Mark A Adelman, M.D.

Increasing ablation distance peripheral to the saphenofemoral junction may result in a diminished rate of ehits
Sadek M.; Kabnick L.S.; Berland T.; Giammaria L.E.; Zhou D.; Mussa F.; Cayne N.S.; Maldonado T.; Rockman C.B.; Jacobowitz G.R.; Lamparello P.J.; Adelman M.A.
2012 ;55(1):298-298, Journal of vascular surgery
Background: The treatment of venous insufficiency using endovenous laser ablation or radiofrequency ablation may result in endothermal heat induced thrombosis (EHIT), a form of deep venous thrombosis. This study sought to assess the effect of ablation distance peripheral to the deep venous system on the incidence of EHIT. Methods: This study was a retrospective review of a prospectively maintained database from 4/2007 to 7/2011. Consecutive patients undergoing great saphenous vein (GSV) or small saphenous vein (SSV) ablation were evaluated. Previous to 2/2011, all venous ablations were performed 2cm peripheral to the saphenofemoral or saphenopopliteal junctions (Group I). Subsequent to 2/2011, ablations were performed 2.5cm peripheral to the respective deep system junctions (Group II). The primary outcome was the development of EHIT II or greater, i.e. thrombus protruding into the deep venous system. Secondary outcomes included procedure-site complications such as hematomas and saphenous nerve injury. Chi-square tests were performed for all discrete variables, and unpaired Students t-tests were performed for all continuous variables. P<.05 was considered statistically significant. Results: A total of 3,526 procedures were performed, Group I (N=2672) and Group II (N=854). General demographics and CEAP classification did not differ significantly between the two groups. EHIT demonstrated a trend towards diminished frequency in Group II (Group I: 2.8% vs Group II: 1.6%, P=.077). There were no reported cases of EHIT III or IV in this patient cohort. Patients in Group I were treated using anticoagulation 56% of the time, and patients in Group II were treated using anticoagulation 100% of the time. The frequency of procedure site complications was low and did not differ significantly between the two groups. Conclusions: This study suggests that changing the treatment distance from 2cm to 2.5cm peripheral to the deep venous junction may result in a diminished incidence of EHIT. Ongoing evaluation is required to validate these results and to reaffirm the durability of the technique
— id: 149973, year: 2012, vol: 55, page: 298, stat: Journal Article,

Endovascular solutions to arterial injury due to posterior spinal surgery
Loh SA; Maldonado TS; Rockman CB; Lamparello PJ; Adelman MA; Kalhorn SP; Frempong-Boadu A; Veith FJ; Cayne NS
2011 Jan 5;:?-? #, Journal of vascular surgery
INTRODUCTION:: Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. METHODS:: We identified five cases of iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe the endovascular treatment of these five patients. RESULTS:: In two patients, intraoperative arterial bleeding was encountered during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patients were placed supine. Angiography in both patients demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting or penetrating the thoracic or abdominal aorta. In all three patients, angiography or intravascular ultrasound (IVUS), or both, confirmed indention or perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. CONCLUSIONS:: Endovascular repair of arterial injuries occurring during posterior spine procedures is feasible and can offer a safe and less invasive alternative to open repair
— id: 120626, year: 2011, vol: , page: ?, stat: Journal Article,

Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients
Loh, Shang A; Rockman, Caron B; Chung, Christine; Maldonado, Thomas S; Adelman, Mark A; Cayne, Neal S; Pachter, H Leon; Mussa, Firas F
2011 Feb;53(2):359-366, Journal of vascular surgery
BACKGROUND: The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. METHODS: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score-Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used chi(2) analysis and Student t-tests. RESULTS: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P = .108). VT patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P = .007). VT patients with an ISS score >24 had a higher mortality compared with NVT patients (61% vs 28.6%, P = .04). VT patients with an APACHE II score <14 also had a higher mortality rate (18.2% vs 0%, P = .007). Finally, VT patients with a TRISS probability of survival of >80% had a higher mortality rate (13.9% vs 0%, P = .05). CONCLUSIONS: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma
— id: 138264, year: 2011, vol: 53, page: 359, stat: Journal Article,

Hormone Replacement Therapy Is Associated with a Decreased Prevalence of Peripheral Arterial Disease in Postmenopausal Women
Rockman, Caron B.; Maldonado, Thomas S.; Jacobowitz, Glenn R.; Adelman, Mark A.; Riles, Thomas S.
2011 JUN ;53(6):24S-25S, Journal of vascular surgery
— id: 134490, year: 2011, vol: 53, page: 24S, stat: Journal Article,

Outcome of carotid artery interventions among female patients, 2004 to 2005
Rockman, Caron B; Garg, Karan; Jacobowitz, Glenn R; Berger, Jeffrey S; Mussa, Firas F; Cayne, Neal S; Adelman, Mark A; Maldonado, Thomas S
2011 Jun;53(6):1457-1464, Journal of vascular surgery
BACKGROUND: The benefit of carotid endarterectomy (CEA) in female patients has been questioned by various randomized, prospective trials, particularly in asymptomatic cases; several have noted an increase in perioperative stroke among women after CEA. The outcome of carotid angioplasty and stenting (CAS) has not been extensively examined in women. This study examined the outcome of CEA and CAS in women vs men by using a national database. METHODS: Outcomes of CEA and CAS were stratified by sex using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. The NIS was used to identify patient discharges that occurred during 2004 and 2005. Appropriate International Classification of Diseases, 9th Revision (ICD-9) procedure and diagnosis codes were used to identify CEA and CAS cases. Outcome measures included in-hospital perioperative stroke and death. Comparisons of demographics, procedures, and outcome were performed between men and women. Additional analysis was performed among women alone to attempt to identify whether improved outcome was noted with either procedure. RESULTS: Of 54,658 procedures, 94.2% were CEA and 5.8% were CAS. Women comprised 42.3% of the analyzed cases. Women and men were equally likely to be symptomatic (5.3% vs 5.3%, P = .8). Women were significantly less likely to undergo CAS than men (5.4% vs 6.1%, P < .001). Women and men had equivalent rates of perioperative stroke when undergoing CEA (1.0% vs 1.0%, P = .9) and CAS (2.7% vs 2.0%, P = .2). Symptomatic women had a significantly higher rate of perioperative stroke overall than did symptomatic men (3.8% vs 2.3%, P = .03). Asymptomatic women had a significantly lower perioperative stroke rate after CEA than after CAS (0.9% vs 2.1%, P < .001). Rates of perioperative showed a trend favoring CEA vs CAS among symptomatic women (3.4% vs 6.2%, P = .1). CONCLUSIONS: The concern regarding an increased perioperative stroke rate after CEA among asymptomatic women appears to be unfounded. The perioperative stroke rate among symptomatic women was higher than that of symptomatic men, but still well within the acceptable range for symptomatic patients undergoing a cerebrovascular intervention. Nationally, women underwent CAS significantly less frequently than did men. Outcome among women for perioperative stroke favored CEA over CAS, particularly in asymptomatic patients. CEA may be the preferred treatment in women seeking intervention for cerebrovascular disease, unless compelling reasons exist to perform CAS
— id: 132879, year: 2011, vol: 53, page: 1457, stat: Journal Article,

Interpreting the EVAR versus OPEN Repair Randomized Trials: A Critical Meta-Analysis
Rockman, Caron; Rubin, Maya; Adelman, Mark A.; Veith, Frank; Berger, Jeffrey S.
2011 FEB ;53(2):554-554, Journal of vascular surgery
— id: 126448, year: 2011, vol: 53, page: 554, stat: Journal Article,

Update on Endovenous Laser Ablation: 2011
Sadek M; Kabnick LS; Berland T; Cayne NS; Mussa F; Maldonado T; Rockman CB; Jacobowitz GR; Lamparello PJ; Adelman MA
2011 Nov 29;:?-?, Perspectives in vascular surgery & endovascular therapy
In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success
— id: 150013, year: 2011, vol: , page: ?, stat: Journal Article,

Endovenous Laser Ablation Using Higher Wavelength Lasers Results in Diminished Post-Procedural Symptoms
Sadek, Mikel; Kabnick, Lowell S.; Berland, Todd; Chasin, Cara; Cayne, Neal S.; Maldonado, Thomas S.; Rockman, Caron B.; Jacobowitz, Glenn R.; Lamparello, Patrick J.; Adelman, Mark A.
2011 JUN ;53(6):67S-68S, Journal of vascular surgery
— id: 134491, year: 2011, vol: 53, page: 67S, stat: Journal Article,

Laser saphenous ablations in more than 1,000 limbs with long-term duplex examination follow-up
Spreafico, Giorgio; Kabnick, Lowell; Berland, Todd L; Cayne, Neal S; Maldonado, Tom S; Jacobowitz, Glenn S; Rockman, Caron R; Lamparello, Pat J; Baccaglini, Ugo; Rudarakanchana, Nung; Adelman, Mark A
2011 Jan;25(1):71-78, Annals of vascular surgery
BACKGROUND: The goal of this study was to evaluate the duplex results of endovenous laser ablation in the treatment of incompetent great saphenous veins (GSV) and small saphenous veins (SSV) with at least 1-year follow-up. METHODS: A retrospective registry was entered by 11 centers from Europe and America, organized by the International Endovenous Laser Working Group. Data concerning 1,020 limbs in patients with incompetence of the GSV and/or SSV, treated with the Endovenous Laser Ablation (EVLA) procedure, were collected. EVLA failures were defined on duplex imaging as reflux confined to the saphenofemoral or saphenopopliteal junction, reflux confined to the main saphenous trunk, or reflux of both junction and main trunk (totally patent saphenous vein) were analyzed at one or more years postoperatively. RESULTS: The mean age of patients was 54 +/- 5 years (range: 18-91 years). The average body mass index was 25. There was a paucity of severe complications: One case of third-degree skin burn, six patients with postsurgical deep vein thrombosis (0.6%), and 27 cases of sensory nerve damage (2.7%). At 1-year, the rate of complete occlusion of the saphenous trunk was 93.1%. There were 79 cases of treatment failures as evidenced by duplex: 22 isolated junction failures (2.2%), 44 isolated trunk failures (4.4%), and 13 totally patent veins (1.3%). Two-year duplex results were reported for 329 limbs with the identification of 19 new cases of failure. No new cases of failure were reported at 3-year follow-up of 130 limbs. Cumulative failure rates estimated by Kaplan-Meier analysis were 7.7% at 1-year and 13.1% at 2- and 3-year follow-up. CONCLUSIONS: On the basis of a duplex scan performed at least 1-year post-treatment, this multicenter registry confirms the safety and efficacy of the EVLA procedure in the treatment of GSV and SSV reflux. Considering the continued failure rate documented in the present study, an annual follow-up by duplex is recommended to 2 years after EVLA
— id: 120627, year: 2011, vol: 25, page: 71, stat: Journal Article,

Experience and Technique for the Endovascular Management of Iatrogenic Subclavian Artery Injury
Cayne, N S; Berland, T L; Rockman, C B; Maldonado, T S; Adelman, M A; Jacobowitz, G R; Lamparello, P J; Mussa, F; Bauer, S; Saltzberg, S S; Veith, F J
2010 Jan;24(1):44-47, Annals of vascular surgery
OBJECTIVES: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. DISCUSSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair
— id: 106166, year: 2010, vol: 24, page: 44, stat: Journal Article,

Improved hemodynamic outcomes with glycopyrrolate over atropine in carotid angioplasty and stenting
Chung, Christine; Cayne, Neal S; Adelman, Mark A; Riles, Thomas S; Lamparello, Patrick; Han, Daniel; Marin, Michael L; Faries, Peter L
2010 Sep;22(3):164-170, Perspectives in vascular surgery & endovascular therapy
OBJECTIVE: Prophylactic atropine traditionally has been used to prevent CAS-associated hemodynamic depression. Glycopyrrolate may serve as an alternative with decreased cardiac effects. This study aims to compare the efficacy of prophylactic glycopyrrolate to atropine in preventing CAS-induced hemodynamic instability and cardiac complications. METHODS: 115 consecutive CAS patients from 2004-2010 were evaluated. Primary endpoints were stroke, MI, bradycardia (HR<60 beats/min), and hypotension (systolic BP <90 mm Hg). Additional outcomes included tachycardia (HR >100 beats/min), hypertension (systolic BP >160 mm Hg), pre- and postoperative systolic BP difference, vasopressor use, arrhythmias, cardiac enzyme elevations, and access site complications. RESULTS: Of 115 patients, 65 (56.5%) patients who received atropine or glycopyrrolate prior to CAS were analyzed [40 (61.5%) patients received glycopyrrolate, 25 (38.5%) received atropine]. Mean age was 70.0 +/- 8.5 years (range, 48-86 years). Mean stenosis was 86.2 +/- 7.4% (range, 70-99%). No MI, major stroke, or death was observed in the 30-day postoperative period. Baseline systolic BP and HR were equivalent between groups. Postoperative bradycardia and hypotension were significantly lower in glycopyrrolate patients compared with atropine patients (30% vs 72%, P = .002; 2.5% vs 36%, P < .001, respectively). Postoperative hypertension was also significantly lower in the glycopyrrolate cohort (2.5% vs 16%, P = .047), whereas tachycardia, pressure changes, vasopressor use, and cardiac complications did not differ significantly. No significant differences in neurologic and access site complications were observed. CONCLUSIONS: Prophylactic glycopyrrolate, compared with atropine, reduces hemodynamic instability during CAS. The authors recommend glycopyrrolate use to prevent CAS-induced bradycardia and hypotension
— id: 133478, year: 2010, vol: 22, page: 164, stat: Journal Article,

Intermediate-term EVAR outcomes in octogenarians
Fonseca, Rodrigo; Rockman, Caron; Pitti, Abhishek; Cayne, Neal; Maldonado, Tom S; Lamparello, Patrick J; Riles, Thomas; Adelman, Mark
2010 Sep;52(3):556-560, Journal of vascular surgery
OBJECTIVE: The utilization of endovascular abdominal aortic aneurysm repair (EVAR) in suitable patients has resulted in decreased perioperative morbidity and mortality. Octogenarians as a subgroup have been more readily offered EVAR, as it is less invasive, and therefore presumably better tolerated than conventional open aortic repair. The purpose of this study is to investigate periprocedural and late EVAR outcomes in octogenarians compared with patients less than 80 years of age. METHODS: From January 2003 to May 2008, 322 patients underwent EVAR. A total of 117 octogenarians were compared with 205 patients less than 80 years of age. A retrospective review of the demographic data, aneurysm details, perioperative morbidity, mortality, and late outcomes were analyzed. RESULTS: Octogenarians were significantly more likely to have a history of diabetes mellitus (51% vs 23%; P < .001), coronary artery disease (45% vs 32%; P = .0165), chronic obstructive pulmonary disease (44% vs 30%; P = .0113), and renal insufficiency (57% vs 31%; P < .0001). There were no significant differences in the rates of perioperative myocardial infarction, stroke, death, intestinal, or arterial ischemic complications between the two groups. Octogenarians had a significant higher rate of pulmonary complications (5.1% vs 1%; P < .03) and access-site hematomas (12% vs 2.4%; P = .001) than younger patients. When all significant perioperative morbidity was combined, octogenarians were twice as likely to develop complications following EVAR than younger patients (27.4% vs 11.7%; P = .001). At 5-year follow-up, younger patients were twice as likely to develop type II endoleaks. CONCLUSIONS: EVAR can be performed safely and effectively in octogenarians, and the incidence of major complications including myocardial infarction, stroke, and death is unchanged compared with younger patients. However, there is a significantly increased rate of access-site hematomas, pulmonary, and perioperative complications in octogenarians as a whole. Our findings suggest EVAR remains a suitable form of therapy in the elderly group provided there is an appropriate preoperative evaluation and perioperative monitoring following repair
— id: 136563, year: 2010, vol: 52, page: 556, stat: Journal Article,

A prospective, randomized, placebo-controlled study evaluating the efficacy of dexmedetomidine for sedation during vascular procedures
Huncke, Tessa Kate; Adelman, Mark; Jacobowitz, Glenn; Maldonado, Thomas; Bekker, Alex
2010 May;44(4):257-261, Vascular & endovascular surgery
OBJECTIVE: To examine the efficacy of dexmedetomidine (DEX) as a primary sedative during vascular procedures performed under monitored anesthesia care (MAC). A total of 55 patients were randomized in a 2:2:1 ratio to receive either DEX 1.0 microg/kg load or DEX 0.5 microg/kg load versus midazolam (MDZ) boluses, the current standard of care. This was followed by a maintenance infusion of DEX versus a normal saline infusion for the control group. Midazolam was given in 0.5 mg increments to maintain an equivalent target level of sedation among the 3 study groups. Fentanyl was given in 25 microg increments to treat pain as needed. The percentage of DEX patients not requiring MDZ and the total dose of MDZ and fentanyl were compared to the control. Dexmedetomidine was efficacious as a sole sedative for 50% of patients. The total dose of MDZ and fentanyl was significantly less during the DEX infusions. Patient satisfaction was superior with DEX
— id: 109213, year: 2010, vol: 44, page: 257, stat: Journal Article,

Comparison of Endovascular and Open Popliteal Artery Aneurysm Repair
Kim, BJ; Garg, K; Rockman, C; Jacobowitz, GR; Maldonado, T; Lamparello, P; Riles, T; Adelman, MA; Veith, FJ; Cayne, NS
2010 JUN ;51(9739):60S-61S, Journal of vascular surgery
— id: 111900, year: 2010, vol: 51, page: 60S, stat: Journal Article,

Time-resolved lower extremity MRA with temporal interpolation and stochastic spiral trajectories: Preliminary clinical experience
Lim, Ruth P; Jacob, Jason S; Hecht, Elizabeth M; Kim, Danny C; Huffman, Steven D; Kim, Sooah; Babb, James S; Laub, Gerhard; Adelman, Mark A; Lee, Vivian S
2010 Mar;31(3):663-672, Journal of magnetic resonance imaging
PURPOSE:: To assess added value of a new time-resolved technique with temporal interpolation and stochastic spiral trajectory through k-space and parallel imaging (TR-MRA) to conventional bolus chase MRA (BC-MRA) for infragenual peripheral artery evaluation. MATERIALS AND METHODS:: An institutional review board-approved retrospective review of peripheral arterial disease patients was performed. Infragenual TR-MRA and BC-MRA were performed in 26 patients over four months. Two readers individually assessed image quality, diagnostic confidence, and stenosis severity and length in 13 defined below knee segments, first with BC-MRA alone, and then with a combined BC-MRA and TR-MRA reading (BC+TR-MRA). Perceived contribution of TR-MRA was rated by each reader. The reference standard was a consensus reading of both sequences. Catheter angiographic (CA) correlation was available in 6 patients. RESULTS:: A total of 646 infragenual segments in 51 extremities were evaluated. Image quality and diagnostic confidence were superior for BC+TR-MRA compared with BC-MRA alone (P < 0.001). Adding TR-MRA improved sensitivity (85.7% versus 80.7%; P < 0.05) and diagnostic accuracy (88.1% versus 85.4%; P < 0.05) for hemodynamically significant stenosis. Venous contamination (0% versus 13.1% segments) and motion (0.9% versus 8.0%) were decreased for BC+TR-MRA versus BC-MRA alone, P < 0.01. For BC+TR-MRA, TR-MRA was rated more useful than BC-MRA in 30/51 legs (58.8%). TR-MRA identified retrograde flow in 5 segments. Where available, there was high concordance between CA and BC+TR-MRA (91.6%) for stenosis. CONCLUSION:: Adding TR-MRA with temporal interpolation and stochastic spiral trajectories to bolus chase MRA improves image quality, diagnostic confidence and accuracy. It provides hemodynamic information and minimizes venous contamination and patient motion. J. Magn. Reson. Imaging 2010;31:663-672. (c) 2010 Wiley-Liss, Inc
— id: 107781, year: 2010, vol: 31, page: 663, stat: Journal Article,

Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair
Pryluck, D S; Kovacs, S; Maldonado, T S; Jacobowitz, G R; Adelman, M A; Charles, H C; Clark, T W I
2010 Nov;44(8):701-707, Vascular & endovascular surgery
PURPOSE: To report preliminary experiences with the treatment of aortic aneurysm sac abscesses following prior endovascular aortic aneurysm repair (EVAR) using computerized tomography (CT)-guided percutaneous drainage. CASE REPORTS: Three patients aged 73 to 78 years with aortic aneurysm sac infections following prior EVAR, 2 of which were associated with aortoduodenal fistula, underwent CT-guided percutaneous drainage and catheter placement. One patient had complete resolution of the aortic aneurysm sac abscess following percutaneous drainage; 1 patient was stabilized to eventual extraanatomic bypass, graft explantation, and fistula repair; and 1 patient was temporized to debridement and fistula repair with endograft preservation. CONCLUSION: CT-guided percutaneous drainage may be a helpful therapy in selected patients for the treatment of aortic aneurysm sac infections following EVAR
— id: 113940, year: 2010, vol: 44, page: 701, stat: Journal Article,

Female Patients Undergoing TEVAR May Have an Increased Risk of Postoperative Spinal Cord Ischemia
Shah, Tejas R; Maldonado, Thomas; Bauer, Stephen; Cayne, Neal S; Schwartz, Charles F; Mussa, Firas; Adelman, Mark A; Rockman, Caron
2010 Jul;44(5):350-355, Vascular & endovascular surgery
Background: There is a paucity of literature regarding thoracic endovascular aneurysm repair (TEVAR) in women. We report our institutional experience with TEVAR. Methods: Retrospective chart review was performed from 2004 to 2008. TEVAR was performed in 59 patients; 29 (49%) were female. Results: Mean age was 73.5 years. Mean thoracic aortic aneurysm (TAA) diameter was larger for women (5.9 cm vs 4.7 cm). A trend toward an increase in paraplegia was noted in women, 10.3% vs 4.8%. This may be related to increase in length of aortic coverage in women, 18.2 cm vs 15.2 cm (P < .05). Conclusion: TEVAR in women is safe and effective. The length of aortic coverage is greater in women, which may be related to larger aneurysms and more diffuse disease. This may be associated with a concerning increase in postoperative paraplegia. Women undergoing TEVAR should be considered for prophylactic maneuvers to prevent spinal cord ischemia (SCI), including minimizing length of coverage
— id: 110870, year: 2010, vol: 44, page: 350, stat: Journal Article,

Intermittent foot claudication with active dorsiflexion: the seminal case of dorsalis pedis artery entrapment
Weichman, Katie; Berland, Todd; MacKay, Brendan; Mroczek, Kenneth; Adelman, Mark
2010 Jan;24(1):113.e1-113.e5, Annals of vascular surgery
BACKGROUND: Atypical claudication is a relatively uncommon problem within the general population. However, suspicion for the diagnosis is raised when young and athletic patients present with symptoms of claudication during exercise. The most common causes of atypical claudication are anatomical variants, including popliteal artery entrapment syndrome and tarsal tunnel syndrome. These variants result in impaired arterial flow and nerve compression, respectively. In this report, we present a seminal case of dorsalis pedis artery entrapment by the extensor hallucis brevis tendon during active dorsiflexion of the foot. METHODS: The patient was a 42-year-old male without significant past medical history, who presented with claudication in both feet upon active dorsiflexion. He underwent dynamic arterial duplex studies that first revealed normal flow in the neutral position and then revealed complete cessation of flow in both duplex and Doppler modes on dorsiflexion of the foot. He also underwent dynamic magnetic resonance angiography of bilateral lower extremities that revealed an incomplete pedal arch with early termination of the posterior tibial artery on static images and termination of the dorsalis pedis artery at notching on the dorsum of the foot during dorsiflexion. The patient was taken to the operating room for bilateral dorsalis pedis artery exploration. During exploration, the patient was found to have entrapment of the dorsalis pedis artery by the extensor hallucis brevis (EHB) tendon. This was documented by both direct visualization and intraoperative cessation of Doppler signal on dorsiflexion. Since the EHB tendon provides only secondary function to the extensor hallucis longus (EHL) tendon, the EHB was transected near its insertion and transposed directly to the EHL tendon. This allowed for normal extensor function of the great toe and restored triphasic Doppler signals during dorsiflexion. CONCLUSION: Dorsalis pedis arterial entrapment is a novel cause of atypical claudication. It is extremely uncommon as patients must have both abnormal anatomy and an incomplete pedal arch to display symptoms. Similar to other entrapment syndromes, if identified before permanent arterial scarring, the treatment does not require a bypass procedure. Removal of the tendon along with transposition will allow cessation of symptoms without impaired dorsiflexion of the great toe
— id: 110774, year: 2010, vol: 24, page: 113.e1, stat: Journal Article,

Current status of investigational devices for EVAR: similarities and differences
Cayne, Neal S; Adelman, Mark A; Veith, Frank J
2009 Sep;22(3):127-131, Seminars in vascular surgery
Improvements in the design of endovascular grafts are based on lessons learned from difficulties encountered with prior-generation devices. The most common difficulties in device design relate to how the device is delivered and how it can safely and durably fix the aneurysm. This concept is especially true in patients with difficult anatomy. Difficult anatomy, such as small, calcified, tortuous access vessels and short angulated sealing zones, continue to challenge engineers. Currently, the US Food and Drug Administration has approved eight endovascular devices for the treatment of aortic aneurysms: five for abdominal aortic aneurysms and three for thoracic aortic aneurysms. Compared to the first-generation devices approved in 1999, current devices have smaller and more flexible delivery systems. The devices themselves are more flexible and have better fixation than prior-generation devices. This article will focus on the next generation of devices that are not yet approved, but currently under investigation in the United States
— id: 102501, year: 2009, vol: 22, page: 127, stat: Journal Article,

Outcome of carotid endarterectomy for acute neurological deficit
Mussa, Firas F; Aaronson, Nicole; Lamparello, Patrick J; Maldonado, Thomas S; Cayne, Neal S; Adelman, Mark A; Riles, Thomas S; Rockman, Caron B
2009 Aug-Sep;43(4):364-369, Vascular & endovascular surgery
We reviewed our experience with urgent carotid intervention in the setting of acute neurological deficits. Between June 1992 and August 2008, a total of 3145 carotid endarterectomies (CEA) were performed. Twenty-seven patients (<1.0%) were categorized as urgent. The mean age was 74.1 years (range 56-93 years) with 16 (60%) men, and 11 (40%) women, Symptoms included extremity weakness or paralysis (n = 13), amaurosis fugax (n = 6), speech difficulty (n = 2), and syncope, (n = 3). Three patients exhibited a combination of these symptoms. Three open thrombectomy were performed. Regional anesthesia was used in 13 patients (52%). Seventeen patients (67%), required shunt placement. At 30-days, 2 patient (7%) suffered a stroke, and 1 (4%) died. Urgent CEA can be performed safely. A stroke rate of 7% is acceptable in those who may otherwise suffer a dismal outcome without intervention
— id: 101891, year: 2009, vol: 43, page: 364, stat: Journal Article,

Hemodynamic changes associated with carotid artery interventions
Cayne, Neal S; Rockman, Caron B; Maldonado, Thomas S; Adelman, Mark A; Lamparello, Patrick J; Veith, Frank J
2008 Sep;20(3):293-296, Perspectives in vascular surgery & endovascular therapy
Carotid artery interventions can be associated with adverse hemodynamic changes, including bradycardia and hypotension. These hemodynamic changes are believed to be caused by direct stimulation of the carotid sinus baroreceptors, mimicking normal physiological response to rises in blood pressure. During open carotid surgery, these hemodynamic changes can be controlled by direct injection of medications that block fast voltage gated sodium channels in the neuron cell membrane, thus preventing depolarization of the presynaptic neuron in the carotid sinus. This form of control is difficult or impossible during percutaneous carotid interventions because direct access to the carotid artery and carotid sinus is not available. This discussion focuses on the cause, effects, and possible treatments for the hemodynamic changes associated with carotid artery stenting procedures
— id: 94023, year: 2008, vol: 20, page: 293, stat: Journal Article,

Early results for below-knee bypasses using Distaflo
Gulkarov, Iosif; Malik, Rajesh; Yakubov, Rakhsim; Gagne, Paul; Muhs, Bart E; Rockman, Caron; Cayne, Neal S; Jacobowitz, Glenn R; Lamparello, Patrick J; Adelman, Mark A; Maldonado, Thomas S
2008 Dec-2009 Jan;42(6):561-566, Vascular & endovascular surgery
In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses
— id: 92678, year: 2008, vol: 42, page: 561, stat: Journal Article,

Endovenous procedures in varicose veins What is the best choice today?
Kabnick, LS; Cayne, N; Jacobowitz, G; Lamparello, P; Maldonado, I; Rockman, C; Adelman, M
2008 NOV ;37(5):229-236, Phlebologie
Over the post ten years endoveous treatment options for varicose veins have evovled considerably,offering clinicians a multitude of options to meet the needs of their patients. The endothermal oblation procedures have moved to the forefront as the choice modality for treating truncal reflux. Both radiofrequency ablation and endovenous loser ablation are widely accepted and interchangeable, showing comparable efficacy and safety. Although numerous endovenous loser wavelengths exist, the data indicates that the differences do not affect the efficacy or postoperative recovery of the procedure. The endovenous laser innovation that has shown early evidence of improved patient outcome is the jacket-tip fiber. The versatility of sclefotheropy makes it a critical component in the endovenous treatment of varicosities. Although not approved by the Food and Drug Administration (USA), the use of a foamed sclerosing agent is the fastest growing segment of sclerotherapy and an important treatment modality in the future of varicose vein treatment. Cutaneous losers and intense pulse light devices contribute a crucial element, enabling clinicians to treat minute veins that may be impossible to treat with other therapies
— id: 91326, year: 2008, vol: 37, page: 229, stat: Journal Article,

Incidence and outcome of filter occlusion during carotid artery stent procedure
Maldonado, Thomas S; Loh, Shang; Fonseco, Rodrigo; Poblete, Honesto; Adelman, Mark A; Cayne, Neal S; Mussa, Firas; Rockman, Caron B; Sadik, Michael; Ellozy, Sharif; Faries, Peter
2008 Nov;22(6):756-761, Annals of vascular surgery
Recent reviews of device-specific complications using neuroprotection have addressed technical difficulties during delivery as well as adverse outcomes, intraoperative and 30-day. Little has been written, however, regarding the relevance of filter occlusion during the carotid stent procedure. A retrospective review was conducted of patients undergoing carotid artery stent procedures using a variety of neuroprotection devices from 2003 to 2007. Prospective databases from two institutions were examined for incidence and management of filter occlusions during procedures as well as adverse neurological events (intraoperative and 30-day) associated with filter occlusion. There were 283 carotid artery stent procedures performed on 256 patients (163 male, 93 female): 177 (62.5%) arteries were asymptomatic and 106 were symptomatic. Neurological adverse events occurred in six patients (2.1%); three of these resolved completely at 72 hr. Neuroprotection was used in 95% of all patients, and filters were used in 221 stent procedures: Boston Scientific Filter Wire (n = 81), Guidant Accunet (n = 100), Angioguard (n = 17), and Abbot Emboshield (n = 23). Filter occlusion occurred in 11 patients (4.9%) in whom this form of neuroprotection was employed: Angioguard (n = 5), Accunet (n = 2), Emboshield (n = 2), and EPI Filter wire (n = 2). Two of the 11 patients with filter occlusions suffered a neurological event. There was no correlation between filter occlusion and gender, symptoms, stent, or filter type (p > 0.05). Filter occlusion was managed with export catheter-directed aspiration in seven patients and with prompt filter retrieval in five patients. Filter occlusion is an infrequent event that does not appear to be filter-specific and can be managed successfully by catheter-directed aspiration or filter retrieval. The majority of patients with filter occlusion do not suffer from atheroemboli as a result of this occlusion
— id: 91485, year: 2008, vol: 22, page: 756, stat: Journal Article,

Total Viabahn endoprosthesis collapse
Ranson, Mark E; Adelman, Mark A; Cayne, Neal S; Maldonado, Thomas S; Muhs, Bart E
2008 Feb;47(2):454-456, Journal of vascular surgery
We present a case of Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) collapse during popliteal artery aneurysm treatment. An elderly man with severe comorbidities presented with a 34-mm popliteal artery aneurysm. Proximal and distal landing sites of 11 and 9 mm, respectively, demonstrated by preoperative computed tomography angiography were confirmed by intraoperative angiography. After Viabahn deployment, angiography revealed a filling defect in the distal popliteal graft with poor flow. Balloon dilatation failed. A femoropopliteal bypass with aneurysm ligation was performed. Transection of the distal popliteal vessel demonstrated complete infolding. Our choice of grafts represented 15% to 18% proximal and distal oversizing. Focal areas of relative vessel narrowing may lead to incomplete graft unfolding and graft failure
— id: 76343, year: 2008, vol: 47, page: 454, stat: Journal Article,

Multidimensional characterization of carotid artery stenosis using CT imaging: a comparison with ultrasound grading and peak flow measurement
van Prehn, J; Muhs, B E; Pramanik, B; Ollenschleger, M; Rockman, C B; Cayne, N S; Adelman, M A; Jacobowitz, G R; Maldonado, T S
2008 Sep;36(3):267-272, European journal of vascular & endovascular surgery
PURPOSE: Clinical decision making for carotid surgery depends largely upon stenosis grade. While digital subtraction angiography remains the gold standard for stenosis grading, many physicians use less invasive modalities. The purpose of this study was to compare the results of multidimensional Computed tomography (CTA) with ultrasound (US) grading and peak flow velocity (PSV). METHODS: 37 stenosed carotid arteries were studied retrospectively in 36 consecutive patients. US grading and PSV were compared to multidimensional CTA analysis (diameter, area and volumetric measurements), performed by a medical software company. Calculations of stenosis percentage on CTA were made using the NASCET and ECST methodology. Diameter measurements were also performed by a neuroradiologist. RESULTS: All CTA diameter, area and volume measurements had only modest correlation with PSV (r<0.5) and ultrasound grading (p<0.5). There was concordant classification of stenosis grades in only 40-60% of cases. CTA diameter, area and volume measurements had good correlation (0.69<r<0.87) with one another using ECST methodology. Using NASCET methodology on CTA, correlation between diameter and area was insignificant (r=0.32). CTA volumetric analysis with the NASCET method yielded 27 negative stenosis grades. Repeatability coefficient for selecting the normal distal ICA 20 mm more distally was 20% for diameter and 43% for area. CTA diameter interobserver repeatability coefficients were 22.9% (NASCET) and 17.8% (ECST) and 0.7 mm (lumen) and 1.9 mm (vessel). CONCLUSIONS: All CTA measurements showed moderate correlation with both ultrasound grading and PSV. Selection of the level of the normal distal ICA influences the NASCET calculations and can produce discrepant stenosis grades. Multidimensional CTA analysis seems to have no additional value for stenosis grading, but provides other useful anatomic information
— id: 106167, year: 2008, vol: 36, page: 267, stat: Journal Article,

Commentary on "Contemporary management of carotid stenosis: carotid endarterectomy is here to stay"
Adelman, Mark A
2007 Sep;19(3):257-258, Perspectives in vascular surgery & endovascular therapy
— id: 75655, year: 2007, vol: 19, page: 257, stat: Journal Article,

Regional nerve block allows for optimization of planning in the creation of arteriovenous access for hemodialysis by improving superficial venous dilatation
Laskowski, I A; Muhs, B; Rockman, C R; Adelman, M A; Ranson, M; Cayne, N S; Leivent, J A; Maldonado, T S
2007 Nov;21(6):730-733, Annals of vascular surgery
Durable vascular access for hemodialysis remains a critical issue in end-stage renal disease patients. Creation of an autogenous arteriovenous (AV) fistula in the most distal location of the nondominant extremity is the preferred technique and provides superior patency over an AV graft. Others have shown that regional anesthesia in the form of axillary block results in the dilatation of the native veins and allows for their increased utilization in creating AV fistulae. We report on 26 patients undergoing creation of a vascular access for hemodialysis. Regional anesthesia consisting of axillary nerve block was used in all cases. All surgical plans with regard to the site and type of access were made based on the physical exam and ultrasound vein measurements taken prior to surgery. On the day of surgery patients were reevaluated with venous ultrasound using tourniquet before and after administration of the regional block. The previously determined operative plan either remained unchanged or was modified depending on the venous dilatation noted after administration of regional block. Among 26 patients, average vein diameter increased from 0.29 +/- 0.12 cm to 0.34 +/- 0.11 cm (P = 0.008). Twenty-one of 26 patients had no modification in operative plan (group 1). Five had some modification of the original operative plan (group 2): AV graft to a brachial vein transposition (n = 2), AV graft to a Cimino fistula (n = 2), and brachiocephalic to a Cimino (n = 1). The average follow-up for all patients was 82.6 +/- 75.6 days and did not differ between the groups. There was one failure in a patient from group 1, and there was no significant difference in the patency rate between study groups (P = 0.29). Following regional nerve block, operative plans in patients undergoing AV access surgery were modified in 29.4% of patients undergoing creation of an AV access for hemodialysis; either from graft to fistula creation or from the proximal to more distal fistula site. The routine use of regional anesthesia as well as intraoperative ultrasound during AV access surgery can lead to improved site selection and increased opportunity for AV fistula creation
— id: 75652, year: 2007, vol: 21, page: 730, stat: Journal Article,

Decreased ischemic complications after endovascular aortic aneurysm repair with newer devices
Maldonado, Thomas S; Ranson, Mark E; Rockman, Caron B; Pua, Brad; Cayne, Neal S; Jacobowitz, Glenn R; Adelman, Mark A
2007 Jun-Jul;41(3):192-199, Vascular & endovascular surgery
Ischemic complications after endovascular abdominal aortic aneurysm repair (EVAR) are well-recognized and have been reported to be as high as 9%. The goal of our study was to examine the incidence, management, and outcome of ischemic complications at our institution after EVAR and to compare complications according to graft type and time period. This is a retrospective review of all EVARs performed at our institution from 1993 through 2005 (n = 430). EVAR was performed in asymptomatic patients in most cases. Follow-up consisted of a computed tomography scan and office visit at 1, 6, and 12 months and yearly thereafter. Ischemic complications after EVAR have decreased significantly with the advent of lower-profile devices with easier delivery systems and supported limbs. Simultaneous coil embolization of internal iliac artery at the time of EVAR implant does not appear to increase the risk of pelvic or lower-extremity ischemia, can be done safely, and does not need to be staged
— id: 73863, year: 2007, vol: 41, page: 192, stat: Journal Article,

Different endovascular referral patterns are being learned in medical and surgical residency training programs
Muhs, Bart E; Maldonado, Thomas; Crotty, Kelly; Jayanetti, Chaminda; Lamparello, Patrick J; Adelman, Mark A; Jacobowitz, Glenn R; Rockman, Caron; Gagne, Paul J
2006 Mar;20(2):217-222, Annals of vascular surgery
Physicians in residency training will be the referring physicians of tomorrow. We sought to determine the current surgical and medical trainees' perception of vascular surgery's endovascular qualifications and capabilities. An anonymous survey was sent to all general surgery and internal medicine residents at a single academic institution. Respondents answered the question 'Which specialty is the most qualified to perform (1) inferior vena cava (IVC) filter insertion; (2) angiograms, angioplasty, and stenting of the carotid arteries; (3) renal arteries; (4) aorta; and (5) lower extremity arteries?' For each question, respondents chose one response, either vascular surgery, interventional radiology, interventional cardiology, or do not know. One hundred respondents completed the survey (general surgery, n=50; internal medicine, n=50). There was a significant difference in the attitudes of surgery and medicine residents when choosing the most qualified endovascular specialist (p<0.05). Surgery residents chose vascular surgery as the most qualified specialty for each listed procedure: carotid (80%, n=40), IVC (56%, n=28), aorta (100%, n=50), extremity (86%, n=43), renal (78%, n=39). Medicine residents chose vascular surgery as the most qualified specialty less frequently: carotid (66%, n=33), IVC (6%, n=3), aorta (88%, n=44), extremity (72%, n=36), renal (16%, n=8). There was no significant difference in specialty selection based on postgraduate year. There is a large discrepancy between surgical and medical trainees' perception of vascular surgery's endovascular abilities, particularly regarding IVC placement and renal artery interventions. If our own institution mirrors the nation, each passing year a significant portion of the 21,722 graduating internal medicine residents go into practice viewing vascular surgeons as second-tier endovascular providers. A concerted campaign should be undertaken to educate medical residents regarding the skills and capabilities of vascular surgeons
— id: 66067, year: 2006, vol: 20, page: 217, stat: Journal Article,

Carotid angioplasty and stent-induced bradycardia and hypotension: Impact of prophylactic atropine administration and prior carotid endarterectomy
Cayne, Neal S; Faries, Peter L; Trocciola, Susan M; Saltzberg, Stephanie S; Dayal, Rajeev D; Clair, Daniel; Rockman, Caron B; Jacobowitz, Glenn R; Maldonado, Thomas; Adelman, Mark A; Lamperello, Patrick; Riles, Thomas S; Kent, K Craig
2005 Jun;41(6):956-961, Journal of vascular surgery
Objective We compared the physiologic effect of selective atropine administration for bradycardia with routine prophylactic administration, before balloon inflation, during carotid angioplasty and stenting (CAS). We also compared the incidence of procedural bradycardia and hypotension for CAS in patients with primary stenosis vs those with prior ipsilateral carotid endarterectomy (CEA). Methods A total of 86 patients were treated with CAS at 3 institutions. Complete periprocedural information was available for 75 of these patients. The median degree of stenosis was 90% (range, 60%-99%). Indications for CAS were severe comorbidities (n = 49), prior CEA (n = 21), and prior neck radiation (n = 5). Twenty patients with primary lesions were treated selectively with atropine only if symptomatic bradycardia occurred (nonprophylactic group). Thirty-four patients with primary lesions received routine prophylactic atropine administration before balloon inflation or stent deployment (prophylactic group). The 21 patients with prior CEA received selective atropine treatment only if symptomatic bradycardia occurred (prior CEA group) and were analyzed separately. Mean age and cardiac comorbidities did not vary significantly either between the prophylactic and nonprophylactic atropine groups or between the primary and prior CEA patient groups. Outcome measures included bradycardia (decrease in heart rate >50% or absolute heart rate <40 bpm), hypotension (systolic blood pressure <90 mm Hg or mean blood pressure <50 mm Hg), requirement for vasopressors, and cardiac morbidity (myocardial infarction or congestive heart failure). Results The overall incidence of hypotension and bradycardia in patients treated with CAS was 25 (33%) of 75. A decreased incidence of intraoperative bradycardia (9% vs 50%; P < .001) and perioperative cardiac morbidity (0% vs 15%; P < .05) was observed in patients with primary stenosis who received prophylactic atropine as compared with patients who did not receive prophylactic atropine. CAS after prior CEA was associated with a significantly lower incidence of perioperative bradycardia (10% vs 33%; P < .05), hypotension (5% vs 32%; P < .05), and vasopressor requirement (5% vs 30%; P < .05), with a trend toward a lower incidence of cardiac morbidity (0% vs 6%; not significant) as compared with patients treated with CAS for primary carotid lesions. There were no significant predictive demographic factors for bradycardia and hypotension after CAS. Conclusions The administration of prophylactic atropine before balloon inflation during CAS decreases the incidence of intraoperative bradycardia and cardiac morbidity in primary CAS patients. Periprocedural bradycardia, hypotension, and the need for vasopressors occur more frequently with primary CAS than with redo CAS procedures. On the basis of our data, we recommend that prophylactic atropine administration be considered in patients with primary carotid lesions undergoing CAS
— id: 55781, year: 2005, vol: 41, page: 956, stat: Journal Article,

Surgical repair of a left subclavian artery aneurysm causing stenosis of a left internal mammary graft-a case report
Douglas, Diah A; Adelman, Mark A; Esposito, Rick; Rockman, Caron
2005 May-Jun;39(3):281-285, Vascular & endovascular surgery
Subclavian artery aneurysms are extremely rare, accounting for approximately 0.1% of peripheral artery aneurysms. We present a case of a proximal left subclavian arterial aneurysm in a patient status post previous coronary artery bypass grafting; the aneurysm was complicated by involvement of the left internal mammary artery that had been previously utilized to revascularize the left anterior descending artery. Ostial stenosis of the internal mammary artery secondary to the aneurysm was present. Simultaneous reoperative coronary bypass surgery and repair of the left subclavian aneurysm was performed, with a good result. This is the second case reported in the literature of concomitant subclavian artery aneurysm repair and coronary revascularization
— id: 55953, year: 2005, vol: 39, page: 281, stat: Journal Article,

Gadolinium-enhanced versus time-of-flight magnetic resonance angiography: what is the benefit of contrast enhancement in evaluating carotid stenosis?
Muhs, Bart E; Gagne, Paul; Wagener, Jael; Baker, Jessica; Ortega, Marta Ramirez; Adelman, Mark A; Cayne, Neal S; Rockman, Caron B; Maldonado, Thomas
2005 Nov;19(6):823-828, Annals of vascular surgery
Accurate patient selection based on preoperative imaging is imperative to good risk reduction in patients undergoing carotid endarterectomy (CEA). The goal of this study was to assess the accuracy of gadolinium-enhanced magnetic resonance angiography (GE MRA) versus time-of-flight (TOF) MRA in the work-up of patients undergoing CEA. Patients undergoing CEA between 1999 and 2001 were identified from a prospectively maintained institutional database. GE or TOF MRA was obtained on extracranial carotid arteries (n = 319) in patients undergoing CEA. Stenosis on MRA images was graded as moderate (n = 76) or severe (n = 243) by an attending radiologist who was blind to duplex results. Duplex imaging was performed in an Intersocietal Commission for the Accreditation of Vascular Labs (ICAVL) accredited lab, and stenosis was stratified as moderate (50-79%, n = 76) or high (80-99%, n = 243) grade using University of Washington criteria. For each patient, the degree of stenosis as determined by MRA (GE versus TOF) was compared to percent stenosis on duplex. For moderate-grade lesions, GE MRA concurred with duplex in 11.1% (4/36), underestimated in 2.8% (1/36), and overestimated in 86.1% (31/36) of carotid arteries imaged. TOF MRA concurred with duplex in 35% (14/40), underestimated in 0% (0/40), and overestimated in 65% (26/40) of carotid arteries. High-grade lesions demonstrated improved concordance between MRA and duplex. For these lesions, GE MRA concurred with duplex in 95.6% (130/136) of carotid arteries imaged, never overestimated stenosis (0/136), and underestimated in 4.4% (6/136). TOF MRA concurred with duplex 96.3% (103/107), overestimated stenosis as an occlusion in 0.9% (1/107), and underestimated in 2.8% (3/107). In addition to neck visualization, the GE technique allowed simultaneous aortic arch imaging. This was accomplished in 79.1% (136/172) of all GE MRAs. Simultaneous aortic arch imaging was not technically feasible with TOF MRA. For moderate-grade lesions, both MR techniques are inaccurate predictors of degree of carotid stenosis and result in a significant overestimation of stenosis. Each technique demonstrates improved concordance with duplex ultrasound in the setting of severe carotid artery stenoses. The ability of GE MRA to simultaneously image the aortic arch and the neck may allow for detection of occult tandem lesions and other anatomic variations, which may be particularly important in preoperative planning for carotid artery stenting
— id: 61845, year: 2005, vol: 19, page: 823, stat: Journal Article,

Arterial injuries from femoral artery cannulation with port access cardiac surgery
Muhs, Bart E; Galloway, Aubrey C; Lombino, Michael; Silberstein, Michael; Grossi, Eugene A; Colvin, Stephen B; Lamparello, Patrick; Jacobowitz, Glenn; Adelman, Mark A; Rockman, Caron; Gagne, Paul J
2005 Mar-Apr;39(2):153-158, Vascular & endovascular surgery
Although minimally invasive (MI) cardiac surgery reduces blood loss, hospital stay, and recovery time, some MI approaches require femoral arterial cannulation, which introduces a heretofore unknown risk of femoral arterial injury. This study was performed to examine the risk of femoral arterial injury after Port Access MI cardiac surgery (PA-MICS) with femoral cannulation. Data were prospectively obtained on 739 consecutive patients who had PA-MICS with femoral cannulation between June 1996 and April 2000, identifying any patient with new (<30 days postoperative) arterial insufficiency from the cannulation site. Patient characteristics (gender, age, height, weight, body surface area, smoking, peripheral vascular disease, diabetes) and operative variables (cannula size, cross-clamp time) were examined with univariate and multivariate analysis to identify risk factors for arterial injury. Injuries were defined and classified by radiologic and intraoperative assessment, and follow-up was obtained by patient examination and from the medical records. Femoral arterial occlusion (FAC) occurred in 0.68% (5/739) of patients (4 women, 1 man; age range 26-74 years). The risk of femoral injury was higher in women: 1.31% vs 0.23% (p = 0.07). One patient had intraoperative limb ischemia from iliofemoral dissection and was treated by axillopopliteal bypass. Four patients presented postoperatively with claudication. Three of these had iliofemoral arterial occlusion or localized iliofemoral dissection and were treated with iliofemoral bypass, and 1 patient had localized femoral artery stenosis treated by angioplasty. With a mean follow-up of 17.8 months (range 13-26 months) limb salvage was achieved in all patients. Secondary or tertiary interventions were required in 40% (2/5), both in patients with iliofemoral occlusion, and 1 patient (20% of femoral injuries, 0.135% of overall series) has chronic graft occlusion and long-term claudication. The risk of arterial injury after femoral arterial cannulation and perfusion for Port Access surgery was low (0.68%). This risk is increased in women and is unpredictable. Initial vascular repair has a significant failure rate, and secondary interventions are often necessary. Although the femoral cannulation and perfusion technique is safe overall, the risk must be clearly recognized
— id: 55954, year: 2005, vol: 39, page: 153, stat: Journal Article,

The safety of carotid endarterectomy in diabetic patients: clinical predictors of adverse outcome
Rockman, Caron B; Saltzberg, Stephanie S; Maldonado, Thomas S; Adelman, Mark A; Cayne, Neal S; Lamparello, Patrick J; Riles, Thomas S
2005 Nov;42(5):878-883, Journal of vascular surgery
OBJECTIVES: Patients with diabetes mellitus have been shown to have an increased incidence of complications after elective major vascular surgery. The objective of this study was to evaluate a large series of diabetic patients undergoing carotid endarterectomy (CEA) to determine if outcome differed from nondiabetic patients and to examine predisposing factors of poor outcome among diabetic patients. METHODS: A retrospective review of a prospectively compiled database was performed. From 1992 through 2000, 2151 CEAs were performed at our institution. Of these, 507 were in diabetic patients (23.6%), and the remaining 1644 procedures were in nondiabetic patients (76.4%). RESULTS: Diabetic patients were significantly more likely than nondiabetic patients to have hypertension (70.8% vs 64.5%, P = .01) and cardiac disease (54.6% vs 49.1%, P = .03). They were more likely than nondiabetic patients to be symptomatic before surgery (52.5% vs 47.1%, P = .04) and to have sustained a preoperative stroke (21.3% vs 17.7%, P = .07). No differences were noted in other recorded demographic factors or in intraoperative factors between diabetic and nondiabetic patients. Despite these differences, diabetic patients had similar perioperative outcomes compared with nondiabetic patients, including perioperative myocardial infarction (0.6% vs 0.4%, P = NS), perioperative death (0.8% vs 0.5%, P = NS), and perioperative neurologic events such as transient ischemic attack and stroke (3.2% vs 2.4%, P = NS). Among diabetic patients alone, cigarette smoking, general anesthesia, the use of a shunt, and the lack of clamp tolerance while under regional anesthesia predicted adverse perioperative neurologic outcome, and contralateral occlusion was associated with increased perioperative mortality. CONCLUSIONS: Despite an increased prevalence of cardiac disease and preoperative neurologic symptoms among diabetic patients undergoing CEA, the rates of perioperative cardiac morbidity, mortality, and stroke were equal to nondiabetic patients. In contrast to nondiabetic patients, current cigarette smoking appeared to predict increased adverse neurologic outcomes among diabetic patients, and the presence of contralateral occlusion among diabetic patients appeared to predispose them towards increased perioperative mortality. The use of a general anesthetic appeared to increased perioperative neurologic risk among diabetic patients; however, this may be related to surgeon bias in the selection of anesthetic technique. Although diabetic patients may have an increase in complications after other major vascular surgical procedures, the presence of diabetes mellitus does not appear to significantly increase risk
— id: 68645, year: 2005, vol: 42, page: 878, stat: Journal Article,

Is Endovascular Therapy the Preferred Treatment for All Visceral Artery Aneurysms?
Saltzberg, Stephanie S; Maldonado, Thomas S; Lamparello, Patrick J; Cayne, Neal S; Nalbandian, Matthew M; Rosen, Robert J; Jacobowitz, Glenn R; Adelman, Mark A; Gagne, Paul J; Riles, Thomas S; Rockman, Caron B
2005 Jul;19(4):507-515, Annals of vascular surgery
Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases
— id: 56278, year: 2005, vol: 19, page: 507, stat: Journal Article,

Dexmedetomidine for awake carotid endarterectomy: efficacy, hemodynamic profile, and side effects
Bekker, Alex Y; Basile, John; Gold, Mark; Riles, Thomas; Adelman, Mark; Cuff, Germaine; Mathew, Jomol P; Goldberg, Judith D
2004 Apr;16(2):126-135, Journal of neurosurgical anesthesiology
: A randomized, double-masked, placebo-controlled study was designed to compare dexmedetomidine as a primary sedative agent with a commonly used drug combination in patients undergoing awake carotid endarterectomy (CEA). Sixty-six patients undergoing CEA (ASA II-IV) were randomly assigned to receive either dexmedetomidine (total dose of 97.5 +/- 54.7 mcg) or normal saline (control). Supplemental doses of midazolam, fentanyl, and/or propofol were administered as deemed necessary by the anesthesiologist. An observer blinded to the study drug assessed sedation level (Observer's Assessment of Alertness-Sedation [OAA/S] scale). The primary outcomes were defined as the number of patients with an OAA/S score of 4 intraoperatively and an OAA/S score of 5 postoperatively. The authors also compared cardiorespiratory parameters, intra- and postoperative side effects, and complications. Chi-square tests were used to analyze the primary endpoints. All secondary parameters were analyzed using the Wilcoxon rank sum test. Three patients in the dexmedetomidine group (10%) had an OAA/S score of 4 at all four time points assessed intraoperatively, while no patient in the control group had a score of 4 at all the time points considered. Thirteen patients in the dexmedetomidine group had a score of 4 at three or more time points (42%) compared with six patients (19%) in the control group. Four patients in the control group (13%) and one patient in the dexmedetomidine group (3%) did not achieve a score of 4 at any of the four critical intraoperative time points (chi for association = 9.9, P < 0.05; chi for a trend = 8.6, P < 0.004, with the trend favoring dexmedetomidine). More patients in the control group required treatment with metoprolol (26% vs. 6%, P = 0.04) and labetalol (48% vs/ 6%, P < 0.01). Plasma levels of norepinephrine were significantly lower in the dexmedetomidine group during and after surgery compared with the control group. Six patients (19%) in the dexmedetomidine group required intra-arterial shunts, while only two patients (6%) required shunts in the control group (P = 0.16). These data show that the use of dexmedetomidine in patients undergoing awake CEA resulted in fewer fluctuations from the desired sedation level. Patients receiving dexmedetomidine required less antihypertensive therapy compared with the midazolam/fentanyl/propofol combination. The effect of dexmedetomidine on cerebrovascular circulation in the study population needs further investigation
— id: 43212, year: 2004, vol: 16, page: 126, stat: Journal Article,

Endovascular abdominal aortic aneurysm repair in patients with challenging anatomy: utility of the hybrid endograft
Jordan, William D Jr; Naslund, Thomas C; Adelman, Mark A; Simoni, Gene; Wirthlin, Douglas J
2004 Mar;12(2):106-113, Vascular
Commercially available aortic stent grafts differ in construction and clinical advantage such that creating hybrid endografts by combining components from different manufacturers is sometimes useful. We describe a multicenter experience using hybrid endografts to treat patients with challenging anatomy. Hospital records and office charts were reviewed from four institutions. Hybrid endografts were defined as those with two types of covered stents in continuity to treat an abdominal aortic aneurysm (AAA). Indications for hybrid grafts were defined by type of endoleak and whether an endoleak was expected or unexpected as determined by the preoperative radiographic evaluation. Endpoints include intraoperative endoleaks, late endoleaks, change in aneurysm size, and rupture. Hybrid endografts were used to treat AAA (endovascular aneurysm repair [EVAR]) in 90 patients, representing 7.9% of the total multicenter experience. In 7 patients (7.8%), a hybrid graft construction as a secondary procedure successfully corrected a type 1 endoleak. In the remaining 83 patients (92.2%), hybrid grafts were created at the time of original EVAR to treat expected challenging anatomy or unexpected endoleaks. Hybrid endografts corrected 88 (97.8%) type 1 endoleaks, but 2 patients (2.2%) persisted with a proximal type 1 leak requiring conversion. During follow-up of 1 to 24 months, computed tomography and ultrasound surveillance, available for 73 patients (81.1%), detected one unresolved distal type 1 (1.1%) and seven type 2 (7.8%) endoleaks. Aneurysm size decreased at least 0.5 cm in 23 of 50 patients (46.0%) at 6 months and in 19 of 31 patients (61.3%) at 12 months. Aneurysm size increased at least 0.5 cm in 4 of 50 patients (8.0%) at 6 months and in 1 of 31 patients (3.2%) at 12 months. There were no ruptures. Hybrid endografts have favorable early and intermediate results in the treatment of AAA. Long-term follow-up will be needed to confirm the absence of significant adverse biomaterial interaction and the effect on AAA exclusion. We advocate the use of hybrid endografts as endovascular therapy for patients whose anatomy may be unsuitable for a single endograft type
— id: 71129, year: 2004, vol: 12, page: 106, stat: Journal Article,

Successful management of carotid stenosis in a high-risk population at an inner-city hospital
Maldonado, Thomas S; Moreno, Ricardo; Gagne, Paul J; Adelman, Mark A; Nalbandian, Matthew M; Bajakian, Danielle; Jacobowitz, Glenn R; Lamparello, Patrick J; Riles, Thomas S; Rockman, Caron B
2004 Nov-Dec;38(6):511-517, Vascular & endovascular surgery
This is a retrospective review of all carotid endarterectomies (CEA) (n=91) done from 1993 to 2002 at an inner-city hospital (Group I). This group was compared to a randomly selected group of patients (n=445) treated at a private hospital (Group II). The same high-volume surgeons performed CEAs at both hospitals. The majority of Group I patients (71.4%) were members of racial minority groups. They were also more likely to be younger (p<0.001), hypertensive (p<0.03), diabetic (p<0.001), and current smokers (p<0.001); have contralateral carotid artery occlusion (p=0.04); and present with stroke (p<0.001) than Group II patients. Despite this, the incidence of postoperative myocardial infarction (2.2% vs 0.2%, p=0.08), stroke (1.1% vs 1.6%, NS), and death (1.1% vs 0%, NS) was comparable between the 2 groups. Aggressive preoperative workup for occult cardiac disease in Group I revealed an incidence of 25.9% (n=15). Of these, 5 (33.3%) were found to have coronary artery disease severe enough to warrant intervention before CEA. In an inner-city population with increased medical comorbidities, more severe cerebrovascular disease, and relatively low volume of carotid surgery, the results of CEA were comparable to those in patients treated at a high-volume private hospital. The presence of high-volume surgeons, operating at the low-volume municipal hospital, may contribute to the low complication rate. Finally, aggressive preoperative cardiac workup in this underserved population revealed a meaningful incidence of occult coronary artery disease requiring intervention before CEA
— id: 49345, year: 2004, vol: 38, page: 511, stat: Journal Article,

Ischemic complications after endovascular abdominal aortic aneurysm repair
Maldonado, Thomas S; Rockman, Caron B; Riles, Eric; Douglas, Diah; Adelman, Mark A; Jacobowitz, Glenn R; Gagne, Paul J; Nalbandian, Matthew N; Cayne, Neal S; Lamparello, Patrick J; Salzberg, Stephanie S; Riles, Thomas S
2004 Oct;40(4):703-710, Journal of vascular surgery
Objectives Limb and pelvic ischemia are known complications after endovascular abdominal aortic aneurysm repair (EVAR). The objective of this paper is to present our experience with the incidence, presentation, and management of such complications. Methods Over 9 years 311 patients with aortic aneurysms underwent EVAR. A retrospective review identified 28 patients (9.0%) with ischemic complications. Results Among 28 patients with ischemic complications, 21 had lower extremity ischemia and 7 had pelvic ischemia: colon (n = 4), buttock (n = 2), and spinal cord (n = 2). Of the 21 patients with lower extremity ischemia, 15 had limb occlusions (71.4%), 3 due to embolization (14.7%) and 3 the result of common femoral artery thromboses (14.7%). Limb occlusions were manifested as severe acute arterial ischemia (n = 6), rest pain (n = 3), intermittent claudication (n = 5), and decreased femoral pulse (n = 1). Limb occlusions were managed with thrombectomy and stent placement (n = 4), femorofemoral bypass (n = 7), eventual explantation because of persistent endoleak (n = 1), and expectant management (n = 3). The 3 patients with occlusions managed expectantly all had intermittent claudication, which has subsequently improved. In the 6 patients with lower extremity ischemia due to embolization or common femoral artery injury presentation was acute, and embolectomy was performed, followed by femoral artery endarterectomy and patch angioplasty or placement of an interposition graft. One patient who had a prolonged postoperative course including cardiac arrest subsequently required distal bypass and ultimately above- knee amputation. Among the 7 patients with pelvic ischemia, 2 patients had unilateral hypogastric artery embolization before the original surgery. Among the patients with colonic ischemia, 3 were seen immediately postoperatively, and required colectomy and colostomy. Two patients who required urgent colectomy subsequently had multiple organ failure, and died in the perioperative period. One patient had abdominal pain 1 week after surgery, which was managed with bowel rest, with subsequent improvement. In 2 patients spinal cord ischemia developed immediately after surgery, w hich resulted in persistent paraplegia. Buttock ischemia developed in 2 patients, 1 of whom required fasciotomy because of gluteal compartment syndrome, and had transient renal failure. Conclusions Ischemic complications are not uncommon after EVAR, and may exceed the incidence with open surgical repair. Limb ischemia is most often a result of limb occlusion, and can be successfully managed with standard interventions. Pelvic ischemia often results from atheroembolization despite preservation of hypogastric arterial circulation. Colonic and spinal ischemia are associated with the highest morbidity and mortality
— id: 45296, year: 2004, vol: 40, page: 703, stat: Journal Article,

Impact of carotid artery angioplasty and stenting on management of recurrent carotid artery stenosis
Rockman, Caron B; Bajakian, Danielle; Jacobowitz, Glenn R; Maldonado, Thomas; Greenwald, Uri; Nalbandian, Matthew M; Adelman, Mark A; Gagne, Paul J; Lamparello, Patrick J; Landis, Roninie M; Riles, Thomas S
2004 Mar;18(2):151-157, Annals of vascular surgery
Citing the higher perioperative risk of redo carotid surgery, balloon angioplasty and stenting of the carotid artery (CAS) has been advocated for recurrent carotid stenosis (RCS). To examine the impact of CAS on the management and outcome of recurrent stenosis, a retrospective review of a prospectively compiled database was performed. From a registry of patients treated for carotid disease, 105 procedures were performed from 1992 to 2002 for RCS. For comparison, two study groups were examined. Time I consisted of 77 reoperations performed through 1998, before CAS was introduced at our institution. Time II included 12 reoperations and 16 CAS procedures performed for RCS from 1999 through 2002. Using perioperative stroke as a measure of outcome, the results for time II were poorer than for time I (7.2% vs. 5.2%, p = NS). Overall, the risk of perioperative stroke was the same for reoperation (5/89) and CAS (1/16) (5.6% vs. 6.3%, p = NS). Although not statistically significant, there was a trend toward a higher risk of perioperative stroke for patients treated with reoperation during the latter time period (8.3% vs. 5.2%, p = NS). This probably relates to the finding that during time II, CAS was most likely to be used in asymptomatic patients (68.6% vs. 41.7%, p = NS) with early (<3 years) RCS (87.5% vs. 41.7%, p= 0.01). No patient with asymptomatic, early RCS had a perioperative stroke with either surgery or CAS (0/35 cases, 0%). The presence of preoperative neurologic symptoms was significantly predictive of a perioperative stroke among all procedures performed for RCS (13.6% vs. 0%, p = 0.004). Contrary to suggestions that CAS might improve the management of RCS, a review of our data shows the overall risk of periprocedural stroke to be no better since CAS has become available. The bias for using CAS for asymptomatic myointimal hyperplastic lesions, and reoperation for frequently symptomatic late recurrent atherosclerotic disease, makes direct comparisons of the two techniques for treating RCS difficult. It is expected that the overall risk for redo carotid surgery will increase, as fewer low-risk patients will be receiving open procedures. However, the increased risk among symptomatic patients undergoing reoperation suggests that endovascular techniques should be investigated among this group of cases as well
— id: 46863, year: 2004, vol: 18, page: 151, stat: Journal Article,

Focused screening for occult carotid artery disease: patients with known heart disease are at high risk
Rockman, Caron B; Jacobowitz, Glenn R; Gagne, Paul J; Adelman, Mark A; Lamparello, Patrick J; Landis, Ronnie; Riles, Thomas S
2004 Jan;39(1):44-51, Journal of vascular surgery
OBJECTIVES: Stroke puts a major financial burden on our healthcare system. However, carotid duplex scanning performed as a screening test for occult carotid artery stenosis (CAS) currently is not reimbursed by Medicare. The goals of this study were to develop a cost-effective stroke screening program, to determine the prevalence of potential causes of stroke in this population, and to define a population at high risk in which screening would be most effective. METHODS: In a community-based stroke screening program, patients were eligible if they were older than 60 years and had a history of either hypertension, heart disease, or cigarette smoking, or a family history of stroke. Screening included blood pressure determination, an electrocardiographic rhythm strip, and a previously validated modified carotid duplex ultrasound examination to detect CAS 50% or greater. The relationships between standard demographic risk factors and screening outcomes were analyzed. RESULTS: Screening was performed in 610 patients. Unilateral or bilateral CAS was detected in 66 patients (10.8%). The finding of occult CAS was more prevalent than that of new hypertension (2.6%) or new atrial fibrillation (0.5%). Patients with known hypertension were significantly more likely to have CAS than were those without hypertension (12.7% vs 7.8%; P =.05). Patients with heart disease were significantly more likely to have CAS than were those without heart disease (18.2% vs 8%; P <.0001). Patients with both risk factors were significantly more likely to have occult carotid artery disease than were patients without either risk factor (22.1% vs 8.5%; P <.0001). Multivariate analysis with logistic regression revealed a history of heart disease as an independent predictor of occult carotid artery disease (odds ratio 95% confidence interval, 1.4-4.4). Type of heart disease was not a significant factor in predicting occult CAS. Direct cost of the screening, including community outreach, nurses, technicians, support staff, and miscellaneous expenses, was less than $75 per patient. CONCLUSIONS: In a screening program for treatable causes of potential stroke, CAS was the most commonly diagnosed disease. More than one of every five patients with known hypertension and heart disease had occult CAS. Known heart disease of any type was a significant independent predictor of occult CAS. Screening for treatable causes of potential stroke can be cost-effective. This information could help to further target populations to screen for occult CAS and to justify reimbursement for screening carotid duplex scanning examinations
— id: 42622, year: 2004, vol: 39, page: 44, stat: Journal Article,

A model for predicting occult carotid artery stenosis: screening is justified in a selected population
Jacobowitz, Glenn R; Rockman, Caron B; Gagne, Paul J; Adelman, Mark A; Lamparello, Patrick J; Landis, Ronnie; Riles, Thomas S
2003 Oct;38(4):705-709, Journal of vascular surgery
OBJECTIVES: The diagnosis and treatment of carotid artery disease is an integral part of stroke prevention. However, a population of patients who would benefit from screening for carotid artery stenosis has not been well defined. As part of an institutional stroke-screening program, a modified, rapid duplex scan was developed to evaluate patients for occult carotid stenosis. The goal of this study was to evaluate risk factors predictive of carotid stenosis in a selected population, and to identify patients who would benefit from carotid screening. METHODS: Patients were eligible for the study if they were >60 years of age and had a history of hypertension, heart disease, current smoking, or family history of stroke. A modified carotid duplex scan that had been previously validated against formal duplex scanning was utilized; this involved visualization of the carotid bulb and proximal internal carotid artery where Doppler flow velocities were obtained and recorded. RESULTS: Screening was performed on 394 patients. Thirty-eight patients (9.6%) had either unilateral or bilateral carotid stenosis of > or =50%. Risk factors evaluated included smoking, hypertension, cardiac disease, or hypercholesterolemia. If none of these risk factors was present, the incidence of carotid stenosis was 1.8%. This increased to 5.8% with one risk factor, 13.5% with two risk factors, and 16.7% with three risk factors. Two of three patients with all four risk factors had carotid stenosis (66.7%). Logistic regression and prespecified contrast statements for multiple comparisons were used to assess the relationship between the presence of risk factors and occult carotid artery stenosis. The presence of any one of these risk factors was associated with a statistically significant increase in the presence of occult carotid stenosis (P <.01). This was also statistically significant for the presence of any two risk factors (P <.01) or three risk factors (P <.05). CONCLUSION: The prevalence of carotid stenosis significantly increases with the presence of one or more identifiable demographic risk factors in a selected population. Assuming the diagnosis and treatment of carotid stenosis are fundamental to stroke prevention, screening for carotid artery disease is justified in this group of patients
— id: 71130, year: 2003, vol: 38, page: 705, stat: Journal Article,

Initial successful management of type I endoleak after endovascular aortic aneurysm repair with n-butyl cyanoacrylate adhesive
Maldonado, T S; Rosen, R J; Rockman, C B; Adelman, M A; Bajakian, D; Jacobowitz, G R; Riles, T S; Lamparello, P J
2003 Oct;38(4):664-670, Journal of vascular surgery
OBJECTIVE: Transcatheter embolization with coils and other agents has been described as a treatment method for type II endoleak after endovascular aortic aneurysm repair (EVAR). Type I endoleak has not been treated commonly with such therapies, although most investigators believe they warrant definitive intervention. The liquid adhesive n-butyl 2-cyanoacrylate (n-BCA) is often used to treat congenital arteriovenous malformations. The objective of this study is to report our initial experience in treating type I endoleak with n-BCA and with a variety of other interventions. METHODS: A retrospective review was performed of 270 patients who underwent EVAR at our institution between January 1994 and December 2002. Of these, 24 patients had type I endoleak (8.9%), diagnosed either intraoperatively (n = 13, 52%) or during follow-up (n = 12, 48%). Among these 24 patients, 17 had proximal leaks and the remaining 8 patients had distal leaks. These cases form the focus of this study. RESULTS: Twenty-two leaks required endovascular intervention, with the following success rate: n-BCA, 12 of 13 cases (92.3%); extender cuffs, 4 of 5 cases (80%); coils with or without thrombin, 3 of 4 cases (75%). In one patient with persistent endoleak despite attempted endovascular intervention the device ultimately was surgically explanted, and the patient did well. Of six patients with endoleak initially managed expectantly, two eventually underwent attempts at definitive intervention, both with n-BCA. Three sealed spontaneously before definitive intervention could be performed; and in one 97-year-old patient who refused intervention, the aneurysm subsequently ruptured and the patient died. In total, 13 patients with type I endoleak underwent n-BCA transcatheter embolotherapy. No serious complications were directly related to this therapy. Colon ischemia developed in one patient, and was believed to be a result of thromboembolism during wire and catheter manipulation rather than n-BCA treatment. Twelve of these 13 leaks remain sealed at mean follow-up of 5.9 months (range, 0-19 months). CONCLUSION: Our initial use of n-BCA occlusion suggests that it may be an effective and safe method of treatment of type I endoleak after EVAR. In particular, n-BCA embolotherapy may be especially useful in treating type I endoleak not amenable to placement of extender cuffs. Larger case series and longer follow-up are needed before this treatment is more broadly recommended. Type I endoleak after EVAR can be treated successfully with a variety of endovascular methods, and surgical explantation is rarely required
— id: 39031, year: 2003, vol: 38, page: 664, stat: Journal Article,

Temporal expression and activation of matrix metalloproteinases-2, -9, and membrane type 1-matrix metalloproteinase following acute hindlimb ischemia
Muhs, Bart E; Plitas, George; Delgado, Yara; Ianus, Ioana; Shaw, Jason P; Adelman, Mark A; Lamparello, Patrick; Shamamian, Peter; Gagne, Paul
2003 May 1;111(1):8-15, Journal of surgical research
OBJECTIVE: Matrix metalloproteinase (MMP) activity is essential for remodeling of ischemic tissue. The murine hindlimb ischemia model exhibits tissue remodeling including revascularization in part due to angiogenesis. MMP-2 and -9 are type IV collagenases necessary for basement membrane degradation as a part of extracellular matrix remodeling and angiogenesis. Polymorphonuclear leukocytes (PMNs) contain MMP-9, and in the presence of membrane type 1 (MT1)-MMP, are able to activate proMMP-2 in vitro. Activation of MMP-2 and -9 may be essential in ischemic limbs both for tissue remodeling and revascularization via angiogenesis. We hypothesized that MMP-2 and -9 would be activated following acute hindlimb ischemia (HI), and this activation would be temporally related to PMN infiltration. DESIGN OF STUDY: HI was achieved by unilateral femoral artery ligation in 20 FVB/N mice. Five mice underwent sham operation without hindlimb ischemia. Gastrocnemius muscle was harvested from both hindlimbs at 1, 3, 14, and 30 days following ligation and assayed for MMP-2, -9 (gelatin zymography), and MT1-MMP (Western blotting). MMP-2 and -9 expression and activation were analyzed by gelatin zymography and quantified by densitometry with NIH Image Analysis software. Neutrophils per high power field were counted. The results were expressed as a ratio of ischemic to nonischemic limbs and compared at each time point using ANOVA. RESULTS: Zymographic analysis revealed a 212% increase in active MMP-2 3 days postligation (P <.05). Active MMP-9 reached its maximum level (800% over baseline) on postoperative day 3 and continued to be elevated on day 14 (737% over baseline) (P <.05). The increase in active MMP-2 and -9 levels paralleled PMN infiltration that also peaked 3 days postligation (1184% over baseline) (P <.05). PMN count, MMP-2, and -9 all returned to baseline levels by postoperative Day 30. MT1-MMP was present in tissue samples from all time points as confirmed by Western blot. CONCLUSIONS: Limb ischemia causes an early activation of MMP-2 and -9 in temporal relation to PMN infiltration. HI may prime PMNs, leading to their sequestration in ischemic tissue. Primed PMNs, along with constitutively expressed MT1-MMP, may activate MMPs-2 and -9 and enable tissue remodeling essential for limb revascularization and angiogenesis
— id: 39162, year: 2003, vol: 111, page: 8, stat: Journal Article,

The benefits of carotid endarterectomy in the octogenarian: a challenge to the results of carotid angioplasty and stenting
Rockman, Caron B; Jacobowitz, Glenn R; Adelman, Mark A; Lamparello, Patrick J; Gagne, Paul J; Landis, Ronnie; Riles, Thomas S
2003 Jan;17(1):9-14, Annals of vascular surgery
Proponents of carotid angioplasty and stenting (CAS) believe that this technique would be preferred over carotid endarterectomy (CEA) for the high-risk patient. Presumably this would include patients over 80 years of age. However, a recent large series of patients undergoing CAS revealed a 16% incidence of nonfatal strokes and deaths for patients over the age of 80; these results were significantly worse than those for younger patients undergoing CAS. The objective of this study was to reassess results of CEA in patients over 80, and to compare surgical results with the published results of CAS in this patient group. A review was conducted of a prospectively maintained database of all carotid surgery performed at our institution. Primary CEA that took place from 1997 through 1999 were included for analysis (n = 698). Our institutional results were compared with representative results from a recently published large series of CAS. Our analysis showed that CEA can be performed safely in the octogenarian, and results are equivalent to those of younger patients. CEA appears to have significantly better results in the octogenarian than CAS. The reasons for the poor outcomes of CAS in the octogenarian are unclear. The results of CAS in the older patient population are worrisome, and this 'less invasive' technique may prove to be an inferior alternative in this patient group
— id: 48172, year: 2003, vol: 17, page: 9, stat: Journal Article,

Transcatheter embolization of extremity vascular malformations: the long-term success of multiple interventions
Rockman, Caron B; Rosen, Robert J; Jacobowitz, Glenn R; Weiswasser, Jonathan; Hofstee, Dirk J; Fioole, B; Lamparello, Patrick J; Adelman, Mark A; Gagne, Paul J; Riles, Thomas S
2003 Aug;17(4):417-423, Annals of vascular surgery
Vascular malformations of the extremities present a difficult therapeutic challenge. Ligation of feeding vessels may lead to tissue necrosis and limb loss and can make subsequent attempts at transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic vascular malformations in the upper and lower extremities in 50 patients. A retrospective review was conducted of a computerized database of all patients undergoing transcatheter therapy of peripheral vascular malformations at our institution. The mean age of the patients was 22 years (range 1-51 years), and 34% were male. The most common presenting symptoms included pain (80%), swelling (68%), ulceration or distal ischemia (18%), and hemorrhage (6%). Previous unsuccessful surgical treatment or embolization had been performed in 24% and 18% of patients, respectively. Predominantly venous lesions were treated by sclerotherapy with injection of ethanol. Arteriovenous and arterial lesions were treated by embolization via the arterial branch feeding vessels with cyanoacrylate. The most common vessels involved and treated were branches of the profunda femoris and tibial arteries (83% of lower extremity lesions), and branches of the brachial and radial arteries (82% of upper extremity lesions). Patients required a mean of 1.6 embolization procedures (range 1-5) over a mean period of 57 months. Sixteen patients (32%) underwent more than one embolization procedure. Of these, one was a planned staged procedure and 15 were performed secondary to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization in three cases (6%). Ninety-two percent of patients remained asymptomatic or improved at a mean follow-up of 56 months. There was one case of limb loss (2%). Diffuse extremity vascular malformations are difficult to eradicate completely and recurrences are common. Although patients may require multiple embolization procedures and occasional adjunctive surgical resection, directed transcatheter embolization should be the treatment of choice for symptomatic extremity vascular malformations
— id: 46294, year: 2003, vol: 17, page: 417, stat: Journal Article,

Postoperative infection associated with polyester patch angioplasty after carotid endarterectomy
Rockman, Caron B; Su, William T; Domenig, Christopher; Lamparello, Patrick J; Adelman, Mark A; Jacobowitz, Glenn R; Pomposelli, Frank B; Riles, Thomas S
2003 Aug;38(2):251-256, Journal of vascular surgery
OBJECTIVES: Postoperative infection is one of the most dreaded complications associated with use of synthetic patches for carotid endarterectomy. Although polyester patches were used extensively for carotid patch angioplasty throughout the last decade, few reports detail cases of deep patch infection. We describe our experience with polyester patch infections after carotid endarterectomy.Patients and methods From January 1996 through December 2001 we treated polyester patch infections after carotid endarterectomy in 10 patients. RESULTS: The interval from primary carotid endarterectomy to presentation with infection ranged from 11 days to 30 months. All patients underwent repeat operation that involved tissue debridement, excision of the polyester patch, and either interposition grafting or patch angioplasty with autologous vein. No perioperative stroke or death occurred; however, 1 patient had transient hoarseness, and in 1 patient a pseudoaneurysm developed that required additional surgical repair with a saphenous vein interposition graft. All patients remain well and free of infection with follow-up as long as 56 months. CONCLUSIONS: Infection is a serious and rare complication of carotid patch angioplasty with polyester material. Nonetheless, it can be treated successfully with good results and acceptable morbidity with soft tissue debridement, prosthetic patch excision, and either patch angioplasty or interposition grafting with autologous vein
— id: 71131, year: 2003, vol: 38, page: 251, stat: Journal Article,

Endovascular abdominal aortic aneurysm (AAA) repair since the FDA approval. Are we going too far?
Adelman, M A; Rockman, C B; Lamparello, P J; Jacobowitz, G R; Tuerff, S; Gagne, P J; Nalbandian, M; Weisswasser, J; Landis, R; Rosen, R J; Riles, T S
2002 Jun;43(3):359-367, Journal of cardiovascular surgery
BACKGROUND: Since the FDA approval of endovascular devices for abdominal aortic aneurysm (AAA) repair, clinicians have been relaxing the strict inclusion criteria of the clinical trials. We have reviewed our experience during and after the clinical trials to examine changes in patient selection, technical aspects of the procedure, and outcome. METHODS: A review of a prospectively compiled database of all endovascular AAA repairs performed at our institution was performed. RESULTS: Endovascular AAA repair was attempted in 130 patients: 46 (35.4%) as a part of clinical trials (Group I), and 84 (64.6%) since the FDA approval of the devices (Group II). Significant differences in patient selection included: a higher proportion of short (<15 mm) proximal necks in Group II (28.6 vs 0.0%, p<0.001), and a higher proportion of iliac occlusive disease in Group II (48.8 vs 15.4%, p=0.001). Additional trends suggested that Group II AAA's were more complex, including increased proximal neck angulation, increased proximal calcification, increased presence of proximal thrombus, and increased iliac tortuosity. Significant differences in technical aspects of the procedure included increased usage of iliac angioplasty (46.4 vs 13.3%, p<0.001), iliac stenting (31 vs 8.9%, p<0.01), and conduit access to the external iliac artery (10.7 vs 0%, p=0.03) in Group II. Analysis of outcome revealed a decreased incidence of the following in Group II cases: conversions to open repair (2.4 vs 10.9%), lower extremity ischemia (3.6 vs 13.0%), and graft limb occlusion (2.4 vs 8.7%). Other major perioperative complications did not differ significantly between the 2 groups. However, although the overall rate of any endoleak noted in the postoperative course was decreased in Group II cases (26.2 vs 32.6%), the incidence of proximal or distal attachment site leaks has increased (11.9 vs 4.3%, p=0.14). Although this comparison did not reach statistical significance, the magnitude of the increase is concerning. CONCLUSIONS: Although we have been able to offer endovascular AAA repair to a larger number of patients since FDA approval, endovascular management of increasingly complex proximal necks and increased iliac artery disease appears to have increased the incidence of attachment site endoleaks. Although many of these leaks have been successfully managed with adjunctive endovascular procedures, their increasing incidence is worrisome and suggests that we may need to re-evaluate current inclusion criteria for using this technology. Although difficult access issues have been handled with adjunctive procedures, the presence of a short, angulated proximal neck may be difficult to overcome, and may not be well suited for endovascular repair with the currently available devices
— id: 32473, year: 2002, vol: 43, page: 359, stat: Journal Article,

Aneurysm morphology as a predictor of endoleak following endovascular aortic aneurysm repair: do smaller aneurysm have better outcomes?
Rockman, Caron B; Lamparello, Patrick J; Adelman, Mark A; Jacobowitz, Glenn R; Therff, Sonya; Gagne, Paul J; Nalbandian, Matthew; Weiswasser, Jonathan; Landis, Ronnie; Rosen, Robert; Riles, Thomas S
2002 Sep;16(5):644-651, Annals of vascular surgery
Since the Food and Drug Administrations' approval of endovascular devices for abdominal aortic aneurysm (AAA) repair, clinicians have been relaxing the strict inclusion criteria present during the clinical trials. Although the long-term natural history of endoleaks remains unclear, attachment site leaks (type I) are believed to represent an ongoing risk for future rupture. We reviewed our experience with endovascular AAA repair to elucidate factors that predispose toward the development of endoleaks and found that larger AAAs are significantly more likely to have a short proximal neck and severe proximal angulation. These factors likely contribute to the significantly increased rate of type I endoleaks that occurred after endovascular repair of large AAAs. Small AAAs (<5) had the lowest rate of endoleaks overall (8.3%) and of type I endoleaks in particular (0%). We conclude that AAA size and morphology can be used to predict which aneurysms will experience attachment site endoleaks in their course; AAAs from 4.5 to 5 cm in diameter may be particularly well suited for endovascular repair in this regard
— id: 71133, year: 2002, vol: 16, page: 644, stat: Journal Article,

A reassessment of carotid endarterectomy in the face of contralateral carotid occlusion: surgical results in symptomatic and asymptomatic patients
Rockman, Caron B; Su, William; Lamparello, Patrick J; Adelman, Mark A; Jacobowitz, Glenn R; Gagne, Paul J; Landis, Ronnie; Riles, Thomas S
2002 Oct;36(4):668-673, Journal of vascular surgery
OBJECTIVE: Total occlusion of the contralateral internal carotid artery has often been considered to be a predictor of poor outcome after carotid endarterectomy (CEA) of ipsilateral carotid stenosis. Data from both the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study have suggested this to be true. However, each of these trials had relatively few patients with contralateral occlusion in the surgical arms of the studies. Recently, advocates of carotid angioplasty and stenting have suggested that this technique may be preferable in patients with a contralateral occlusion because of the perceived poor outcome with surgery. The purpose of this study was to review a large series of CEAs performed in patients with contralateral occlusion to see whether results differed from patients with patent contralateral arteries and to determine whether the presence of preoperative symptoms was an important factor in outcome in these cases. PATIENTS AND METHODS: A review was conducted of a prospectively compiled database of all primary CEAs performed at our institution from 1985 to 1999. Surgery was performed on 2420 patients, of whom 338 (14.0%) had contralateral total occlusion. RESULTS: Patients with contralateral total occlusion were more likely to be symptomatic (65.7% versus 60.1%; P =.1), male (70.9% versus 58%; P <.001), and hypertensive (63.9% versus 58.4%; P =.07) with a positive smoking history (42.6% versus 31.4%; P <.001) than patients with patent contralateral carotid artery. No significant difference was seen in the rates of perioperative neurologic events between patients with contralateral occlusion (3.0%) and those without (2.1%; P =.34). Among the total of 913 asymptomatic patients, of whom 115 had contralateral occlusion, no difference was seen in the rate of perioperative neurologic events (1.8% for contralateral occlusion cases; 1.9% for cases without contralateral occlusion). Among the total of 1507 symptomatic patients, of whom 223 had contralateral occlusion, no significant difference was seen in the rate of perioperative neurologic events (3.7% for contralateral occlusion cases; 2.2% for cases without contralateral occlusion; P =.2). CONCLUSION: The presence of contralateral occlusion does not appear to increase the perioperative risk of CEA. Although the risk of CEA in symptomatic patients with contralateral occlusion may be slightly increased, this must be weighed against the risk with medical treatment alone. CEA can be performed safely in patients with contralateral occlusion, which should not necessarily be considered a high-risk condition for surgery in favor of angioplasty and stenting
— id: 71132, year: 2002, vol: 36, page: 668, stat: Journal Article,

Are type II (branch vessel) endoleaks really benign?
Tuerff, Sonya N; Rockman, Caron B; Lamparello, Patrick J; Adelman, Mark A; Jacobowitz, Glenn R; Gagne, Paul J; Nalbandian, Matthew M; Weiswasser, Jonathan; Landis, Ronnie; Rosen, Robert J; Riles, Thomas S
2002 Jan;16(1):50-54, Annals of vascular surgery
The natural history and clinical significance of type II or branch vessel endoleaks following endovascular aortic aneurysm (AAA) repair remain unclear. Some investigators have suggested that these endoleaks have a benign course and outcome and that they can be safely observed. The purpose of this study was to document the natural history and outcome of all type II endoleaks that have occurred following endovascular AAA repair at our institution. A review of a prospectively compiled database of all endovascular AAA repairs performed at our institution was performed. From this review, we determined that type II endoleaks appear to have a relatively benign course, with a reasonable chance of spontaneously sealing within a 2-year period. No cases of rupture or aneurysm enlargement were documented in patients with open type II leaks. However, almost one-third of the patients did not manifest a type II leak until after their initial CT scan. The implications of such a 'delayed' leak are unclear. Careful follow-up remains mandatory in patients with type II endoleaks to better define outcome
— id: 95785, year: 2002, vol: 16, page: 50, stat: Journal Article,

Internal iliac occlusion without coil embolization during endovascular abdominal aortic aneurysm repair - Discussion
Veith, FJ; Wyers, MC; Brener, BJ; Adelman, MA
2002 ;36(6):1144-1145, Journal of vascular surgery
— id: 80090, year: 2002, vol: 36, page: 1144, stat: Journal Article,

Long-term follow-up of saphenous vein, internal jugular vein, and knitted Dacron patches for carotid artery endarterectomy
Jacobowitz GR; Kalish JA; Lee AM; Adelman MA; Riles TS; Landis R
2001 May;15(3):281-287, Annals of vascular surgery
To determine whether choice of material used for patch closure following carotid artery endarterectomy (CAE) influences rates of early or late restenosis, stroke, and death, 274 consecutive CAEs were retrospectively reviewed. Saphenous vein (SV) was used in 159 (58.0%) procedures; everted, double-thickness jugular vein (JV) was used in 25 (9.1%); and knitted Dacron (KD) was used in 90 (32.9%). Primary closure was not used in this series. There were four perioperative strokes: two (1.3%) in SV, one (4%) in JV, and one (1.1%) in KD (NS). Follow-up was obtained on 263 (96%) operated arteries (mean 41.5 months). Duplex scan results were available for 236 (89.7%) of these arteries (mean follow-up time 33.7 months). There were three (2%) late strokes in SV and two (2.2%) in KD (NS). In long-term follow-up, one patient (0.7%) in SV and two (2.4%) in KD developed > 80% stenosis (NS). One patient (0.7%) in SV, one (5.3%) in JV, and one (1.2%) in KD had total occlusion of the operated vessel (NS). Three procedures (2.2%) in SV, 1 (5.3%) in JV, and 7 (8.5%) in KD demonstrated moderate stenosis (50-79%) (NS). Three-year follow-up shows that choice of patch material does not affect early or late stroke rate, stroke-related death rate, rate of high-grade (> 80%) restenosis, or rate of total occlusion. There is a higher incidence of moderate stenosis in KD. Although our results and a review of the literature do not indicate that these patients are at increased risk for symptoms or progression of stenosis, they should be followed by duplex scanning to ensure that this is the case
— id: 21180, year: 2001, vol: 15, page: 281, stat: Journal Article,

Causes of perioperative stroke after carotid endarterectomy: special considerations in symptomatic patients
Jacobowitz GR; Rockman CB; Lamparello PJ; Adelman MA; Schanzer A; Woo D; Landis R; Gagne PJ; Riles TS; Imparato AM
2001 Jan;15(1):19-24, Annals of vascular surgery
In order to maximize the efficacy of carotid endarterectomy (CEA), the rate of perioperative stroke must be kept to a minimum. A recent analysis of carotid surgery at our institution found that most perioperative strokes were due to technical errors resulting in thrombosis or embolization. From 1992 through 1997 we have performed nearly 1200 additional CEAs; the purpose of this study was to examine recent trends in the causes of perioperative stroke, with specific attention to differences in symptomatic and asymptomatic patients. The records of 1041 patients undergoing 1165 CEAs were reviewed from a prospectively compiled database. Analysis of these data showed that a history of preoperative stroke appears to increase the risk of perioperative stroke after CEA. Surgical factors associated with perioperative stroke include an inability to tolerate clamping, use of an intraarterial shunt, and having surgery performed under general anesthesia; these factors are clearly interrelated and only the use of intraarterial shunting remains a risk factor by multivariate analysis. Over half of all perioperative strokes (54%) appear to be caused by intraoperative or postoperative thrombosis and embolization. The patient requiring use of intraarterial shunting and/or with a preoperative stroke most likely has a significant watershed area of brain at increased risk of infarction. However, technical errors are still the most common cause of perioperative stroke in these high-risk patients. Such high-risk patients may manifest clinical stroke from small emboli that may be tolerated by asymptomatic clamp-tolerant patients. Technical precision and appropriate cerebral protection are particularly critical for successful outcomes in high-risk patients
— id: 17982, year: 2001, vol: 15, page: 19, stat: Journal Article,

Transcatheter embolization of complex pelvic vascular malformations: results and long-term follow-up
Jacobowitz GR; Rosen RJ; Rockman CB; Nalbandian M; Hofstee DJ; Fioole B; Adelman MA; Lamparello PJ; Gagne P; Riles TS
2001 Jan;33(1):51-55, Journal of vascular surgery
OBJECTIVES: Vascular malformations of the pelvis are rare and present a difficult therapeutic challenge. Surgical treatment is notoriously difficult and carries a high likelihood of recurrence. Surgical proximal ligation of a feeding vessel may in fact be contraindicated, because it can make subsequent transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic complex pelvic vascular malformations in 35 patients. METHODS: A retrospective review was conducted of a prospectively compiled database of all patients undergoing transcatheter therapy of a pelvic vascular malformation at our institution. RESULTS: The mean age of the patients was 34 years (range, 16 months-66 years), and 51% were male. The most common presenting symptoms included pain (59%), a visible or palpable lesion (62%), associated palpable pulsation or thrill (44%), hemorrhage (27%), congestive heart failure (18%), and symptoms due to mass effect (35%). A significant number of patients had undergone previous, unsuccessful attempted surgical treatment of the lesion (32%). The most common type of lesion noted on arteriography was arteriovenous shunting (89%). Patients required a mean of 2.4 embolization procedures (range, 1-11 procedures) over a mean period of 23.3 months (range, 1-144 months). The most common agents used were rapidly polymerizing acrylic adhesives. The most common vessels involved and treated were branches of the hypogastric artery (82%). More than one procedure were performed in 20 patients (53%). Seven were planned as staged embolizations, whereas 13 were due to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization therapy in five patients (15%). Eighty-three percent of patients were asymptomatic or significantly improved at a mean follow-up of 84 months (range, 1-204 months). CONCLUSIONS: Pelvic vascular malformations are difficult to eradicate completely, and recurrences are common. Many patients require multiple therapeutic interventions. However, most of these difficult cases have good results in the long term. Transcatheter embolization plays a significant role in, and may be the treatment of choice for, symptomatic pelvic vascular malformations
— id: 17984, year: 2001, vol: 33, page: 51, stat: Journal Article,

Infrarenal abdominal aortic aneurysms at multi-detector row CT angiography: intravascular enhancement without a timing acquisition
Macari M; Israel GM; Berman P; Lisi M; Tolia AJ; Adelman M; Megibow AJ
2001 Aug;220(2):519-523, Radiology
In 70 patients referred for evaluation of aortoiliac aneurysm disease, multi-detector row computed tomography was performed with a uniform 25-second delay from the initiation of intravenous administration of a 150-mL bolus of contrast material at 4 mL/sec. In all patients, adequate enhancement (>200 HU) of the aorta and intense enhancement of iliofemoral runoff was achieved without venous contamination
— id: 26720, year: 2001, vol: 220, page: 519, stat: Journal Article,

Abdominal aortic aneurysms and thoracic aortic atheromas
Reynolds HR; Tunick PA; Kort S; Rosenzweig BP; Freedberg RS; Katz ES; Applebaum RM; Portnay EL; Adelman MA; Attubato MJ; Kronzon I
2001 Nov;14(11):1127-1131, Journal of the American Society of Echocardiography
BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with atherosclerosis elsewhere. Thoracic aortic atheromas (ATHs) seen on transesophageal echocardiography (TEE) are an important cause of stroke and peripheral embolization. The purposes of this study were to determine whether an association exists between AAA and ATHs and to assess the importance of screening patients with ATHs for AAA. METHODS: For the retrospective analysis, 109 patients with AAA and 109 matched controls were compared for the prevalence of ATHs on TEE and for historical variables. For the prospective analysis, screening for AAA on ultrasonography was performed in 364 patients at the time of TEE. RESULTS: Results of the retrospective analysis showed that ATHs were present in 52% of patients with AAA and in 25% of controls (odds ratio [OR] = 3.3; P =.00003). There was a significantly higher prevalence of hypertension, myocardial infarction, heart failure, smoking, and carotid or peripheral arterial disease in patients with AAA. However, only ATHs were independently associated with AAA on multivariate analysis (P =.001). Results of the prospective analysis showed that screening at the time of TEE in 364 patients revealed AAA in 13.9% of those with ATHs and in 1.4% of those without ATHs (P <.0001; OR = 11.4). CONCLUSIONS: (1) There is a strong, highly significant association between abdominal aneurysm and thoracic atheromas. (2) Patients with AAA may be at high risk for stroke because of the concomitance of thoracic aortic atheromas. (3) The high prevalence of abdominal aneurysm in patients with thoracic atheromas suggests that screening for abdominal aneurysm should be carried out in all patients with thoracic atheromas identified by TEE
— id: 26574, year: 2001, vol: 14, page: 1127, stat: Journal Article,

Carotid endarterectomy in female patients: are the concerns of the Asymptomatic Carotid Atherosclerosis Study valid?
Rockman CB; Castillo J; Adelman MA; Jacobowitz GR; Gagne PJ; Lamparello PJ; Landis R; Riles TS
2001 Feb;33(2):236-240, Journal of vascular surgery
OBJECTIVES: Although the results of the Asymptomatic Carotid Atherosclerosis Study clearly demonstrated the benefit of surgical over medical management of severe carotid artery stenosis, the results for women in particular were less certain. This was to some extent because of the higher perioperative complication rate observed in the 281 women (3.6% vs 1.7% in men). The objective of this study was to review a large experience with carotid endarterectomy in female patients and to determine whether the perioperative results differed from those of male patients. METHODS: A review was conducted of a prospectively compiled database on all carotid endarterectomies performed between 1982 and 1997. Operations performed in 991 female patients were compared with those performed in 1485 male patients. RESULTS: Female patients had a significantly lower incidence of diabetes, coronary artery disease, and contralateral carotid artery occlusion than did male patients. Female patients had a significantly higher incidence of hypertension. There were no significant differences in the age, smoking history, anesthetic route, shunt use, or clamp tolerance between the two groups. Of 991 female patients, 659 (66.5%) had preoperative symptoms, whereas 332 (33.5%) cases were performed for asymptomatic stenosis. Among 1485 male patients, 1041 (70.1%) had symptoms, and 444 (29.9%) were symptom free before surgery. There were no significant differences noted in the perioperative stroke rates between men and women overall (2.3% vs 2.4%, P =.92), or when divided into symptomatic (2.5% vs 3.0%, P =.52) and asymptomatic (2.0% vs 1.2%, P =.55) cases. CONCLUSIONS: Carotid endarterectomy can be performed with equally low perioperative stroke rates in men and women in both symptomatic and asymptomatic cases. In this series, symptom-free female patients had the lowest overall stroke rate. The concerns of the Asymptomatic Carotid Atherosclerosis Study regarding the benefit of carotid endarterectomy in female patients should therefore not prevent clinicians from recommending and performing carotid endarterectomy in appropriately selected symptom-free female patients
— id: 17983, year: 2001, vol: 33, page: 236, stat: Journal Article,

Carotid endarterectomy in patients 55 years of age and younger
Rockman CB; Svahn JK; Willis DJ; Lamparello PJ; Adelman MA; Jacobowitz GR; Lee AM; Gagne P; Deutsch E; Landis R; Riles TS
2001 Sep;15(5):557-562, Annals of vascular surgery
Prior studies have suggested that young patients may be more prone to recurrent disease after carotid endarterectomy (CEA). The goal of this study was to review a series of CEAs performed on younger patients (< or = 55 years) and to determine if these patients are more likely to develop recurrent stenosis. A review was conducted of CEAs performed from 1985 through 1994. Analysis was performed on a study group of 94 young patients who underwent 109 CEAs during this time. A control group of 222 patients older than 55 years who underwent 256 CEAs during the years 1991 through 1993 was selected for comparison. During a mean of nearly 4 years of follow-up, younger patients were significantly more likely to experience a late failure of CEA, including total occlusion of the operated artery, or recurrent stenosis requiring redo surgery. Careful patient evaluation is important in choosing younger patients who require CEA. Implications of these data include mandating careful noninvasive follow-up examinations for younger patients undergoing CEA
— id: 25661, year: 2001, vol: 15, page: 557, stat: Journal Article,

The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin
Greer SE; Adelman M; Kasabian A; Galiano RD; Scott R; Longaker MT
2000 Sep;53(6):484-487, Plastic & reconstructive surgery
Groin lymphorrhea is an uncommon but serious complication of vascular and cardiac surgery as well as interventional procedures that cannulate the femoral vessels. Treatment options are somewhat controversial. For lymphocutaneous fistulas, a commonly used current modality is early surgical ligation with the assistance of blue-dye staining of the lymphatic anatomy. The purpose of this case series is to give the first description of a new, less invasive, approach using subatmospheric pressure dressing therapy for the treatment of the challenging problem of lymphocutaneous fistulas of the groin.
— id: 11567, year: 2000, vol: 53, page: 484, stat: Journal Article,

Immediate reexploration for the perioperative neurologic event after carotid endarterectomy: is it worthwhile?
Rockman CB; Jacobowitz GR; Lamparello PJ; Adelman MA; Woo D; Schanzer A; Gagne PJ; Landis R; Riles TS
2000 Dec;32(6):1062-1070, Journal of vascular surgery
PURPOSE: When managing a new neurologic deficit after carotid endarterectomy (CEA), the surgeon is often preoccupied with determining the cause of the problem, requesting diagnostics tests, and deciding whether the patient should be surgically reexplored. The goal of this study was to analyze a series of perioperative neurologic events and to determine if careful analysis of their timing and mechanisms can predict which cases are likely to improve with reoperation. METHODS: A review of 2024 CEAs performed from 1985 to 1997 revealed 38 patients who manifested a neurologic deficit in the perioperative period (1.9%). These cases form the focus of this analysis. RESULTS: The causes of the events included intraoperative clamping ischemia in 5 patients (13.2%); thromboembolic events in 24 (63.2%); intracerebral hemorrhage in 5 (13.2%); and deficits unrelated to the operated artery in 4 (10.5%). Neurologic events manifesting in the first 24 hours after surgery were significantly more likely to be caused by thromboembolic events than by other causes of stroke (88.0% vs. 12.0%, P<.002); deficits manifesting after the first 24 hours were significantly more likely to be related to other causes. Of 25 deficits manifesting in the first 24 hours after surgery, 18 underwent immediate surgical reexploration. Intraluminal thrombus was noted in 15 of the 18 reexplorations (83. 3%); any technical defects were corrected. After the 18 reexplorations, in 12 cases there was either complete resolution of or significant improvement in the neurologic deficit that had been present (66.7%). CONCLUSIONS: Careful analysis of the timing and presentation of perioperative neurologic events after CEA can predict which cases are likely to improve with reoperation. Neurologic deficits that present during the first 24 hours after CEA are likely to be related to intraluminal thrombus formation and embolization. Unless another etiology for stroke has clearly been established, we think immediate reexploration of the artery without other confirmatory tests is mandatory to remove the embolic source and correct any technical problems. This will likely improve the neurologic outcome in these patients, because an uncorrected situation would lead to continued embolization and compromise
— id: 17985, year: 2000, vol: 32, page: 1062, stat: Journal Article,

MR angiography in the evaluation of atherosclerotic peripheral vascular disease
Rofsky NM; Adelman MA
2000 Feb;214(2):325-338, Radiology
Magnetic resonance (MR) angiography of lower extremity occlusive vascular disease has evolved into a feasible diagnostic imaging option. The previous emphasis on time-of-flight techniques was associated with lengthy acquisition times and artifactual signal losses. Those limitations presented an obstacle to widespread clinical implementation. However, the emergence of rapid imaging sequences combined with gadolinium chelate enhancement offers time-efficient alternatives that can yield a truer representation of the vascular anatomic structure. The technology is now poised to serve as a routine screening study, provided that radiologists understand all factors needed to generate clinically relevant MR angiograms. This article is intended to provide a useful resource directed toward achieving that understanding
— id: 11834, year: 2000, vol: 214, page: 325, stat: Journal Article,

Compartment syndrome complicating lower extremity thrombolysis
Reuss PM; Rosen RJ; Adelman M
1999 Sep;10(8):1075-1082, Journal of vascular & interventional radiology
— id: 6205, year: 1999, vol: 10, page: 1075, stat: Journal Article,

Abdominal aortic aneurysms are strongly associated with thoracic aortic atheromas seen on TEE
Reynolds, HR; Tunick, PA; Adelman, MA; Attubato, MJ; Kronzon, I
1999 NOV 2 ;100(18):168-169, Circulation
— id: 53788, year: 1999, vol: 100, page: 168, stat: Journal Article,

Redo carotid surgery: An analysis of materials and configurations used in carotid reoperations and their influence on perioperative stroke and subsequent recurrent stenosis
Rockman CB; Riles TS; Landis R; Lamparello PJ; Giangola G; Adelman MA; Jacobowitz GR
1999 Jan;29(1):72-80, Journal of vascular surgery
OBJECTIVE: The ideal method of arterial reconstruction in operations for recurrent carotid disease after prior endarterectomy is unknown. The goal of this study was to review a series of carotid reoperations and to determine whether the surgical technique influenced the rate of perioperative stroke, late stroke, or secondary restenosis. METHODS: A retrospective review was conducted of 82 carotid reoperations performed on 74 patients at our institution. RESULTS: The patient population included 39 men (52.7%) and 35 women (47.3%), with a mean age of 67.5 years. The indications for redo surgery included transient ischemic attack or amaurosis fugax in 35.3% of the patients, stroke in 6.1%, and asymptomatic restenosis (>80%) in 58.5%. Patch angioplasty with or without redo endarterectomy was used in 47 cases (57.3%), with saphenous vein in 26 (31.7%), Dacron in 15 (18.3%), and polytetrafluoroethylene in 6 (7.3%). Interposition grafting was used in 35 cases (42.7%), with saphenous vein in 9 (11.0%), Dacron in 10 (12.2%), and polytetrafluoroethylene in 16 (19.5%). The perioperative complications included three strokes (3.7%). There was a trend toward increased perioperative neurologic complications with interposition grafting when compared with patch angioplasty (8.6% vs 2.1%), although this did not reach statistical significance. Long-term clinical follow-up was obtained in all cases with a mean duration of 35 months, with follow-up duplex scanning performed in 89.2%. The late failures of redo surgery included four significant secondary restenoses and five total occlusions. There was a trend towards improved long-term results with interposition grafting as opposed to patch angioplasty. However, the cases in which reconstruction was performed with a vein had a significantly higher rate of late failures (stroke, secondary recurrent stenosis, or occlusion) than those in which reconstruction was performed with any prosthetic material (26.7% vs 2.3%; P =.002 by Fisher exact test). CONCLUSION: The use of autologous material for redo carotid surgery in any configuration appears to significantly increase the rate of subsequent recurrent stenosis or total occlusion of the operated artery. The reason for this finding is unclear but may be related to both host and technical factors. Prosthetic material may be more durable in the long-term for redo carotid surgery. Interposition grafting for redo carotid surgery may increase the perioperative neurologic complication rate to some degree; however, this was not statistically significant in this series. Interposition grafting may be a more durable solution in long-term follow-up than redo endarterectomy and patch angioplasty. A longer follow-up period will be needed to confirm this conclusion
— id: 7435, year: 1999, vol: 29, page: 72, stat: Journal Article,

A review of carotid endarterectomy in patients 55 years of age or less
Rockman CB; Riles TS; Svahn JK; Willis D; Lamparello PJ; Adelman MA; Jacobowitz GR; Deutsch E; Landis R
1999 ;30(1):257-257, Stroke
— id: 8144, year: 1999, vol: 30, page: 257, stat: Journal Article,

Improved gadolinium-enhanced subtraction MR angiography of the femoropopliteal arteries: reintroduction of osseous anatomic landmarks
Rofsky NM; Morana G; Adelman MA; Lee VS; Krinsky GA
1999 Oct;173(4):1009-1011, American journal of roentgenology
— id: 6217, year: 1999, vol: 173, page: 1009, stat: Journal Article,

Body MR angiography: a surgeon's perspective
Adelman MA; Jacobowitz GR
1998 May;6(2):397-416, Magnetic resonance imaging clinics of North America
This article addresses the indications for surgical procedures and the anatomic relationships that must be imaged to effectively plan surgical intervention. Treatment and imaging of aortic aneurysm, aortic dissection, splanchnic artery aneurysms, renal artery disease, and arterial disease of the lower extremities are reviewed
— id: 12114, year: 1998, vol: 6, page: 397, stat: Journal Article,

Long-term follow-up of saphenous vein, internal jugular vein, and knitted Dacron patches for carotid artery endarterectomy
Jacobowitz, GR; Kalish, JA; Lee, AM; Adelman, MA; Riles, TS; Landis, R
1998 JAN ;29(1):333-333, Stroke
— id: 53593, year: 1998, vol: 29, page: 333, stat: Journal Article,

Anesthetic methods in reoperative carotid surgery
Rockman CB; Riles TS; Lamparello PJ; Giangola G; Adelman MA; Jacobowitz GR; Landis R; Imparato AM
1998 Mar;12(2):163-167, Annals of vascular surgery
It has been suggested that general anesthesia is the preferred method for reoperative carotid surgery for several reasons, including: the difficulty of the reoperative dissection; the disease may extend unusually high into the internal carotid artery; and the reconstruction required may be more complex than a typical endarterectomy. The purpose of this study is to show that reoperative carotid surgery can be performed safely under regional anesthesia. The records of 109 reoperative carotid operations performed on 96 patients over the past 25 years were reviewed. Procedures performed under regional anesthesia were compared to those performed under general anesthesia with respect to patient characteristics, intraoperative courses, and perioperative results. Regional anesthesia was utilized in 79 operations (72.5%); 30 operations were performed with general anesthesia (27.5%). The two patient groups were essentially equivalent with regard to atherosclerotic risk factors, preoperative neurologic symptoms, and the prevalence of contralateral total occlusion. The etiologies for recurrent disease included recurrent atherosclerosis (50.4%), intimal hyperplasia (30.3%), and vein patch aneurysm (9.2%). The methods of reconstruction employed included saphenous vein patch (47.7%), vein interposition graft (11.9%), prosthetic patch (20.2%), and prosthetic graft (20.2%). Perioperative strokes occurred in one case performed under regional anesthesia (1.3%), and in two cases under general anesthesia (6.6%); this difference was not statistically significant. Reoperative carotid artery surgery can be performed under regional anesthesia safely in the majority of instances. The aforementioned theoretical factors in favor of general anesthesia could also lead to technical difficulties with intraarterial shunt insertion. Having the patient awake, even if just long enough to prove that the patient will tolerate carotid artery clamping, might simplify many of these operations by avoiding shunt insertion. Regional anesthesia should therefore be considered an acceptable option in cases of reoperative carotid surgery
— id: 7761, year: 1998, vol: 12, page: 163, stat: Journal Article,

Gadolinium-enhanced MR angiography of the carotid arteries: a small step, a giant leap?
Rofsky NM; Adelman MA
1998 Oct;209(1):31-34, Radiology
— id: 7762, year: 1998, vol: 209, page: 31, stat: Journal Article,

A multidisciplinary approach to the treatment of Paget-Schroetter syndrome
Adelman MA; Stone DH; Riles TS; Lamparello PJ; Giangola G; Rosen RJ
1997 Mar;11(2):149-154, Annals of vascular surgery
To assess the results of thrombolytic therapy and surgical decompression of the thoracic outlet in the management of spontaneous axillary vein thrombosis (AVT), the records of 38 patients at New York University Medical Center (NYUMC) with AVT were reviewed. Excluded from this report were 20 patients who had AVT secondary to an underlying medical condition, a subclavian catheter, or a failed dialysis access graft. Of the 18 remaining patients with no underlying medical condition, all were found to have effort-related axillo-subclavian thrombosis, Paget-Schroetter syndrome. Urokinase was used for thrombolysis in 17 of the 18 patients, (94.4%) with complete lysis in 14 (82.4%). The remaining patient received anticoagulation only following a favorable response to an initial heparin infusion. Of the patients achieving complete thrombolysis, all but one received urokinase within 8 days of the onset of symptoms. Clot lysis revealed axillary vein compression secondary to a thoracic outlet syndrome in 11 patients, and these underwent staged transaxillary thoracic outlet decompression by first rib resection. All 17 patients have been followed for a mean of 21 months, and none receiving lytic therapy have reoccluded. Review of these data confirms earlier reports showing that with early diagnosis, thrombolysis and, if indicated, thoracic outlet decompression, patients with spontaneous AVT can expect excellent clinical results with a good long-term prognosis
— id: 7098, year: 1997, vol: 11, page: 149, stat: Journal Article,

Transesophageal echocardiographic identification of a retrograde dissection of the ascending aorta caused by inadvertent cannulation of the common carotid artery
Applebaum RM; Adelman MA; Kanschuger MS; Jacobowitz G; Kronzon I
1997 Sep;10(7):749-751, Journal of the American Society of Echocardiography
Retrograde aortic dissections can be a complication of vascular procedures. We describe a case of an inadvertent cannulation of the right common carotid artery during an attempt at inserting a pulmonary artery catheter. This resulted in dissection of the right common carotid, subclavian, and innominate arteries. Transesophageal echocardiography was able to visualize a retrograde dissection extending back into the ascending aorta
— id: 12268, year: 1997, vol: 10, page: 749, stat: Journal Article,

Regional anesthesia for carotid endarterectomy
Riles TS; Gold MS; Lamparello PJ; Adelman MA
Management of extracranial cerebrovascular disease Philadelphia : Lippincott-Raven, 1997,
— id: 3455, year: 1997, vol: , page: 111, stat: Chapter,

Causes of the increased stroke rate after carotid endarterectomy in patients with previous strokes
Rockman CB; Cappadona C; Riles TS; Lamparello PJ; Giangola G; Adelman MA; Landis R
1997 Jan;11(1):28-34, Annals of vascular surgery
Patients who have sustained a preoperative stroke are at increased risk for perioperative stroke after carotid endarterectomy. At our institution this risk was recently shown to be increased two-to threefold. The purpose of this study was to investigate the reasons for the increased surgical risk in these patients. Records of 606 patients undergoing 704 consecutive carotid endarterectomies from 1988 through 1993 were reviewed. Patients who suffered preoperative strokes (n = 183) were compared to those who were either asymptomatic or experienced only transient ischemic attacks (TIAs) preoperatively (n = 423). Of the 183 patients who had suffered preoperative strokes, eight patients who experienced perioperative strokes after endarterectomy were compared with 175 who successfully underwent surgery. Patients with a prior stroke had an increased perioperative stroke rate (4.4% versus 1.2%, p = 0.01). They had a significantly higher incidence of hypertension (62.6% versus 47.9%, p < 0.001), cardiac disease (54.7% versus 40.7%, p = 0.001), and positive smoking history (52% versus 40.6%, p = 0.01) than did the asymptomatic/TIA patients. The presence of contralateral total occlusion was also significantly increased (22% versus 10.3%, p < 0.001). Although not statistically significant due to the overall small number of patients who sustained perioperative strokes, the preoperative stroke patients who sustained perioperative strokes had a higher incidence of hypertension (87.5% versus 61.5%) and contralateral total occlusion (37.5% versus 21.3%) than did those who successfully underwent surgery. Patients with both a prior stroke and contralateral total occlusion had a 7.5% perioperative stroke rate. Patients with both a prior stroke and hypertension had a 6.1% perioperative stroke rate. The perioperative strokes in patients with prior strokes were not related to the severity of the prior stroke, the interval between the stroke and surgery, the use of a shunt, or the type of anesthesia employed. Patients who have sustained preoperative strokes have a higher incidence of significant medical illnesses and overall cerebrovascular disease. Hypertension and total occlusion of the contralateral carotid artery appear to be particularly poor prognostic indicators of outcome after endarterectomy in these patients. Patients who have sustained preoperative strokes may be more likely to display clinical neurologic symptoms in response to any form of cerebral ischemia. In this higher risk subgroup, intraoperative and surgeon-dependent factors appear to play less of a role
— id: 12414, year: 1997, vol: 11, page: 28, stat: Journal Article,

Natural history and management of the asymptomatic, moderately stenotic internal carotid artery
Rockman CB; Riles TS; Lamparello PJ; Giangola G; Adelman MA; Stone D; Guareschi C; Goldstein J; Landis R
1997 Mar;25(3):423-431, Journal of vascular surgery
PURPOSE: Although it has been widely accepted as the evidence supporting prophylactic carotid endarterectomy, aspects of the Asymptomatic Carotid Atherosclerosis Study have left unease among clinicians who must decide which individuals without symptoms should undergo surgery. Additional confusion has been created by the fact that the several large randomized trials investigating the efficacy of carotid endarterectomy have classified and analyzed different categories of carotid stenosis. In an effort to provide more information on the natural history of asymptomatic, moderate carotid artery stenosis (50% to 79%), we have reviewed data on approximately 500 arteries. METHODS: Records of our vascular laboratory from 1990 to 1992 were reviewed. We identified 425 patients with asymptomatic, moderate carotid artery stenosis; 71 patients had bilateral stenoses in this category, resulting in 496 arteries for study. RESULTS: The mean length of follow-up was 38 +/- 18 months. New ipsilateral strokes occurred in 16 (3.8%) patients. New ipsilateral transient ischemic attacks occurred in 25 (5.9%) patients. Documented progression of stenosis occurred in 48 (17%) of the 282 arteries for which a repeat duplex examination was available. Arteries that progressed to > 80% stenosis were significantly more likely to have caused strokes than those that remained in the 50% to 79% range (10.4% vs 2.1%, p < 0.02). Conversely, arteries that remained stable in the degree of stenosis were significantly more likely to have remained asymptomatic than those that progressed (92.7% vs 62.5%, p < 0.001). With life-table analysis the estimated cumulative ipsilateral stroke rate was 0.85% at 1 year, 3.6% at 3 years, and 5.4% at 5 years. The respective estimated cumulative transient ischemic attack rates were 1.9%, 5.5%, and 6.3%. The respective estimated cumulative rates for progression of stenosis were 4.9%, 16.7%, and 26.5%. Life-table comparison of ipsilateral stroke revealed a significantly higher cumulative rate among arteries that progressed in the degree of stenosis than among those that remained stable (p < 0.001). CONCLUSIONS: Based on the low rate of permanent neurologic events in these cases, prophylactic carotid endarterectomy for the asymptomatic, moderately stenotic internal carotid artery cannot currently be recommended. The only factor that appears to predict increased risk for future stroke is progression of stenosis. Careful follow-up with serial repeat duplex examinations must be performed in these patients. Until there are widely accepted duplex parameters that can provide all clinicians with accurate identification of arteries with narrowing corresponding to 60% stenosis as defined by the Asymptomatic Carotid Atherosclerosis Study, all surgeons will need to be aware of specifically how their noninvasive laboratories are deriving their results. For the many laboratories that continue to use the University of Washington criteria, 80% should remain the level above which prophylactic carotid endarterectomy is warranted
— id: 12369, year: 1997, vol: 25, page: 423, stat: Journal Article,

Peripheral vascular disease evaluated with reduced-dose gadolinium-enhanced MR angiography
Rofsky NM; Johnson G; Adelman MA; Rosen RJ; Krinsky GA; Weinreb JC
1997 Oct;205(1):163-169, Radiology
PURPOSE: To demonstrate the utility of low-dose gadolinium-enhanced magnetic resonance (MR) angiography of two consecutive anatomic areas for assessment of peripheral vascular disease. MATERIALS AND METHODS: Fifteen patients underwent gadolinium-enhanced MR angiography for evaluation of lower extremity peripheral vascular disease after conventional digital subtraction angiography (DSA). MR angiography was performed with three-dimensional coronal gradient-echo acquisitions before and during administration of gadopentetate dimeglumine. Two separate, contiguous areas were studied with separate doses of 0.075 and 0.1 mmol/kg gadopentetate dimeglumine. MR angiography findings were compared with DSA findings; DSA was the standard of reference. Treatment options were determined first with MR angiograms and then with DSA images. RESULTS: For distinguishing greater than 50% stenosis from 50% or less stenosis, gadolinium-enhanced MR angiography yielded a sensitivity of 97%, a specificity of 96%, and an accuracy of 97%. In 146 (97%) of 150 anatomic segments, there was essential or total agreement on treatments determined with MR angiography and DSA. In two cases (one case of vascular stent placement and one case of surgical anastomosis), extent of disease was overestimated with MR angiography. The MR study of one infrapopliteal area was insufficient for evaluation. CONCLUSION: Accurate gadolinium-enhanced MR angiography of multiple peripheral vascular areas of the lower extremities can be performed in most patients with less than 0.2 mmol/kg contrast material
— id: 7249, year: 1997, vol: 205, page: 163, stat: Journal Article,

A unique approach in the management of vena caval thrombosis in a patient with Klippel-Trenaunay syndrome
Stone DH; Adelman MA; Rosen RJ; Riles TS; Lamparello PJ; Jacobowitz GR; Rockman CB
1997 Jul;26(1):155-159, Journal of vascular surgery
Vena caval thrombosis has posed a surgical therapeutic challenge for many years. Historically, spiral vein grafts and synthetic materials used as prostheses have had variable results. The use of the stent may serve as a more promising alternative when used in the capacity to relieve caval obstruction. A case is reported in which a young woman with Klippel-Trenaunay syndrome has exercise intolerance and associated hypotensive cardiovascular collapse caused by inferior vena caval thrombosis. Recanalization of her inferior vena cava was successfully achieved and subsequently maintained through the placement of two Wallstents across the lesion. Although most venous stenting procedures have thus far been used in the treatment of venous obstruction caused by malignancy, inferior vena cava stenting in this patient with inferior vena caval thrombosis and Klippel-Trenaunay syndrome suggests that venous stenting might offer an alternative therapeutic modality in treating a broader spectrum of occlusive venous disease
— id: 7263, year: 1997, vol: 26, page: 155, stat: Journal Article,

Perioperative morbidity and mortality in combined vs. staged approaches to carotid and coronary revascularization
Giangola G; Migaly J; Riles TS; Lamparello PJ; Adelman MA; Grossi E; Colvin SB; Pasternak PF; Galloway A; Culliford AT; Esposito R; Ribacove G; Crawford BK; Glassman L; Baumann FG; Spencer FC
1996 Mar;10(2):138-142, Annals of vascular surgery
Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five. Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization). Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%). In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA
— id: 12638, year: 1996, vol: 10, page: 138, stat: Journal Article,

Declining incidence of myocardial infarction in patients undergoing major vascular surgery
Pasternack, PF; Riles, TS; Baumann, G; Grossi, EA; Lamparello, PJ; Giangola, G; Adelman, M; Imparato, AM
1996 OCT 15 ;94(8):1375-1375, Circulation
— id: 33442, year: 1996, vol: 94, page: 1375, stat: Journal Article,

The surgical management of carotid artery stenosis in patients with previous neck irradiation
Rockman CB; Riles TS; Fisher FS; Adelman MA; Lamparello PJ
1996 Aug;172(2):191-195, American journal of surgery
BACKGROUND: A history of therapeutic irradiation to the neck complicates the management of carotid artery occlusive disease. Serious surgical concerns are raised regarding alternative incisions, difficult dissections, and adequate wound closure. Pathology may be typical atherosclerotic occlusive disease or radiation-induced arteritis. In order to establish guidelines for the treatment of these patients, we have reviewed our operative experience. PATIENTS AND METHODS: A review of our operative experience over the past 15 years revealed 10 patients with a history of prior irradiation to the neck who underwent 14 carotid operations. RESULTS: The indications for radiation included laryngeal carcinoma and lymphoma. Five patients had undergone previous radical neck dissections, and four patients had permanent tracheostomies. The surgical indications were asymptomatic high-grade stenosis in 7 cases, transient ischemic attack in 4 cases, stroke in 2 cases, and a pseudoaneurysm in 1 case. Conventional carotid endarterectomy with patch angioplasty was used in 10 of the 14 operations. In the remaining four operations, saphenous vein interposition grafting was utilized to replace the diseased segment of carotid artery secondary to a panarteritis. Wound closure required dermal grafting in two of five cases where surgery was performed ipsilateral to a prior radical neck dissection. One perioperative cerebral infarction occurred; there were no other neurologic or non-neurologic complications. All patients are doing well in one- to five-year follow-up, with serial postoperative duplex scans demonstrating no signs of recurrent stenosis. CONCLUSIONS: Patients with a history of irradiation to the neck should be screened for the presence of carotid disease. Carotid occlusive disease should be treated surgically in these patients with the usual indications. Intraoperative surgical management is similar to that of non-irradiated patients. Concerns about difficulty in achieving an adequate endarterectomy plane and about problems with wound closure have generally been unfounded
— id: 7042, year: 1996, vol: 172, page: 191, stat: Journal Article,

A comparison of regional and general anesthesia in patients undergoing carotid endarterectomy
Rockman CB; Riles TS; Gold M; Lamparello PJ; Giangola G; Adelman MA; Landis R; Imparato AM
1996 Dec;24(6):946-953, Journal of vascular surgery
PURPOSE: The optimal anesthetic for use during carotid endarterectomy is controversial. Advocates of regional anesthesia suggest that it may reduce the incidence of perioperative complications in addition to decreasing operative time and hospital costs. To determine whether the anesthetic method correlated with the outcome of the operation, a retrospective review of 3975 carotid operations performed over a 32-year period was performed. METHODS: The records of all patients who underwent carotid endarterectomy at our institution from 1962 to 1994 were retrospectively reviewed. Operations performed with the patient under regional anesthesia were compared with those performed with the patient under general anesthesia with respect to preoperative risk factors and perioperative complications. RESULTS: Regional anesthesia was used in 3382 operations (85.1%). There were no significant differences in the age, gender ratio, or the rates of concomitant medical illness between the two patient populations. The frequency of perioperative stroke in the series was 2.2%; that of myocardial infarction, 1.7%; and that of perioperative death, 1.5%. There were no statistically significant differences in the frequency of perioperative stroke, myocardial infarction, or death on the basis of anesthetic technique. A trend toward higher frequencies of perioperative stroke (3.2% vs 2.0%) and perioperative death (2.0% vs 1.4%) in the general anesthesia group was noted. In examining operative indications, however, there was a significant increase in the percentage of patients receiving general anesthesia who had sustained preoperative strokes when compared with the regional anesthesia patients (36.1% vs 26.4%; p < 0.01). There was also a statistically significant higher frequency of contralateral total occlusion in the general anesthesia group (21.8% vs 15.4%; p = 0.001). The trend toward increased perioperative strokes in the general anesthesia group may be explicable either by the above differences in the patient populations or by actual differences based on anesthetic technique that favor regional anesthesia. CONCLUSIONS: In a retrospective review of a large series of carotid operations, regional anesthesia was shown to be applicable to the vast majority of patients with good clinical outcome. Although the advantages over general anesthesia are perhaps small, the versatility and safety of the technique is sufficient reason for vascular surgeons to include it in their armamentarium of surgical skills. Considering that carotid endarterectomy is a procedure in which complication rates are exceedingly low, a rigidly controlled, prospective randomized trial may be required to accurately assess these differences
— id: 7247, year: 1996, vol: 24, page: 946, stat: Journal Article,

Causes of the increased stroke rate after carotid endarterectomy in patients with previous neurologic deficits
Rockman, CB; Cappadona, CR; Riles, TS; Lamparello, PJ; Giangola, G; Adelman, MA; Landis, R
1996 JAN ;27(1):20-20, Stroke
— id: 53109, year: 1996, vol: 27, page: 20, stat: Journal Article,

Carotid endarterectomy in the presence of a contralateral occlusion: a review of 315 cases over a 27-year experience
Adelman MA; Jacobowitz GR; Riles TS; Imparato AM; Lamparello PJ; Baumann FG; Landis R
1995 Jun;3(3):307-312, Cardiovascular surgery
Recent data from the North American Symptomatic Carotid Endarterectomy Trial revealed a 14.3% perioperative risk of stroke or death with carotid endarterectomy contralateral to a carotid artery occlusion. Since last reporting on this topic in the mid-1980s, the authors have reviewed 180 patients with occlusion of one internal carotid artery (ICA) and who underwent endarterectomy of the stenotic contralateral ICA operated from 1965 to 1984 (group A) compared with 135 operated on from 1985 to 1991. The two groups were similar with respect to age, sex, incidence of coronary artery disease, hypertension, diabetes and history of smoking, but group B had a significantly increased incidence of patients who were neurologically symptom-free before surgery (21.5% versus 7.8%, P < 0.001). The combined perioperative stroke or death rate for patients in group B was significantly lower than for those in group A (0.7% versus 6.7%, P < 0.01). Comparison of the operative techniques showed more frequent placement of intra-arterial shunt (52.6% versus 29.4%, P < 0.001) and increased use of general anesthesia (20.0% versus 9.4%, P < 0.01) in patients of group B. Analysis of the etiology of the complications, however, showed that shunting alone could not account for the improved results. Lower incidences of postoperative thrombosis, embolization and intracerebral hemorrhage were equally important.(ABSTRACT TRUNCATED AT 250 WORDS)
— id: 6800, year: 1995, vol: 3, page: 307, stat: Journal Article,

A COMPARISON OF SEVERITY OF ILLNESS SCORING SYSTEMS FOR INTENSIVE-CARE UNIT PATIENTS - RESULTS OF A MULTICENTER, MULTINATIONAL STUDY
CASTELLA, X; ARTIGAS, A; BION, J; KARI, A; BENZER, H; HUBER, C; ALEXANDER, JP; DELANDE, M; LEDOUX, D; CANIVET, JL; DAMAS, P; DEMEYER, I; VISSERS, K; DUGERNIER, T; HUYGHENS, L; DILTOUR, M; DEWIT, N; NAGLER, J; COOLS, F; NOLLET, G; VERBEKE, J; POELAERT, J; COLLARDYN, F; LATERRE, PF; DOUGNAC, A; REYNAERT, M; RUTSAERT, R; COLEMONT, L; SCHETZ, M; LAUWERS, P; HAMILTON, S; NORRIS, C; SHUSTACK, A; JOHNSTON, R; KONOPAD, E; HANNONEN, P; HERSIO, K; KAIRI, P; KLOSSNER, J; SAARELA, E; VAHAMURTO, M; ARICE, C; BEDOCQ, B; BLETTERY, B; MISSET, B; CARLET, J; MIER, L; DREYFUSS, D; FOSSE, JP; GARO, B; DEMINGEON, G; HOLZHAPFEL, L; KOPFERSCHMITT, J; MAHUL, P; NITEMBERG, G; PLOUVIER, F; SAULNIER, F; VILLERS, D; WIEDECK, H; BURCHARDI, H; KLINGLER, H; DICK, W; BROST, F; ECKART, J; WENGERT, P; GELGER, K; ARMBRUSTER, K; KAMP, HD; ROTHE, M; LANDAUER, B; SCHMID, TO; PETER, K; FORST, H; PIPER, C; REINHART, K; RUDOLPH, T; RUGHEIMER, E; PSCHEIDL, E; SCHMITZ, J; SCHUSTER, HP; BODMANN, KF; STOBER, D; DRESSLER, C; ALBERTARIO, F; CARNEVALE, L; BASSI, F; GRAZIANI, BM; PALLAVICINI, FB; CASSINI, C; CINELLA, G; BRIENZA, A; CONTI, G; DEBLASI, A; FIANDRI, MT; COSCO, D; FUMAGALLI, R; AVALLI, L; GIUDICI, D; GALLIOLI, G; CAPUZZO, M; RAGAZZI, R; VOLTA, CA; GUARINO, A; MERLI, G; SERRA, L; FASIOLO, S; IAPICHINO, G; ROTELLI, S; LACQUANITI, L; MORETTI, T; MELOTTI, R; NEGRO, G; MERGONI, M; SACCANI, A; RAVIZZA, A; CASELLA, G; RIPAMONTI, D; FAVERO, A; SIMINI, G; MANUALI, A; VERNERO, S; VIALE, A; VESCONI, S; SICIGNANO, A; BRUINING, HA; DEHAAS, J; DEJONG, D; DEJONG, M; HAANSTRA, WP; HULSTAERT, PF; JAIRAM, R; VANDALEN, R; VANDERGEEST, S; WOITTIEZ, AJJ; ZWAVELING, JH; ABIZANDA, R; BALERDI, B; SOCIAS, L; MESTRE, J; BONET, A; ALVAREZ, A; BOVEDA, JL; MANZANARES, I; SALGADO, I; CABRE, L; CARRASCO, G; CASANOVAS, M; FARAIDUN, E; BAUSILI, JM; CERDA, M; IBARS, M; GIMENO, C; PRIETO, AD; TORRADO, H; GUARDIOLA, JJ; BOQUE, C; GUIRADOALAIZ, M; ITURBE, F; BARBERA, C; RABASSO, C; CABALLERO, JMN; ROGLAN, A; RUIZ, J; GARCIA, L; SARMIENTO, X; TOBOSO, JM; SOLSONA, J; VAZQUEZ, A; NOLLA, M; BAUMANN, PC; VONWILLER, HM; DOMENIGHETTI, G; ERBA, D; CHEVROLET, JC; JOLLIET, P; CHIOLERO, R; MESSIKOMMER, A; ENRICO, JF; KEHTARI, R; DETORRENTE, A; KOCHER, A; LUPI, G; FRUTIGER, A; REIGNER, M; RITZ, R; DURRER, S; PERRET, CH; SCHALLER, MD; SUTER, P; RICOU, B; BOWDEN, M; GARRARD, C; RANDALLS, B; WILSON, I; ADELMAN, M; MILLER, RA; QUINONES, B; BAER, CL; SCHWAMACHER, J; RENNER, L; COX, PM; PRATO, S; FEIN, IA; VEEDER, A; GETTINGER, A; HOLMES, K; ASTIZ, ME; SAXON, J; DEGENT, G; GROSSBARD, L; RUCHTI, R; GUTIERREZ, G; CLARK, C; WITHERSPOON, J; HARRIS, F; HIGGINS, M; JASTREMSKI, MS; MILEWSKI, A; BUNCH, K; KARRAS, G; BARGHOUD, C; RICHARD, N; BOOTH, FVM; KERINS, R; BOOTH, J; NASRAWAY, SA; SOTTILE, FD; SIGEL, P; ORTIZ, CR; CROMILLER, J; PORTER, KA; RAFKIN, H; ERMAKOV, S; RETCHIN, S; REINES, HD; CASADO, M; ROGOVE, H; MORROW, S; CHUPKA, K; FOSTER, E; SCHWAITZBERG, SD; HAYES, J; SCARAMUZZI, J; SMITH, JL; BURNS, R; HAMMAKER, D; TERES, D; DESROSIERS, C; MOINEAU, A; THOMPSON, D; SIPPERLY, ME; HEISELMAN, D; HOFER, T; VIDOVICH, R; ODONNELL, JM; GRAY, A; DAVIS, FG; TONNESEN, AS; CRONIN, LS; JENNINGS, C
1995 ;23(8):1327-1335, Critical care medicine
Objective: To compare the performance of three severity of illness scoring systems used commonly for intensive care unit (ICU) patients in a large international data set. The systems analyzed were versions II and III of the Acute Physiology and Chronic Health Evaluation (APACHE) system, versions I and II of the Simplified Acute Physiology Score (SAPS), and versions I and II of the Mortality Probability Model (MPM), computed at admission and after 24 hrs in the ICU. Design: A multicenter, multinational cohort study. Setting: One hundred thirty-seven ICUs in 12 European and North American countries. Patients: During a 3-month period, 14, 745 patients were consecutively admitted to 137 ICUs enrolled in the study. Interventions: Collection of information necessary to compute the APACHE II and APACHE III scores, SAPS I and SAPS II, and MPM I and MPM II scores. Patients were followed until hospital discharge. Statistical comparison, including indices of calibration (goodness-of-fit) and discrimination (are!a under the receiver operating characteristic curve). Measurements and Main Results: Despite having acceptable receiver operating characteristic areas, the older versions of the systems analyzed (APACHE II, SAPS, and MPM I computed at admission-MPM I computed after 24 hrs in the ICU) demonstrated poor calibration for the whole database. The new versions of the systems (SAPS II and MPM II) were superior to their older counterparts. This superiority is reflected by larger receiver operating characteristic areas and better fit. The APACHE III system improved its receiver operating characteristic area compared with the APACHE II system, which showed the best fit of the old systems analyzed. Conclusions: The new versions of the severity systems analyzed (APACHE III, SAPS II, MPM II) perform better than their older counterparts (APACHE II, SAPS I, and MPM I). APACHE II, SAPS II, and MPM II show good discrimination and calibration in this international database. $$:
— id: 109619, year: 1995, vol: 23, page: 1327, stat: Journal Article,

A comparative study of saphenous vein, internal jugular vein, and knitted Dacron patches for carotid artery endarterectomy
Goldman KA; Su WT; Riles TS; Adelman MA; Landis R
1995 Jan;9(1):71-79, Annals of vascular surgery
To determine whether the choice of material used for patch closure following carotid artery endarterectomy (CAE) affected the immediate operative results, the early follow-up results, or the incidence of early restenosis, a retrospective study of 275 consecutive carotid endarterectomies by two vascular surgeons was performed. Among 275 primary CAEs performed between July 1991 and August 1993, 159 (57.8%) were closed with saphenous vein (SV), 25 (9.1%) with double-thickness internal jugular vein (JV), and 91 (33.1%) with knitted Dacron (KD). Primary closure was not used in any of the arteries in this series. The overall perioperative mortality rate was 1.1% and the rate of major and minor morbidity was 4.4% There were four (1.5%) perioperative strokes: two (1.3%) in the SV group, one (4.0%) in the JV group, and one (1.1%) in the KD group. Two-hundred fifty-eight (93.8%) of the 275 endarterectomies were followed postoperatively for 2 to 35 months (mean 14.4). Two-hundred nineteen (79.6%) were evaluated using duplex scans during follow-up with a mean interval of 13.7 months. Of the arteries studied, four (3.6%) in the SV group, none in the JV group, and six (8.4%) in the KD group demonstrated restenosis of > 50% at the time of follow-up (NS). In addition, one (0.9%) artery in the SV group, one (5.6%) in the JV group, and none in the KD group demonstrated complete occlusion. Retrospective analysis of the data showed no statistically significant differences in perioperative morbidity, mortality, or early postoperative restenosis whether the artery was closed with saphenous vein, jugular vein, or knitted Dacron patches. Longer follow-up is needed to determine whether rates of late restenosis and aneurysmal dilation will differ between synthetic and autologous patches
— id: 56643, year: 1995, vol: 9, page: 71, stat: Journal Article,

Long-term follow-up of patients undergoing carotid endarterectomy in the presence of a contralateral occlusion
Jacobowitz GR; Adelman MA; Riles TS; Lamparello PJ; Imparato AM
1995 Aug;170(2):165-167, American journal of surgery
BACKGROUND: Patients with stenosis of one carotid artery and occlusion of the contralateral carotid artery (stenosis-occlusion) who are treated medically are at high risk for stroke. We have recently reported that carotid endarterectomy on the stenotic artery has a low perioperative risk in these patients. We now present follow-up data to define the long-term effectiveness of this operation. PATIENTS AND METHODS: From 1985 to 1991, 135 patients with stenosis-occlusion underwent endarterectomy of the stenotic carotid artery. Selective intra-arterial shunting was performed based on mental status changes under regional anesthesia, preoperative neurologic deficit, or evidence of preoperative cerebral infarction on computed tomography scan. Shunting was used in 70 patients (52%). Saphenous vein was used for patch closure in 132 patients (98%), and polytetrafluoroethylene in 3 (2%). RESULTS: By life-table analysis, 92% of patients have remained stroke-free at 5 years. Fourteen deaths, none related to cerebrovascular disease, have occurred during follow-up. The life-table cumulative stroke-free survival rate at 5 years is 74%, and the overall survival rate is 82%. CONCLUSION: Carotid endarterectomy in the presence of a contralateral occlusion provides long-term benefit to the patient with respect to prevention of stroke. With lower perioperative stroke rates and proven long-term benefit, carotid endarterectomy of the stenotic artery should be the treatment of choice in the patient with stenosis-occlusion
— id: 6835, year: 1995, vol: 170, page: 165, stat: Journal Article,

Retroperitoneal caval filter as a source of abdominal pain
Goldman KA; Adelman MA
1994 Feb;2(1):85-87, Cardiovascular surgery
A patient with a Mobin-Uddin vena caval filter placed 10 years earlier was referred with abdominal pain, nausea, anorexia and weight loss. Diagnostic studies confirmed that the filter was in an extracaval position in the retroperitoneum, with the filter struts impinging on the right kidney, duodenum and colon. Following surgical removal of the filter the patient is now symptom-free with good appetite and weight gain
— id: 13000, year: 1994, vol: 2, page: 85, stat: Journal Article,

Is there detrimental gender bias in preoperative cardiac management of patients undergoing vascular surgery?
Hutchinson LA; Pasternack PF; Baumann FG; Grossi EA; Riles TS; Lamparello PJ; Giangola G; Adelman M; Imparato AM
1994 Nov;90(5 Pt 2):II220-II223, Circulation
BACKGROUND: To investigate the possibility of gender bias in the cardiac management of patients who undergo peripheral vascular surgery, we examined the hospital data and outcomes for 350 adult men and 128 women who underwent vascular surgery from September 1987 to December 1991. METHODS AND RESULTS: There were no significant differences between the two groups in age at operation, incidence of standard risk factors for myocardial infarction, or incidence or duration of episodes of perioperative silent ischemia. Nevertheless, a significantly lower percentage of women than men had undergone prior coronary bypass procedures (6.3% and 17.1%, respectively; P < .01), an apparent example of gender bias. However, there was no significant difference in the incidence of perioperative myocardial infarction in women (3.9%) compared with men (4.0%). Furthermore, actuarial analysis showed that at 24 months after operation a significantly higher percentage of women (77.9%) had escaped late cardiac death and cardiac complications than men (71.9%; P < .05). CONCLUSIONS: These findings indicate that apparent gender bias in the preoperative cardiac management of this group of women who underwent vascular surgery may have had no detrimental effect on short- and long-term incidence of cardiac death and complications, and may represent sound clinical judgment rather than true bias. However, the possibility that female patients might have had even better short- and long-term cardiac results if they had undergone more preoperative cardiac revascularization cannot be discounted
— id: 56661, year: 1994, vol: 90, page: II220, stat: Journal Article,

The cause of perioperative stroke after carotid endarterectomy
Riles TS; Imparato AM; Jacobowitz GR; Lamparello PJ; Giangola G; Adelman MA; Landis R
1994 Feb;19(2):206-214, Journal of vascular surgery
PURPOSE: The purpose of this study was to examine the cause of perioperative stroke after carotid endarterectomy. METHODS: The records of 2365 patients undergoing 3062 carotid endarterectomies from 1965 through 1991 were reviewed. Sixty-six (2.2%) operations were associated with a perioperative stroke. The mechanism of stroke was determined in 63 of 66 cases. Patient risk factors and surgeon-dependent factors were analyzed. RESULTS: More than 20 different mechanisms of perioperative stroke were identified, but most could be grouped into broad categories of ischemia during carotid artery clamping (n = 10), postoperative thrombosis and embolism (n = 25), intracerebral hemorrhage (n = 12), strokes from other mechanisms associated with the surgery (n = 8), and stroke unrelated to the reconstructed artery (n = 8). Dividing the operative experience approximately into thirds, during the years 1965 to 1979, 1980 to 1985, and 1986 to 1991 the perioperative stroke rates were 2.7%, 2.2%, and 1.5%, respectively. This, in part, is associated with a better selection of patients (more symptom free, fewer with neurologic deficits). There has been a notable decrease in perioperative stroke caused by ischemia during clamping and intracerebral hemorrhage, but postoperative thrombosis and embolism remain the major cause of neurologic complications. CONCLUSIONS: Although patient selection seems to play a role, most perioperative strokes were due to technical errors made during carotid endarterectomy or reconstruction and were preventable
— id: 6497, year: 1994, vol: 19, page: 206, stat: Journal Article,

Long-term follow-up of patients undergoing reoperation for recurrent carotid artery disease
Gagne PJ; Riles TS; Jacobowitz GR; Lamparello PJ; Giangola G; Adelman MA; Imparato AM; Mintzer R
1993 Dec;18(6):991-998, Journal of vascular surgery
PURPOSE: We examined the perioperative course and long-term fate of individuals who required reoperation for recurrent carotid artery disease. METHODS: The records of 2289 patients undergoing 2961 consecutive operations during a 22-year period were reviewed. Forty-two patients (1.8%) who underwent reoperations were studied. Forty-seven redo carotid artery reconstructions were performed on these 42 patients for neurologic symptoms or asymptomatic high-grade stenosis. Long-term follow-up was obtained on 41 of 42 patients (mean 54 months; range 9 to 202 months). RESULTS: The forty-seven reoperations consisted of endarterectomy with patch angioplasty (n = 36), saphenous vein or polytetrafluoroethylene interposition graft (n = 7), or simply vein or polytetrafluoroethylene patch angioplasty (n = 4). There were no perioperative strokes or deaths. Three patients had perioperative transient ischemic attacks and two had cranial nerve injuries. The incidence of late failure after secondary surgery was 19.5% (8/41 patients). These failures consisted of one stroke, three transient ischemic attacks, and four asymptomatic occlusions. One tertiary carotid artery reconstruction was performed for a restenosis at the site of the secondary reconstruction. CONCLUSION: The factors responsible for the high incidence of late failures after secondary carotid artery reconstruction are unclear. Reoperation for recurrent carotid artery disease appears less durable than primary carotid endarterectomy. Close postoperative surveillance is recommended after carotid artery reoperation
— id: 6377, year: 1993, vol: 18, page: 991, stat: Journal Article,

IS THERE DETRIMENTAL GENDER BIAS IN PREOPERATIVE CARDIAC MANAGEMENT OF PATIENTS UNDERGOING VASCULAR-SURGERY
HUTCHINSON, LA; PASTERNACK, PF; BAUMANN, FG; GROSSI, EA; RILES, TS; LAMPARELLO, PJ; GIANGOLA, G; ADELMAN, M; IMPARATO, AM
1993 OCT ;88(4):146-146, Circulation
— id: 33451, year: 1993, vol: 88, page: 146, stat: Journal Article,