Publications by authors named "Ruth L Bush"

166 Publications

Treatment strategies for various venous disorders.

Authors:
Ruth L Bush

J Cardiovasc Surg (Torino) 2021 Apr 23. Epub 2021 Apr 23.

University of Houston College of Medicine, Houston, TX, USA -

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http://dx.doi.org/10.23736/S0021-9509.21.11930-5DOI Listing
April 2021

A morphovolumetric analysis of aneurysm sac evolution after elective endovascular abdominal aortic repair.

J Vasc Surg 2021 Apr 14. Epub 2021 Apr 14.

Objectives: Abdominal aortic aneurysm (AAA) sac shrinkage after endovascular repair (EVAR) has been regarded as positive marker of EVAR success durability. The purpose of this study was to describe the morphovolumetric changes of the AAA sac during follow-up after elective EVAR, and to analyze sac shrinkage related variables.

Methods: This is a single center, retrospective, observational cohort study from a tertiary referral university hospital. All patients treated with EVAR between January 2013 and December 2018 were identified. Inclusion criteria were: elective EVAR for AAA, preoperative computed tomography angiography (CTA) within six months before EVAR and at least one postoperative CTA during the follow-up, using a standardized protocol. Aneurysm sac shrinkage was defined as diameter reduction ≥1 cm, volume shrinkage threshold was identified by a 16% reduction compared to the preoperative value. Primary outcomes were early (≤30 days) and late survival, and freedom from aneurysm-related mortality (ARM), and aortic reintervention.

Results: There were 149/325 (45.8%) who met the inclusion criteria: 133 (89.3%) were male and 16 (10.7%) female. The mean age was 74 years ± 7 (range 55-87 years); median AAA diameter was 56 mm (IQR, 50-61.2) and median volume was 138.8cm3 (range 99-178.3). Primary technical success was achieved in 145 (97.3%) patients. In-hospital mortality rate was 1.3%. The median follow-up was 42 months (IQR, 22.5-58). Both AAA diameter and volume decreased (p = 0.001 and p = 0.035, respectively) compared to preoperative measurements. Diameter shrinkage was adjudicated in 27 (18.1%) patients, volume shrinkage was observed in 42 (28.2%) patients. Cox's regression analysis demonstrated an association between the AAA diameter shrinkage and the preoperative diameter (p = 0.002; HR: 1.03; 95%CI: 1.011-1.052). The presence of a persistent endoleak predicted the absence of volume shrinkage (p = 0.001; HR: 7.75; 95%CI: 2.282-26.291). Estimated freedom from ARM was 97.5% ± 1 (95% CI, 93-99) at 12 months, and 96 ± 2 (95% CI, 90-98) at both 36 and 60 months. Aortic reintervention during the follow-up period was necessary in 7 (4.7%) patients. Aneurysm-related mortality was only observed in the group characterized by the concomitant absence of diameter and volume shrinkage.

Conclusions: Volumetric analysis showed to have higher sensitivity than the simple two-dimensional measurement of the diameter to study AAA sac changes post-EVAR. While no predictor was found to be associated with AAA volume shrinkage, ARM occurred only in the group of AAAs with the absence of volume shrinkage.
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http://dx.doi.org/10.1016/j.jvs.2021.03.034DOI Listing
April 2021

To drain or not to drain following carotid endarterectomy: a systematic review and meta-analysis.

J Cardiovasc Surg (Torino) 2021 Apr 8. Epub 2021 Apr 8.

Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi Universitary Teaching Hospital, Varese, Italy.

Introduction: A postoperative neck hematoma can be a life-threatening complication after carotid endarterectomy necessitating urgent surgical decompression to avoid airway compromise. The practice of routine incisional drain placement is variable with few published studies evaluating the "to drain versus not to drain" approach. We conducted a systematic review and meta-analysis of the safety and efficacy of neck drain placement for prevention of neck hematoma requiring re-exploration for decompression.

Evidence Acquisition: It was a systematic review and meta-analysis performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled odds ratios with 95% confidence intervals were calculated for the outcome of surgical re-exploration for neck decompression among patients receiving or not receiving wound drainage.

Evidence Synthesis: We identified 5 studies for inclusion, comprising 48.297 patients with 19.832 (41.1%) patients receiving a drain after carotid endarterectomy. Patients in the drain group had a significantly higher re-exploration rate after carotid endarterectomy compared to those who did not receive a drainage (OR, 1.24, 95%CI: 1.03-1.49; p =.02) with no heterogeneity (I2 = 0%).

Conclusions: Routine drain placement does not offer complete protection against neck hematoma development and may give the surgeon a false sense of security in wound drainage. Thus, we conclude that drain placement following carotid endarterectomy should be selective, not routine.
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http://dx.doi.org/10.23736/S0021-9509.21.11767-7DOI Listing
April 2021

Preliminary results from a multicenter Italian registry on the use of a new branched device for the treatment of thoracoabdominal aortic aneurysms.

J Vasc Surg 2021 Feb 4. Epub 2021 Feb 4.

Vascular and Endovascular Surgery - Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy. Electronic address:

Objective: The study purpose was to present early outcomes of patients treated for thoracoabdominal aortic aneurysms or complex abdominal aortic diseases using endovascular repair with a new branched endograft.

Methods: This multicenter, retrospective, observational cohort study included all patients treated with a new branched endograft. All elective patients were treated with a staged operative strategy and spinal drainage Primary outcomes of interest were technical success, early (≤30 days) mortality, and late (≥30 days) survival, and freedom from adverse aortic events.

Results: A total of 16 consecutive patients were treated for Crawford's extent type I (n = 1), type II (n = 7), type III (n = 1), and type IV (n = 5) endoleaks, with an additional two complex pararenal abdominal aortic lesions (enlarging type Ia endoleak, n = 1; anastomotic pseudoaneurysm, n = 1). There were 13 male (81%) and 3 female (19%) patients with a median age of 72.5 years (interquartile range [IQR], 69-78 years). The median diameter of the aortic aneurysm was 65 mm (IQR, 58-81 mm) and the median EuroSCORE prediction for mortality was 18% (IQR, 12%-36%). Thoracoabdominal aortic aneurysm was secondary to a previous dissection in four patients. A total of 62 of the 64 visceral vessels (96.9%) were stented. Technical success was achieved in 14 (87.5 %) and the cumulative aorta-related mortality rate was 19%. Spinal cord ischemia did not occur. The mean follow-up was 8 ± 4 months (range, 2-15 months). No type I or type III endoleaks were detected. Primary bridging stent patency was 98% (one asymptomatic thrombotic occlusion of a celiac trunk branch). No aortic reintervention was required.

Conclusions: Endovascular repair of complex aortic aneurysms with this new branched endograft can be performed with high technical success and acceptable morbidity. A 19% mortality is quite high; however, it is tolerable in such a high-risk cohort. The survival rate was acceptable, and graft-related outcomes at early follow-up included an absence of threatening endoleaks and a high target visceral vessel patency.
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http://dx.doi.org/10.1016/j.jvs.2020.12.092DOI Listing
February 2021

Bridging Stents in Fenestrated and Branched Endovascular Aneurysm Repair: A Systematic REVIEW.

Ann Vasc Surg 2021 Jan 5. Epub 2021 Jan 5.

Vascular Surgery, University Hospital of Verona, Italy.

Background: Concern exists about durability of stent grafts used to bridge aortic grafts to visceral and renal arteries during fenestrated and branched endovascular aneurysm repair (F/B-EVAR). There are no guidelines regarding the ideal technique for joining target vessels (TVs).

Methods: We systematically reviewed data published from 2014 to 2019 using PRISMA guidelines and PICO models. Keywords were searched in MEDLINE, EMBASE, and Cochrane Library. All articles were screened by two authors (a third author in case of discrepancies). Only original articles regarding F/B-EVAR in complex aortic aneurysm, reporting the number and type of TVs mated, the onset of bridging stent complications, and reinterventions on TVs were included. Analysis included quality assessment scoring, types of stent grafts, and complications related to bridging stents.

Results: 19 studies were included with 2,796 patients and 9556 TV; 4,797 renal arteries (50.2%), 4,174 visceral arteries (43.6%), and undefined TV (n = 585; 6.1%) were bridged. Balloon-expandable stent-grafts (B-EXP) were used in 40.9% and self-expandable (S-EXP) in 22.7% and undefined stents in 36.3%. The included studies had quality assessment scores ranging between 11/15 and 15/15, with high grade of accordance on reporting general results, but a low grade of accordance on reporting detailed data. Despite study heterogeneity, high-volume analysis confirmed a higher rate of complication in renal arteries than visceral arteries, 6% (95% CI 4-8) vs. 2% (95% CI 1-3), respectively. The rate of reinterventions was similar, 3% (95% CI 2-4) and 2% (95% CI 1-3). S-EXP versus B-EXP stent complication was 4% (95% CI 2-7) vs. 3% (95% CI 2-5), respectively.

Conclusions: This systematic review underlines the low grade of accordance in reporting detailed data of bridging stents in F/B-EVAR. Renal TVs were more prone to complications, with an equivalent reintervention rate to visceral TVs. As to B-EVAR, the choice of B-EXP over S-EXP is still uncertain.
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http://dx.doi.org/10.1016/j.avsg.2020.10.052DOI Listing
January 2021

A pilot study of the enhanced recovery after surgery protocol in aortic surgery.

J Vasc Surg 2020 Dec 17. Epub 2020 Dec 17.

Department of Vascular Surgery, University of Florence, Florence, Italy.

Objective: We tested the outcomes with the use of the enhanced recovery after surgery protocol in patients who had undergone open abdominal aortic aneurysm (AAA) repair (enhanced recovery after vascular surgery [ERAVS] protocol). We compared them with those obtained for patients who had undergone endovascular aneurysm repair (EVAR) and for a historical control group of standard open AAA repair in a prospective, single-center pilot study.

Methods: From June to December 2019, all patients who were candidates for open AAA repair at our department were enrolled in the ERAVS protocol (ERAVS group; 17 patients). During the same period, 18 patients had undergone EVAR (EVAR group). The historical control group of standard open AAA repair included 32 patients who had undergone surgery during the 6 months before the study period (standard protocol open repair [OR] group). The three groups were compared on an "on-treatment" basis (prospectively for the ERAVS and EVAR groups and retrospectively for the OR group) in terms of the time to discharge (TTD), interval to the resumption of oral intake, time to ambulation, resumption of bowel function, and postoperative pain. Comparisons were performed using the one-way analysis of variance test, Tukey post hoc test for quantitative data, and χ test for qualitative data.

Results: The ERAVS protocol was successfully applied for all but one patient (feasibility rate, 94%). The mean TTD was 5.1 days in the ERAVS group, 3.5 days in the EVAR group, and 8.4 days in the OR group [P < .001; F(2,64) = 11.3], with a significant difference between the OR and ERAVS and EVAR groups (P = .1 and P < .001, respectively) but not between the EVAR and ERAVS groups (P = .4). The ERAVS group had intervals to the resumption of oral intake and ambulation similar to those of the EVAR group. In contrast, these were significantly longer for the OR group. The mean time to the resumption of bowel function was similar in the ERAVS and OR groups (2.6 and 2.9 days, respectively; P = .6). In the ERAVS group, the mean value of the maximum referred pain using the numeric rating scale was 3.75 (range, 1-6). The corresponding values for the EVAR and OR groups were 2.6 (range, 0-6) and 4.9 [range, 1-8; F(2,62) = 15.4; P < .001]. The post hoc test showed a significant difference between the OR group and the ERAVS and EVAR group (P = .01 and P < .001, respectively) but not between the ERAVS and EVAR groups (P = .07).

Conclusions: In our early experience, the ERAVS protocol appeared to be effective in reducing the TTD and improving the postoperative outcomes compared with the OR group, without significant differences compared with the EVAR group.
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http://dx.doi.org/10.1016/j.jvs.2020.11.042DOI Listing
December 2020

Thoracic Endovascular Aortic Repair in "Shaggy Thoracic Aortic Aneurysms".

Cardiovasc Intervent Radiol 2021 Feb 19;44(2):220-229. Epub 2020 Oct 19.

Vascular Surgery-IRCCS Ospedale Maggiore Policlinico Fondazione Cà Granda, Milan, Italy.

Objectives: To report the outcomes of thoracic endovascular aortic repair (TEVAR) for shaggy thoracic aortic aneurysms (STA).

Methods: It is a single center, retrospective, observational, cohort study. Data were collected prospectively between January 2005 and May 2019. STA was defined, based on computed tomography angiography findings, as the presence of an irregular/ulcerated atheroma protruding and/or thrombus thickness ≥ 5 mm protruding into the aortic lumen, and/or occupying more than two thirds of the circumference of the aortic diameter axially. Primary outcomes were early (≤ 30 days) and late survival and freedom from major complication due to end-organ or peripheral ischemic embolization.

Results: Nine (2.3%) of 391 patients met the inclusion criteria. Mean age was 71 years ± 10 (range 55-83). Mean aneurysm diameter was 68 mm ± 0.5 (range 60-75). Four patients presented symptomatic: rupture (n = 2), blue toe syndrome (n = 2). TEVAR was performed in 7 of the 9 patients. Operative-related embolization occurred in 1 patient (transient ischemic attack and acute kidney injury). In-hospital mortality was observed in 1 patient following spinal cord ischemia and multiple organ failure development. Median follow-up was 48 months (IQR 5-84). Freedom from major complication due to end-organ or peripheral ischemic embolization was achieved in all patients. No patient developed further localization of STA in the proximal or distal aorta, and did not experience reno-visceral or peripheral atheroembolization episodes.

Conclusions: Risk of atheroembolism in STA is still threatening but TEVAR proved to be an effective and durable treatment in this high-risk cohort.
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http://dx.doi.org/10.1007/s00270-020-02676-2DOI Listing
February 2021

Hybrid repair of extensive thoracic aortic aneurysms.

Eur J Cardiothorac Surg 2020 11;58(5):940-948

Vascular Surgery, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy.

Objectives: Our goal was to report the midterm results of hybrid treatment of extensive thoracic aortic aneurysm (ETAA) with the completion of thoracic endovascular aortic repair after proximal ascending-arch graft replacement.

Methods: This was a multicentre, observational study. Data were collected prospectively between January 2002 and March 2019 and analysed retrospectively. Inclusion criteria for the final analysis were the treatment of elective or urgent ETAA performed in a single-stage or a planned two-stage approach. Early and late survival rates were the primary outcomes.

Results: Indications for repair were degenerative ETAA in 27 (64.3%) patients and dissection-related ETAA in 15 (35.7%). The mean aortic diameter was 68 ± 16 mm (interquartile range 60-75). Five (11.9%) patients had a single-stage repair; and 37 underwent a two-stage approach. Three (7.1%) patients died in-hospital. The median follow-up was 49 months (range 0-204). During the follow-up period, 4 (9.5%) patients underwent aortic reintervention after a median of 32 months; however, no aortic rupture of the treated segment occurred. Overall, the estimated survival rate was 85% ± 6% [95% confidence interval (CI) 70.8-93] at 12 and 36 months and 69.5% ± 9% (95% CI 49.7-84) at 60 months.

Conclusions: Hybrid repair of ETAA had satisfactory early results in this cohort of patients. At the midterm follow-up, the aneurysm-related mortality rate was acceptable with the reconstruction proving to be durable and safe with few distal aortic events.
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http://dx.doi.org/10.1093/ejcts/ezaa178DOI Listing
November 2020

A Retrospective Comparison Between Hybrid Treatment and Prosthetic Above-the-Knee Femoro-Popliteal Bypass in the Management of the Obstructive Disease of the Superficial Femoral Artery.

World J Surg 2020 10;44(10):3555-3563

Department of Vascular Surgery, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.

Objective: We assessed early and late outcomes following hybrid intervention (common femoral artery endarterectomy and superficial femoral artery (SFA) stenting) versus above-the-knee (AK) femoro-popliteal bypass performed for peripheral artery occlusive disease (PAOD) in a double-center retrospective comparative cohort study.

Materials And Methods: From January 2006 to December 2017, 82 hybrid revascularizations with femoral endarterectomy and SFA stenting (HY Group) and 98 AK femoro-popliteal bypasses with femoral endarterectomy (BP Group) were performed at two academic vascular centers. The two groups were compared in terms of preoperative and intraoperative details and of perioperative (<30 days) outcomes with χ test. Long-term results were compared using Kaplan-Meier curves and log-rank test.

Results: No differences were found in demographics variables, risk factors, comorbidities and clinical presentation between the two groups. Also perioperative outcomes were similar between the two groups. Median duration of follow-up was 38 months. At five years, the estimated survival rate was 60% in HY Group and 77.5% in BP Group (p = 0.002) Five-year primary patency rates were 46% in HY Group and 64% in BP Group (p = 0.005). Overall, 13 patients in HY Group required conversion to open surgery and 6 patients in BP Group underwent below-knee (n = 4) or distal (n = 2) bypass. The 5-year rate of limb maintenance was 85% in HY Group and 94% in BP Group (p = 0.1) and was not significantly different regardless of presentation, claudication or critical limb ischemia.

Conclusions: In patients with PAOD due to complex long lesions of the infrainguinal arteries, open-surgical treatment with AK bypass provided better long-term survival and patency rates compared to a hybrid approach.
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http://dx.doi.org/10.1007/s00268-020-05616-wDOI Listing
October 2020

Venous ulcers and the need for more appropriate use of venous interventions.

J Vasc Surg Venous Lymphat Disord 2020 07 5;8(4):503-504. Epub 2020 May 5.

University of Houston College of Medicine, Houston, Tex.

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http://dx.doi.org/10.1016/j.jvsv.2020.04.024DOI Listing
July 2020

Acute limb ischemia in patients with COVID-19 pneumonia.

J Vasc Surg 2020 12 29;72(6):1864-1872. Epub 2020 Apr 29.

College of Medicine, University of Houston, Houston, Tex.

Objective: The aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic.

Methods: We performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early (<30 days) re-occlusion or major amputation or death within 24 hours. The primary outcomes were successful revascularization, early (≤30 days) and late (≥30 days) survival, postoperative (≤30 days) complications, and limb salvage.

Results: We evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%];  < .001)]. Of the 20 included patients, 18 were men (90%) and two were women (10%). Their mean age was 75 ± 9 years (range, 62-95 years). All 20 patients already had a diagnosis of COVID-19 pneumonia. Operative treatment was performed in 17 patients (85%). Revascularization was successful in 12 of the 17 (70.6%). Although successful revascularization was not significantly associated with the postoperative use of intravenous heparin (64.7% vs 83.3%;  = .622), no patient who had received intravenous heparin required reintervention. Of the 20 patients, eight (40%) had died in the hospital. The patients who had died were significantly older (81 ± 10 years vs 71 ± 5 years;  = .008). The use of continuous postoperative systemic heparin infusion was significantly associated with survival (0% vs 57.1%;  = .042).

Conclusions: In our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.
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http://dx.doi.org/10.1016/j.jvs.2020.04.483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188654PMC
December 2020

The 2020 update of the CEAP classification system and reporting standards.

J Vasc Surg Venous Lymphat Disord 2020 05 27;8(3):342-352. Epub 2020 Feb 27.

Division of Vascular Surgery, University of Michigan, Ann Arbor, Mich.

The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is an internationally accepted standard for describing patients with chronic venous disorders and it has been used for reporting clinical research findings in scientific journals. Developed in 1993, updated in 1996, and revised in 2004, CEAP is a classification system based on clinical manifestations of chronic venous disorders, on current understanding of the etiology, the involved anatomy, and the underlying venous pathology. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD, C2-C6) continue to develop, the CEAP classification needs periodic analysis and revisions. In May of 2017, the American Venous Forum created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions, where needed. Guided by four basic principles (preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based, and practical for clinical use), the Task Force has adopted the revised Delphi process and made several changes. These changes include adding Corona phlebectatica as the C4c clinical subclass, introducing the modifier "r" for recurrent varicose veins and recurrent venous ulcers, and replacing numeric descriptions of the venous segments by their common abbreviations. This report describes all these revisions and the rationale for making these changes.
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http://dx.doi.org/10.1016/j.jvsv.2019.12.075DOI Listing
May 2020

Comparison of Hybrid Vascular Grafts and Standard Grafts in Terms of Kidney Injury for the Treatment of Thoraco-Abdominal Aortic Aneurysm.

World J Surg 2020 06;44(6):2010-2019

Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Via Guicciardini, 9, 21100, Varese, Italy.

Background: We present a comparison of renal function outcomes during HTAR with the use of a new hybrid vascular graft (GHVG) or standard graft.

Methods: It is a multicenter, retrospective, observational study. Between January 2015 and March 2019, 36 patients were treated with HTAR. We compared HTAR performed with the use of the GHVG and with the use of standard bypass graft. Primary outcome measures were hospital mortality, acute kidney injury (AKI) at 30 days and GHVG patency.

Results: Mean GHVG ischemia time was significantly lower for both renal arteries (right: GHVG, 4 ± 2 vs. standard graft, 15 ± 7 min; 95% CI 2.23-6.69, P < 0.001; left: GHVG, 3 ± 2 vs. standard graft, 13 ± 7 min; 95% CI 2.44-5.03, P < 0.001). Hospital mortality was 17% (6/36); while mortality did not differ between the two groups, postoperative acute kidney injury rate was 30.5% (11/36 patients) and was more common in the standard graft group (7% vs. 29%; OR 3.2, P = 0.074). Estimated primary patency was 92% ± 2 (95% CI 79.5-97%) at 36 months and was not different between the two groups (GHVG 94% ± 6 vs. standard graft 91% ± 6; log-rank χ = 0.260, P = 0.610).

Conclusions: In our experience of HTAR, ischemia time was significantly shorter and postoperative AKI occurrence was lower with GHVG if compared to standard graft bypass, with satisfactory midterm patency rate comparable to that of standard graft bypass.
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http://dx.doi.org/10.1007/s00268-020-05415-3DOI Listing
June 2020

Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair.

Ann Cardiothorac Surg 2019 Jul;8(4):471-482

Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy.

Background: To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs).

Methods: This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications.

Results: On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period.

Conclusions: Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.
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http://dx.doi.org/10.21037/acs.2019.06.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687961PMC
July 2019

Increased Vascular Pathology in Older Veterans With a Purple Heart Commendation or Chronic Post-Traumatic Stress Disorder.

J Geriatr Psychiatry Neurol 2020 07 19;33(4):195-206. Epub 2019 Aug 19.

Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.

The goal of this retrospective cohort study was to determine whether stressors related to military service, determined by a diagnosis of chronic post-traumatic stress disorder (cPTSD) or receiving a Purple Heart (PH), are associated with an increased risk of vascular risk factors and disease, which are of great concern for veterans, who constitute a significant portion of the aging US population. The Veterans Integrated Service Network (VISN) 16 administrative database was searched for individuals 65 years or older between October 1, 1997 to September 30, 1999 who either received a PH but did not have cPTSD (PH+/cPTSD-; n = 1499), had cPTSD without a PH (PH-/cPTSD+; n = 3593), had neither (PH-/cPTSD-; n = 5010), or had both (PH+/cPTSD+; n = 153). In comparison to the control group (PH-/cPTSD-), the PH+/cPTSD- group had increased odds ratios for incidence and prevalence of diabetes mellitus, hypertension, and hyperlipidemia. The PH-/cPTSD+ group had increased odds ratios for prevalence of diabetes mellitus and for the incidence and prevalence of hyperlipidemia. The PH-/cPTSD+ and PH+/cPTSD- groups were associated with ischemic heart disease and cerebrovascular disease, but not independently of the other risk factors. The PH+/cPTSD+ group was associated only with an increase in the incidence and prevalence of hyperlipidemia, though this group's much smaller sample size may limit the reliability of this finding. We conclude that certain physical and psychological stressors related to military service are associated with a greater incidence of several vascular risk factors in veterans aged 65 years or older, which in turn are associated with greater rates of ischemic heart disease and cerebrovascular disease.
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http://dx.doi.org/10.1177/0891988719868308DOI Listing
July 2020

Outcomes From the Multicenter Italian Registry on Primary Endovascular Treatment of Aortoiliac Occlusive Disease.

J Endovasc Ther 2019 10 22;26(5):623-632. Epub 2019 Jul 22.

Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy.

To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (<30 days) endpoints included mortality, thrombosis, and major complications. Late major outcomes were primary and secondary patency and freedom from reintervention as estimated by Kaplan-Meier analysis; estimates are given with the 95% confidence intervals (CIs). Associations between baseline variables and primary patency were sought with multivariate analysis; the results are presented as the hazard ratio (HR) and 95% CI. Technical success was achieved in 708 (99%) lesions; in-hospital mortality was 0.6% (n=4). The median follow-up was 11 months (range 0-42). The estimated primary patency rate was 96% (95% CI 94% to 97%) at 1 year and 94% (95% CI 91% to 96%) at 2 years. The estimated secondary patency was 99% (95% CI 97% to 99%) at 1 year and 98% (95% CI 95% to 99%) at 2 years. The estimated freedom from reintervention was 98% (95% CI 96% to 99%) at 1 year and 97% (95% CI 94% to 98.5%) at 2 years. Cox regression analysis demonstrated that the application of a covered stent was associated with an increased need for reintervention (HR 1.4, 95% CI 1.10 to 1.74, p=0.005). Chronic obstructive pulmonary disease was associated with decreased primary patency (HR 3.7, 95% CI 1.25 to 10.8, p=0.018). Endovascular intervention with primary stent placement for aortoiliac occlusive disease achieved satisfactory 2-year patency regardless of the complexity of the lesion. Almost all TASC lesions should be considered for primary endovascular intervention if suitable.
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http://dx.doi.org/10.1177/1526602819863081DOI Listing
October 2019

Prevalence and risk factors for heparin-bonded expanded polytetrafluoroethylene vascular graft infection after infrainguinal femoropopliteal bypasses.

J Vasc Surg 2019 10 27;70(4):1299-1307.e1. Epub 2019 May 27.

Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy.

Background: To analyze the prevalence and predictors of prosthetic vascular graft infection (PVGI) in a multicenter registry.

Methods: This registry-based, multicenter study retrospectively evaluated PVGI that developed after infrainguinal revascularization performed with a heparin-bonded expanded polytetrafluoroethylene graft that was used in 1400 interventions between 2002 and 2016. A prosthetic graft with infection was defined as direct involvement of the graft with positive bacterial cultures of graft or perigraft material, intraoperative gross purulence or failure of graft incorporation, or exposed graft in an infected wound.

Results: Critical limb ischemia (CLI) was the main indication for bypass (n = 915 [65%]). The median duration of follow-up was 29 months (range, 1-168 months; interquartile range, 12-60 months). A total of 33 heparin-bonded expanded polytetrafluoroethylene grafts (2.3%) became infected; the median time to occurrence was 5 months (range, 1-54 months; interquartile range; 2.00-13.25 months). Freedom from PVGI at 1 year was 98% (standard error, 0.4; 95% confidence interval [CI], 97.2-98.9), and 97% (standard error, 0.6; 95% CI, 95.6-98.0) at 5 years. The multivariate model identified CLI (P = .042; hazard ratio, 0.39; 95% CI, 0.164-0.969) to be independently associated with PVGI. In-hospital mortality of PVGI treatment was 12% (n = 4/33). Freedom from major amputation was significantly different between patients with PVGI and those who did not experience this complication (at 1 year, 67.0% vs 88.5%; Log-rank χ = 22.5; P = .001).

Conclusions: In our "real-world" multicenter experience the prevalence of PVGI after infrainguinal femoropopliteal bypasses was relatively low at 2.3%, but still associated with significant mortality and limb loss. CLI was the only significant predictor of PVGI. This conclusion is reasonable; however, more comprehensive data are required to confirm these findings, because the presence of ischemic ulcers or gangrene was not predictive of PVGI.
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http://dx.doi.org/10.1016/j.jvs.2019.03.023DOI Listing
October 2019

Review of Socioeconomic Disparities in Lower Extremity Amputations: A Continuing Healthcare Problem in the United States.

Cureus 2018 Oct 5;10(10):e3418. Epub 2018 Oct 5.

Surgery, University of Houston College of Medicine, Houston, USA.

Lower extremity amputation is one of the most unfortunate, yet preventable, consequences of uncontrolled lower limb ischemia occurring secondary to diabetes mellitus or peripheral arterial disease. In the United States, racial and socioeconomic disparities are associated with significant differences seen in the incidence and type or level of lower extremity amputation among patients. Due to shifting demographics and the uncertain state of healthcare coverage, lower extremity amputation rates are only projected to increase in the future. Given the potential societal and individual costs associated with the loss of a limb, this review seeks to summarize the recent findings on disparities in the identification, treatments offered, and outcomes of lower limb ischemia in order to elucidate potential interventions at the practitioner and policy levels.
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http://dx.doi.org/10.7759/cureus.3418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6284870PMC
October 2018

Corrigendum to 'Pre-operative Color Doppler Ultrasonography Predicts Endovenous Heat Induced Thrombosis After Endovenous Radiofrequency Ablation' [European Journal of Vascular & Endovascular Surgery 56/1 (2018) 94-100].

Eur J Vasc Endovasc Surg 2018 12 3;56(6):921. Epub 2018 Oct 3.

Vascular Surgery II and Thoracic Aortic Research Centre, IRCCS Policlinico San Donato Teaching Hospital, University of Milan School of Medicine, Milan, Italy.

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http://dx.doi.org/10.1016/j.ejvs.2018.09.015DOI Listing
December 2018

Pre-operative Color Doppler Ultrasonography Predicts Endovenous Heat Induced Thrombosis after Endovenous Radiofrequency Ablation.

Eur J Vasc Endovasc Surg 2018 07 23;56(1):94-100. Epub 2018 May 23.

Vascular Surgery II and Thoracic Aortic Research Centre, IRCCS Policlinico San Donato Teaching Hospital, University of Milan School of Medicine, Milan, Italy.

Objectives: The aim was to identify pre-operative color Doppler ultrasound (CDUS) variables predictive of post-operative endovenous heat induced thrombosis (EHIT) after radiofrequency ablation (RFA) of the saphenous veins.

Design: This was a single centre, observational study with retrospective analysis of consecutive patients treated from December 2010 to February 2017.

Materials And Methods: Pre-operatively, the diameter of the sapheno-femoral junction (dSFJ), distance between superficial epigastric vein and SFJ (dSEV-SFJ) [corrected], maximum great saphenous vein (GSV) diameter (mdGSV), diameter of the saphenous-popliteal junction (dSPJ), and mean small saphenous vein (SSV) diameter (adSSV) were measured. All patients received low molecular weight heparin (LWMH) at a prophylactic dose for a week. Post-operatively, CDUS was performed after 72 h, 1 week, and 3 months.

Results: Venous interventions on 512 patients were performed: 449 (87.7%) underwent RFA of the GSV (Group 1), and 63 (12.3%) of the SSV (Group 2). At Day 3 post-operatively, CDUS documented 100% complete closure of the treated saphenous vein segment. Overall, 40 (7.8%) cases of post-operative EHIT were identified: 29 in Group 1, and 11 in Group 2 (6.4% vs. 17.5%, p = .005). Deep venous thrombosis or pulmonary embolism did not occur in either group. At the 1 month follow up, all cases of EHIT regressed. In Group 1, on multivariate analysis, dSEV-SFJ [corrected] (OR, 1.13, p = .036; 95% CI 1.01-1.27) was the only statistically significant predictor for EHIT. A dSEV-SFJ [corrected] distance of 4.5 mm yielded an 84% of sensitivity for EHIT prediction with a 72.4% positive predictive value. In Group 2, univariate analysis did not identify independent risk factors for EHIT occurrence.

Conclusions: EHIT was higher than previously reported. The dSEV-SFJ [corrected] was the most significant predictor for EHIT in the GSV group. A greater distance between the tip of the radiofrequency catheter and the SFJ may decrease the risk of developing this complication.
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http://dx.doi.org/10.1016/j.ejvs.2018.02.025DOI Listing
July 2018

Statin prescription rates and their facility-level variation in patients with peripheral artery disease and ischemic cerebrovascular disease: Insights from the Department of Veterans Affairs.

Vasc Med 2018 06 30;23(3):232-240. Epub 2018 Mar 30.

2 Health Policy, Quality & Informatics Program, Michael E DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends moderate to high-intensity statin therapy in patients with peripheral artery disease (PAD) and ischemic cerebrovascular disease (ICVD). We examined frequency and facility-level variation in any statin prescription and in guideline-concordant statin prescriptions in patients with PAD and ICVD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system between October 2013 and September 2014. Guideline-concordant statin intensity was defined as the prescription of high-intensity statins in patients with PAD or ICVD ≤75 years and at least moderate-intensity statins in those >75 years. We calculated median rate ratios (MRR) after adjusting for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns independent of patient characteristics. Among 194,151 PAD patients, 153,438 patients (79.0%) were prescribed any statin and 79,435 (40.9%) were prescribed a guideline-concordant intensity of statin. PAD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin therapy less frequently (69.1% and 28.9%, respectively). Among 339,771 ICVD patients, 265,491 (78.1%) were prescribed any statin and 136,430 (40.2%) were prescribed a guideline-concordant intensity of statin. ICVD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin less frequently (70.9% and 30.5%, respectively). MRRs for both PAD and ICVD patients demonstrated a 20% and 28% variation among two facilities in treating two identical patients with statin therapy and guideline-concordant intensity of statin therapy, respectively. The prescription of statins, especially guideline-recommended intensity of statin therapy, is suboptimal in PAD and ICVD patients, with significant facility-level variation not explained by patient-level factors.
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http://dx.doi.org/10.1177/1358863X18758914DOI Listing
June 2018

Invited commentary.

Authors:
Ruth L Bush

J Vasc Surg 2017 04;65(4):1013

Bryan, Tex.

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http://dx.doi.org/10.1016/j.jvs.2016.08.113DOI Listing
April 2017

Sex differences in stroke: Review of current knowledge and evidence.

Vasc Med 2017 04 3;22(2):135-145. Epub 2016 Nov 3.

2 Baylor College of Medicine, Houston, TX, USA.

Stroke is a leading cause of death among women in the United States, and women are more affected by stroke than men. With women living longer than men, women experience not only a higher incidence of stroke but also more negative outcomes. Despite its lethal impact and high morbidity rate, the road from innovative bench research to improved clinical outcomes has been slow. This review explores the differential physiology, epidemiology, and clinical presentation of stroke between men and women, as well as the current status of laboratory and clinical data.
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http://dx.doi.org/10.1177/1358863X16668263DOI Listing
April 2017

Design and verification of a shape memory polymer peripheral occlusion device.

J Mech Behav Biomed Mater 2016 10 23;63:195-206. Epub 2016 Jun 23.

Department of Biomedical Engineering, Texas A&M University, MS 3120, 5045 Emerging Technologies Building, College Station, TX 77843-3120, USA. Electronic address:

Shape memory polymer foams have been previously investigated for their safety and efficacy in treating a porcine aneurysm model. Their biocompatibility, rapid thrombus formation, and ability for endovascular catheter-based delivery to a variety of vascular beds makes these foams ideal candidates for use in numerous embolic applications, particularly within the peripheral vasculature. This study sought to investigate the material properties, safety, and efficacy of a shape memory polymer peripheral embolization device in vitro. The material characteristics of the device were analyzed to show tunability of the glass transition temperature (Tg) and the expansion rate of the polymer to ensure adequate time to deliver the device through a catheter prior to excessive foam expansion. Mechanical analysis and flow migration studies were performed to ensure minimal risk of vessel perforation and undesired thromboembolism upon device deployment. The efficacy of the device was verified by performing blood flow studies that established affinity for thrombus formation and blood penetration throughout the foam and by delivery of the device in an ultrasound phantom that demonstrated flow stagnation and diversion of flow to collateral pathways.
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http://dx.doi.org/10.1016/j.jmbbm.2016.06.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508979PMC
October 2016

Rapidly Evolving Outbreak of a Febrile Illness in Rural Haiti: The Importance of a Field Diagnosis of Chikungunya Virus in Remote Locations.

Vector Borne Zoonotic Dis 2015 Nov;15(11):678-82

Texas A & M Health Science Center College of Medicine , Bryan, Texas.

Although rarely fatal, chikungunya virus (CHIKV) infection can lead to chronic debilitating sequelae. We describe the outbreak of suspected CHIKV in 93 subjects who presented voluntarily over 2 months to a remote rural Haitian general medical clinic staffed by international health care providers. Diagnosis was made on clinical signs and symptoms because no serum analysis was available in this remote rural site. The subjects were 18.0 ± 16.2 (median ± standard deviation) years of age and were of similar gender distribution. The presenting vital signs included a temperature of 102.3°F ± 0.6°F with fever lasting for 3.0 ± 0.7 days. Symptoms mainly consisted of symmetrical polyarthralgias in 82.8%, headache in 28.0%, abdominal pain in 17.2%, cough in 8.6%, maculopapular rash in 30.0%, and extremity bullae in 12.9%. In 84.9% of subjects, symptoms persisted for 7.1 ± 8.3 days with 16.1% having ongoing disability due to persistent pain (≥ 14 days duration). There were no deaths. In Haiti, especially in remote, rural regions, the risk for CHIKV spread is high given the shortage of detection methods and treatment in this tropical climate and the lack of preventative efforts underway. Implications for global public health are likely, with outbreak expansion and spread to neighboring countries, including the United States.
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http://dx.doi.org/10.1089/vbz.2014.1763DOI Listing
November 2015

Preoperative optimization of the vascular surgery patient.

Vasc Health Risk Manag 2015 1;11:379-85. Epub 2015 Jul 1.

Texas A&M Health Science Center College of Medicine, Bryan, TX, USA.

It is well known that patients who suffer from peripheral (noncardiac) vascular disease often have coexisting atherosclerotic diseases of the heart. This may leave the patients susceptible to major adverse cardiac events, including death, myocardial infarction, unstable angina, and pulmonary edema, during the perioperative time period, in addition to the many other complications they may sustain as they undergo vascular surgery procedures, regardless of whether the procedure is performed as an open or endovascular modality. As these patients are at particularly high risk, up to 16% in published studies, for postoperative cardiac complications, many proposals and algorithms for perioperative optimization have been suggested and studied in the literature. Moreover, in patients with recent coronary stents, the risk of non-cardiac surgery on adverse cardiac events is incremental in the first 6 months following stent implantation. Just as postoperative management of patients is vital to the outcome of a patient, preoperative assessment and optimization may reduce, and possibly completely alleviate, the risks of major postoperative complications, as well as assist in the decision-making process regarding the appropriate surgical and anesthetic management. This review article addresses several tools and therapies that treating physicians may employ to medically optimize a patient before they undergo noncardiac vascular surgery.
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http://dx.doi.org/10.2147/VHRM.S83492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492637PMC
April 2016

A model for rural health education for first year medical students: understanding barriers to care.

Educ Prim Care 2015 05;26(3):176-81

Associate Professor of Internal Medicine, Baylor Scott and White Healthcare, Temple, Texas.

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http://dx.doi.org/10.1080/14739879.2015.11494337DOI Listing
May 2015

Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses.

J Rural Health 2015 19;31(3):244-53. Epub 2015 Jan 19.

Department of Health Services, School of Public Health, University of Washington, Seattle, Washington.

Purpose: Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis.

Methods: The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees.

Findings: For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees.

Conclusions: Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.
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http://dx.doi.org/10.1111/jrh.12105DOI Listing
July 2016