We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculat... more We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded po...
surgical group were associated with incompetence of the below knee GSV. Perhaps length of GSV str... more surgical group were associated with incompetence of the below knee GSV. Perhaps length of GSV stripping should more reflect the length of the refluxing vein and not concerns about injuring the saphenous nerve? Another interesting point is that neovasculariztion, thought to be the leading cause of recurrence of varicosities in patients with traditional open surgical treatment of GSV varicosities, appears rare after EVLA. The reason for this is unclear, but may be due to decreased inflammation following EVLA. Interestingly, all patients with recanalization after EVLA in this trial, were treated with an energy density of 60 J/cm. No recanaliztion was seen when energy densities were above 115 J/cm.
The management of patients with splenic artery aneurysms (SAAs) is variable since the natural his... more The management of patients with splenic artery aneurysms (SAAs) is variable since the natural history of these aneurysms is poorly delineated. The objective of this study was to review our experience with open repair, endovascular therapy, and observation of SAAs over a 14-year interval. Methods: Between January 1, 1996 and December 31, 2009, 128 patients with SAAs were evaluated. Sixty-two patients underwent surgical repair (n ؍ 13) or endovascular coil/glue ablation (n ؍ 49), while 66 patients underwent serial observation. The original medical records and computed tomography (CT) imaging were reviewed. Statistical analyses were performed using 2 or Fisher's exact test for categorical patient characteristics and t-test for continuous variables. Kaplan-Meier estimates for survival were calculated. Mortality was verified via the Social Security Death Index. Results: Patients (61 ؎ 11 years, 69% female) were investigated for abdominal symptoms (49%) or had the incidental finding of SAA (mean size, 2.4 ؎ 1.4 cm). Seven patients (5.5%) presented with rupture and were treated emergently with two perioperative mortalities (29%). Patients requiring surgical or endovascular treatment were more likely male (40% vs 21%, P ؍ .031), younger (58 vs 64 years; P ؍ .004), and current smokers (18% vs 5%; P ؍ .035). Increased aneurysm calcification was associated with decreased SAA size (P ؍ .013). The mean aneurysm size at initial diagnosis was 1.67 cm for patients undergoing observation and 3.13 cm for the treated group (P < .001). Endovascular repair was safe and durable with a mean 1.5-mm regression in SAA size over 2 years. The mean rate of growth for observed SAA was 0.2 mm/y. Ten-year survival was 89.4% (95% confidence interval: 82.0, 97.4) for all patients (observed group, 94.9%; treated group, 85.1%; P ؍ .18). No late aneurysm-related mortality was identified. Conclusions: Ruptured SAAs are lethal. Large SAAs can undergo endovascular ablation safely with durable SAA regression. Smaller SAAs (<2 cm) grow slowly and carry a negligible rupture risk.
Objectives: Endovascular stent grafting offers a potentially less invasive option for treatment o... more Objectives: Endovascular stent grafting offers a potentially less invasive option for treatment of abdominal aortic aneurysm. Clinical benefit has been demonstrated with respect to early parameters such as blood transfusion, return of gastrointestinal function, and length of hospital stay. Endovascular repair, however, has been criticized on the basis of inferior long-term outcome. Secondary procedures may be necessary to address durability issues such as migration, high-pressure endoleak, graft limb thrombosis, and degeneration of the stent-fabric structure itself, issues that may compromise the primary goal of aneurysm repair, protection from rupture. Methods: Between 1996 and 2002, 703 patients underwent endovascular treatment of infrarenal abdominal aortic aneurysm at The Cleveland Clinic Foundation. During this time, five devices were used: Ancure, AneuRx, Excluder, Talent, and Zenith. Outcome was assessed with physical examination, lower extremity arterial studies, plain abdominal radiography, and computed tomography at discharge, at 1, 6, and 12 months postoperatively, and annually thereafter. Secondary procedures were defined as any procedure, exclusive of diagnostic angiography, performed after stent graft implantation, directed at treatment of aneurysm-related events. Multivariable statistical techniques for censored data (Cox proportional hazards modeling) were used to determine baseline parameters associated with need for secondary procedures over follow-up, with calculation of hazards ratio (HR) and 95% confidence interval (CI). Results: Patient follow-up averaged 12.2 ؎ 11.7 months. Patient survival was 90% ؎ 1.4% at 1 year, 78% ؎ 2.6% at 2 years, and 70% ؎ 3.8% at 3 years. Aneurysm rupture occurred in 3 patients (0.4%), accounting for rupture risk of 1.4% over the first 2 years of follow-up (Kaplan-Meier method). Overall, 128 secondary procedures were required in 104 patients (15%), with a cumulative risk of 12% ؎ 1.5% at 1 year, 24% ؎ 2.8% at 2 years, and 35% ؎ 4.4% at 3 years after stent graft implantation. Among the secondary procedures, new stent grafts and extensions were placed in 34 patients (27%), embolization of endoleak was performed in 33 patients (26%), and open surgical conversion was undertaken in 11 patients (9%). Periprocedural mortality of secondary procedures was 8% overall, but was 18% for patients undergoing open surgical conversion. Multivariable modeling identified the date the procedure was performed (HR, 1.53 per 3-month period of study; CI, 1.22-1.92; P < .001) and aneurysm size (HR, 1.35 per centimeter of minor axis; CI, 1.13-1.60; P < .001) as independent predictors of need for secondary procedures. Conclusions: Current endovascular devices are associated with a relatively high rate of complications over mid-term follow-up, culminating in frequent need for secondary remedial procedures. With strict follow-up imaging compliance, however, risk for rupture and aneurysm-related death remain exceedingly low. Newer technology may achieve improved durability and a lower requirement for secondary procedures, while maintaining the minimally invasive nature of presently available devices.
Background: Acute limb ischemia (ALI) of the lower extremities remains a challenging clinical dil... more Background: Acute limb ischemia (ALI) of the lower extremities remains a challenging clinical dilemma. Treatment of ALI has shifted toward endovascular therapies. The purpose of this study was to assess outcomes in patients treated for ALI with intra-arterial thrombolysis and/or adjuvant endovascular techniques. Methods: Consecutive patients with ALI of the lower extremities treated via endovascular intra-arterial methods between January 1, 2005 and September 30, 2007 were identified and reviewed. Comparisons of success, thrombolysis days, and all 30-day outcomes except mortality were performed using generalized estimating equations with logistic and proportional odds regression. Thirty-day mortality was assessed using logistic regression. Long-term patency, limb salvage, and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models. Results: The analyzed dataset included 129 limbs treated in 119 patients presenting with ALI (class I 68%, class IIa 23%, class IIb 9%). The mean follow-up was 16.8 months (range: 0-43 months). Technical success was achieved in 82% cases. The 30-day mortality rate was 6.0% with all 30-day deaths occurring in females (P ؍ .002). One (0.76%) central nervous system hemorrhage (CNS) was noted in this cohort. Primary patency for the entire cohort at 12 and 24 months was 50.1% (95% confidence interval [CI], 39.5-60.7) and 37.7% (95% CI, 26.2-49.1), respectively, while secondary patency was 74.0% (95% CI, 64.9-83.1) and 65.3% (95% CI, 54.5-76.2). Multivariable analyses identified patients presenting with femoropopliteal (hazard ratio [HR] 2.63) or tibial thrombosis (HR 2.80); graft thrombosis (vs native artery thrombosis, HR 2.57) and long-term dialysis (HR 3.66, 95% CI, 2.35-5.71, P < .001) were associated with poorer primary patency rates. Cumulative limb salvage at 24 months was 68.8% (95% CI: 59.5-78.1) with female gender (HR 3.34, P ؍ .002) and thrombolysis >3 days (HR 2.35, P ؍ .019) associated with an increased risk of limb loss. Overall 36-month survival was 84.5% (95% CI: 77.5-91.6). Women had decreased survival rates both in the short-and midterm (HR 6.29; 95% CI, 1.78-22.28; P ؍ .004). Conclusions: Endovascular therapy with thrombolysis remains an effective treatment option for patients presenting with lower extremity ALI. Thrombolysis should be limited to <3 days. Female gender negatively affects the rates of limb salvage and survival.
The increasing use of aortic endografts predictably will add to the complexity of open abdominal ... more The increasing use of aortic endografts predictably will add to the complexity of open abdominal aortic aneurysm (AAA) repair and, therefore, the proportion of surgically treated infrarenal AAAs that are juxtarenal in location (JRA) will grow. This study reviews a single-center experience with JRAs. Methods: Between June 1994 and December 2000, 138 patients underwent elective repair of a JRA, comprising 16.1% of 859 consecutive asymptomatic and intact symptomatic nonruptured infrarenal AAAs repaired over the same period. All patients with JRA needed proximal suprarenal clamping (SRC) or supravisceral (SVC) clamping. Patient demographics, selected risk factors, and operative details were recorded. Univariate analyses of selected risk factors for an adverse perioperative event were assessed, and multivariate analyses were performed with linear and logistic regression with backwards selection. Results: SRC was used in 95 patients (69%), and 43 patients (31%) underwent SVC. The mortality rate was 5.1% (7/138) for JRA repair, and 2.8% (20/720) for infrarenal AAA repair (P ؍ .03). The mortality rate was significantly greater for those patients who received SVC compared with SRC (11.6% versus 2.1%; P ؍ .02). Multivariate analysis identified SVC position as the only independent predictor of mortality (odds ratio [OR], 6.1; 95% CI, 1.1 to 32.9; P ؍ .035). Transient renal insufficiency occurred in 39 patients (28.3%), but only eight patients (5.8%) needed dialysis. Patients who had SVC had a significantly greater rate of renal insufficiency than those who received SRC (41.9% versus 22.1%; P ؍ .02). Multivariate analysis showed SVC position (OR, 3.3; 95% CI, 1.4 to 7.8; P ؍ .008), diabetes (OR, 3.7; 95% CI, 1.1 to 12.9; P ؍ .04), and preoperative renal insufficiency (OR, 5.8; 95% CI, 2.2 to 15.4; P < .001) were independent predictors of postoperative renal insufficiency. Renal ischemia during proximal clamping cannot alone explain renal complications because clamp time was shorter in patients with SVC (24.9 ؎ 2.4 minutes versus 32.2 ؎ 1.5 minutes; P ؍ .009). Conclusion: JRA repair can be accomplished with a low mortality rate, but a more proximal clamp position may adversely affect outcome in these patients. Postoperative renal insufficiency is related to diabetes, preoperative renal insufficiency, and SVC position. These results suggest SRC is safer than SVC for proximal aortic clamp control of JRAs. Although clamp level must be tailored to patient anatomy, outcome may be improved if the clamp level can be kept distal to the superior mesenteric artery origin.
To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percu... more To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques. Methods: Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 Ϯ 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. Results: Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 Ϯ 29.6 months. Conclusions: Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.
Background COVID-19 has created an urgent need for reorganization and surge planning among depart... more Background COVID-19 has created an urgent need for reorganization and surge planning among departments of surgery across the USA. Methods Review of the COVID-19 planning process and work products in preparation for a patient surge. Organizational and process changes, workflow redesign, and communication plans are presented. Results The planning process included widespread collaboration among leadership from many disciplines. The department of surgery played a leading role in establishing clinical protocols, guidelines, and policies in preparation for a surge of COVID-19 patients. A multidisciplinary approach with input from clinical and nonclinical stakeholders is critical to successful crisis planning. A clear communication plan should be implemented early and input from trainees, staff, and faculty should be solicited. Conclusion Major departmental and health system reorganization is required to adapt academic surgical practices to a widespread crisis. Surgical leadership, innovation, and flexibility are critical to successful planning and implementation.
Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. ... more Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay th...
We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculat... more We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded po...
surgical group were associated with incompetence of the below knee GSV. Perhaps length of GSV str... more surgical group were associated with incompetence of the below knee GSV. Perhaps length of GSV stripping should more reflect the length of the refluxing vein and not concerns about injuring the saphenous nerve? Another interesting point is that neovasculariztion, thought to be the leading cause of recurrence of varicosities in patients with traditional open surgical treatment of GSV varicosities, appears rare after EVLA. The reason for this is unclear, but may be due to decreased inflammation following EVLA. Interestingly, all patients with recanalization after EVLA in this trial, were treated with an energy density of 60 J/cm. No recanaliztion was seen when energy densities were above 115 J/cm.
The management of patients with splenic artery aneurysms (SAAs) is variable since the natural his... more The management of patients with splenic artery aneurysms (SAAs) is variable since the natural history of these aneurysms is poorly delineated. The objective of this study was to review our experience with open repair, endovascular therapy, and observation of SAAs over a 14-year interval. Methods: Between January 1, 1996 and December 31, 2009, 128 patients with SAAs were evaluated. Sixty-two patients underwent surgical repair (n ؍ 13) or endovascular coil/glue ablation (n ؍ 49), while 66 patients underwent serial observation. The original medical records and computed tomography (CT) imaging were reviewed. Statistical analyses were performed using 2 or Fisher's exact test for categorical patient characteristics and t-test for continuous variables. Kaplan-Meier estimates for survival were calculated. Mortality was verified via the Social Security Death Index. Results: Patients (61 ؎ 11 years, 69% female) were investigated for abdominal symptoms (49%) or had the incidental finding of SAA (mean size, 2.4 ؎ 1.4 cm). Seven patients (5.5%) presented with rupture and were treated emergently with two perioperative mortalities (29%). Patients requiring surgical or endovascular treatment were more likely male (40% vs 21%, P ؍ .031), younger (58 vs 64 years; P ؍ .004), and current smokers (18% vs 5%; P ؍ .035). Increased aneurysm calcification was associated with decreased SAA size (P ؍ .013). The mean aneurysm size at initial diagnosis was 1.67 cm for patients undergoing observation and 3.13 cm for the treated group (P < .001). Endovascular repair was safe and durable with a mean 1.5-mm regression in SAA size over 2 years. The mean rate of growth for observed SAA was 0.2 mm/y. Ten-year survival was 89.4% (95% confidence interval: 82.0, 97.4) for all patients (observed group, 94.9%; treated group, 85.1%; P ؍ .18). No late aneurysm-related mortality was identified. Conclusions: Ruptured SAAs are lethal. Large SAAs can undergo endovascular ablation safely with durable SAA regression. Smaller SAAs (<2 cm) grow slowly and carry a negligible rupture risk.
Objectives: Endovascular stent grafting offers a potentially less invasive option for treatment o... more Objectives: Endovascular stent grafting offers a potentially less invasive option for treatment of abdominal aortic aneurysm. Clinical benefit has been demonstrated with respect to early parameters such as blood transfusion, return of gastrointestinal function, and length of hospital stay. Endovascular repair, however, has been criticized on the basis of inferior long-term outcome. Secondary procedures may be necessary to address durability issues such as migration, high-pressure endoleak, graft limb thrombosis, and degeneration of the stent-fabric structure itself, issues that may compromise the primary goal of aneurysm repair, protection from rupture. Methods: Between 1996 and 2002, 703 patients underwent endovascular treatment of infrarenal abdominal aortic aneurysm at The Cleveland Clinic Foundation. During this time, five devices were used: Ancure, AneuRx, Excluder, Talent, and Zenith. Outcome was assessed with physical examination, lower extremity arterial studies, plain abdominal radiography, and computed tomography at discharge, at 1, 6, and 12 months postoperatively, and annually thereafter. Secondary procedures were defined as any procedure, exclusive of diagnostic angiography, performed after stent graft implantation, directed at treatment of aneurysm-related events. Multivariable statistical techniques for censored data (Cox proportional hazards modeling) were used to determine baseline parameters associated with need for secondary procedures over follow-up, with calculation of hazards ratio (HR) and 95% confidence interval (CI). Results: Patient follow-up averaged 12.2 ؎ 11.7 months. Patient survival was 90% ؎ 1.4% at 1 year, 78% ؎ 2.6% at 2 years, and 70% ؎ 3.8% at 3 years. Aneurysm rupture occurred in 3 patients (0.4%), accounting for rupture risk of 1.4% over the first 2 years of follow-up (Kaplan-Meier method). Overall, 128 secondary procedures were required in 104 patients (15%), with a cumulative risk of 12% ؎ 1.5% at 1 year, 24% ؎ 2.8% at 2 years, and 35% ؎ 4.4% at 3 years after stent graft implantation. Among the secondary procedures, new stent grafts and extensions were placed in 34 patients (27%), embolization of endoleak was performed in 33 patients (26%), and open surgical conversion was undertaken in 11 patients (9%). Periprocedural mortality of secondary procedures was 8% overall, but was 18% for patients undergoing open surgical conversion. Multivariable modeling identified the date the procedure was performed (HR, 1.53 per 3-month period of study; CI, 1.22-1.92; P < .001) and aneurysm size (HR, 1.35 per centimeter of minor axis; CI, 1.13-1.60; P < .001) as independent predictors of need for secondary procedures. Conclusions: Current endovascular devices are associated with a relatively high rate of complications over mid-term follow-up, culminating in frequent need for secondary remedial procedures. With strict follow-up imaging compliance, however, risk for rupture and aneurysm-related death remain exceedingly low. Newer technology may achieve improved durability and a lower requirement for secondary procedures, while maintaining the minimally invasive nature of presently available devices.
Background: Acute limb ischemia (ALI) of the lower extremities remains a challenging clinical dil... more Background: Acute limb ischemia (ALI) of the lower extremities remains a challenging clinical dilemma. Treatment of ALI has shifted toward endovascular therapies. The purpose of this study was to assess outcomes in patients treated for ALI with intra-arterial thrombolysis and/or adjuvant endovascular techniques. Methods: Consecutive patients with ALI of the lower extremities treated via endovascular intra-arterial methods between January 1, 2005 and September 30, 2007 were identified and reviewed. Comparisons of success, thrombolysis days, and all 30-day outcomes except mortality were performed using generalized estimating equations with logistic and proportional odds regression. Thirty-day mortality was assessed using logistic regression. Long-term patency, limb salvage, and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models. Results: The analyzed dataset included 129 limbs treated in 119 patients presenting with ALI (class I 68%, class IIa 23%, class IIb 9%). The mean follow-up was 16.8 months (range: 0-43 months). Technical success was achieved in 82% cases. The 30-day mortality rate was 6.0% with all 30-day deaths occurring in females (P ؍ .002). One (0.76%) central nervous system hemorrhage (CNS) was noted in this cohort. Primary patency for the entire cohort at 12 and 24 months was 50.1% (95% confidence interval [CI], 39.5-60.7) and 37.7% (95% CI, 26.2-49.1), respectively, while secondary patency was 74.0% (95% CI, 64.9-83.1) and 65.3% (95% CI, 54.5-76.2). Multivariable analyses identified patients presenting with femoropopliteal (hazard ratio [HR] 2.63) or tibial thrombosis (HR 2.80); graft thrombosis (vs native artery thrombosis, HR 2.57) and long-term dialysis (HR 3.66, 95% CI, 2.35-5.71, P < .001) were associated with poorer primary patency rates. Cumulative limb salvage at 24 months was 68.8% (95% CI: 59.5-78.1) with female gender (HR 3.34, P ؍ .002) and thrombolysis >3 days (HR 2.35, P ؍ .019) associated with an increased risk of limb loss. Overall 36-month survival was 84.5% (95% CI: 77.5-91.6). Women had decreased survival rates both in the short-and midterm (HR 6.29; 95% CI, 1.78-22.28; P ؍ .004). Conclusions: Endovascular therapy with thrombolysis remains an effective treatment option for patients presenting with lower extremity ALI. Thrombolysis should be limited to <3 days. Female gender negatively affects the rates of limb salvage and survival.
The increasing use of aortic endografts predictably will add to the complexity of open abdominal ... more The increasing use of aortic endografts predictably will add to the complexity of open abdominal aortic aneurysm (AAA) repair and, therefore, the proportion of surgically treated infrarenal AAAs that are juxtarenal in location (JRA) will grow. This study reviews a single-center experience with JRAs. Methods: Between June 1994 and December 2000, 138 patients underwent elective repair of a JRA, comprising 16.1% of 859 consecutive asymptomatic and intact symptomatic nonruptured infrarenal AAAs repaired over the same period. All patients with JRA needed proximal suprarenal clamping (SRC) or supravisceral (SVC) clamping. Patient demographics, selected risk factors, and operative details were recorded. Univariate analyses of selected risk factors for an adverse perioperative event were assessed, and multivariate analyses were performed with linear and logistic regression with backwards selection. Results: SRC was used in 95 patients (69%), and 43 patients (31%) underwent SVC. The mortality rate was 5.1% (7/138) for JRA repair, and 2.8% (20/720) for infrarenal AAA repair (P ؍ .03). The mortality rate was significantly greater for those patients who received SVC compared with SRC (11.6% versus 2.1%; P ؍ .02). Multivariate analysis identified SVC position as the only independent predictor of mortality (odds ratio [OR], 6.1; 95% CI, 1.1 to 32.9; P ؍ .035). Transient renal insufficiency occurred in 39 patients (28.3%), but only eight patients (5.8%) needed dialysis. Patients who had SVC had a significantly greater rate of renal insufficiency than those who received SRC (41.9% versus 22.1%; P ؍ .02). Multivariate analysis showed SVC position (OR, 3.3; 95% CI, 1.4 to 7.8; P ؍ .008), diabetes (OR, 3.7; 95% CI, 1.1 to 12.9; P ؍ .04), and preoperative renal insufficiency (OR, 5.8; 95% CI, 2.2 to 15.4; P < .001) were independent predictors of postoperative renal insufficiency. Renal ischemia during proximal clamping cannot alone explain renal complications because clamp time was shorter in patients with SVC (24.9 ؎ 2.4 minutes versus 32.2 ؎ 1.5 minutes; P ؍ .009). Conclusion: JRA repair can be accomplished with a low mortality rate, but a more proximal clamp position may adversely affect outcome in these patients. Postoperative renal insufficiency is related to diabetes, preoperative renal insufficiency, and SVC position. These results suggest SRC is safer than SVC for proximal aortic clamp control of JRAs. Although clamp level must be tailored to patient anatomy, outcome may be improved if the clamp level can be kept distal to the superior mesenteric artery origin.
To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percu... more To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques. Methods: Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 Ϯ 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. Results: Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 Ϯ 29.6 months. Conclusions: Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.
Background COVID-19 has created an urgent need for reorganization and surge planning among depart... more Background COVID-19 has created an urgent need for reorganization and surge planning among departments of surgery across the USA. Methods Review of the COVID-19 planning process and work products in preparation for a patient surge. Organizational and process changes, workflow redesign, and communication plans are presented. Results The planning process included widespread collaboration among leadership from many disciplines. The department of surgery played a leading role in establishing clinical protocols, guidelines, and policies in preparation for a surge of COVID-19 patients. A multidisciplinary approach with input from clinical and nonclinical stakeholders is critical to successful crisis planning. A clear communication plan should be implemented early and input from trainees, staff, and faculty should be solicited. Conclusion Major departmental and health system reorganization is required to adapt academic surgical practices to a widespread crisis. Surgical leadership, innovation, and flexibility are critical to successful planning and implementation.
Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. ... more Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay th...
Uploads
Papers by Timur Sarac