Thomas S Riles, M.D.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Feb;16(1):35-77, Vascular medicine
— id: 146971, year: 2011, vol: 16, page: 35, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Feb 22;57(8):e16-e94, Journal of the American College of Cardiology
— id: 146969, year: 2011, vol: 57, page: e16, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Jul 26;124(4):e54-130, Circulation
— id: 146967, year: 2011, vol: 124, page: e54, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Jun;3(2):100-130, Journal of neurointerventional surgery
— id: 146982, year: 2011, vol: 3, page: 100, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Feb 22;57(8):1002-1044, Journal of the American College of Cardiology
— id: 146970, year: 2011, vol: 57, page: 1002, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Jul 26;124(4):489-532, Circulation
— id: 146968, year: 2011, vol: 124, page: 489, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine and Society for Vascular Surgery Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J
2011 Jun 1;3(2):100-130, Journal of neurointerventional surgery
— id: 146984, year: 2011, vol: 3, page: 100, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J; Jacobs, Alice K; Smith, Sidney C Jr
2011 Aug;42(8):e464-e540, Stroke
— id: 146965, year: 2011, vol: 42, page: e464, stat: Journal Article,

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Brott, Thomas G; Halperin, Jonathan L; Abbara, Suhny; Bacharach, J Michael; Barr, John D; Bush, Ruth L; Cates, Christopher U; Creager, Mark A; Fowler, Susan B; Friday, Gary; Hertzberg, Vicki S; McIff, E Bruce; Moore, Wesley S; Panagos, Peter D; Riles, Thomas S; Rosenwasser, Robert H; Taylor, Allen J; Jacobs, Alice K; Smith, Sidney C Jr
2011 Aug;42(8):e420-e463, Stroke
— id: 146966, year: 2011, vol: 42, page: e420, stat: Journal Article,

Two case presentations and surgical management of Bow Hunter's syndrome associated with bony abnormalities of the C7 vertebra
Lee, Victoria; Riles, Thomas S; Stableford, Jennifer; Berguer, Ramon
2011 May;53(5):1381-1385, Journal of vascular surgery
Bow Hunter's syndrome is a condition in which patients experience vertebrobasilar symptoms on head turn. It may be a consequence of intrinsic factors such as atherosclerosis, or it may be secondary to mechanical compression. Most commonly, this occurs at the level of C2 or above. We present two rare cases of Bow Hunter's syndrome secondary to mechanical compression at the level of C7. Discussed are the anatomic conditions leading to this syndrome in these two patients, the methodology for confirming the diagnosis, and the successful management by partial resection of the transverse processes compressing the vertebral arteries
— id: 134269, year: 2011, vol: 53, page: 1381, stat: Journal Article,

Is carotid artery stenting a fair alternative to carotid endarterectomy for symptomatic carotid artery stenosis?
Paraskevas, K I; Veith, F J; Riles, T S; Moore, W S
2011 Jun;41(6):717-719, European journal of vascular & endovascular surgery
— id: 136463, year: 2011, vol: 41, page: 717, stat: Journal Article,

Is carotid artery stenting a fair alternative to carotid endarterectomy for symptomatic carotid artery stenosis? A commentary on the AHA/ASA guidelines
Paraskevas, Kosmas I; Veith, Frank J; Riles, Thomas S; Moore, Wesley S
2011 Aug;54(2):541-543, Journal of vascular surgery
The recent guidelines by the American Heart Association/American Stroke Association (AHA/ASA) and several other associations recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients (Class I; Level of Evidence: B). The term 'alternative' may easily be misinterpreted as 'equivalent' to justify the widespread use of CAS. However, current evidence indicates that for symptomatic patients, CAS produces inferior outcomes compared with CEA. It is likely that with technical improvements, better patient selection, and better physician experience, CAS outcomes will improve in the future. CAS may then become a fair alternative to CEA, at least in certain patient subgroups. Based on current evidence, however, we are not there yet and it seems unfair to spin the AHA/ASA guidelines to conclude that we are
— id: 139441, year: 2011, vol: 54, page: 541, stat: Journal Article,

Regarding "Clinical course of asymptomatic patients with carotid duplex scan end diastolic velocities of 100 to 124 centimeters per second" Reply
Riles, Thomas S.
2011 JAN ;53(1):262-262, Journal of vascular surgery
— id: 126447, year: 2011, vol: 53, page: 262, stat: Journal Article,

Celiac artery dissection from heavy weight lifting
Riles, Thomas S; Lin, Judith C
2011 Jun;53(6):1714-1715, Journal of vascular surgery
In this case report, we present a 45-year-old man who experienced abdominal pain while bench-pressing heavy weights. A computed tomography angiogram showed a dissection of the celiac artery extending into the hepatic and splenic arteries, with thrombus in the false lumen into the common hepatic artery. With resolution of his symptoms, he was discharged after several days of warfarin and metoprolol therapy. To our knowledge, this is the first reported case of a dissection of the celiac artery and its branches caused by weight lifting
— id: 132878, year: 2011, vol: 53, page: 1714, 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,

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,

Carotid Artery Disease: Risk Factor Analysis in a Cohort of 3.9 Million Individuals
Greco, G; Egorova, NN; Kent, KC; Zwolak, RM; Manganaro, A; Moskowitz, A; Gelijns, A; Riles, TS
2010 JUN ;51(9739):95S-96S, Journal of vascular surgery
— id: 111902, year: 2010, vol: 51, page: 95S, stat: Journal Article,

Development of a Novel Scoring Tool for the Identification of Large >/=5 cm Abdominal Aortic Aneurysms
Greco, Giampaolo; Egorova, Natalia N; Gelijns, Annetine C; Moskowitz, Alan J; Manganaro, Andrew J; Zwolak, Robert M; Riles, Thomas S; Kent, K Craig
2010 Oct;252(4):675-682, Annals of surgery
OBJECTIVE:: Current screening recommendations for abdominal aortic aneurysm (AAA) target >3-cm diameter aneurysms in ever-smoking 65- to 75-year-old males. However, more than 50% of AAA ruptures occur in individuals outside this patient cohort, and only a subset of AAAs detected are large enough to warrant surgery. In this analysis, we evaluated more than 3 million screened individuals and developed a scoring tool to identify >/=5-cm diameter AAAs in the entire population at risk. METHODS:: Between 2003 and 2008, demographics and risk factors were collected from 3.1 million people undergoing ultrasound screening for AAA by Life Line Screening, Inc. Using multivariable logistic regression analysis, we identified risk factors and developed a scoring system to predict the presence of >/=5-cm diameter AAAs. RESULTS:: Smoking had a profound influence on the risk of AAA, which increased with number of cigarettes smoked and years of smoking, and decreased following smoking cessation. Novel findings included a protective effect of exercise, normal weight, and Black/Hispanic race/ethnicity. Using these and other factors, the scoring system provided good predictive accuracy (C-statistic = 0.82), when tested against the validation subset of the study cohort. The model predicts the presence of 121,000 >/=5 cm AAA in the US population (prevalence: 0.14%). Demonstrating the inadequacy of the current screening recommendations, only 35% of these aneurysms were among males aged 65 to 75 years. CONCLUSIONS:: Based on the largest cohort of patients ever screened for AAA, we developed a screening strategy that can identify large AAAs in a broad population of individuals at risk
— id: 113668, year: 2010, vol: 252, page: 675, 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,

Asymptomatic Carotid Stenosis: Mainly a Medical Condition Response
Riles, T
2010 MAY-JUN ;18(3):127-129, Vascular
— id: 110114, year: 2010, vol: 18, page: 127, stat: Journal Article,

Commentary on "Role of carotid revascularization in stroke treatment and prevention"
Riles, Thomas S
2010 Mar;22(1):16-17, Perspectives in vascular surgery & endovascular therapy
— id: 112043, year: 2010, vol: 22, page: 16, stat: Journal Article,

Clinical course of asymptomatic patients with carotid duplex scan end diastolic velocities of 100 to 124 centimeters per second
Riles, Thomas S; Lee, Victoria; Cheever, David; Stableford, Jennifer; Rockman, Caron B
2010 Oct;52(4):914-9, 919.e1, Journal of vascular surgery
OBJECTIVE: With the decline of diagnostic angiography, clinicians increasingly rely upon duplex scan criteria to select appropriate asymptomatic candidates for carotid intervention. Some recent trials have enrolled patients for intervention based upon end diastolic velocities (EDVs) as low as 100 cm/second, and peak systolic velocities (PSVs) as low as 230 cm/second. In as much as we have used more selective duplex scan criteria, we reviewed the course of asymptomatic patients who had EDVs from 100 to 124 cm/second. METHODS: Of the patients evaluated in our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) accredited laboratory from 2002 to 2007, 144 patients had an EDV 100 to 124 cm/second. Of these, 47 patients underwent initial carotid intervention for concomitant symptoms (10), contralateral occlusion (3), or other imaging findings felt to warrant intervention. The remaining 97 asymptomatic patients were followed. One patient had both arteries fall within this EDV range. The mean follow-up for the 98 arteries was 29.1 months (range, 2-116 months). RESULTS: Five patients (5.2%) developed ipsilateral symptoms consisting of one stroke and four transient ischemic attacks (TIAs), at a mean time of 35.3 months (range, 12-58 months). Twenty-six patients (26.8%), including 3 who also developed ipsilateral symptoms, progressed to having an EDV of >/= 125 cm/second at a mean time of 24 months (range, 2-58). Two of these (2.1%) progressed directly to occlusion without symptoms and with no documented interim worsening of stenosis. CONCLUSION: For asymptomatic individuals with an initial EDV of 100 to 124 cm/second, the risk of ipsilateral stroke is small and, therefore, medical management is appropriate in most cases. However, the risk of progression to a more severe degree of stenosis, often warranting carotid intervention, is clinically meaningful. Yearly duplex scan follow-up is necessary to assess disease progression in this patient cohort
— id: 119223, year: 2010, vol: 52, page: 914, stat: Journal Article,

Carotid artery disease: selecting the appropriate asymptomatic patient for intervention
Rockman, Caron; Riles, Thomas
2010 Mar;22(1):30-37, Perspectives in vascular surgery & endovascular therapy
Despite randomized controlled trials demonstrating the superiority of carotid endarterectomy over medical management in the prevention of stroke in asymptomatic patients with severe carotid artery stenosis, considerable controversy remains with regard to selecting the appropriate asymptomatic patient for carotid intervention. Adding to the complexity of this issue is the fact that the extensive existing literature on this topic is heterogeneous, with trials having used varying definitions of high-grade stenosis, inclusion criteria for patients, and outcome measurements. The current article will review the existing randomized controlled trials on this topic, data regarding the risk of stroke in asymptomatic patients with severe stenosis, data regarding subsets of asymptomatic patients that may be at a higher-than-average risk of future stroke, and data regarding the efficacy of current medical therapy on the risk of stroke in asymptomatic patients with high-grade stenosis. Ultimately, the challenge for clinicians is to ensure that asymptomatic patients with the highest risk of future stroke are offered carotid revascularization and that the intervention is performed with the lowest possible complication rate, in order to maintain the benefit of prophylactic treatment
— id: 112044, year: 2010, vol: 22, page: 30, stat: Journal Article,

Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study
Halm, Ethan A; Tuhrim, Stanley; Wang, Jason J; Rockman, Caron; Riles, Thomas S; Chassin, Mark R
2009 Jan;40(1):221-229, Stroke
BACKGROUND AND PURPOSE: The benefit of carotid endarterectomy is heavily influenced by the risk of perioperative death or stroke. This study developed a multivariable model predicting the risk of death or stroke within 30 days of carotid endarterectomy. METHODS: The New York Carotid Artery Surgery (NYCAS) Study is a population-based cohort of 9308 carotid endarterectomies performed on Medicare patients from January 1998 through June 1999 in New York State. Detailed clinical data were abstracted from medical charts to assess sociodemographic, neurological, and comorbidity risk factors. Deaths and strokes within 30 days of surgery were confirmed by physician overreading. Multivariable logistic regression was used to identify independent patient risk factors. RESULTS: The 30-day rate of death or stroke was 2.71% among asymptomatic patients with no history of stroke/transient ischemic attack (TIA), 4.06% among asymptomatic ones with a distant history of stroke/TIA, 5.62% among those operated on for carotid TIA, 7.89% of those with stroke, and 13.33% in those with crescendo TIA/stroke-in-evolution. Significant multivariable predictors of death or stroke included: age >/=80 years (OR, 1.30; 95% CI, 1.03 to 1.64), nonwhite (OR, 1.83; 1.23 to 2.72), admission from the emergency department (OR, 1.95; 1.50 to 2.54), asymptomatic but distant history of stroke/TIA (OR, 1.40; 1.02 to 1.94), TIA as an indication for surgery (OR, 1.81; 1.39 to 2.36), stroke as the indication (OR, 2.40; 1.74 to 3.31), crescendo TIA/stroke-in-evolution (OR, 3.61; 1.15 to 11.28), contralateral carotid stenosis >/=50% (OR, 1.44; 1.15 to 1.79), severe disability (OR, 2.94; 1.91 to 4.50), coronary artery disease (OR, 1.51; 1.20 to 1.91), and diabetes on insulin (OR, 1.55; 1.10 to 2.18). Presence of a deep carotid ulcer was of borderline significance (OR, 2.08; 0.93 to 4.68). CONCLUSIONS: Several sociodemographic, neurological, and comorbidity risk factors predicted perioperative death or stroke after carotid endarterectomy. This information may help inform decisions about appropriate patient selection, assessments about the impact of different surgical processes of care on outcomes, and facilitate comparisons of risk-adjusted outcomes among providers
— id: 94452, year: 2009, vol: 40, page: 221, stat: Journal Article,

Racial and ethnic disparities in outcomes and appropriateness of carotid endarterectomy: impact of patient and provider factors
Halm, Ethan A; Tuhrim, Stanley; Wang, Jason J; Rojas, Mary; Rockman, Caron; Riles, Thomas S; Chassin, Mark R
2009 Jul;40(7):2493-2501, Stroke
BACKGROUND AND PURPOSE: Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy. Less is known about disparities in outcomes and appropriateness of carotid endarterectomy or reasons for such inequalities. METHODS: This was a population-based cohort of carotid endarterectomy performed in Medicare beneficiaries in New York. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for carotid endarterectomy, disease severity, comorbidities, and deaths and strokes within 30 days of surgery. Appropriateness was based on validated criteria from a national expert panel. Differences in patients, providers, outcomes, and appropriateness were compared using chi(2) tests. Differences in risk-adjusted rates of death or nonfatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital-level risk factors. RESULTS: Overall, 95.3% of patients undergoing carotid endarterectomy were white, 2.5% black, and 2.2% Hispanic (N=9093). Minorities had more severe neurological disease and more comorbidities and were more likely to be cared for by lower-volume surgeons and hospitals (P<0.0001). Rates of 30-day death/stroke were higher in Hispanics (9.5%) and blacks (6.9%) than whites (3.8%; P<0.0001). Multivariable analyses that adjusted for presurgical patient risk and provider characteristics found that blacks no longer had significantly worse outcomes (OR=1.37; CI, 0.78 to 2.40), although the higher risk of death/stroke in Hispanics persisted (OR=1.87; CI, 1.09 to 3.19). Minorities had higher rates of inappropriate surgery (Hispanics 17.6%, black 13.0%, white 7.9%; P<0.0001) largely due to higher comorbidity. CONCLUSIONS: Minorities had worse outcomes and higher rates of inappropriate surgery. Differences in underlying presurgical risk factors and provider characteristics explained the higher risk of complications in blacks, but not Hispanics
— id: 120629, year: 2009, vol: 40, page: 2493, 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,

A study of cognitive dysfunction in patients having carotid endarterectomy performed with regional anesthesia
Heyer, Eric J; Gold, Mark I; Kirby, E Will; Zurica, Joseph; Mitchell, Elizabeth; Halazun, Hadi J; Teverbaugh, Lauren; Sciacca, Robert R; Solomon, Robert A; Quest, Donald O; Maldonado, Thomas S; Riles, Thomas S; Connolly, E Sander Jr
2008 Aug;107(2):636-642, Anesthesia & analgesia
BACKGROUND: In previous studies, we found that approximately 25% of patients having carotid endarterectomy with general anesthesia (CEA general) develop cognitive dysfunction compared with a surgical control Group 1 day and 1 mo after surgery. In this study, we tested the hypothesis that patients having CEA with regional anesthesia (CEA regional) will develop significant cognitive dysfunction 1 day after surgery compared with a control group of patients receiving sedation 1 day after surgery. We did not study persistence of dysfunction. METHODS: To test this hypothesis, we enrolled 60 patients in a prospective study. CEA regional was performed with superficial and deep cervical plexus blocks in 41 patients. The control group consisted of 19 patients having coronary angiography or coronary artery stenting performed with sedation. A control group is necessary to account for the 'practice effect' associated with repeated cognitive testing. The patients from the CEA regional group were enrolled at New York Medical Center and the control group at Columbia-Presbyterian Medical Center. The cognitive performance of all patients was evaluated using a previously validated battery of neuropsychometric tests. Differences in performance, 1 day after compared with before surgery, were evaluated by both event-rate and group-rate analyses. RESULTS: On postoperative day 1, 24.4% of patients undergoing CEA regional had significant cognitive dysfunction, where 'significant' was defined as a total deficit score > or =2 SD worse than the mean performance in the control group. CONCLUSIONS: Patients undergoing CEA regional had an incidence of cognitive dysfunction which was not different than patients having CEA general as previously published and compared with a contemporaneously enrolled group
— id: 94453, year: 2008, vol: 107, page: 636, stat: Journal Article,

Cerebrovascular disease
Riles, Thomas Stuart; Rockman, Caron B
Sabiston textbook of surgery : the biological basis of modern surgical practice Philadelphia : Saunders/Elsevier, 2008,
— id: 4870, year: 2008, vol: , page: ?, stat: Chapter,

Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study
Greenstein, Alexander J; Chassin, Mark R; Wang, Jason; Rockman, Caron B; Riles, Thomas S; Tuhrim, Stanley; Halm, Ethan A
2007 Dec;46(6):1138-1144, Journal of vascular surgery
OBJECTIVE: Most studies on outcomes of carotid endarterectomy (CEA) have focused on the major complications of death and stroke. Less is known about minor but more common surgical complications such as hematoma, cranial nerve palsy, and wound infection. This study used data from a large, population-based cohort study to describe the incidence of minor surgical complications after CEA and examine associations between minor and major complications. METHODS: The New York Carotid Artery Surgery (NYCAS) study examined all Medicare beneficiaries who underwent CEA from January 1998 to June 1999 in NY State. Detailed clinical information on preoperative characteristics and complications < or =30 days of surgery was abstracted from hospital charts. Associations between minor (cranial nerve palsies, hematoma, and wound infection) and major complications (death/stroke) were examined with chi(2) tests and multivariate logistic regression. RESULTS: The NYCAS study had data on 9308 CEAs performed by 482 surgeons in 167 hospitals. Overall, 10% of patients had a minor surgical complication (cranial nerve (CN) palsy, 5.5%; hematoma, 5.0%; and wound infection, 0.2%). Cardiac complications occurred in 3.9% (myocardial 1.1%, unstable angina 0.9%, pulmonary edema 2.1%, and ventricular tachycardia 0.8%). In both unadjusted and adjusted analyses, the occurrence of any minor surgical complication, CN palsy alone, or hematoma alone was associated with 3 to 4-fold greater odds of perioperative stroke or combined risk of death and nonfatal stroke (P < 0.0001). Patients with cardiac complications had 4 to 5-fold increased odds of stroke or combined risk of death and stroke. CONCLUSION: Minor surgical complications are common after CEA and are associated with much higher risk of death and stroke. Patient factors, process factors, and direct causality are involved in this relationship, but future work will be needed to better understand their relative contributions
— id: 94454, year: 2007, vol: 46, page: 1138, stat: Journal Article,

Preliminary evaluation of the Web Initiative for Surgical Education (WISE-MD)
Kalet, Adina L; Coady, Sarah H; Hopkins, Mary Ann; Hochberg, Marc S; Riles, Thomas S
2007 Jul;194(1):89-93, American journal of surgery
BACKGROUND: Major changes in health care delivery and financing have negatively impacted students' experience during the surgery clerkship, particularly their exposure to physicians' decision-making processes and to the continuity of patient care. In response to these dilemmas in surgical education, we have developed the Web Initiative for Surgical Education (WISE-MD), a comprehensive surgery clerkship curriculum delivered through multimedia teaching modules and designed to enhance exposure to surgical disease and clinical reasoning. METHODS: As part of the process of creating WISE-MD, we conducted preliminary studies to assess the impact of this computer-assisted approach on students' knowledge, clinical reasoning, and satisfaction. RESULTS: Compared to students who did not view the modules, early data show a trend toward improved knowledge and an improvement in clinical reasoning for students who used the WISE-MD modules. This effect was specific to the clinical content area addressed in the module seen by the students. Most students felt the module was superior to traditional teaching methods and enhanced their understanding of surgical technique and anatomy. CONCLUSIONS: WISE-MD, a theory-driven example of a concerted technology-based approach to surgical education, has the potential to address the myriad problems of today's clinical learning environment.
— id: 73032, year: 2007, vol: 194, page: 89, stat: Journal Article,

Dexmedetomidine does not increase the incidence of intracarotid shunting in patients undergoing awake carotid endarterectomy
Bekker, Alex; Gold, Mark; Ahmed, Raza; Kim, Jung; Rockman, Caron; Jacobovitz, Glenn; Riles, Thomas; Fisch, Gene
2006 Oct;103(4):955-958, Anesthesia & analgesia
Systemic administration of dexmedetomidine (DEX) decreases cerebral bloodflow (CBF) via direct alpha-2-mediated constriction of cerebral blood vessels and indirectly via its effect on the intrinsic neural pathway modulating vascular smooth muscle. Reduction in CBF without a concomitant decrease in cerebral metabolic rate has raised concerns that DEX may limit adequate cerebral oxygenation of brain tissue in patients with already compromised cerebral circulation (e.g., carotid endarterectomy [CEA]). In this study, we established the incidence of intraarterial shunting used as a sign of inadequate oxygen delivery in a consecutive series of 123 awake CEA performed in our institution using DEX as a primary sedative. Data were prospectively recorded in 151 patients who underwent CEA during the study period. Eighteen patients were sedated with midazolam and fentanyl (M/F) for medical or logistical reasons. Patients thought to be at risk of an intraoperative stroke were treated with a prophylactic intraarterial shunt. These patients, as well as those who required general anesthesia, were excluded from the final analysis. Five patients (4.3%) in the DEX group required intraarterial shunts. The incidence of shunting in patient undergoing awake CEA in our institution is 10% (historical control). No patients developed a stroke or other serious complications. It appears that the use of DEX as a primary sedative drug for CEA does not increase the incidence of intraarterial shunts
— id: 68990, year: 2006, vol: 103, page: 955, stat: Journal Article,

Carotid artery stent implantation: evaluation with multi-detector row CT angiography and virtual angioscopy--initial experience
Orbach, Darren B; Pramanik, Bidyut K; Lee, Julie; Maldonado, Thomas S; Riles, Tom; Grossman, Robert I
2006 Jan;238(1):309-320, Radiology
Approval for this HIPAA-compliant study was obtained from the institutional review board; informed consent was not required for retrospective review of patient studies that had been performed for clinical evaluation. The purpose of this study was to retrospectively compare the accuracy of intrastent luminal diameter, as measured on transverse computed tomographic (CT) angiograms and virtual angioscopic views, with the manufacturer's specifications for phantom diameter and with digital subtraction angiographic (DSA) measurements of stent diameter obtained in patients. Intrastent diameter was measured by using standard and stent-optimized reconstruction kernels with three window settings. Endoluminal virtual angioscopic views of the stent-containing vessels were also generated. Measurements at CT angiography were compared with known specifications for the phantom and with DSA measurements in patients. Erroneous measurements of intrastent diameter occurred when a standard kernel and nonoptimized window settings were used. A set of parameters that minimized error relative to measurements obtained at DSA was also identified. Virtual angioscopy helped demonstrate morphologic aspects of stenosis that were otherwise difficult to appreciate
— id: 61246, year: 2006, vol: 238, page: 309, stat: Journal Article,

Department of Surgery, New York University School of Medicine
Riles, Thomas S
2006 Feb;141(2):120-122, Archives of Surgery (Chicago)
— id: 62752, year: 2006, vol: 141, page: 120, stat: Journal Article,

Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes
Rockman, Caron B; Maldonado, Thomas S; Jacobowitz, Glenn R; Cayne, Neal S; Gagne, Paul J; Riles, Thomas S
2006 Sep;44(3):480-487, Journal of vascular surgery
OBJECTIVE: The optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients. METHODS: A retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1,158 (45.6%) were in symptomatic patients. Patients who were operated on emergently <or=48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered 'early' if performed <or=4 weeks of symptoms, and 'delayed' if performed after a minimum of a 4-week interval following the most recent symptom. RESULTS: Of nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1,046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA. CONCLUSIONS: In a large institutional experience, patients who underwent CEA <or=4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA
— id: 68644, year: 2006, vol: 44, page: 480, 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,

Clinical and operative predictors of outcomes of carotid endarterectomy
Halm, Ethan A; Hannan, Edward L; Rojas, Mary; Tuhrim, Stanley; Riles, Thomas S; Rockman, Caron B; Chassin, Mark R
2005 Sep;42(3):420-428, Journal of vascular surgery
OBJECTIVE: The net benefit for patients undergoing carotid endarterectomy is critically dependent on the risk of perioperative stroke and death. Information about risk factors can aid appropriate selection of patients and inform efforts to reduce complication rates. This study identifies the clinical, radiographic, surgical, and anesthesia variables that are independent predictors of deaths and stroke following carotid endarterectomy. METHODS: A retrospective cohort study of patients undergoing carotid endarterectomy in 1997 and 1998 by 64 surgeons in 6 hospitals was performed (N = 1972). Detailed information on clinical, radiographic, surgical, anesthesia, and medical management variables and deaths or strokes within 30 days of surgery were abstracted from inpatient and outpatient records. Multivariate logistic regression models identified independent clinical characteristics and operative techniques associated with risk-adjusted rates of combined death and nonfatal stroke as well as all strokes. RESULTS: Death or stroke occurred in 2.28% of patients without carotid symptoms, 2.93% of those with carotid transient ischemic attacks, and 7.11% of those with strokes (P < .0001). Three clinical factors increased the risk-adjusted odds of complications: stroke as the indication for surgery (odds ratio [OR], 2.84; 95% confidence interval [CI] = 1.55-5.20), presence of active coronary artery disease (OR, 3.58; 95% CI = 1.53-8.36), and contralateral carotid stenosis > or =50% (OR, 2.32; 95% CI = 1.33-4.02). Two surgical techniques reduced the risk-adjusted odds of death or stroke: use of local anesthesia (OR, 0.30; 95% CI = 0.16-0.58) and patch closure (OR, 0.43; 95% CI = 0.24-0.76). CONCLUSIONS: Information about these risk factors may help physicians weigh the risks and benefits of carotid endarterectomy in individual patients. Two operative techniques (use of local anesthesia and patch closure) may lower the risk of death or stroke
— id: 94456, year: 2005, vol: 42, page: 420, stat: Journal Article,

Primary closure of the carotid artery is associated with poorer outcomes during carotid endarterectomy
Rockman, Caron B; Halm, Ethan A; Wang, Jason J; Chassin, Mark R; Tuhrim, Stanley; Formisano, Patricia; Riles, Thomas S
2005 Nov;42(5):870-877, Journal of vascular surgery
INTRODUCTION: Arterial endarterectomy and reconstruction during carotid endarterectomy (CEA) can be performed in a variety of ways, including standard endarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion endarterectomy. The optimal method of arterial reconstruction remains a matter of controversy. The objective of this study was to determine the effect of the method of arterial reconstruction during CEA on perioperative outcome. METHODS: A retrospective cohort study of consecutive CEAs performed by 81 surgeons during 1997 and 1998 in six regional hospitals was performed. Detailed clinical data regarding each case and all deaths and nonfatal strokes within 30 days of surgery were ascertained by an independent review of the inpatient chart, outpatient surgeon record, and the hospitals' administrative databases. Two physician investigators--one neurologist and one internist--confirmed each adverse event by independently reviewing patients' medical records. RESULTS: A total of 1972 CEAs were performed. The mean age of the patients was 72.3 years, and 57.2% were male. Preoperative neurologic symptoms occurred in 28.7% of cases (n = 566), and the remaining 71.3% were asymptomatic before surgery (n = 1406). The method of arterial reconstruction was chosen by the surgeon. Primary closure was performed in 11.8% (n = 233), patch angioplasty in 69.8% (n = 1377), and eversion endarterectomy in 18.4% (n = 362). There was no significant difference in the preoperative symptom status of patients who underwent primary closure compared with the other methods of reconstruction (72.5% asymptomatic vs 71.1%, p = NS). Primary closure cases were significantly more likely to experience perioperative stroke compared with the other closure techniques (5.6% vs 2.2%, P = .006). Primary closure cases also had a higher incidence of perioperative stroke or death compared with the other closure techniques (6.0% vs 2.5%, P = .006). There were no significant differences with regard to either perioperative stroke, or perioperative stroke/death noted when comparing patch angioplasty with eversion endarterectomy: stroke, 2.2% vs 2.5% (P = NS) and stroke/death, 2.5% vs 2.5% (P = NS) respectively. CONCLUSION: It appears that primary closure is associated with significantly worse perioperative outcomes compared with endarterectomy with patch angioplasty and eversion endarterectomy, even when the preoperative symptom status of the patient cohorts is equivalent. Although some of its advocates have reported that they can properly select appropriate patients for primary closure based on the size of the artery and other factors, the data demonstrate that these patients have poorer outcomes nonetheless. Primary closure during carotid endarterectomy should predominantly be abandoned in favor of either standard endarterectomy with patch angioplasty or eversion endarterectomy
— id: 94455, year: 2005, vol: 42, page: 870, 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,

A rapid clerkship redesign to address new realities
Kalet, Adina; Hopkins, Mary Ann; Riles, Thomas
2004 Nov;38(11):1193-1194, Medical education
— id: 55904, year: 2004, vol: 38, page: 1193, stat: Journal Article,

Screening for abdominal aortic aneurysm: a consensus statement
Kent, K Craig; Zwolak, Robert M; Jaff, Michael R; Hollenbeck, Scott T; Thompson, Robert W; Schermerhorn, Marc L; Sicard, Gregorio A; Riles, Thomas S; Cronenwett, Jack L
2004 Jan;39(1):267-269, Journal of vascular surgery
— id: 94457, year: 2004, vol: 39, page: 267, stat: Journal Article,

Screening for abdominal aortic aneurysms - a consensus statement - Reprinted from J Vacs Surg, 2004; 39 : 267-69
Kent, KC; Zwolak, RM; Jaff, MR; Hollenbecka, ST; Thompson, RW; Schermerhorn, ML; Sicard, GA; Riles, TS; Cronenwett, JL
2004 JUL ;9(1):87-89, Vascular medicine
— id: 46606, year: 2004, vol: 9, page: 87, 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 mandatory resident work hour limitations on medical students' interest in surgery
Miller, George; Bamboat, Zubin M; Allen, Frederick; Biernacki, Peter; Hopkins, Mary Ann; Gouge, Thomas H; Riles, Thomas S
2004 Nov;199(4):615-619, Journal of the American College of Surgeons
BACKGROUND: The number of US medical students applying for general surgery residency has been declining. Recent studies have shown that the issue of 'controllable lifestyle' has become a critical factor in medical students' decision-making process. We postulate that widespread implementation of resident work hour limitations would bolster medical students' interest in pursuing surgical careers. STUDY DESIGN: Students from New York University School of Medicine were surveyed about their attitudes toward work hour limitations and its effect on their interest in pursuing a surgical residency. One hundred thirty-two students participated. RESULTS: Nearly 95% of respondents believed that work hour limitations were a positive change and, if all other factors were equal, they would choose a training program that used work hour limitations over one that did not. The most common reasons cited in favor of limits were improvements in resident lifestyle (42%) and patient safety (34%). Fifty-three percent of respondents indicated that presence of work hour limitations alone would increase their interest in considering a surgical residency and only 2% of medical students indicated that it would lessen their interest in surgery. Not surprisingly, intellectual interest in a specialty was the most important factor in choosing a residency for 86% of students. Nevertheless, work hour limitations were designated a higher priority than future salary by 55% of medical students. CONCLUSIONS: The presence of work hour limitations has a positive impact on medical students' interest in surgery. Widespread implementation of work hour limitations may bolster the number of applications for surgical residency
— id: 46084, year: 2004, vol: 199, page: 615, stat: Journal Article,

Attitudes of applicants for surgical residency toward work hour limitations
Miller, George; Bamboat, Zubin M; Allen, Frederick; Hopkins, Mary Ann; Gouge, Thomas H; Riles, Thomas S; Nalbandian, Matthew M
2004 Sep;188(2):131-135, American journal of surgery
BACKGROUND: There is an ongoing debate regarding the merits of resident work-hour limitations. We postulated that this issue would be a factor in the decision-making process of applicants to surgical residency. METHODS: Candidates for surgical residency at a university-based program completed an anonymous survey during their visit. Data was analyzed by analysis of variance and the chi-square test. RESULTS: Most candidates viewed work-hour limitations as being favorable to their future training. Nevertheless, work-hour limitations ultimately were not a critical factor in the decision-making process compared with issues such as quality of training and program reputation. Candidates ranked 'reading in surgery' the most likely way they would spend the leisure time afforded by work-hour limitations. CONCLUSIONS: Most applicants for surgical residency consider work hour-limitations as being favorable to their training and view the extra free time as an opportunity for furthering their education. However, other issues take precedence when choosing a residency
— id: 46008, year: 2004, vol: 188, page: 131, stat: Journal Article,

Periaortitis: gadolinium-enhanced magnetic resonance imaging and response to therapy in four patients
Mitnick, Hal; Jacobowitz, Glenn; Krinsky, Glen; Eberle, Mark; Rosenzweig, Barry; Willis, David; Rockman, Caron; Riles, Thomas
2004 Feb;18(1):100-107, Annals of vascular surgery
The objective of this study was to define clinical and imaging characteristics of periaortitis prior to and after therapy with immunosuppressive drugs. Four consecutive patients with periaortitis (two secondary to atherosclerosis and two with rheumatic diseases) were studied with contrast-enhanced CT and magnetic resonance angiography (MRA), rheumatologic serologies, and acute-phase reactants. All were treated with corticosteroids and two patients received immunosuppressive agents. Patients were followed with serial MRA scans, CT scans, and clinical exams. Prior to treatment, all patients demonstrated a rind of periaortic tissue, which was enhanced with both contrast-enhanced CT as well as gadolinium-enhanced MRA. Clinical symptoms resolved and rind contracture occurred in all cases following therapy. Enhancement of the rind persisted despite the clinical improvement in all patients. No patient developed an aortic aneurysm or retroperitoneal fibrosis during the follow-up period. Corticosteroid/immunosuppressive treatment was continued for an average of 41 months. At 62 months of total follow-up, there has been no recurrence of periaortitis by clinical and/or radiologic exam. Treatment of periaortitis with corticosteroids and immunosuppression therapy leads to resolution of clinical symptoms and radiologic contracture of the periaortic rind. Patients responded to therapy without developing progressive fibrosis or aneurysm. MRA allows safe and repetitive imaging of periaortitis and provides excellent definition of lumenal abnormalities including plaque rupture
— id: 46180, year: 2004, vol: 18, page: 100, stat: Journal Article,

Successful limb reperfusion using prolonged intravascular shunting in a case of an unstable trauma patient--a case report
Nalbandian, M M; Maldonado, T S; Cushman, J; Jacobowitz, G J; Lamparello, P J; Riles, T S
2004 Jul-Aug;38(4):375-379, Vascular & endovascular surgery
When peripheral vascular injuries present in conjunction with life threatening emergencies, controlling hemorrhage from a peripheral blood vessel may take initial priority, however, sacrificing a limb to preserve life is a well-established dictum. The use of intravascular shunts has allowed arterial and venous injuries to be controlled and temporized while treating other injuries. Typically, intravascular shunts are used for short time periods while orthopedic injuries are repaired or other life threatening injuries are managed. The following case demonstrates the long-term use of an intravascular arterial shunt to treat a traumatic transection of the common femoral artery and vein in a patient with an open pelvic fracture from blunt trauma. A 20-year-old woman fell between a subway platform and an oncoming train. She sustained a crush injury to her lower extremity and pelvis as she was pinned between the train and platform. The patient presented with active hemorrhage from a groin laceration, quickly became hemodynamically unstable, and was brought to the operating room. In addition to a pelvic fracture with massive pelvic hematoma she sustained a complete transection of the bifurcation of the common femoral artery (CFA), the common femoral vein (CFV), and associated orthopedic injuries. Vascular shunts were placed in the common femoral artery and vein. The patient became hypotensive from an expanding retroperitoneal hematoma. Pelvic bleeding was controlled with angioembolization and the venous injury was repaired. At this time the patient became cold, acidotic, and coagulopathic. It was thought unsafe to proceed with the arterial repair and it was elected to keep her arterial shunts in place and perform a planned reexploration in 24 hours after correcting her physiologic status. The patient returned to the operating room for an elective repair of her CFA the following day. Her shunt had remained patent throughout this time. She underwent a reverse saphenous vein graft from her CFA to her SFA. After a prolonged hospital course she was ultimately transferred to a rehabilitation center with intact pulses in both lower extremities. This case demonstrates the effectiveness of prolonged (>6 hours) use of an intravascular shunt as part of damage control surgery for peripheral arterial and venous injuries. In a patient who would otherwise undergo an amputation for their injury, the risk of shunt thrombosis, or infection, during damage control resuscitation may not be a contraindication for placement
— id: 47852, year: 2004, vol: 38, page: 375, stat: Journal Article,

Presidential address: the next quarter
Riles, Thomas S
2004 Feb;39(2):275-278, Journal of vascular surgery
— id: 42607, year: 2004, vol: 39, page: 275, 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,

Revisiting the appropriateness of carotid endarterectomy
Halm, Ethan A; Chassin, Mark R; Tuhrim, Stanley; Hollier, Larry H; Popp, A John; Ascher, Enrico; Dardik, Herbert; Faust, Glenn; Riles, Thomas S
2003 Jun;34(6):1464-1471, Stroke
BACKGROUND AND PURPOSE: In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs. METHODS: Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery. RESULTS: Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%. CONCLUSIONS: Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds
— id: 127284, year: 2003, vol: 34, page: 1464, 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,

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,

Have published RCTs improved the appropriateness and use of carotid endarterectomy?
Halm, EA; Tuhrim, S; Hollier, LH; Riles, TS; Faust, G; Popp, JA; Ascher, E; Dardik, H; Chassin, MR
2002 Apr;17(5):196-196, Journal of general internal medicine
— id: 27451, year: 2002, vol: 17, page: 196, 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,

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,

Transesophageal echocardiography in intimal flap fenestration
Kronzon I; Tunick PA; Riles T; Rosen R
2001 Sep;14(9):934-936, Journal of the American Society of Echocardiography
In selected patients with descending aortic dissection, percutaneous intimal flap fenestration is a less-invasive alternative to surgery. We describe a patient with decreased renal and mesenteric blood flow as a result of descending aortic dissection. Percutaneous balloon intimal fenestration was performed under guidance of transesophageal echocardiography. Transesophageal echocardiography provided crucial information about the intimal flap puncture site and true- and false-lumen blood flow. After the flap fenestration, false-lumen blood flow increased, and the patient improved clinically
— id: 26620, year: 2001, vol: 14, page: 934, stat: Journal Article,

A name change and a refocused society
Porter JM; Riles TS
2001 Jan;33(1):207-208, Journal of vascular surgery
— id: 25662, year: 2001, vol: 33, page: 207, stat: Journal Article,

The American Association for Vascular Surgery
Porter JM; Riles TS
2001 Feb;9(1):1-2, Cardiovascular surgery
— id: 25664, year: 2001, vol: 9, page: 1, 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,

Lower extremity paraparesis or paraplegia subsequent to endovascular management of abdominal aortic aneurysms
Rockman CB; Riles TS; Landis R
2001 Jan;33(1):178-180, Journal of vascular surgery
Lower extremity paraplegia or paraparesis is an extremely rare event after operative repair of infrarenal abdominal aortic aneurysms (AAAS). We report two such cases that occurred after endovascular repair or attempted endovascular repair of routine AAAS. To our knowledge, these are the first two cases reported specifically in the literature. These cases may have significant implications with regard to the endovascular management of AAAS, because atheroembolization to the spinal cord appears to be the underlying cause
— id: 25663, year: 2001, vol: 33, page: 178, 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,

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,

Internal jugular vein thrombosis in association with the ovarian hyperstimulation syndrome
Schanzer A; Rockman CB; Jacobowitz GR; Riles TS
2000 Apr;31(4):815-818, Journal of vascular surgery
Thrombosis of the internal jugular vein is a rare entity with the potential for serious consequences. Most of the reported cases of jugular venous thrombosis have occurred in the presence of an indwelling venous catheter, an established hypercoagulable state, or in association with head and neck sepsis. This report presents a case of a patient in whom jugular venous thrombosis developed during the first trimester of pregnancy after in vitro fertilization. Thromboembolism in these circumstances can be related to a condition known as the ovarian hyperstimulation syndrome. The presentation of severe neck pain in pregnant women, especially in those who have undergone assisted reproduction procedures, should prompt evaluation by duplex scan to evaluate the jugular veins for thrombosis. Anticoagulation is the treatment of choice
— id: 11769, year: 2000, vol: 31, page: 815, stat: Journal Article,

Immediate and late explantation of endovascular aortic grafts: the endovascular technologies experience
Jacobowitz GR; Lee AM; Riles TS
1999 Feb;29(2):309-316, Journal of vascular surgery
PURPOSE: The morbidity and clinical outcome of the failure to successfully repair an abdominal aortic aneurysm with Endovascular Technologies (EVT) grafts, resulting in explantation of the device, was assessed. METHODS: The records of all patients worldwide undergoing attempted endovascular repair with EVT devices from February 1993 to October 1997 were retrospectively reviewed. Of 669 patients, 19 (3%) were converted to open procedure with immediate explantation during the initial attempt at endovascular repair, and 27 patients (4%) required explantation at a later date, ranging from 1 day to 40 months. The incidence, morbidity, mortality, and effect on clinical outcome were evaluated. RESULTS: Causes of immediate conversion with explantation were: inaccurate deployment of the proximal or distal attachment systems (11 of 19; 58%); twists in the system (3 of 19; 16%); mechanism malfunction during deployment (4 of 19; 21%); and an aortic tear (1 of 19; 5%). Among the 27 patients undergoing late explantation, 20 (74%) did so because of persistent endoleaks. Three cases (11%) were performed because of aneurysm rupture, three (11%) because of graft occlusion, one because of aortic dissection (4%), and one (4%) because of graft migration into the aneurysm sac. The overall perioperative mortality rate was 11% (2 of 19) for immediate explantation and 7% (2 of 27) for late explantation. The average length-of-stay was 11 days for immediate explantation and 14 days for late explantation (NS). Complications included myocardial infarction (4%), pulmonary insufficiency (13%), wound infection (4%), and permanent renal failure (2%). There were no significant differences in the incidence rates of these complications between immediate and late explants. No cases of limb loss occurred. Median American Society of Anesthetists (ASA) classification was 3, and there was no correlation between ASA classification and mortality rate. Average operating time was 374 minutes for immediate explantation (including the time for the failed endovascular procedure) and 185 minutes for late explantation. CONCLUSION: Immediate and late explantation are infrequent events, occurring in 3% and 4%, respectively, of attempted EVT endovascular aortic stent placements. The mortality rate was higher for both immediate (11%; P <.05) and late (7%; NS) explantation when compared with the mortality rate of all patients undergoing EVT aortic endograft placement (1.5%). There does not appear to be increased long-term morbidity among patients undergoing successful explantation. Early recognition of the need to convert to open procedure, device improvement, and increased operator experience should continue to minimize the incidence of immediate and late explantation and their associated complications
— id: 7356, year: 1999, vol: 29, page: 309, stat: Journal Article,

The significance and management of the leaking endograft
Jacobowitz GR; Rosen RJ; Riles TS
1999 Sep;12(3):199-206, Seminars in vascular surgery
Endoleak is the persistence of blood flow outside the lumen of an endograft, but within an aneurysm sac or adjacent vessel being treated by the graft. Diagnosis may be difficult, and treatment remains somewhat controversial. The purpose of this article is to discuss the clinical significance and appropriate management of endoleaks within the context of our current understanding of this phenomenon. The diagnosis of an endoleak can be made by conventional angiography, duplex ultrasound, intravascular ultrasound (IVUS), and computed tomography (CT) angiography. All of these modalities are effective, although CT angiography may be the most sensitive. Endoleaks can be categorized into 5 classes: (1) perigraft flow around the proximal end of the endograft; (2) perigraft flow around the distal end of the endograft; (3) flow through a defect in the body of the endograft; (4) flow between segments of a multicomponent endovascular graft; and (5) flow between arterial branches within an aneurysm sac. The first 4 classes have been shown to represent a clinical situation in which systemic arterial pressure is transmitted to an inadequately excluded aneurysm sac, placing the sac at risk of rupture. In contrast, branch-flow leaks do not appear to carry an increased risk of rupture, provided there is no increase in aneurysm sac diameter. However, an increase in the diameter of an aneurysm sac after endograft implantation may be a sign of occult endoleak, even if not visualized by current imaging techniques. Thus, we believe that collateral branch leaks with no associated aneurysm sac expansion may be observed with regular follow-up by CT angiography. All other endoleaks should be treated with adjunctive endovascular maneuvers or explanation of the endograft with standard open repair-in short, routine follow-up imaging on endografts to detect the presence of late endoleaks or aneurysm sac expansion
— id: 6209, year: 1999, vol: 12, page: 199, stat: Journal Article,

Transcatheter, Endovascular Repair of Abdominal Aortic Aneurysm: Feasibility, Noninvasive Diagnosis, Problems, and Follow-Up
Kronzon I I; Varkey M; Tunick PA; Riles T; Rosen R
1999 Aug;16(6):617-623, Echocardiography
Until recently, the repair of an abdominal aortic aneurysm (AAA) required major surgery. Recently, the transcatheter technique has allowed minimally invasive endovascular stenting of infrarenal AAAs. This procedure is less traumatic and is associated with a shorter hospital stay than conservative surgery. With the stent placement, the effective aortic lumen diameter decreases and the aneurysmal space is excluded from the circulation. Ultrasonographic studies have allowed imaging of the abdominal aorta, its main branches, and the endovascular stent. The aortic blood flow after the repair is ideally limited to the stent lumen. Follow-up studies have permitted reevaluation of the aorta and the stent, with special emphasis on the aortic expansion and blood flow within the excluded space. These studies have correlated well with other imaging techniques such as intravascular ultrasound, computed tomography scanning, and aortography
— id: 39446, year: 1999, vol: 16, page: 617, stat: Journal Article,

Report of a single-institution experience using the EVT endovascular abdominal aortic aneurysm graft in 25 patients
Lee AM; Rockman CB; Riles TS; Rosen RJ; Lamparello PJ; Landis R
1999 Jan;13(1):60-66, Annals of vascular surgery
The purpose of this study was to review a single-institution experience with the Endovascular Technologies [(EVT) Menlo Park, CA] transfemoral, endovascular system of abdominal aortic aneurysm repair. This study was performed at a medical center participating in the phase 1 and phase 2 evaluations of the EVT device. We reviewed the 25 cases performed at our institution. The patient population consisted of 21 males (84%) and 4 females (16%), with a mean age of 73.4 years. A total of eight tube grafts (32%) and 17 bifurcated grafts (68%) were attempted. Twenty-two of the twenty-five grafts were successfully implanted endovascularly (88%). Implantation failures were due to tortuosity or inadequate caliber of the iliac arteries, or incorrect positioning of the graft. The results show that endovascular repair of abdominal aortic aneurysms is an appropriate treatment for selected patients. Conversions to open repair have decreased as experience has grown; careful patient selection can minimize the number of unsuccessful implantations. Patient selection and accurate technique can also minimize the number of endoleaks
— id: 7383, year: 1999, vol: 13, page: 60, 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,

Regional anesthesia in carotid surgery: technique and results
Imparato AM; Rockman CB; Riles TS; Gold M; Lamparello PJ; Giangola G; Ramirez A; Landis R
Perioperative monitoring in carotid surgery: methods, limits, and results: long-term results in carotid surgery Darmstadt : Steinkopff; Springer, 1998,
— id: 3379, year: 1998, vol: , page: ?, stat: Chapter,

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,

Ultrasound evaluation of endovascular repair of abdominal aortic aneurysms
Kronzon I; Tunick PA; Rosen R; Riles T
1998 Apr;11(4):377-380, Journal of the American Society of Echocardiography
Endovascular repair of an abdominal aortic aneurysm (AAA) offers a minimally invasive alternative to an open surgical procedure in selected patients. The purpose of this study was to examine the usefulness of ultrasonography for evaluating the results of endovascular repair. METHODS: We studied 17 patients who underwent endovascular repair. In 10 patients a bifurcated prosthesis was positioned below the renal arteries with the bifurcated branches in the iliac arteries. The other 7 patients had a nonbifurcated infrarenal prosthesis. RESULTS: In each patient the AAA and the entire prosthesis, including its bifurcated branches, were visualized. The mean AAA diameter was 5.0 +/- 0.6 cm. The mean prosthesis body diameter was 2.2 +/- 0.3 cm, and the diameters of the bifurcated limbs were 1.0 to 1.2 cm. Color Doppler studies revealed blood flow limited to the prosthetic lumen and its bifurcation in 16 patients; the space between the prosthesis and the AAA wall was clotted in these patients. In 1 patient a communication was seen between the prosthesis and the AAA lumen through a dehiscence in the distal attachment. CONCLUSION: Ultrasonography is a simple, noninvasive tool for the evaluation of the results of endovascular repair of AAA and can detect complications of this procedure
— id: 7639, year: 1998, vol: 11, page: 377, stat: Journal Article,

Ultrasound evaluation after endovascular repair of abdominal aortic aneurysm
Kronzon, I; Tunick, PA; Riles, TS; Rosen, R
1998 FEB ;31(2):217A-217A, Journal of the American College of Cardiology
— id: 53549, year: 1998, vol: 31, page: 217A, 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,

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,

Comparison of lumbar and thoracic epidural narcotics for postoperative analgesia in patients undergoing abdominal aortic aneurysm repair [see comments]
Gold MS; Rockman CB; Riles TS
1997 Apr;11(2):137-140, Journal of cardiothoracic & vascular anesthesia
OBJECTIVE: To determine whether there is an advantage of thoracic over lumbar epidural narcotics for postoperative analgesia in patients undergoing abdominal aortic aneurysm repair. DESIGN: A prospective randomized study. SETTING: Subjects were inpatients at an academic medical center. PARTICIPANTS: Fifty-two patients scheduled for elective abdominal aortic aneurysm repair. INTERVENTIONS: Subjects were randomly assigned to receive lumbar or thoracic epidural narcotics. Group 1 (n = 26) had lumbar, and group 2 (n = 26) had thoracic epidural catheters placed preoperatively. All patients were monitored with pulmonary artery catheters and arterial catheters, and had general endotracheal anesthesia, in addition to epidural anesthesia with 2% lidocaine. All patients received 5 mg of epidural morphine after intubation. Pain scores were monitored hourly for 36 hours using a visual analog scale, and additional narcotics were given, depending on the level of pain. Complications caused by epidural narcotics were recorded. RESULTS: There was no difference between groups as to the daily dose of narcotics or the time between narcotic doses. Hourly pain scores showed significant differences during hours 6, 7, 8, 20, 34, and 36, with pain scores being lower in group 1. There was no difference in the rate of complications between the groups. CONCLUSION: There is no advantage of thoracic over lumbar epidural analgesia using morphine in patients undergoing abdominal aortic aneurysm repair
— id: 7155, year: 1997, vol: 11, page: 137, stat: Journal Article,

Periaortitis: Gadolinium enhanced MR imaging and response to therapy in four patients
Mitnick, H; Krinsky, G; Eberle, M; Willis, D; Riles, T
1997 SEP ;40(9):816-816, Arthritis & rheumatism
— id: 53193, year: 1997, vol: 40, page: 816, 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,

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,

Alternatives to general anesthesia for carotid endarterectomy
Riles TS; Gold MS
Surgery for cerebrovascular disease Philadelphia : W.B. Saunders, 1996,
— id: 3456, year: 1996, vol: , page: 338, stat: Chapter,

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,

Deep venous thrombosis with pulmonary embolus after selective embolization of an internal iliac artery aneurysm
Su WT; Goldman KA; Riles TS; Rosen R
1996 Jan;23(1):152-155, Journal of vascular surgery
A 69-year-old man with an isolated right internal iliac artery aneurysm measuring 5.6 cm in diameter was treated with percutaneous embolization inducing thrombosis of the aneurysm. Four months later, he was seen with thrombosis of the right common iliac vein and pulmonary embolus. He subsequently underwent ligation of the aneurysm and repair of the right common iliac artery. Computed tomographic and operative findings suggested that the iliac vein thrombosis was the result of direct compression by the aneurysm itself, as well as perianeurysmal inflammation that encased the right common iliac vein. This report summarizes this case and presents a new potential long-term complication after successful selective embolization of an internal iliac artery aneurysm
— id: 6304, year: 1996, vol: 23, page: 152, 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 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,

MR angiography in carotid stenosis. A clinical prospective
Lamparello PJ; Riles TS
1995 Aug;3(3):455-465, Magnetic resonance imaging clinics of North America
MR angiography is a major advancement in the diagnosis and treatment of patients with carotid artery stenosis. It has become the major preoperative diagnostic test for these patients. An understanding of the principles of MR imaging allows the clinician to overcome the occasional drawback of MR angiography. Use of MR imaging with duplex scanning allows the surgeon to have an extremely accurate image of the carotid artery bifurcation. Studies conclude that by using these tests as the preoperative assessment for the patient undergoing carotid artery endarterectomy, the procedure is performed with decreased complication, as the risks of conventional cerebral angiography are avoided
— id: 12746, year: 1995, vol: 3, page: 455, 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,

3. Surgical management of internal carotid artery stenosis: preventing complications
Riles TS
1994 Apr;37(2):124-127, Canadian journal of surgery = Journal canadien de chirurgie
Although the North American Symptomatic Carotid Endarterectomy Trial and the European Collaborative Trial demonstrated the efficacy of carotid surgery for the prevention of stroke in patients with symptomatic high grade stenosis, it is important to remember that within the surgical arms of these studies the perioperative stroke rate was 5.5% and 7.5% respectively. Few studies have addressed the factors responsible for perioperative stroke. In a recent report from our institution, 66 of 3062 carotid endarterectomies were complicated by perioperative stroke. Of these, 65% were due to a failure in surgical technique. The mechanisms of failure included ischemia during carotid clamping (10), postoperative thrombosis and embolism (25) and other factors (8). Strokes not related to technical failures were due to reperfusion injuries and intracranial hemorrhage (12) and other events in the postoperative period (30 days). Specific problems and possible solutions are discussed. Further improvements in the technique of carotid endarterectomy may lead to lower complication rates and a wider acceptance of surgery for the prevention of stroke
— id: 25666, year: 1994, vol: 37, page: 124, stat: Journal Article,

Immediate and long-term results of carotid endarterectomy for asymptomatic high-grade stenosis
Riles TS; Fisher FS; Lamparello PJ; Giangola G; Gibstein L; Mintzer R; Su WT
1994 Mar;8(2):144-149, Annals of vascular surgery
We examined the operative risks and long-term results of carotid endarterectomy for asymptomatic patients in terms of stroke, death, and recurrent stenosis. The results of a nonrandomized study with a follow-up of 1 to 104 months (mean 46 months) is reported. A tertiary referral center served as the setting for this report. One hundred consecutive patients with severe but asymptomatic carotid artery stenosis out of a total of 514 patients undergoing carotid endarterectomy were entered into this study. The severity of carotid disease was determined by duplex scanning and confirmed arteriographically. No patients were lost to follow-up after surgery. Eighty-nine operations (77%) were done under cervical block anesthesia and all arteries were closed with saphenous vein patches. Life-table analysis showed that the stroke-free rate at 5 years was 96.3% with an ipsilateral stroke-free rate of 98.2%. The 5-year overall survival rate was 78.2% with a stroke-free survival rate of 75%. Carotid endarterectomy can be performed safely for asymptomatic patients believed to be at risk for stroke. The potential for early death due to myocardial disease, late stroke, and recurrent stenosis do not justify advising patients against undergoing prophylactic carotid endarterectomy for asymptomatic high-grade stenosis
— id: 56579, year: 1994, vol: 8, page: 144, stat: Journal Article,

Preoperative risk factors for carotid endarterectomy
Riles TS; Imparato AM
1994 Oct;25(10):2096-2097, Stroke
— id: 25665, year: 1994, vol: 25, page: 2096, 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,

Differences in carotid shunt flow rates and implications for cerebral blood flow
Grossi EA; Giangola G; Parish MA; Baumann FG; Riles TS; Spencer FC
1993 Jan;7(1):39-43, Annals of vascular surgery
A wide variety of carotid shunts are available for use in extracranial carotid surgery. Since it is commonly assumed that when properly positioned all shunts are equal in ability to protect the brain from cerebral ischemia, the choice of shunt is usually based on handling characteristics. However, after an intraoperative stroke occurred in a patient, we compared shunt flow rates using a simple and reproducible method of measurement. A mock circuit was created using a saline-filled fluid reservoir connected to the particular shunt being tested via 1/2-inch tubing. Hydrostatic pressure across the shunt was varied by changing the height of the reservoir, and the flow was collected over 30-second intervals. Multiple flow rate measurements were performed for each shunt with pressure gradients varying from 25 to 150 cm H2O. The data show significant hemodynamic differences among commercially available carotid shunts. A pressure gradient of 75 cm H2O produced a 2.8-fold variation in the amount of fluid delivered by various shunts. Minimal cerebral blood flow requirements and the possibility of underperfusion require that the surgeon consider such data in choosing an appropriate carotid shunt
— id: 56538, year: 1993, vol: 7, page: 39, 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,

Abdominal aortic pseudoaneurysm after blunt trauma
Pisters PW; Heslin MJ; Riles TS
1993 Aug;18(2):307-309, Journal of vascular surgery
A 4-year-old male child was admitted with a large 12 x 15 cm suprarenal abdominal aortic pseudoaneurysm 7 months after an episode of blunt abdominal trauma. Aneurysmorrhaphy was performed through a left thoracoabdominal approach with Dacron patch aortoplasty. This report summarizes this case and reviews the literature on abdominal aortic pseudoaneurysms after blunt abdominal trauma
— id: 13100, year: 1993, vol: 18, page: 307, stat: Journal Article,

Reconstruction of the ligated external carotid artery for embolization of cervicofacial arteriovenous malformations
Riles TS; Berenstein A; Fisher FS; Persky MS; Madrid M
1993 Mar;17(3):491-498, Journal of vascular surgery
PURPOSE: Until recently, the accepted management of life-threatening complications of unresectable cervicofacial arteriovenous malformations (AVMs) has been ligation of the major feeding vessels, usually the branches or the main trunk of the external carotid artery. Rapid enlargement of collateral vessels around the ligature is usually associated with an early return of symptoms. Percutaneous transcatheter embolization of the nidus of the arteriovenous malformation is now the preferred treatment for symptomatic AVMs that cannot be excised. Previous ligation of the main feeding vessels prevents catheter access and embolization therapy of the lesion. The purpose of this report is to describe our experience with the treatment of patients with symptomatic unresectable cervicofacial AVMs and previous external carotid artery ligation. METHODS: Six patients with symptoms from cervicofacial arteriovenous malformations required surgical reconstruction of their previously ligated external carotid artery with the anticipation of catheter embolization therapy to the branch vessels feeding the malformation. Saphenous vein was used in five reconstructions; a polytetrafluoroethylene graft was used in one. RESULTS: After successful arterial reconstruction, massive swelling of the tongue and perioral tissue developed in two patients, which necessitated tracheostomy in one patient; and embolization therapy before extubation could be safely performed in the other patient. In all, four patients underwent successful embolization therapy. One refused subsequent treatment. In one patient with severe epistaxis, external carotid artery revascularization led to the healing of the nasal ulcers without need for embolization therapy. CONCLUSIONS: For patients with previous ligations of the external carotid artery and symptomatic AVMs, revascularization of the external carotid artery is an important step in treatment. The surgery must be carefully coordinated with the interventional radiologist for possible emergency postoperative embolization therapy. External carotid artery ligation only complicates the treatment of patients with cervicofacial AVMs, and should no longer be used in the treatment of these individuals
— id: 13232, year: 1993, vol: 17, page: 491, stat: Journal Article,

Plasma catecholamine concentrations during abdominal aortic aneurysm surgery: the link to perioperative myocardial ischemia
Riles TS; Fisher FS; Schaefer S; Pasternack PF; Baumann FG
1993 May;7(3):213-219, Annals of vascular surgery
Cardiac disease continues to be the leading cause of morbidity and mortality following peripheral vascular surgical procedures. Although the mechanism of sudden myocardial infarction remains elusive, many possibilities exist. The role of catecholamines is intriguing in view of the evidence that beta-adrenergic blockers reduce cardiac morbidity and mortality in vascular surgical patients. To ascertain whether the plasma catecholamine levels rise significantly during abdominal aortic aneurysm repair, serial determinations of plasma epinephrine and norepinephrine levels were performed in 18 patients. Epinephrine levels rose significantly from preoperative baseline values both during the operation and postoperatively, and norepinephrine levels rose significantly at 24 hours postoperatively. Although only one patient studied developed a myocardial infarction, the finding that patients undergoing aortic surgery uniformly experienced abnormally high serum catecholamine levels supports other evidence that perioperative myocardial ischemic events have a hormonal component
— id: 13183, year: 1993, vol: 7, page: 213, stat: Journal Article,

INTERNAL CAROTID-ARTERY DISSECTION CAUSED BY EXERCISE - 3 CASE-REPORTS
SILLER, KA; RILES, TS; GOPINATHAN, G
1993 AUG ;34(2):318-319, Annals of neurology
— id: 63775, year: 1993, vol: 34, page: 318, stat: Journal Article,

The influence of human immunodeficiency virus infection and intravenous drug abuse on complications of hemodialysis access surgery
Brock JS; Sussman M; Wamsley M; Mintzer R; Baumann FG; Riles TS
1992 Dec;16(6):904-910, Journal of vascular surgery
To examine the influence of human immunodeficiency virus (HIV) infection on complications in dialysis access surgery, a review was performed on patients undergoing hemodialysis at two major metropolitan medical centers over a 30-month period. One hundred eight patients underwent a total of 169 graft procedures; mean follow-up was 14 1/2 months. There were 18 (17%) patients who were HIV-positive who had no symptoms, 11 (10%) patients with acquired immunodeficiency syndrome (AIDS), and 79 (73%) patients who were HIV-negative. Twenty-three percent (25/108) of patients had a history of intravenous drug abuse (IVDA), most of whom also had either AIDS or asymptomatic HIV infection. Dialysis procedures included 44 autogenous reconstructions (26%), 117 polytetrafluoroethylene (PTFE) grafts (69%), and 8 (5%) procedures of unknown type. Arteriovenous fistula or graft thrombosis was a frequent complication. The overall 12-month graft patency rate was 41%, and patients with HIV infection or a history of IVDA did not have a significantly increased risk of thrombosis. Multivariate analysis showed that the use of PTFE as opposed to autogenous reconstruction was the only significant risk factor found for occlusion within the first 12 months after operation (p < 0.01). Twenty-five graft infections occurred, all in PTFE grafts. The PTFE graft infection rate was 43% in patients with AIDS, 36% in patients who were HIV-positive and who had no symptoms, and 15% in patients who were HIV-negative (p < 0.05). Patients with a history of IVDA had a 41% PTFE graft infection rate versus a 13% infection rate in patients who did not have a history of IVDA (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
— id: 13351, year: 1992, vol: 16, page: 904, stat: Journal Article,

Silent myocardial ischemia monitoring predicts late as well as perioperative cardiac events in patients undergoing vascular surgery
Pasternack PF; Grossi EA; Baumann FG; Riles TS; Lamparello PJ; Giangola G; Yu AY; Mintzer R; Imparato AM
1992 Aug;16(2):171-179, Journal of vascular surgery
In a previous study we have shown that perioperative monitoring for silent myocardial ischemia can noninvasively identify those patients undergoing peripheral vascular surgery who are at significantly increased risk for perioperative myocardial infarction. In the present study a group of 385 patients undergoing peripheral vascular surgery was studied long-term as well as short-term to determine whether perioperative monitoring for silent ischemia can identify those patients who are at significantly increased risk of late cardiac death or late cardiac complications as well as those patients at increased risk of perioperative myocardial infarction. All patients were monitored before, during, and after operation and were divided into two groups on the basis of results of monitoring: patients whose total duration of silent ischemia as a percentage of the total duration of perioperative monitoring was 1% or greater (group I, n = 120) and those for whom this value was less than 1% (group II, n = 265). Among patients in group I 13.3% (16 of 120) suffered a perioperative myocardial infarction in contrast to only 1.1% (3 of 265) patients in group II (p less than 0.001). Multivariate logistic regression analysis of preoperative and perioperative characteristics showed that the presence of a total perioperative percent time ischemic 1% or greater and age were the only significant predictors of perioperative myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)
— id: 13494, year: 1992, vol: 16, page: 171, stat: Journal Article,

Comparison of magnetic resonance angiography, conventional angiography, and duplex scanning
Riles TS; Eidelman EM; Litt AW; Pinto RS; Oldford F; Schwartzenberg GW
1992 Mar;23(3):341-346, Stroke
BACKGROUND AND PURPOSE: To determine the accuracy of magnetic resonance angiography in assessing patients with cerebrovascular disease, we performed a study comparing the results of conventional cerebral angiography, duplex scanning, and magnetic resonance angiography. METHODS: From 42 patients, a total of 25 carotid arteries were evaluated by all three techniques. The studies were independently read and sorted into five categories according to the degree of stenosis: 0-15%, normal; 16-49%, mild; 50-79%, moderate; 80-99%, severe; and totally occluded. RESULTS: Magnetic resonance angiography correlated exactly with conventional angiography in 39 arteries (52%); duplex scanning correlated with conventional angiography in 49 cases (65%). Compared with conventional angiography, both magnetic resonance angiography and duplex scanning tended to overread the degree of stenosis. The most critical errors associated with magnetic resonance angiography were three readings of total occlusion in vessels found to be patent on conventional angiograms. CONCLUSIONS: Although magnetic resonance angiography offers great hope of providing high-quality imaging of the carotid artery with no risk and at less cost, data from this study suggest that misreading the degree of stenosis, or misinterpreting a stenosis for an occlusion, could lead to errors in clinical decisions. Guidelines for use of magnetic resonance angiography in a clinical setting are offered
— id: 13678, year: 1992, vol: 23, page: 341, stat: Journal Article,

Celiomesenteric anomaly and aneurysm: clinical and etiologic features
Bailey RW; Riles TS; Rosen RJ; Sullivan LP
1991 Aug;14(2):229-234, Journal of vascular surgery
The development of aneurysmal disease involving the rarely encountered celiomesenteric anomaly is extremely unusual. Aneurysmal disease of the celiac or superior mesenteric arteries is itself an extremely uncommon finding, accounting for less than 10% of all visceral artery aneurysms. The existence of aneurysmal disease involving a celiomesenteric anomaly has been alluded to only briefly in two previous clinical reports. We review the case of a young woman with aneurysmal disease involving a common celiomesenteric trunk. The patient underwent excision of the aneurysm with successful vascular reconstruction. Although extremely unusual, the development of this extremely rare lesion can be predicted on the basis of specific etiologic theories. Variations in the patterns of embryologic formation of the visceral arteries account for the development of celiomesenteric anomalies, whereas atherosclerosis, medial degeneration, and infection lead to the development of most visceral aneurysms. Surgical treatment of celiac or mesenteric aneurysms is almost always indicated. Awareness of potential vascular anomalies and patterns of collateral circulation are necessary for appropriate surgical intervention
— id: 13956, year: 1991, vol: 14, page: 229, stat: Journal Article,

Redo endarterectomy for recurrent carotid artery stenosis
Gagne PJ; Riles TS; Imparato AM; Lamparello PJ; Giangola G; Landis RM
1991 Apr;5(2):135-140, European journal of vascular surgery
From a registry of 2406 carotid endarterectomies performed on 1818 patients over a 19-year period, 29 patients (1.6%) underwent reoperations for recurrent stenosis. Reoperations were performed for symptomatic stenosis for 23 and asymptomatic greater than 80% stenosis for six patients. Compared to the entire series, there was no difference in the incidence of restenosis for men and women. The pathologic findings were myointimal hyperplasia in 27%, atherosclerosis in 53%, thrombus with vessel dilatation in 17% and extrinsic scar in 3%. Redo endarterectomy with patch angioplasty was used for reconstruction in 27 patients and patch angioplasty alone in two. There were no operative deaths or strokes. Late follow-up (mean 50 months) revealed only one stroke and six other deaths. Although 21 (75%) were alive and stroke-free, follow-up studies suggest a high incidence (21%) of tertiary lesions among patients who have undergone redo endarterectomy for recurrent stenosis
— id: 14073, year: 1991, vol: 5, page: 135, stat: Journal Article,

Vertebral artery angioplasty in patients younger than 55 years: long-term follow-up
Giangola G; Imparato AM; Riles TS; Lamparello PJ
1991 Mar;5(2):121-124, Annals of vascular surgery
Since 1964 we have performed 136 vertebral artery reconstructions representing 4% of all operations on extracranial cerebral arteries by our staff. Fifteen of our patients were under age 55 years and had symptoms of dizziness, bilateral visual disturbances, ataxia, presyncopal episodes, and occasionally localized extremity weakness. Dizziness, often severe and incapacitating, has been the most common and consistent symptom. The diagnosis of vertebral artery lesions was made using aortic arch four-vessel cerebral arteriography. Operations were performed for severely obstructing bilateral vertebral artery lesions and included only unilateral vertebral vein patch angioplasty with or without suture plication of the artery in 13 patients. Unilateral carotid vertebral bypass was performed in one patient and unilateral vertebral reimplantation to the carotid in another. Follow-up averaged 8.9 years, ranging from ten months to 20 years. Eleven of 15 patients have remained asymptomatic and without strokes. Recurrent dizziness was present in three, two of whom had vertebral arteriography showing patent vertebral reconstructions. Another had a stroke related to the anterior circulation in follow-up at nine years. Atherosclerotic obstruction of vertebral arteries does occur in patients in the preatherosclerotic age group. Even atypical symptoms suggestive of vertebrobasilar insufficiency may be associated with isolated correctable bilateral flow-impeding vertebral lesions. These symptoms warrant evaluation with cardiac neurological and cerebrovascular studies. Vertebral angioplasty relieves symptoms and the incidence of stroke during follow-up is low
— id: 14106, year: 1991, vol: 5, page: 121, stat: Journal Article,

Diagnosis of carotid artery stenosis: comparison of 2DFT time-of-flight MR angiography with contrast angiography in 50 patients
Litt AW; Eidelman EM; Pinto RS; Riles TS; McLachlan SJ; Schwartzenberg S; Weinreb JC; Kricheff II
1991 Jan-Feb;12(1):149-154, AJNR. American journal of neuroradiology
Fifty patients underwent 2DFT time-of-flight MR angiography and intraarterial contrast angiography for evaluation of possible carotid atherosclerotic disease. The MR angiography technique employed contiguous axial flow-sensitive (short TR/TE) slices that were reformatted and postprocessed by using a maximum-intensity projection algorithm to provide 16 angiographic views of the carotid arteries. Both studies were independently reviewed by two observers in a blinded manner. Carotid arteries were categorized as normal, mildly stenotic, moderately stenotic, severely stenotic, or occluded. For the 94 carotid arteries available for review, one observer reported a 70% agreement between the two techniques and the second observer reported a 56% agreement (p = .0001). The best correlation was in the severely stenotic category and the worst was in the occluded category. Agreement between observers was 67% for MR angiography and 72% for contrast angiography, which was similar to that between the two techniques. Although not all carotid atherosclerotic disease was visualized equally well, 2DFT time-of-flight MR angiography had a good overall correlation with the 'gold standard' of intraarterial contrast angiography, supporting its use as a screening technique. While further improvements are needed, use of MR angiography as the primary diagnostic tool for many patients with suspected carotid stenosis should continue to increase
— id: 14187, year: 1991, vol: 12, page: 149, stat: Journal Article,

DIAGNOSIS OF CAROTID-ARTERY STENOSIS - COMPARISON OF 2DFT TIME- OF-FLIGHT MR-ANGIOGRAPHY WITH CONTRAST ANGIOGRAPHY IN 50 PATIENTS
Litt, AW; Eidelman, EM; Pinto, RS; Riles, TS; Mclachlan, SJ; Schwartzenberg, ST; Weinreb, JC; Kricheff, II
1991 Mar;156(3):611-616, American journal of roentgenology
Fifty patients underwent 2DFT time-of-flight MR angiography and intraarterial contrast angiography for evaluation of possible carotid atherosclerotic disease. The MR angiography technique employed contiguous axial flow-sensitive (short TR/TE) slices that were reformatted and postprocessed by using a maximum- intensity projection algorithm to provide 16 angiographic views of the carotid arteries. Both studies were independently reviewed by two observers in a blinded manner. Carotid arteries were categorized as normal, mildly stenotic, moderately stenotic, severely stenotic, or occluded. For the 94 carotid arteries available for review, one observer reported a 70% agreement between the two techniques and the second observer reported a 56% agreement (p = .0001). The best correlation was in the severely stenotic category and the worst was in the occluded category. Agreement between observers was 67% for MR angiography and 72% for contrast angiography, which was similar to that between the two techniques. Although not all carotid atherosclerotic disease was visualized equally well, 2DFT time-of-flight MR angiography had a good overall correlation with the 'gold standard' of intraarterial contrast angiography, supporting its use as a screening technique. While further improvements are needed, use of MR angiography as the primary diagnostic tool for many patients with suspected carotid stenosis should continue to increase
— id: 32191, year: 1991, vol: 156, page: 611, stat: Journal Article,

IS MAGNETIC-RESONANCE ANGIOGRAPHY SUFFICIENTLY ACCURATE FOR SELECTING PATIENTS FOR CAROTID ENDARTERECTOMY
RILES, TS; EIDELMAN, E; LITT, A; PINTO, R; OLDFORD, F
1991 JAN ;22(1):147-147, Stroke
— id: 51748, year: 1991, vol: 22, page: 147, stat: Journal Article,

Angiosarcoma at the site of a Dacron vascular prosthesis: a case report and literature review
Weiss WM; Riles TS; Gouge TH; Mizrachi HH
1991 Jul;14(1):87-91, Journal of vascular surgery
Four of 32 reported sarcomas related to the aorta have arisen around previously placed aortic vascular prostheses suggesting that the graft may have been an etiologic factor. Our recent experience with such an angiosarcoma arising around a Dacron aortic graft prompted a review of the lesion to identify risk factors, diagnostic approaches, and treatment options. The diagnosis of these sarcomas is seldom made before operation. Animal studies have implicated plastic polymers including Dacron as carcinogenic materials capable of inducing sarcoma in 7% to 50% of exposures. Because of the rarity of these tumors and the thousands of vascular implants used over the past 30 years, it is unlikely that this degree of risk can be extrapolated to humans. However, a tumor should be included in the differential diagnosis of any mass or thromboembolic event associated with a vascular prosthesis
— id: 13985, year: 1991, vol: 14, page: 87, stat: Journal Article,

Carotidynia managed by surgical denervation of the carotid bulb
de Vries AC; Geuder J; Riles TS
1990 Jun;4(3):325-326, European journal of vascular surgery
Carotidynia is a syndrome of pain in the neck and face accompanied by local tenderness of the carotid artery. The symptoms are often misdiagnosed due to similarities with more common syndromes involving the cervical region. Spontaneous remission is common; more severe cases generally respond to anti-inflammatory medication or prophylactic drugs used for migraine. A case of severe carotidynia, unassociated with migraine is reported. Failure to respond to medical therapy led to surgical denervation of the carotid bulb. The immediate relief of symptoms following surgery confirms earlier observations regarding the mechanism of the symptoms. In severe cases of carotidynia, surgical denervation of the carotid artery may be indicated if medical therapy has failed
— id: 25667, year: 1990, vol: 4, page: 325, stat: Journal Article,

Should proximal saphenous vein be used for carotid patch angioplasty: a clinical study of the need for vein in subsequent operations
de Vries AC; Riles TS; Lamparello PJ; Giangola G; Landis R
1990 Jun;4(3):301-304, European journal of vascular surgery
Reluctance to use saphenous vein (SV) for patch closure of the carotid arteriotomy is due in part to the concern of vascular surgeons that the SV should be preserved for possible future coronary or lower extremity reconstruction. Even among those who favour vein patch closure of the arteriotomy for improved immediate and late results, an effort has been made to use the ankle portion of the SV, preserving the upper, larger segment for later surgery. Recent reports of rupture of the patches formed from ankle SV and a study showing a decrease in strength of the ankle segment of vein, raised the question of the importance of trying to preserve the proximal SV and the impact of use of this segment in those patients requiring secondary vascular procedures. We reviewed 134 consecutive carotid patients from 1981 who had proximal SV harvested for patch angioplasty. Of those 122 were available (mean 44.9 months). Thirteen had secondary vascular procedures. Adequate saphenous vein was available in twelve. We conclude from this study that (1) less than 15% of patients undergoing carotid surgery will require a secondary vascular surgery within 5 years and (2) harvesting SV from the thigh rarely compromises future revascularisation
— id: 25668, year: 1990, vol: 4, page: 301, stat: Journal Article,

COMPARISON OF HETASTARCH TO ALBUMIN FOR PERIOPERATIVE BLEEDING IN PATIENTS UNDERGOING ABDOMINAL AORTIC-ANEURYSM SURGERY - A PROSPECTIVE, RANDOMIZED STUDY
Gold, MS; Russo, J; Tissot, M; Weinhouse, G; Riles, T
1990 Apr;211(4):482-485, Annals of surgery
— id: 31884, year: 1990, vol: 211, page: 482, stat: Journal Article,

[Need for surgery in asymptomatic carotid stenosis]
Riles TS; Lamparello PJ; Giangola G
1990 ;107(1):563-569, Langenbecks archiv fur chirurgie. Suppl. II. Verhandlungen der Deutschen Gesellschaft fur Chirurgie
1. Asymptomatic carotid stenosis up to 80% do not require prophylactic surgery, but should be followed non-infasively. 2. Stenoses of 80-99% are associated with a significant incidence of stroke which is estimated to be 4-10%/year. 3. Occlusion is considered to be an unfavorable end point, since the risk of stroke remains higher than those with patent arteries. 4. The role of carotid endarterectomy is related to the stroke morbidity and mortality of the procedure. To show significant benefits of surgical therapy during the first two years, it is necessary to have a stroke/death rate of less than 3%
— id: 25670, year: 1990, vol: 107, page: 563, stat: Journal Article,

Rupture of the vein patch: a rare complication of carotid endarterectomy
Riles TS; Lamparello PJ; Giangola G; Imparato AM
1990 Jan;107(1):10-12, Surgery
Vein patch closure after carotid endarterectomy has been used to reduce the incidence of residual and recurrent stenosis at the carotid bifurcation. A rare but potential serious complication is rupture of the vein patch during the early postoperative period. In our experience of 2359 carotid operations performed from 1962 through 1986, saphenous vein was used for closure in 2275 (96.5%) operations. In three patients out of 75 in whom the vein patch had been harvested from the ankle, rupture of the patch occurred 2 to 5 days after uneventful carotid surgery. At emergency reoperation, the central portion of the vein was necrotic, with no evidence of infection. In each case the carotid artery was closed again with fresh thigh saphenous vein, and recovery was uneventful. The use of ankle vein was discontinued in December 1983 in favor of groin saphenous vein, and similar complications have not occurred in more than 600 carotid endarterectomies performed since. Early noninfectious ruptures of the saphenous vein patches have been mentioned in other reported series of carotid operations and have often been related to the use of ankle vein, but they remain unexplained
— id: 25669, year: 1990, vol: 107, page: 10, stat: Journal Article,

Is duplex scanning sufficient evaluation before carotid endarterectomy?
Geuder JW; Lamparello PJ; Riles TS; Giangola G; Imparato AM
1989 Feb;9(2):193-201, Journal of vascular surgery
Recent reports have suggested that cerebral angiography may not be necessary before carotid endarterectomy is performed in selected patients. To determine if arteriography provides additional information that might influence the decision to operate or the conduct of the operation, a retrospective review was performed of 100 consecutive patients undergoing cerebral angiography and carotid duplex scanning. Eighty of the 100 patients subsequently underwent carotid endarterectomy for neurologic symptoms or asymptomatic stenosis greater than 80%. Among the 20 patients not operated on, three would have undergone unnecessary surgery for mistaken diagnoses had the arteriogram not been obtained. Two other patients in this group of 20 would have had carotid endarterectomy for asymptomatic stenosis in the presence of an equally stenotic tandem lesion. Among the 80 patients operated on, an additional three had the operative procedure altered because arteriographic studies revealed pathologic findings outside the area of duplex scan examination. Thus the use of arteriography altered the management of eight (8%) patients in this group of 100
— id: 10735, year: 1989, vol: 9, page: 193, stat: Journal Article,

Beta blockade to decrease silent myocardial ischemia during peripheral vascular surgery
Pasternack PF; Grossi EA; Baumann FG; Riles TS; Lamparello PJ; Giangola G; Primis LK; Mintzer R; Imparato AM
1989 Aug;158(2):113-116, American journal of surgery
The incidence and duration of intraoperative silent myocardial ischemia have been shown to be significantly correlated with the incidence of perioperative myocardial infarction in patients undergoing peripheral vascular surgery. To assess the effectiveness of intraoperative beta blockade in limiting such silent myocardial ischemia, a group of 48 patients was treated with oral metoprolol immediately prior to peripheral vascular surgery. The total duration of intraoperative silent myocardial ischemia, the percentage of intraoperative time silent myocardial ischemia was present, the number of intraoperative episodes of silent myocardial ischemia, and the intraoperative heart rate in the treated patients were compared with those in 152 similar but untreated peripheral vascular surgery patients. The patients treated with oral metoprolol had significantly less intraoperative silent ischemia with respect to relative duration and frequency of episodes, a significantly lower intraoperative heart rate, and less intraoperative silent myocardial ischemia in terms of total absolute duration. These results suggest that beta-adrenergic activation may play a major role in the pathogenesis of silent myocardial ischemia during peripheral vascular surgery
— id: 10539, year: 1989, vol: 158, page: 113, stat: Journal Article,

The value of silent myocardial ischemia monitoring in the prediction of perioperative myocardial infarction in patients undergoing peripheral vascular surgery
Pasternack PF; Grossi EA; Baumann FG; Riles TS; Lamparello PJ; Giangola G; Primis LK; Mintzer R; Imparato AM
1989 Dec;10(6):617-625, Journal of vascular surgery
Real-time electrocardiographic monitoring for silent myocardial ischemia was performed on 200 patients undergoing peripheral vascular surgery to try to better define those at high risk of perioperative myocardial infarction. The patients were divided into those undergoing abdominal aortic aneurysm or lower extremity revascularization procedures (group I, n = 120) and those undergoing carotid artery endarterectomy (group II, n = 80). Silent ischemia was detected during the preoperative, intraoperative, or post-operative periods in 60.8% of group I and 67.5% of group II patients. Six group I and three group II patients suffered an acute perioperative myocardial infarction with two cardiac deaths. In both groups I and II a variety of parameters based on monitoring of silent myocardial ischemia were compared between the subgroups of patients who had myocardial infarction and those who did not. The results show that in both groups there was a significantly (p less than or equal to 0.05) greater total duration of perioperative ischemic time, total number of perioperative ischemic episodes, and total duration of perioperative ischemic time as a percent of total monitoring time in patients who suffered a perioperative myocardial infarction compared to those who did not. Multivariate logistic regression analysis of preoperative characteristics in all 200 patients showed the occurrence of preoperative silent myocardial ischemia and angina at rest to be the only significant predictors of perioperative myocardial infarction. Thus perioperative monitoring for silent myocardial ischemia might noninvasively identify those patients undergoing peripheral vascular surgery who are at increased risk for perioperative myocardial infarction, permitting implementation of timely preventive measures in selected patients
— id: 10416, year: 1989, vol: 10, page: 617, stat: Journal Article,

Suggested standards for reports dealing with cerebrovascular disease. Subcommittee on Reporting Standards for Cerebrovascular Disease, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery
Baker JD; Rutherford RB; Bernstein EF; Courbier R; Ernst CB; Kempczinski RF; Riles TS; Zarins CK
1988 Dec;8(6):721-729, Journal of vascular surgery
The evaluation of clinical reports on vascular disease is often made difficult by variations in descriptive terms, clinical classification, and outcome criteria. In 1983 the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery created the Ad Hoc Committee on Reporting Standards to address these problems and recommend solutions. Some general problems were addressed in the initial report dealing with lower extremity ischemia. This article concerns clinical standards for reports dealing with cerebrovascular disease, suggests a scheme for clinical classification, and recommends standardized reporting practices for grading risk factors, angiographic and other diagnostic findings, and the results and complications of therapeutic intervention
— id: 25671, year: 1988, vol: 8, page: 721, stat: Journal Article,

Revascularization of the external carotid artery
Friedman SG; Lamparello PJ; Riles TS; Imparato AM
1988 Apr;123(4):497-499, Archives of Surgery (Chicago)
Numerous reports describe the relative effectiveness of external carotid artery (ECA) revascularization in patients with ipsilateral internal carotid artery occlusion. Most, however, suffer from small numbers of patients or lack of detailed follow-up data. In addition, controversy persists regarding the safety with which this procedure can be performed. Twenty-two patients underwent a total of 27 ECA revascularizations. There were no perioperative strokes or deaths. During a mean follow-up period of 46 months, no strokes occurred and only two patients suffered transient ischemic attacks. Revascularization of the ECA is an effective means of treating the patient with ipsilateral internal carotid artery occlusion and may be performed with minimal morbidity and mortality
— id: 25672, year: 1988, vol: 123, page: 497, stat: Journal Article,

Intracranial hemorrhage after carotid endarterectomy
Pomposelli FB; Lamparello PJ; Riles TS; Craighead CC; Giangola G; Imparato AM
1988 Feb;7(2):248-255, Journal of vascular surgery
Among 1500 carotid endarterectomies performed between 1975 and 1984, 11 ipsilateral intracranial hemorrhages (IH) occurred between the first and tenth postoperative days for an incidence of 0.7%. The mortality rate among these patients was 36%. The only recognizable predisposing factor was relief of high-grade carotid stenosis (greater than 90%) whereas other factors such as age (58 to 81 years), preoperative hypertension (systolic blood pressure 120 to 160 mm Hg), preoperative head CT scans showing recent infarction (only one in five positive), and preoperative cerebral infarction (only 1 of 11 patients) did not play a role. All patients had normal coagulation studies. No patient required a shunt because all tolerated cross-clamping of the carotid artery. Postoperative systolic blood pressures were 200 to 240 mm Hg in 6 of 11 patients. The time of occurrence of IH extended from the immediate postoperative period to the tenth postoperative day (mean interval 3.3 days). Treatment consisted of craniotomy in five patients; four survived and one recovered completely. Of the six patients treated nonoperatively, three survived and two completely recovered. IH shares equal incidence with recurrent thrombosis, cross-clamping ischemia, and embolization as a cause of perioperative stroke. Although all except IH can be prevented by current practice, the means of preventing IH are not apparent; however, careful monitoring of blood pressure to prevent uncontrolled hypertension deserves consideration
— id: 11189, year: 1988, vol: 7, page: 248, stat: Journal Article,

Surgical management of the patient with bilateral internal carotid artery occlusion
Friedman SG; Lamparello PJ; Riles TS; Imparato AM; Sakwa MP
1987 May;5(5):715-718, Journal of vascular surgery
The patient with bilateral internal carotid artery occlusion is at high risk for development of stroke. Medical management and extracranial-intracranial bypass do not appear to offer these patients any protection from symptoms of cerebrovascular insufficiency. Our initial treatment in 11 of 12 patients who had this pattern of extracranial arterial occlusion has been external carotid artery revascularization. Nineteen procedures were performed for symptomatic lesions in all cases except one. There were no perioperative strokes or deaths. During a mean follow-up of 44.7 months, no new strokes occurred. Among 10 patients undergoing external carotid artery revascularization alone, only one transient ischemic attack occurred in follow-up. Seven of the eight surviving patients are presently asymptomatic. External carotid artery revascularization may be an effective and durable treatment for the patient with bilateral internal carotid artery occlusion
— id: 25674, year: 1987, vol: 5, page: 715, stat: Journal Article,

Surgical therapy for the patient with internal carotid artery occlusion and contralateral stenosis
Friedman SG; Riles TS; Lamparello PJ; Imparato AM; Sakwa MP
1987 Jun;5(6):856-861, Journal of vascular surgery
With demonstration of the failure of extracranial-intracranial (EC-IC) bypass to reduce the incidence of stroke in patients with internal carotid artery (ICA) occlusion, controversy continues regarding the best method of stroke prevention in these high-risk persons. One approach, endarterectomy of stenotic lesions of the contralateral carotid bifurcation, has been used for 145 patients with ICA occlusion during the past 25 years. Presenting symptoms included focal transient ischemic attacks (TIAs) in 62 patients, stroke (CVA) in 57, and nonfocal TIAs in 16. Ten patients were asymptomatic. Nine patients (6.2%) sustained perioperative strokes, only three of which were ipsilateral to the endarterectomy. There were three perioperative deaths (2.1%). During the follow-up period (mean 4 years) there were 13 new strokes (9.2%), four of which were fatal. These late results compare favorably with patients from the cooperative study of EC-IC bypass with occlusion of one ICA, whether they received surgical treatment or were managed nonoperatively. With the exception of select situations where an occluded ICA may be reopened, we conclude that the best current therapy for these patients is close observation of the nonoccluded ICA and endarterectomy once a stenotic lesion is encountered
— id: 25673, year: 1987, vol: 5, page: 856, stat: Journal Article,

The hemodynamics of beta-blockade in patients undergoing abdominal aortic aneurysm repair
Pasternack PF; Imparato AM; Baumann FG; Laub G; Riles TS; Lamparello PJ; Grossi EA; Berguson P; Becker G; Bear G
1987 Sep;76(3 Pt 2):III1-III7, Circulation
To assess the intraoperative and postoperative hemodynamic effects of beta-blockade and its benefits in limiting myocardial ischemia and infarction, a group of 32 patients scheduled for abdominal aortic aneurysm (AAA) surgery (group 1) was treated with oral metoprolol immediately before surgery and with intravenous metoprolol during the postoperative period. Mean age was 71 years, and mean ejection fraction was 56% (range 36% to 83%). Eight patients had a preoperative history of angina, 13 had a history of myocardial infarction, and five had electrocardiographic evidence of prior myocardial infarction. A group of 51 closely matched patients with AAA who did not receive metoprolol served as controls (group 2). In group 1, overall hemodynamic tolerance of metoprolol intraoperatively and postoperatively was good, and there was no incidence of congestive heart failure, hypotension, or asthma. Furthermore, in group 1 significant reduction of systolic blood pressure and heart rate was consistently noted at frequent intraoperative intervals and for 48 hr after surgery, with only a transient reduction of cardiac index. In group 1, only one patient (3%) suffered an acute myocardial infarction. In contrast, nine group 2 patients (18%; p less than .05) suffered perioperative myocardial infarction. Furthermore, only four (12.5%) group 1 patients developed significant cardiac arrhythmias as opposed to 29 group 2 patients (56.9%; p less than .001). These data demonstrate that beta-blockade with metoprolol is effective in controlling systolic blood pressure and heart rate both intraoperatively and postoperatively in patients undergoing repair of AAA and can significantly reduce the incidence of perioperative myocardial infarction and arrhythmias
— id: 18209, year: 1987, vol: 76, page: III1, stat: Journal Article,

PERCUTANEOUS LUMBAR SYMPATHECTOMY
ROSEN, RJ; SPIES, JB; MINTZER, R; RILES, TS; IMPARATO, AM
1987 SEP ;4(3):189-194, Seminars in interventional radiology
— id: 41676, year: 1987, vol: 4, page: 189, stat: Journal Article,

Glossopharyngeal nerve injury complicating carotid endarterectomy
Rosenbloom M; Friedman SG; Lamparello PJ; Riles TS; Imparato AM
1987 Mar;5(3):469-471, Journal of vascular surgery
Injury can occur to several of the cranial nerves during carotid endarterectomy. Among these, glossopharyngeal nerve injury is an uncommon complication because it is remote from the field of dissection in most carotid procedures. From more than 2000 carotid operations four cases of symptomatic ninth cranial nerve injury were identified. Analysis revealed that dissection cephalad to the level of the hypoglossal nerve was a common feature of each and severe functional disability can result from glossopharyngeal nerve paresis. When mobilization of this nerve and division of the posterior belly of the digastric muscle and styloid process become necessary for additional exposure, the risk of glossopharyngeal nerve injury increases. Specific recommendations are made regarding management and maneuvers to help reduce the incidence of this uncommon, yet potentially serious, complication
— id: 25675, year: 1987, vol: 5, page: 469, stat: Journal Article,

THE HEMODYNAMICS OF BETA BLOCKADE IN PATIENTS UNDERGOING ABDOMINAL AORTIC-ANEURYSM REPAIR
PASTERNACK, PF; IMPARATO, AM; BAUMANN, FG; LAUB, G; RILES, TS; LAMPARELLO, PJ; GROSSI, EA; BERGUSON, P; BECKER, G; BEAR, G
1986 OCT ;74(4 Pt. 2):8-8, Circulation
— id: 33454, year: 1986, vol: 74, page: 8, stat: Journal Article,

Contralateral neurologic symptoms after carotid surgery: a nine-year follow-up
Sobel M; Imparato AM; Riles TS; Mintzer R
1986 Apr;3(4):623-628, Journal of vascular surgery
A study was undertaken to observe the long-term clinical behavior of the contralateral, asymptomatic carotid artery of patients after unilateral carotid endarterectomy (UCE). A consecutive series of 182 patients undergoing UCE were followed up for 1 to 9 years (mean 4.2 years). The operated artery was symptomatic in 169 cases (92.8%) whereas in 13 (7.2%) it was asymptomatic but stenotic. Follow-up included an accounting of all hemispheric or focal neurologic events in the territory of the nonoperated artery, as well as associated cardiovascular risk factors. A total of 11 patients (6%) suffered stroke (CVA) and six (3.3%) had transient ischemic attacks (TIAs) in the distribution of the nonoperated carotid artery. By life-table analysis, major neurologic symptoms developed in 11.6% of patients within 5 years. Hypertension was an important prognostic factor: significantly more hypertensive patients had late contralateral neurologic symptoms (p less than 0.05, chi square). The cumulative incidence of CVA and TIA in these patients was 17.3% by life-table analysis at 5 years vs. 9.1% for normotensive patients. Since only a small proportion of the patients studied had a high-grade stenosis of the nonoperated artery, no conclusions could be made regarding its prognostic importance. The relevant published studies are discussed and compared with this report. Guidelines for the management and follow-up of the patient after UCE are discussed
— id: 25676, year: 1986, vol: 3, page: 623, stat: Journal Article,

A comparison of methods of valve destruction with respect to acute thrombogenicity and flow rate of in situ femoral artery vein bypass grafts
Giangola G; Baumann FG; Riles TS
1985 Jan-Feb;42(1):13-17, Current surgery
— id: 25680, year: 1985, vol: 42, page: 13, stat: Journal Article,

Late axillary artery thrombosis in patients with occluded axillary-femoral bypass grafts
Hartman AR; Fried KS; Khalil I; Riles TS
1985 Mar;2(2):285-287, Journal of vascular surgery
The axillary-femoral bypass graft is an alternative to direct anatomic procedures for patients with aortoiliac occlusive disease. Touted for its low morbidity and mortality rates, with corresponding improved patency rates, this extra-anatomic procedure has been considered safe and effective. Noncompromising upper extremity ischemia and one case of upper extremity loss, associated with early graft thrombosis, have been reported previously. This article describes two cases of late axillary artery thrombosis, occurring 4 and 6 months after graft thrombosis, which severely jeopardized the viability of the ipsilateral upper extremity. Experience with these patients has shown that a thrombosed axillary-femoral bypass graft may jeopardize the viability of the ipsilateral upper extremity many months after its failure. The absence of information in the literature regarding this complication suggests this is a rare complication of thrombosed axillary-femoral grafts
— id: 25678, year: 1985, vol: 2, page: 285, stat: Journal Article,

Anaesthetic management in carotid artery surgery
Imparato AM; Riles TS; Ramirez AA; Lamparello PJ; Mintzer R
1985 Aug;55(4):315-319, Australian & New Zealand journal of surgery
— id: 25677, year: 1985, vol: 55, page: 315, stat: Journal Article,

The value of the radionuclide angiogram in the prediction of perioperative myocardial infarction in patients undergoing lower extremity revascularization procedures
Pasternack PF; Imparato AM; Riles TS; Baumann FG; Bear G; Lamparello PJ; Benjamin D; Sanger J; Kramer E
1985 Sep;72(3 Pt 2):II13-II17, Circulation
To better define the group of patients at high risk of myocardial infarction (MI) and death associated with lower extremity revascularization procedures, resting gated blood pool studies were obtained in 100 such patients before surgery and results were correlated with the prevalence of perioperative MI. The results indicated that three patient groups could be distinguished on the basis of cardiac ejection fraction. Group I (n = 50) had preoperative ejection fractions ranging from 56% to 83%. None of the patients in group I suffered an acute perioperative MI. Group II (n = 42) comprised patients with ejection fractions ranging from 36% to 55%. There was a 19.0% prevalence of MI in group II, with one cardiac death. Group III included eight patients with ejection fractions ranging from 26% to 35%. There was a 75% prevalence of perioperative MI in these patients, with one cardiac death. All perioperative MIs occurred within the first 48 hr after surgery. Statistical analysis demonstrated a significantly higher prevalence of perioperative MI in patients with gated pool ejection fractions of 35% or less compared with the prevalence in patients with one or more of the other widely used clinical signs of increased cardiac operative risk (p less than .02)
— id: 18210, year: 1985, vol: 72, page: II13, stat: Journal Article,

The use of digitized intravenous angiography in a clinical setting. A retrospective review of 58 patients
Roederer GO; Ramirez AA; Lamparello PJ; Riles TS; Imparato AM
1985 Mar;2(2):327-331, Journal of vascular surgery
Digitized intravenous angiography (DIVA) is a frequently used alternative to conventional intra-arterial angiography for the evaluation of cerebrovascular disease. In an attempt to identify factors that may increase the diagnostic capacity of DIVA, a retrospective study of 58 patients evaluated by DIVA for cerebrovascular disease was performed. The reason for the DIVA study was the presence of focal symptoms in 25 patients and nonfocal or vertebrobasilar symptoms in nine. Twenty-four patients were asymptomatic. DIVA was found to be adequately diagnostic in 37 patients (64%), and further evaluation was required in 21 (36%). When the 42 patients who had ocular pneumoplethysmography (OPG-Gee) results available were classified according to their presenting symptoms, 85% of those with focal symptoms and positive OPG-Gee had a diagnostically successful DIVA study. A high DIVA accuracy rate was also obtained in the asymptomatic patients, whether the OPG-Gee results were positive (60%) or negative (78%). The category of patients for whom the DIVA was the least successful was the group with nonfocal or vertebrobasilar symptoms. As many as 56% of these patients required additional testing. Thus it appears that the yield of diagnostic DIVA is increased when the clinical presentation and noninvasive testing are considered. A prospective study is underway to further verify this hypothesis
— id: 25679, year: 1985, vol: 2, page: 327, stat: Journal Article,

Early complications of carotid surgery
Imparato AM; Riles TS; Ramirez AA; Lamparello PJ
1984 Jul-Sep;69(3):223-229, International surgery
The early complications of carotid endarterectomy are attributed to clamping ischemia, intraoperative embolization, and thrombosis of the newly endarterectomized carotid artery. An unusual mechanism is due to intracranial hemorrhage. The differential diagnosis can usually be established by a combination of oculoplethysmography, CT scanning of the brain, exploration of thrombosed carotid arteries, and repeat angiographic studies. Other complications, including acute myocardial infarction, wound hemorrhage, and infection, are discussed
— id: 25682, year: 1984, vol: 69, page: 223, stat: Journal Article,

AORTO-ILIAC FEMORAL ENDARTERECTOMY - A REAPPRAISAL
IMPARATO, AM; RILES, TS; WEINTRAUB, N
1984 ;70(4):2-2, Circulation
— id: 40894, year: 1984, vol: 70, page: 2, stat: Journal Article,

The value of radionuclide angiography as a predictor of perioperative myocardial infarction in patients undergoing abdominal aortic aneurysm resection
Pasternack PF; Imparato AM; Bear G; Riles TS; Baumann FG; Benjamin D; Sanger J; Kramer E; Wood RP
1984 Mar;1(2):320-325, Journal of vascular surgery
To define the group of patients at high risk for myocardial infarction (MI) and death associated with abdominal aortic aneurysm repair, resting gated blood pool studies were obtained on 50 such aneurysm patients preoperatively. The results indicated that three groups could be distinguished among these patients by cardiac ejection fraction. Group I (n = 25) had preoperative ejection fractions ranging from 56% to 85%. None of the patients in group I suffered an acute perioperative MI. Group II (n = 20) comprised patients with ejection fractions ranging from 36% to 55%. There was a 20% incidence of MI in group II but no cardiac deaths. Group III included five patients with ejection fractions ranging from 27% to 35%. There was an 80% incidence of perioperative MI in these patients, with one cardiac death and one cardiac arrest. All perioperative MIs occurred within the first 48 hours after surgery. In addition there was a 50% incidence of perioperative MI among all those patients who were 80 years of age or older. These results indicate guidelines for the management of patients undergoing abdominal aortic aneurysm repair based on their preoperative ejection fraction. The data further suggest that the noninvasive gated blood pool method of determining ejection fraction may serve a more broadly useful function in helping to determine which of those patients about to undergo major surgical procedures are at high risk for perioperative MI
— id: 18211, year: 1984, vol: 1, page: 320, stat: Journal Article,

THE VALUE OF RADIONUCLIDE ANGIOGRAPHY AS A PREDICTOR OF PERIOPERATIVE MYOCARDIAL-INFARCTION IN PATIENTS UNDERGOING LOWER-EXTREMITY REVASCULARIZATION PROCEDURES
PASTERNACK, PF; IMPARATO, AM; RILES, TS; BAUMANN, FG; BEAR, G
1984 ;70(4):163-163, Circulation
— id: 40896, year: 1984, vol: 70, page: 163, stat: Journal Article,

RADIONUCLIDE ANGIOGRAPHY STRATIFIES RISK OF PERIOPERATIVE MYOCARDIAL-INFARCTION IN PATIENTS UNDERGOING CAROTID ENDARTERECTOMY OR PERIPHERAL VASCULAR-SURGERY
PASTERNACK, PF; IMPARATO, AM; RILES, TS; BAUMANN, FS; BEAR, G
1984 ;15(1):190-190, Stroke
— id: 41029, year: 1984, vol: 15, page: 190, stat: Journal Article,

Deep venous thrombosis: detection by high-resolution real-time ultrasonography
Raghavendra, B N; Rosen, R J; Lam, S; Riles, T; Horii, S C
1984 Sep;152(3):789-793, Radiology
High-resolution real-time ultrasonography was performed in 11 patients with clinically suspected deep venous thrombosis (DVT) of the lower extremity. Contrast venography was performed in all patients within 24 hours of sonographic examination. The common femoral vein at the groin and the popliteal vein in the popliteal fossa were evaluated for presence or absence of intraluminal soft-tissue mass (thrombi), compressibility of the veins, and response to performance of the Valsalva maneuver. Of the 11 patients, six were shown to have DVT by contrast venography. In all six cases there was complete agreement between sonography and contrast venography as to the presence or absence of thrombi in the common femoral vein or the popliteal vein
— id: 124450, year: 1984, vol: 152, page: 789, stat: Journal Article,

Common carotid occlusion. Assessment of the distal vessels
Riles TS; Imparato AM; Posner MP; Eikelboom BC
1984 Mar;199(3):363-366, Annals of surgery
In patients with common carotid artery (CCA) occlusion, successful vascular reconstruction can be performed if there is a patent internal or external carotid distal to the occlusion. Preoperative selection of suitable candidates is often difficult because of the inability to visualize patent distal vessels with conventional angiography. In reviewing 24 patients operated upon for CCA occlusion since 1962, the distal internal or external carotid arteries were visualized in only four (17%) of the preoperative angiograms. When these 24 patients were explored, the internal carotid was found to be patent in 11 (46%) patients and the external patent in 15 (62%) cases. Of the 15 patients reconstructed, thromboendarterectomy was performed in six and saphenous vein bypass in nine. In the remaining nine patients, exploration revealed both the internal and external carotids to be thrombosed and unsuitable for CCA reconstruction. Recently we have used rapid sequential computerized tomography (RSCT) scanning to aid in the evaluation of the nonvisualized internal carotid artery (ICA). In two patients with CCA occlusion, RSCT correctly diagnosed patency of the ICA although it appeared to be occluded on angiography. Preliminary data suggest that RSCT will permit accurate preoperative selection of those CCA occlusion patients who are suitable surgical candidates and eliminate the need for surgical exploration
— id: 25683, year: 1984, vol: 199, page: 363, stat: Journal Article,

Asymptomatic vena caval fistulization complicating abdominal aortic aneurysm
Weinbaum FI; Riles TS; Imparato AM
1984 Jul;96(1):126-128, Surgery
Aortocaval fistulization is usually manifested by signs of rupture of an aneurysm or of the large fistula. Absence of symptoms is unusual with this rare complication. Two cases of asymptomatic aortocaval fistula are presented. An awareness of this possibility should facilitate management when unexpected venous bleeding is encountered
— id: 25681, year: 1984, vol: 96, page: 126, stat: Journal Article,

RESULTS OF CAROTID SURGERY FOR PATIENTS WITH PERMANENT NEUROLOGIC DEFICITS
WEINBAUM, F; RILES, TS; LAMPARELLO, PJ; RAMIREZ, AA; IMPARATO, AM; MINTZER, R
1984 ;70(4):136-136, Circulation
— id: 40895, year: 1984, vol: 70, page: 136, stat: Journal Article,

Criteria for interpretation of ocular pneumoplethysmography (Gee)
Eikelboom B; Riles TS; Folcarelli P; Imparato AM
1983 Oct;118(10):1169-1172, Archives of Surgery (Chicago)
Ocular pneumoplethysmography (OPG) (Gee) is one of the most widely used tests for evaluation of carotid artery disease. Its usefulness depends on its diagnostic accuracy, which depends on the criteria used for interpretation of OPG tracings. Application of different criteria as suggested in the literature by Gee et al, McDonald et al, Baker et al, Eikelboom, and O'Hara et al on 200 OPG tests compared with angiography resulted in variations of sensitivity from 70% to 95%, specificity from 70% to 94%, and overall accuracy from 75% to 90%. In validating OPG, one has to be aware of these substantial differences. We found the criteria of McDonald et al the most suitable for clinical use
— id: 25685, year: 1983, vol: 118, page: 1169, stat: Journal Article,

Inaccuracy of angiography in the diagnosis of carotid ulceration
Eikelboom BC; Riles TR; Mintzer R; Baumann FG; DeFillip G; Lin J; Imparato AM
1983 Nov-Dec;14(6):882-885, Stroke
It is generally stated that ulceration of the carotid bifurcation plaque may give rise to embolization and symptoms of cerebral ischemia. It has been suggested that prophylactic carotid endarterectomy is indicated in asymptomatic patients if the angiogram is interpreted as showing ulceration. We therefore determined the accuracy of the radiologic diagnosis of ulceration by comparing the radiologic and morphologic findings in 155 carotid endarterectomies. Ulceration was diagnosed in 54% of the angiograms and 47% of the surgical specimens and was not related to the degree of stenosis. Angiography had a sensitivity of 73%, a specificity of 62% and an overall accuracy of 67%. For the non-flow-restrictive lesions these figures were 65%, 66%, and 66%. If surgery were based on the angiographic diagnosis of ulceration in plaques with less than 50% stenosis, 16 out of 42 operations (38%) would have been done unnecessarily. Variability of the angiographic diagnosis of ulceration is also shown by a high interobserver variability; two sets of two authors read the angiograms independently and disagreed in 24% of the cases. The decision to operate should not depend entirely upon the angiographic diagnosis of ulceration
— id: 60022, year: 1983, vol: 14, page: 882, stat: Journal Article,

The importance of hemorrhage in the relationship between gross morphologic characteristics and cerebral symptoms in 376 carotid artery plaques
Imparato AM; Riles TS; Mintzer R; Baumann FG
1983 Feb;197(2):195-203, Annals of surgery
In a prospective study 376 carotid artery plaques (275 symptomatic, 101 asymptomatic) were obtained from endarterectomies (184 unilateral and 96 bilateral) in 280 patients. The gross morphologic features of each plaque were noted at surgery and, together with the patient's clinical history, stored in computer memory. These data were analyzed in order to investigate the relationship of gross morphologic plaque characteristics with both the presence of cerebral symptoms and the degree of stenosis associated with the plaque. Ulceration was the most frequently observed of the five major gross plaque morphologic characteristics (46.0% of all plaques), but only intramural hemorrhage (30.6% of all plaques) was significantly more common in all symptomatic compared with all asymptomatic plaques (p less than 0.02). Hemorrhage was also the only gross characteristic significantly more common in focal symptomatic plaques when compared with either asymptomatic plaques (p less than 0.05) or nonfocal symptomatic plaques (p less than 0.01). When all the plaques were divided into three broad degrees of stenosis groups (0-39%, 40-69%, 70-99%) on the basis of angiographic data, only hemorrhage showed a significant correlation in incidence with increased degree of plaque stenosis, both when all plaques were considered (p less than 0.001) and when only symptomatic plaques were examined (p less than 0.001). The results indicate that intramural hemorrhage is the only carotid plaque gross morphologic characteristic significantly more frequent in symptomatic compared with asymptomatic plaques and the only characteristic significantly correlated with increased plaque size. These findings indicate that factors other than plaque ulceration and intraluminal thrombus play an important role in carotid plaque related cerebral symptoms. The data also raise questions concerning the unequivocal value of anticoagulant therapy in carotid artery disease, especially in highly stenotic lesions
— id: 25689, year: 1983, vol: 197, page: 195, stat: Journal Article,

Cost effectiveness of rapid sequential computed tomography in neuroradiology
Kricheff, I I; Pinto, R; Cohen, W; Riles, T
1983 ;10(2):176-180, Journal of neuroradiology = Journal de neuroradiologie
— id: 99480, year: 1983, vol: 10, page: 176, stat: Journal Article,

Axilloaxillary bypass for symptomatic stenosis of the subclavian artery
Posner MP; Riles TS; Ramirez AA; Lamparello PJ; Eikelboom BC; Imparato AM
1983 May;145(5):644-646, American journal of surgery
Since the association has been made between stenosis of the subclavian artery and neurologic symptoms, controversy has existed over the preferred surgical procedure for bypass. In addition, concern has been raised regarding the long-term patency and effectiveness of this extraanatomic procedure in relieving neurologic symptoms. Twenty-seven patients underwent this operation for posterior cerebral symptoms between 1973 and 1982; 25 were followed for up to 77 months (mean 26 months). Twenty-two patients had complete relief of symptoms, although 3 of them required a subsequent carotid endarterectomy. Two other patients had partial relief, and one patient's symptoms remained unchanged. Upper extremity symptoms, present in nine patients, were relieved by the operation. All grafts remained patent during follow-up. Axilloaxillary bypass is a durable procedure for symptomatic stenosis of the subclavian artery. It is a low-risk procedure and is therefore particularly suited for older patients with associated carotid artery disease
— id: 25688, year: 1983, vol: 145, page: 644, stat: Journal Article,

Ocular pneumoplethysmography (OPG-Gee) in noninvasive evaluation of carotid artery stenosis
Riles TS; Eikelboom BC; Pauliukas P; Folcarelli P; Baumann FG; Imparato AM
1983 Nov;34(11):724-730, Angiology
Carotid artery stenosis can be evaluated noninvasively by ocular pneumoplethysmography (OPG-Gee). This simultaneously measures both ophthalmic artery pressures and is therefore capable of detecting pressure-reducing or hemodynamically significant carotid lesions. An OPG-angiography correlation was made for 200 carotid arteries in 110 patients. Sensitivity, specificity and overall accuracy were 91%, 89%, and 90% respectively, if calculated per artery. On a per patient basis these figures were 94%, 88%, and 91%. Applications of this rapid and simple technique in clinical practice include selection of patients for angiography and carotid endarterectomy, as well as early and late control of the operative results
— id: 25684, year: 1983, vol: 34, page: 724, stat: Journal Article,

Percutaneous phenol sympathectomy in advanced vascular disease
Rosen RJ; Miller DL; Imparato AM; Riles TS
1983 Sep;141(3):597-600, American journal of roentgenology
Percutaneous phenol sympathectomy has been performed under fluoroscopic or CT guidance in 37 patients with extremely advanced vascular disease of the lower extremities. The technique is simple and well tolerated by the patient with a remarkably low incidence of complications. Of the 37 patients, 14 (38%) showed objective improvement and none of the patients experienced worsening of their ischemia. Results to date suggest that this procedure provides a sympathetic blockade as effectively as surgical sympathectomy in these patients with advanced disease
— id: 25686, year: 1983, vol: 141, page: 597, stat: Journal Article,

Evaluation of aorto-iliac occlusive disease by intravenous digital subtraction angiography
Rosen RJ; Roven SJ; Taylor RF; Imparato AM; Riles TS
1983 Jul;148(1):7-8, Radiology
Intravenous digital subtraction angiography (DSA) was used to evaluate 22 patients with Leriche syndrome. The technique successfully demonstrated both the level of obstruction and the reconstitution of arterial flow to the lower extremities. In view of the relative safety of DSA, compared with the axillary approach in standard angiography, the authors believe that it should be the initial procedure for presurgical evaluation of Leriche syndrome
— id: 25687, year: 1983, vol: 148, page: 7, stat: Journal Article,

Cerebral protection in carotid surgery
Imparato AM; Ramirez A; Riles T; Mintzer R
1982 Aug;117(8):1073-1078, Archives of Surgery (Chicago)
We performed 956 carotid endarterectomies in 661 conscious patients who were under cervical block anesthesia and in whom the stroke rate was 2.5%. They were analyzed to determine the mechanisms of strokes and the risk factor for perioperative stroke. Twenty-three patients with perioperative strokes, regardless of severity, were analyzed as to the mechanism of cause. One half were due to technical problems, one quarter to intraoperative embolization, one sixth to intracerebral hemorrhage, and the remainder were not directly related to the operative procedures. Perioperative stroke rate varied by group from 0.6% to 28.4%, highest when the contralateral carotid was occluded, where there was a preoperative persistent neurologic deficit, and when the patient failed to tolerate carotid clamping. Regional block monitoring was accurate and no stroke could be ascribed to anesthetic technique. Standard reporting techniques should be used in classifying patients into appropriate risk groups to permit meaningful comparisons among groups using different techniques for cerebral protection
— id: 60024, year: 1982, vol: 117, page: 1073, stat: Journal Article,

CAT scans of inflammatory aneurysms: a new technique for preoperative diagnosis
Ramirez AA; Riles TS; Imparato AM; Megibow AJ
1982 Apr;91(4):390-393, Surgery
— id: 25691, year: 1982, vol: 91, page: 390, stat: Journal Article,

Comparison of results of bilateral and unilateral carotid endarterectomy five years after surgery
Riles TS; Imparato AM; Mintzer R; Baumann FG
1982 Mar;91(3):258-262, Surgery
Consecutive patients who successfully underwent carotid endarterectomy (C) between 1970 and 1975 were followed during a 5-year period (mean follow-up 4.3 years). The patients were divided into three groups. Group I comprised 146 patients who had unilateral CE with a patent, nonstenotic contralateral carotid artery. Group II included 45 patients who underwent unilateral CE but whose contralateral internal carotid artery was found to be totally occluded. Group III consisted of 86 patients who underwent bilateral CE. There was no significant difference between the groups with respect to age, sex, neurologic status, or associated diseases, and all were maintained on antiplatelet medications for surgery. During the follow-up period a total of 22 of the 277 patients had a new hemispheric stroke; four others became comatose and died, presumably of stroke. Among the group I patients, 17 had new strokes, only six of which involved the hemisphere ipsilateral to the CE. Five later strokes occurred in group II, one ipsilateral to the CE. Four patients in group III had new strokes. The cumulative stroke rates at 5 years by the life-table method were 17.6% for group I, 16.4% for group II, and 5.6% for group III. The difference between group I and III was significant (P less than 0.05). The results suggest that patients undergoing unilateral CE should have close postoperative monitoring of the contralateral vessel
— id: 25692, year: 1982, vol: 91, page: 258, stat: Journal Article,

The totally occluded internal carotid artery. Preliminary observations using rapid sequential computerized tomographic scanning
Riles TS; Posner MP; Cohen WS; Pinto R; Imparato AM; Baumann FG
1982 Sep;117(9):1185-1188, Archives of Surgery (Chicago)
Cerebral angiography often cannot distinguish between complete thrombosis or fibrosis of the internal carotid artery (ICA) and nonvisualization due to a total occlusion of the common carotid or origin of the ICA. Whereas surgery may be beneficial if the distal carotid is patent (type 1), thromboendarterectomy may be contraindicated if thrombus or fibrosis extend to the intracranial branches (type 2). Rapid sequential computerized tomography (RSCT) was used to examine 15 patients whose ICAs appeared occluded by angiography. Of four ICAs classed as type 1 by RSCT, three were found to be patent during surgical exploration, and carotid reconstruction was successfully performed. Three other ICAs classed as type 2 by RSCT were also surgically explored, and complete thrombosis was confirmed. The RSCT technique provides an effective and nonoperative means of determining whether a nonvisualized ICA is reconstructible
— id: 25690, year: 1982, vol: 117, page: 1185, stat: Journal Article,

THE SIGNIFICANCE OF INTRAMURAL HEMORRHAGE IN THE CAROTID BIFURCATION PLAQUE
Riles, TS; Baumann, FG; Mintzer, R; Imparato, AM
1982 ;13(1):124-124, Stroke
— id: 30493, year: 1982, vol: 13, page: 124, stat: Journal Article,

RAPID SEQUENTIAL CT SCANNING OF THE OCCLUDED INTERNAL CAROTID- ARTERY
Riles, TS; Posner, M; Cohen, WA; Imparato, AM; Pinto, R
1982 ;13(1):124-124, Stroke
— id: 30494, year: 1982, vol: 13, page: 124, stat: Journal Article,

Limited success of lumbar sympathectomy in the prevention of ischemic limb loss in diabetic patients
DaValle MJ; Baumann FG; Mintzer R; Riles TS; Imparato AM
1981 Jun;152(6):784-788, Surgery, gynecology & obstetrics
The results of 93 consecutive lumbar sympathectomies performed over a five year period upon 54 patients with diabetes and 39 without diabetes were compared in terms of subsequent amputation using life table analysis methods. Cumulative success rates for avoiding amputation were significantly lower in those with diabetes as compared with rates for those without diabetes at five years and at most shorter six month intervals. Although there are a number of possible explanations for this difference, an important contributing factor may be the prior spontaneous denervation of diabetic blood vessels. The results demonstrate that better predictive indexes for lumbar sympathectomy are needed
— id: 25695, year: 1981, vol: 152, page: 784, stat: Journal Article,

Effect of surgical lumbar sympathectomy on innervation of arterioles in the lower limb of patients with diabetes
Grover-Johnson N; Baumann FG; Riles TS; Imparato AM
1981 Jul;153(1):39-41, Surgery, gynecology & obstetrics
The innervation of lower limb epineurial arterioles, specimens of which were obtained from six patients in the sympathectomy and from six patients in the nonsympathectomy diabetic groups at amputation for ischemic peripheral vascular disease, was compared by quantitative ultrastructural methods. Results demonstrated no statistically significant difference in the number of vasomotor axons present, the average axon to smooth muscle cell distance or the axon distribution pattern in the adventitia between the two diabetic groups of patients. A previous investigation has established that innervation of these arterioles is significantly reduced in patients with diabetes having end-stage ischemia of the lower limb when compared with similar patients without diabetes. The present results demonstrate that surgical lumbar sympathectomy does not significantly further reduce the already severely diminished number of vasomotor nerves in some diabetic arterioles. This observation offers a possible explanation for the poorer success rate of those with diabetes compared with those without diabetes in avoiding amputation of the limb after lumbar sympathectomy
— id: 25694, year: 1981, vol: 153, page: 39, stat: Journal Article,

Cervical vertebral angioplasty for brain stem ischemia
Imparato AM; Riles TS; Kim GE
1981 Nov;90(5):842-852, Surgery
Fifty-eight patients underwent unilateral vertebral arterial reconstructions over a 16-year period. Thirty-four underwent carotid operations as well. The first 18 patients underwent vertebral arterial reconstructions in conjunction with carotid endarterectomy as mandated in the Joint Study of Extracranial Arterial Occlusion as a Cause of Stoke. The next 40 underwent vertebral procedures for either brain stem symptoms alone, or for combined cerebral cortical and stem symptoms for specific indications after flow-obstructing carotid lesions had been corrected, but symptoms failed to subside. The surgical procedure consisted of subclavian-vertebral angioplasty except in one patient who underwent a subclavian distal-vertebral bypass graft to the level of the second cervical vertebral body. Syncopal episodes occurred as a major symptom in 16 and was controlled by either carotid and vertebral or vertebral artery operation alone except in four who also required cardiac pacemakers and one who needed correction of aortic stenosis. The long-term follow-up reveals that the stroke rate per average year for the first 14 years of follow-up was 1.2% per patient year with only five strokes having occurred in 410 patient years of follow-up and 70% of the patients having sustained no new neurologic episodes at the fourteenth year. Survival, however, was 45% at the fourteenth year with most deaths caused by myocardial infarction. The surgical procedure of vertebral angioplasty is indicated when bilateral vertebral arterial flow-obstructing lesions are found in patients with brain stem ischemia including drop attacks and syncopal episodes if flow-obstructing carotid lesions have been corrected and symptoms persist. The surgical procedure can be performed with a high degree of safety. The differential diagnosis of drop attacks and syncope in this age group should include, in addition to vertebrobasilar arterial insufficiency, transient cardiac arrhythmias, aortic stenosis, and convulsive disorders
— id: 25693, year: 1981, vol: 90, page: 842, stat: Journal Article,

Symptoms, stenosis, and bruit: interrelationships in carotid artery disease
Riles TS; Lieberman A; Kopelman I; Imparato AM
1981 Feb;116(2):218-220, Archives of Surgery (Chicago)
The relationship between focal neurologic symptoms, carotid artery stenosis, and cervical bruits was studied in 495 patients. Among the 990 carotid arteries, 562 (57%) were considered to be symptomatic and 505 (51%) were associated with bruit. There was a linear relationship between the degree of stenosis and symptoms. Of the highly stenotic vessels (80% to 99% narrowing), 253 of 350 (72%) were symptomatic; 85 of 104 (82%) occluded vessels were symptomatic. There was a linear relationship between the occurrence of cervical bruit and degree of stenosis, up to but not including total occlusion. The relationship between bruits and focal neurologic symptoms was less direct. Among 562 symptomatic arteries, 297 (53%) had a bruit and 265 (47%) did not. In symptomatic patients, the absence of a cervical bruit should not delay a workup for extracranial vascular disease
— id: 25696, year: 1981, vol: 116, page: 218, stat: Journal Article,

COMPARISON OF RESULTS OF BILATERAL AND UNILATERAL CAROTID ENDARTERECTOMY 5 YEARS AFTER SURGERY
RILES, T; IMPARATO, A; MINTZER, R
1981 ;12(1):124-124, Stroke
— id: 40267, year: 1981, vol: 12, page: 124, stat: Journal Article,

Long-term results in superficial femoral artery endarterectomy
Walker PM; Imparato AM; Riles TS; Mintzer R; Kopelman I
1981 Jan;89(1):23-30, Surgery
Semiclosed femoral popliteal endarterectomy, herein described as extending from groin to knee and performed with an arterial stripper, has proved to be a satisfactory alternative to revascularization of comparable occluded segments of thigh arteries employing autologous saphenous vein. Cumulative patency of 95.7% in all groups initially decreases to 59.6% in claudicators at 5 years and 30.6% in those who had surgery for limb salvage, whereas the limb salvage rate exceeds patency rate, being 62.9% at 5 years
— id: 25697, year: 1981, vol: 89, page: 23, stat: Journal Article,

PITFALLS IN THE ANGIOGRAPHIC DIAGNOSIS OF CAROTID-ARTERY DISEASE
EDWARDS, JH; KRICHEFF, LL; RILES, T; IMPARATO, A
1980 ;1(1):115-115, AJNR. American journal of neuroradiology
— id: 40288, year: 1980, vol: 1, page: 115, stat: Journal Article,

Aortic graft infection; secondary to diverticular abscess
Krieger KH; Riles TS; Eng K; Edwards P
1980 Sep;80(10):1608-1610, New York state journal of medicine
— id: 25698, year: 1980, vol: 80, page: 1608, stat: Journal Article,

Carotid artery stenosis with contralateral internal carotid occlusion: long-term results in fifty-four patients
Riles TS; Imparato AM; Kopelman I
1980 Apr;87(4):363-368, Surgery
— id: 25699, year: 1980, vol: 87, page: 363, stat: Journal Article,

Management of acute aortic occlusion
Drager SB; Riles TS; Imparato AM
1979 Aug;138(2):293-295, American journal of surgery
Acute aortic occlusion is most often seen in elderly patients with advanced cardiac disease. The management of these patients has been facilitated by the use of extraanatomic bypass. Over the past 2 years, six patients aged 55 to 87 years presented to our medical center with acute aortic occlusion, three after major operative procedures. One patient had a thrombosed abdominal aortic aneurysm; in the other five patients differentiation between saddle embolus and thrombosis of the distal aorta was impossible. There was one operative death. Four of the other five patients underwent axillobifemoral bypass and one underwent aortofemoral thrombectomy. All survived, and none required amputation. Two of the three patients who underwent preoperative aortography developed transient renal failure postoperatively. Aortography is of little value in diagnosis and is probably contraindicated in acute aortic occlusion. Our recommendation for operative management includes (1) preparation of the patient for possible axillobifemoral bypass, (2) angiography of distal runoff via both femoral arteries, (3) attempt at bilateral aortofemoral embolectomy with Fogarty catheters, and (4) axillobifemoral bypass if embolectomy fails to restore normal pulsatile flow
— id: 25701, year: 1979, vol: 138, page: 293, stat: Journal Article,

Atherosclerotic subintimal hematoma of the carotid artery
Edwards, J H; Kricheff, I I; Gorstein, F; Riles, T; Imparato, A
1979 Oct;133(1):123-129, Radiology
A presumed new radiological-pathological entity of atherosclerotic subintimal of the carotid artery is described. Subintimal hematomas were found in 12 of 50 (24%) carotid bifurcations during surgery for repeated transient ischemic attacks in a single hemispheric distribution; only 33% were associated with ulcerations. The typical angiographic appearance was a sharply marginated, rounded, eccentric filling defect located near the extracranial carotid bifurcation, although occasionally it may simulate a typical smooth or even ulcerated atherosclerotic plaque. Pathological mechanisms responsible for the hemorrhage into the atherosclerotic plaque resulting in the hematoma are discussed
— id: 99492, year: 1979, vol: 133, page: 123, stat: Journal Article,

Angiographically undetected ulceration of the carotid bifurcation as a cause of embolic stroke
Edwards, J H; Kricheff, I I; Riles, T; Imparato, A
1979 Aug;132(2):369-373, Radiology
The accuracy of angiographic diagnosis of carotid artery ulceration was evaluated. Of those carotid bifurcations showing ulceration at surgery, 60% were diagnosed as having ulcers at angiography. Half of the remaining ulcers occurred in smooth, benign-appearing plaques and were too small to be seen at angiography. An incorrect angiographic diagnosis of ulceration was made in 17 of 50 carotid arteries; in most cases this was due to the presence of a subintimal hematoma in the wall of the artery
— id: 99495, year: 1979, vol: 132, page: 369, stat: Journal Article,

Dilation of synthetic grafts and junctional aneurysms
Geun-Eun-Kim; Imparato AM; Nathan I; Riles TS
1979 Nov;114(11):1296-1303, Archives of Surgery (Chicago)
Dilation of prosthetic graft has been noted by authors in association with junctional aneurysm between the synthetic graft and host arteries. Dilation of graft materials was suspected as one of the etiologic factors of the junctional aneurysm. Increase in transverse diameter was observed as early as a few minutes to five years postimplantation in clinical cases. The phenomenon of dilation was studied experimentally. Nine different types of graft materials were tested using intraluminal pulse pressure of 100/60 mm Hg, and the transverse diameters were measured at various time intervals. Knitted grafts showed the more pronounced changes compared with the woven. Degree of dilation differed considerably among the different types of knitted grafts
— id: 25700, year: 1979, vol: 114, page: 1296, stat: Journal Article,

The carotid bifurcation plaque: pathologic findings associated with cerebral ischemia
Imparato AM; Riles TS; Gorstein F
1979 May-Jun;10(3):238-245, Stroke
Embolization from or decreased flow through cervical carotid and vertebral arteries causes ischemic stroke syndromes. Specific pathologic findings were studied in 50 symptomatic patients who underwent 69 carotid endarterectomies. Detailed analyses of their carotid plaques included correlations between photographs of gross specimens, microscopic findings, angiograms, preoperative symptoms and long-term postoperative follow up. Carotid plaques were primarily fibrous with significant (greater than 70%) stenoses encountered in 70% of the arteries. Stenoses were due to simple fibrous thickening in only 20%; the remainder due to intraplaque hemorrhage, atheromatous debris and, least often, luminal thrombus with or without ulceration. Intramural hemorrhage was frequent in plaques associated with focal neurologic symptoms and may have preceded localized collections of atheromatous debris. Ulceration occurred in 1/3 of all plaques, symptomatic or not. It is concluded that the carotid plaques start as fibrointimal thickening evolving to symptomatic stages by the occurrence of one or more of a number of pathologic changes, intraplaque hemorrhage being prominent. A single rational therapeutic regimen seems impossible until patients can be classified according to their pathologic changes diagnosed non-invasively
— id: 25702, year: 1979, vol: 10, page: 238, stat: Journal Article,

Myocardial infarction following carotid endarterectomy: a review of 683 operations
Riles TS; Kopelman I; Imparato AM
1979 Mar;85(3):249-252, Surgery
In a series of 683 consecutive carotid endarterectomies, there were 16 postoperative myocardial infarctions which resulted in five deaths. Of 399 operations on patients with no previous history of heart disease, there were only two myocardial infarctions (0.5%). Two hundred and eighty-four operations were performed on patients with heart disease, and vasopressors were administered in 135 of these procedures. For these patients the risk of myocardial infarction increased from 2.0% to 8.1% with the use of vasopressors (P less than 0.001). The management of the patient with stable heart disease undergoing carotid endarterectomy is discussed
— id: 25703, year: 1979, vol: 85, page: 249, stat: Journal Article,

Heparin
Pachter HL; Riles TS
1977 Aug;56(2):327-328, Circulation
— id: 25705, year: 1977, vol: 56, page: 327, stat: Journal Article,

Low dose heparin: bleeding and wound complications in the surgical patient. A prospective randomized study
Pachter HL; Riles TS
1977 Dec;186(6):669-674, Annals of surgery
A randomized prospective study of low dose heparin was performed in 175 surgical patients to determine the frequency of bleeding and wound complications. The patients were divided into three groups: (1) low dose heparin (5000 units two hours before operation and 5000 units every 12 hours following operation for five days); (2) low dose heparin postoperatively only; and (3) a control group. The frequency of bleeding and wound complications was 27% in group I, 7.5% in group II, and 1.4% in group III. The difference between the control patients and those heparinized pre- and postoperatively is statistically significant (p less than 0.005). None of the patients in any of the three groups had a pulmonary embolus, but the number of patients involved is too small to assess the significance of this finding. However, a bleeding and wound complication rate of 27% is significant. These findings indicate that perhaps the routine use of low dose heparin should be reserved for those patients with preoperative factors indicating an increased risk from thromboembolism
— id: 25704, year: 1977, vol: 186, page: 669, stat: Journal Article,