surg 2019 Aug 22;59:134-142. Epub 2019 Feb 22.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA.

Background: General anesthesia (GA) and locoregional anesthesia (LA) are two anesthetic options for endovascular repair of ruptured abdominal aortic aneurysms (REVAR). Studies on elective endovascular repair of nonruptured aneurysms have indicated that in select patients, LA may provide improved outcomes compared with GA. We aimed to examine the 30-day outcomes in patients undergoing REVAR using GA and LA in a contemporary nationwide cohort of patients presenting with ruptured abdominal aortic aneurysms.

Methods: Patients who underwent REVAR using GA and LA from January 2011 through December 2015, inclusively, were studied in the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)-targeted EVAR database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and 30-day postoperative outcomes between the two groups.

Results: Six-hundred ninety patients were identified to have undergone REVAR from 2011 to 2015, of which 12.5% (86) were performed under LA. For the entire cohort, the mean age was 74.3 years, and 80% were male. Mean aneurysm size was 7.6 cm and did not differ between the two anesthetic groups. Major comorbidities were similar between both groups, except a slightly higher rate of congestive heart failure in the LA group (7.0% vs. 2.5%, P = 0.02). Proximal or distal aneurysm extent also did not differ between the two groups. There was a significantly higher rate of bilateral percutaneous access in the LA group (59.3% vs. 25.2%, P < 0.01). REVAR under LA had shorter mean operative time (132 vs. 166 min, P < 0.01) and lower rate of concomitant lower extremity revascularization (2.3% vs. 10.6%, P < 0.01). There were no differences in need for perioperative transfusion or any other adjunctive procedures. Ultimately, 30-day mortality was significantly lower in the LA group (16.3% vs. 25.2%, P < 0.01). This difference was more pronounced in the subgroup of patients with hemodynamic instability (15.4% vs. 39.4%, P < 0.01). The LA group also demonstrated significantly shorter intensive care unit (ICU) length of stay (3.0 vs. 5.0 days, P = 0.01) and low rates of postoperative pneumonia (3.5% vs. 10.9%, P = 0.03). After adjustment for demographics, comorbid conditions, hypotensive status, and aneurysm characteristics, there was a two-fold higher mortality in patients undergoing REVAR using GA versus LA, with a four-fold increase in the hemodynamically unstable cohort.

Conclusions: The ACS NSQIP-targeted EVAR database shows that LA is used in only 12.5% of patients undergoing REVAR in this nationwide cohort. This rate does not change when examining the subset of patients who are hemodynamically unstable. Other benefits include shorter ICU lengths of stay and lower rates of pneumonia. These data suggest that LA should be considered in patients undergoing REVAR, regardless of hemodynamic instability.
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http://dx.doi.org/10.1016/j.avsg.2018.12.083DOI Listing
August 2019

Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury.

Vascular 2019 Jun 14;27(3):252-259. Epub 2018 Nov 14.

1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA.

Objective: Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury.

Methods: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis.

Results: Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001).

Conclusions: The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.
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http://dx.doi.org/10.1177/1708538118811231DOI Listing
June 2019

Decreased National Rate of below the Knee Amputation in Patients with Popliteal Artery Injury.

Ann Vasc Surg 2019 May 25;57:1-9. Epub 2018 Jul 25.

Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA.

Background: Popliteal arterial injury (PAI) is the second most common infrainguinal arterial injury after femoral artery injury with an incidence < 0.2%. A 2003 analysis of the National Trauma Data Bank (NTDB) reported a below the knee amputation (BKA) rate of 7.1% in patients with PAI as well as higher risk in those with an associated fracture or nerve injury. Given advances in vascular surgical techniques, improved multidisciplinary care, and expeditious diagnosis with computed tomography angiography, we hypothesized that the national rate of BKA in patients with PAI has decreased and sought to identify risk factors for BKA in patients with PAI.

Methods: A retrospective analysis of the NTDB was performed from 2007 to 2015. Patients ≥15 years of age with PAI were included and grouped by mechanism of injury (blunt versus penetrating). Interfacility transfers were excluded. The primary outcome of interest was BKA. Univariable and multivariable analyses were performed to identify predictors of BKA in patients with PAI.

Results: From 4,385,698 patients, 5,143 were identified with PAI (<0.2%) with most involved in a blunt mechanism (56.8%). The overall limb loss rate was 5.1% (decreased from 7.1% in 2003, P = 0.0037). After adjusting for covariates, a blunt mechanism (odds ratio [OR] = 3.53, confidence intervals [CI] = 2.49-5.01, P < 0.001) and open proximal tibia/fibula fracture or dislocation (OR = 2.71, CI = 2.08-3.54, P < 0.001) were independent risk factors for BKA in patients with PAI. A combined popliteal vein injury (PVI) did not increase the risk for BKA (P = 0.64).

Conclusions: The national rate of limb loss in trauma patients with PAI has decreased from 7.1 to 5.1%. A blunt mechanism of injury as well as proximal open tibia/fibula fracture or dislocation continue to be the independent risk factors for BKA. Confirming a previous report, we found a combined PVI not to be associated with higher risk for BKA. Future prospective research to determine other possible contributing factors such as intraoperative hemodynamics and utilization of vascular shunt and fasciotomy appears warranted.
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http://dx.doi.org/10.1016/j.avsg.2018.07.002DOI Listing
May 2019

Blunt cerebrovascular injury incidence, stroke-rate, and mortality with the expanded Denver criteria.

Surgery 2018 09 6;164(3):494-499. Epub 2018 Jun 6.

University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA.

Background: Blunt carotid and vertebral artery injury, collectively termed blunt cerebrovascular injury occur in less than 1% of blunt traumas. Conventional indications for screening miss up to 20% of blunt cerebrovascular injuries. Therefore, the expanded Denver criteria were created in 2012. We hypothesized the introduction of the expanded Denver criteria would lead to an increase in the national detection of blunt cerebrovascular injury with a subsequent decrease in stroke rate.

Methods: The National Trauma Data Bank was queried for blunt trauma admissions. Patients were divided into 2 groups: pre-expanded Denver criteria (2007-2011) or post-expanded Denver criteria era (2013-2015). The primary endpoint was the incidence of blunt cerebrovascular injury, which was used as a surrogate for detection.

Results: There were 10,183 blunt cerebrovascular injuries with 5,364 blunt cerebrovascular injuries in the pre-expanded Denver criteria group (0.19%) and 4,819 blunt cerebrovascular injuries in the post-expanded Denver criteria group (0.22%; P < .001). The stroke-rate in the post-expanded Denver criteria was significantly higher (9.2% vs 5.5%; OR 2.73, CI 2.29-3.25, P < .001). The strongest associated injury with blunt cerebrovascular injury was skull-base fracture (OR 3.61, CI 3.46-3.77, P < .001).

Conclusion: The detection of blunt cerebrovascular injury has increased by 16% since the publication of the expanded Denver criteria. Skull-base fracture is the strongest traumatic risk factor for blunt cerebrovascular injury. Although detection may have increased, the stroke-rate nearly doubled in the post-eDC era. This warrants future research.
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http://dx.doi.org/10.1016/j.surg.2018.04.032DOI Listing
September 2018

REBOA in hemorrhagic shock: a unique non-responder?

Trauma Surg Acute Care Open 2017 9;2(1):e000100. Epub 2017 Jun 9.

Department of Surgery, University of California Irvine, Irvine, California, USA.

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http://dx.doi.org/10.1136/tsaco-2017-000100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877911PMC
June 2017

Perioperative risk factors for hospital readmission after elective endovascular aortic aneurysm repair.

J Vasc Surg 2018 09 3;68(3):731-738.e1. Epub 2018 Apr 3.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California Irvine Medical Center, Orange, Calif.

Background: Elective endovascular aneurysm repair (EVAR) is generally well tolerated. However, the incidence of hospital readmission after EVAR and the risk factors and reasons for it are not well studied. This study sought to determine the incidence, to characterize the indications, and to identify perioperative patient-centered risk factors for hospital readmission within 30 days after elective EVAR.

Methods: All patients who underwent EVAR electively in 2012 to 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular database (n = 3886). Preoperative demographics, operation-specific variables, and postoperative outcomes were compared between those who were readmitted within 30 days of the index operation and those who were not. Multivariate logistic regression was then used to determine independent predictors of hospital readmission.

Results: The unadjusted 30-day readmission rate after EVAR was 8.2%. Of all readmissions, 55% were for reasons related to the procedure. Median time to readmission was 12 days. Significant preoperative risk factors associated with readmission were female sex, preoperative steroid use, congestive heart failure, and dialysis dependence (P < .05). Multiple postoperative medical complications were independently predictive of readmission, including myocardial infarction and deep venous thrombosis (P < .05). Surgical complications that were independently predictive of readmission were surgical site infection (odds ratio, 10.24; 95% confidence interval, 5.31-19.75; P < .01) and need for unplanned reoperation (odds ratio, 17.50; 95% confidence interval, 10.43-29.37; P < .01). Readmitted patients ultimately had significantly higher rates of 30-day mortality (3.5% vs 0.3%; P < .01).

Conclusions: Hospital readmissions remain a costly problem after vascular surgery and are associated with 30-day mortality after elective EVAR. Whereas female sex and certain irreversible medical comorbidities are nonmodifiable, focusing on medical optimization and identifying those perioperative variables that can affect the need for post-EVAR interventions will be an important step in decreasing hospital readmission.
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http://dx.doi.org/10.1016/j.jvs.2017.12.042DOI Listing
September 2018

Comparison of percutaneous versus open femoral cutdown access for endovascular repair of ruptured abdominal aortic aneurysms.

J Vasc Surg 2017 11;66(5):1364-1370

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif. Electronic address:

Objective: Ruptured endovascular aortic aneurysm repair (REVAR) is being increasingly used to treat ruptured abdominal aortic aneurysms (rAAAs). However, the comparison between totally percutaneous (pREVAR) vs femoral cutdown (cREVAR) access for REVAR has not been studied. We used a national surgical database to evaluate the 30-day outcomes in patients undergoing pREVAR vs cREVAR.

Methods: Patients who underwent EVAR for rAAA between 2011 and 2014, inclusively, were studied in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and postoperative outcomes between those who had pREVAR and cREVAR.

Results: We identified 502 patients who underwent REVAR, of which 129 had pREVAR (25.7%) and 373 cREVAR (74.3%). Between 2011 and 2014, the use of totally percutaneous access for repair increased from 14% to 32%. Of all patients undergoing REVAR, 24% had bilateral percutaneous access, 2% had attempted percutaneous access converted to cutdown, 64% had bilateral femoral cutdowns, and 10% had single femoral cutdown. Univariate analysis showed there were no significant differences in age, gender, body mass index, AAA size, or other high-risk physiologic comorbidities between the two groups. There was also no difference in rates of preoperative hemodynamic instability (48.1% vs 45.0%; P = .55) or need for perioperative transfusion (67.4% vs 67.8%; P = .94). There was a higher incidence of use of regional anesthesia for pREVAR compared with cREVAR (20.9% vs 7.8%; P < .01). The incidence of postoperative wound complications was similar between both groups (4.8% vs 5.4%; P = .79), whereas hospital length of stay was shorter in the pREVAR group (mean difference, 1.3 days). Overall 30-day mortality was higher in the pREVAR group (28.7% vs 20.1%; P = .04), and operative time was longer (mean difference, 6.3 minutes). However, when pREVARs done in 2011 to 2012 were compared with those done in 2013 to 2014, 30-day mortality decreased from 38.2% to 25.3% and operative time decreased by 25 minutes (188 to 163 minutes). Multivariate analysis showed there were no significant differences in mortality, wound complications, hospital length of stay, or operative time between pREVAR and cREVAR.

Conclusions: The ACS NSQIP targeted vascular database shows that there has been increased adoption of pREVAR in recent years, with improved mortality and operative time over the 4-year study period. At this point, pREVAR has not yet been shown to be superior to cREVAR for rAAA, but these outcome improvements are encouraging and likely attributable to increased operator experience.
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http://dx.doi.org/10.1016/j.jvs.2017.03.431DOI Listing
November 2017

Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease.

J Vasc Surg 2017 06;65(6):1680-1689

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif. Electronic address:

Objective: Concern over perioperative and long-term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI).

Methods: Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently.

Results: From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below-knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below-knee). Patients undergoing LEE had higher rates of female gender, hypertension, end-stage renal disease, and diabetes (all P ≤ .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P < .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P = .02). On risk-adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.13; P = .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23-0.45; P < .01) and no statistically significant difference in 30-day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17-1.97; P = .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37-1.52; P = .42,). Also in IC group, there was a trend for lower major amputation rates ≤30 days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB.

Conclusions: In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb-threatening IC.
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http://dx.doi.org/10.1016/j.jvs.2017.01.025DOI Listing
June 2017

Physiologic Cryoamputation in Managing Critically Ill Patients with Septic, Advanced Acute Limb Ischemia.

Ann Vasc Surg 2017 Jul 7;42:50-55. Epub 2017 Mar 7.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA. Electronic address:

Background: Certain critically ill patients with advanced acute limb ischemia with a nonviable extremity may be unsuitable for transport to the operating room to undergo definitive amputation. In these unstable patients, rapid regional cryotherapy allows for prompt infectious source control and correction of hemodynamic and metabolic abnormalities, thereby lessening the risk associated with definitive surgical amputation. We describe our refined technique for lower extremity physiologic cryoamputation and review our institutional experience.

Methods: After adequate analgesia is administered to the patient, a heating pad is secured circumferentially at the proximal amputation margin and the affected extremity is placed in a customized Styrofoam cooler. A circumferential seal is secured at the proximal chill zone without use of a tourniquet and dry ice is placed into the cooler to surround the entire affected leg. Delayed definitive lower extremity amputation is later performed when hemodynamic and metabolic derangements are corrected.

Results: We reviewed 5 patients who underwent lower extremity cryoamputation with this technique identified at our institution between 2005 and 2015. Age ranged from 31 to 79 years old. All presented with severe foot infection and septic shock requiring vasopressor support. All 5 patients stabilized hemodynamically following the initial cryoamputation and later underwent definitive lower extremity amputation, with a median time of 3 days following initial cryoamputation.

Conclusions: Lower extremity physiologic cryoamputation is an effective, immediate bedside procedure that can provide local source control and the opportunity for correction of metabolic derangements in initially unstable patients to lessen the risk for definitive major lower extremity amputation. Refinement of the cryoamputation technique, as described in this report, allows for a predictable and reproducible physiologic amputation.
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http://dx.doi.org/10.1016/j.avsg.2016.11.006DOI Listing
July 2017

Novel endovascular technique for removal of adherent PICC.

J Vasc Access 2016 Nov 2;17(6):e153-e155. Epub 2016 Nov 2.

Division of Vascular and Endovascular Surgery, University of California Irvine, Irvine, California - USA.

Introduction: Peripherally inserted central catheters (PICCs) are a popular alternative to central venous lines. PICCs can provide reliable long-term access for intravenous fluids, antibiotics and total parenteral nutrition. Multiple factors can contribute to difficult PICC removal including adherent fibrin and thrombus formation around the catheter. We discuss a novel endovascular retrieval technique to remove tightly adherent PICCs.

Case Presentation: A 42-year-old male with history of chronic pancreatitis requiring intravenous pain medications, presented with right upper extremity single lumen PICC that could not be removed by standard techniques. The PICC line had been in place for approximately three years and was no longer functioning appropriately. Ultrasonography demonstrated thrombus alongside the length of the PICC.

Results: In order to remove the PICC we utilized a novel endovascular technique. A 0.018" mandril wire was passed through the lumen of the PICC. Next, a puncture alongside the PICC was performed to place a 6 French (Fr) sheath. A snare was then maneuvered through the sheath and used to capture the tip of the mandril wire. The snare, mandril wire and PICC where withdrawn in unison, looping the PICC tip within the basilic vein. The tip of the PICC was positioned near the antecubital fossa. A small incision was performed to capture the tip of the PICC to remove the catheter.

Discussion: Tightly adherent PICCs can result after prolonged intraluminal dwell times. We describe a novel endovascular technique that can be utilized for safe and successful removal of difficult embedded PICCs.
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http://dx.doi.org/10.5301/jva.5000580DOI Listing
November 2016

Endovascular Management of Concomitant Thoracic and Abdominal Aortic Ruptures Resulting from Brucellosis Aortitis.

Ann Vasc Surg 2017 Jan 20;38:190.e1-190.e4. Epub 2016 Aug 20.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA. Electronic address:

Background: Acute aortic symptomatology is an unusual manifestation of Brucella melitensis infection. We present a rare case of acute multifocal thoracic and abdominal aortic ruptures arising from Brucellosis aortitis managed exclusively with endovascular surgery.

Methods: A 71-year-old Hispanic male with a history of atrial fibrillation and prior stroke on chronic anticoagulation presented with shortness of breath and malaise. In addition, he had been treated approximately 1 year previously in Mexico for B. melitensis bacteremia after eating fresh unpasteurized cheese. Computed tomography (CT) angiography demonstrated an acute rupture of the descending thoracic aorta just proximal to the celiac trunk and synchronous rupture at the abdominal aortic bifurctation.

Results: The patient was taken emergently to the hybrid operating room, where synchronous supraceliac thoracic aorta and abdominal aortoiliac stent grafts were deployed under local anesthesia. Completion angiography demonstrated total exclusion of the thoracic and abdominal extravasation with no evidence of endoleak. Twenty hours postoperatively, the patient became acutely obtunded and hypotensive. Repeat CT angiography demonstrated contrast extravasation at the level of the excluded aortic bifurcation. Emergent angiography confirmed a type II endoleak with free extraluminal rupture. Multiple coils were placed at the level of the aortic bifurcation between the left limb of the stent graft and the aortic wall to tamponade the endoleak. No further extravasation was noted on final aortography. Postoperatively, blood cultures confirmed the diagnosis of B. melitensis. The patient was treated with systemic doxycycline, gentamicin, and rifampin. Resolution of the acute event occurred without additional sequelae and he was discharged from the hospital to a rehabilitation facility.

Conclusions: Concomitant multifocal aortic ruptures arising from Brucellosis aortic infection is a very rare event. In this case, the patient was successfully treated with thoracic and abdominal endovascular stent-graft exclusion, coiling, and long-term targeted antibiotics.
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http://dx.doi.org/10.1016/j.avsg.2016.08.007DOI Listing
January 2017

Development and evaluation of a retroperitoneal dialysis porcine model.

Clin Nephrol 2016 Aug;86(2):70-7

Objectives: We attempted to create a surgical model to evaluate the retroperitoneal space for the ability to transfer solutes through the retroperitoneal membrane. Our dual objectives were to develop a technique to assess the feasibility of retroperitoneal dialysis (RPD) in a porcine model.

Methods: We incorporated two 35-kg Yorkshire pigs for this pilot study. In the first animal, we clamped renal vessels laparoscopically. In the second animal, we embolized renal arteries. In both animals, we dilated the retroperitoneal space bilaterally and deployed dialysis catheters. We measured serum creatinine (Cr), urea, and electrolytes at baseline 6 hours before the dialysis and every 4 hours after.

Results: We successfully created retroperitoneal spaces bilaterally and deployed dialysis catheters in both animals. In the first animal, dialysate and plasma Cr ratio (D/P) on the left and right side were 0.43 and 0.3, respectively. Cr clearance by 40 minutes of dialysis treatment was 6.3 mL/min. The ratio of dialysate glucose at 4 hours dwell time to dialysate glucose at 0 dwell time (D/D0) for left/rights sides were 0.02 and 0.02, respectively. kt/Vurea was 0.43. In the second animal, D/P Cr for left/right sides were 0.34 and 0.33, respectively. kt/Vurea was 0.17. We euthanized the pigs due to fluid collection in the peritoneal space and rapid increase of serum Cr, urea, and electrolytes.

Conclusions: We demonstrated the feasibility of creation of a functionally anephric porcine model with successful development of retroperitoneal spaces using balloon inflation. Notwithstanding minimal clearance and limited diffusion capacity in this experiment, additional studies are needed to examine potential use of retroperitoneal space for peritoneal dialysis.
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http://dx.doi.org/10.5414/CN108775DOI Listing
August 2016

Influence of gender and use of regional anesthesia on carotid endarterectomy outcomes.

J Vasc Surg 2016 Jul 13;64(1):9-14. Epub 2016 May 13.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif. Electronic address:

Objective: Carotid endarterectomy (CEA) is the most commonly performed surgical procedure to reduce the risk of stroke. The operation may be performed under general anesthesia (GA) or regional anesthesia (RA). We used a national database to determine how postoperative outcomes were influenced by gender and type of anesthesia used.

Methods: All patients who underwent CEA between 2005 and 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database (N = 41,442). Incidence of stroke and myocardial infarction (MI) within 30 days as well as other postoperative complications, operative time, and hospital length of stay were examined in groups separated by gender and anesthesia type. Multivariable logistic regression with effect modification was used to determine significant risk-adjusted differences between genders and type of anesthesia to assess outcomes after CEA.

Results: The male-to-female ratio among CEA cases performed was approximately 3:2. Most cases were performed under GA (85% male patients, 86% female patients). Adjusted multivariable analysis showed no statistical difference in rates of MI and stroke based on gender or type of anesthesia used. There were, however, higher 30-day postoperative local complications and MI (both P < .05) in those who had GA vs RA regardless of gender before adjustment. Total operative time was decreased (mean difference, -8.15 minutes; 95% confidence interval, -10.09 to -6.21; P < .001) and length of stay was increased (mean difference, 0.34 day; 95% confidence interval, 0.14-0.54; P < .02) in women, with statistical significance, whether RA or GA was used.

Conclusions: On adjusted multivariate analysis, there is no statistically significant difference in postoperative incidence of MI or stroke between men and women undergoing CEA. Use of RA vs GA did not affect this finding. Furthermore, there was no correlation between gender and the type of anesthesia chosen. Women, however, experienced decreased operative times and increased length of stay regardless of anesthesia type.
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July 2016
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