Biomedical subjects

Nicholas J Gargiulo

Publications and source records attributed to Nicholas J Gargiulo.

11 recordsLinked to original sources

PubMed2004

Discontinuous, staccato growth of abdominal aortic aneurysms.

BACKGROUND: To evaluate whether abdominal aortic aneurysm (AAA) growth in individual patients can be characterized as continuous or discontinuous (staccato). STUDY DESIGN: From 1996 to 2002, 609 patients presented with unruptured AAAs. Of these, 278 underwent prompt repair and 331 were observed. In this study, we included 52 patients (16% of the latter group) who had at least four CT scans and were observed for 18 months or longer without any intervention. AAA growth was defined as any increase in diameter of >/= 3 mm over any observation period(s). AAA nongrowth was defined as absence of growth for at least 6 months. Staccato growth was defined as at least one period of nongrowth combined with at least one period of growth. RESULTS: The 52 patients had a mean age of 75 +/- 8 (SD) years. The mean observation period was 42 +/- 20 months and the mean AAA diameter growth rate was 3.6 +/- 2.4 mm/y. Only 12 of these 52 patients (23%) demonstrated continuous growth. Staccato growth occurred in 34 patients (65%). Six patients (12%) showed no growth at all over 18 to 57 months (mean 30 months). No correlation was observed between initial diameter of AAAs and a patient's individual growth rate during the whole observation period (R = 0.04, p = 0.46). CONCLUSIONS: Individual AAA behavior is usually characterized by periods of nongrowth alternating with periods of growth, ie, staccato growth. Some aneurysms may have long periods of nongrowth. Accordingly, management decisions cannot be based on the presumption that observed growth rates of AAAs can be extrapolated to predict future growth rates.

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PubMed2004

System to decrease length of stay for vascular surgery.

OBJECTIVES: Reduction of length of stay (LOS) is critical for optimal use of hospital resources. We developed and evaluated a system to aggressively reduce LOS for vascular surgery. METHOD: Key to this system, which we introduced on January 1, 2001, was appointment of a LOS officer, who communicated daily during hospitalization with patients and families about discharge planning, organized outpatient services for wound care and rehabilitation to transition patients quickly to nonhospital care, and had biweekly meetings with relevant paramedical services. LOS for 509 patients operated on in 2000 (standard group) was compared with LOS for 474 operated on in 2001 and 595 patients operated on in 2002 (LOS reduction groups). Data for all patients with aortic aneurysm, carotid artery stenosis, lower extremity critical ischemia or amputation, and foot debridement were included. RESULTS: LOS in 2000 averaged 8.5 days, compared with 5.9 days in 2001 and 5.6 days in 2002. All decreases in LOS for each diagnostic category in 2001 and 2002 were statistically significant (P = <.001-.03). There was no significant increase in readmission rate (2.2% vs 1.9% and 2.0%, respectively), mortality rate (0.8% vs 0.6% and 0.7%, respectively), or percent of patients who received endovascular treatment (18% vs 16% and 14%, respectively). These decreases in LOS saved the hospital more than US dollars 616200 in 2001, and US dollars 847550 in 2002 (US dollars 500/patient-day). CONCLUSIONS: A committed LOS officer with major specific daily responsibilities for decreasing LOS and discharging patients resulted in a 31% to 33% decrease in LOS, with important cost savings to the hospital and no negative effect on patient care.

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PubMed2004

Predicting aneurysm enlargement in patients with persistent type II endoleaks.

OBJECTIVE: The clinical significance of type II endoleaks is not well understood. Some evidence, however, indicates that some type II endoleaks might result in aneurysm enlargement and rupture. To identify factors that might contribute to aneurysm expansion, we analyzed the influence of several variables on aneurysm growth in patients with persistent type II endoleaks after endovascular aortic aneurysm repair (EVAR). METHODS: In a series of 348 EVARs performed during a 10-year period, 32 patients (9.2%) developed type II endoleaks that persisted for more than 6 months. Variables analyzed included those defined by the reporting standards for EVAR (SVS/AAVS) as well as other endoleak characteristics. Univariate, receiver operating characteristic curve, and Cox regression analyses were used to determine the association between variables and aneurysm enlargement. RESULTS: The median follow-up period was 26.5 months (range, 6-88 months). Thirteen patients (41%) had aneurysm enlargement by 5 mm or more (median increase in diameter, 10 mm), whereas 19 (59%) had stable or shrinking aneurysm diameter. Univariate and Cox regression analyses identified the maximum diameter of the endoleak cavity, ie, the size of the nidus as defined on contrast computed tomography scan, as a significant predictor for aneurysm enlargement (relative risk, 1.12; 95% confidence interval, 1.04-1.19; P =.001). The median size of the nidus was 23 mm (range, 13-40 mm) in patients with aneurysm enlargement and 8 mm (range, 5-25 mm) in those without expansion (Mann-Whitney U test, P <.001). Moreover, receiver operating characteristic curve and Cox regression analyses showed that a maximum nidus diameter greater than 15 mm was particularly associated with an increased risk of aneurysm enlargement (relative risk, 11.1; 95% confidence interval, 1.4-85.8; P =.02). Other risk factors including gender, smoking history, hypertension, need of anticoagulation, aneurysm diameter, type of endograft used, and number or type of collateral vessels were not significant predictors of aneurysm enlargement. CONCLUSIONS: In patients with persistent type II endoleaks after EVAR, the maximum diameter of the endoleak cavity or nidus is an important predictor of aneurysm growth and might indicate the need for more aggressive surveillance as well as earlier treatment.

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PubMed2004

Fate of collateral vessels following subintimal angioplasty.

PURPOSE: To evaluate the fate of collateral vessels adjacent to and within the target lesion following subintimal angioplasty (SIA). METHODS: Pre and postprocedural angiograms were reviewed for 29 patients undergoing SIA of the lower extremity arteries over a 3-year period. The number of patent collateral vessels </=5 cm proximal to the occlusion (proximal segment) and </=5 cm distal to the occlusion (distal segment) were recorded pre and postprocedurally and compared. In addition, the number of collateral vessels that were re-opened within the recanalized segment following SIA was counted. RESULTS: The mean number of patent collaterals in the proximal segment was 1.9 (range 0-4) preprocedurally and 1.4 (range 0-4) postprocedurally (p<0.002). The mean number of patent collaterals in the distal segment was 1.9 (range 0-4) pre-procedurally and 1.0 (range 0-4) postprocedurally (p<0.0001). Previously absent collaterals within the recanalized segment were observed in 4 (14%) of 29 patients post-SIA. The mean number of collateral vessels within all 3 segments (proximal, treated, and distal) was 3.9 collaterals preprocedurally and 2.9 collaterals postprocedurally. CONCLUSIONS: Some collateral vessels are sacrificed during SIA, but the majority are preserved. In addition, SIA has the potential to open new collaterals within the occluded segment. These collaterals may play an important role should restenosis develop within the target segment.

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PubMed2003

Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct.

OBJECTIVES: The purpose of this study was to review our experience with delayed open conversion (>30 days) following endovascular aortoiliac aneurysm repair (EVAR) and to introduce the concept and advantages of endograft retention in this setting. METHODS: From January 1992 to January 2003, a total of 386 EVARs using a variety of endografts were successfully deployed. Eleven (2.8%) patients required delayed conversion to open repair at an average of 30 months (range, 10-64). Data from all patients undergoing both EVAR and open conversion were prospectively collected. RESULTS: EVARs were performed using grafts made by Talent (4), Vanguard (2,) AneuRx (1), and Surgeon (4). Conversion to open repair (9 transabdominal, 1 retroperitoneal, 1 transabdominal plus thoracotomy) was performed for aneurysm rupture in 7 patients (4 type 1 endoleak, 2 type 2 endoleak, 1 aortoenteric fistula) and aneurysm enlargement in 4 patients (1 type 1 endoleak, 1 type 2 endoleak, 1 type 3 endoleak, 1 endotension). Patients with aneurysm rupture were treated on an emergent basis. Complete removal of the endograft with supraceliac cross-clamping was performed in two cases. One patient (rupture) did not survive the operation, and one patient (aortoenteric fistula) died 2 weeks postoperatively. In the remaining nine cases, the endograft was either completely (1) or partially (6) removed, or left in situ (2). Supraceliac balloon control (2), supraceliac clamping (1), suprarenal clamping (1), or infrarenal clamping (5) was used in these cases. All nine of these patients survived the operation. In one procedure in which the endograft was left intact (endotension), repair was accomplished by exposing the endograft and by placing a standard tube graft over it as a sleeve. In the second procedure in which the graft was left in situ (rupture), the graft was well incorporated, and bleeding lumbar arteries were oversewn and the sac was closed tightly over the endograft. In the remaining 7 cases, the endograft was transected and the proximal portion only (6) or the proximal and distal portions (1) were excised. All surviving patients continue to do well and remain without complications associated with the endograft remnant at a mean follow-up of 22 months (range, 3-56) from the time of open conversion and 46 months (range, 10-73) from the time of original EVAR. CONCLUSIONS: Open repair in the setting of a long-standing endograft offers several unique technical challenges but can be successfully accomplished in most patients. Preservation of all or part of the endograft is possible in many patients. This technique simplifies the operative approach and is preferred over complete endograft removal if possible.

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PubMed2003

Iliac artery stenting in patients with poor distal runoff: Influence of concomitant infrainguinal arterial reconstruction.

OBJECTIVE: Inadequate infrainguinal runoff is considered an important risk factor for iliac stent failure. However, the influence of concomitant infrainguinal arterial reconstruction (CIAR) on iliac stent patency is unknown. This study evaluated the influence of CIAR on outcome of iliac angioplasty and stenting (IAS) in patients with poor distal runoff. METHODS: Over 5 years (1996 to 2001), 68 IAS procedures (78 stents) were performed in 62 patients with poor distal runoff (angiographic runoff score >or=5). The SVS/AAVS reporting standards were followed to define outcome variables and risk factors. Data were analyzed with both univariate analysis (Kaplan-Meier method [K-M]) and regression analysis (Cox proportional hazards model). RESULTS: Indications for iliac artery stenting were disabling claudication (59%) and limb salvage (41%). Of the 68 procedures, IAS with CIAR was performed in 31 patients (46%), and IAS alone was performed in 37 patients (54%). Patients undergoing IAS with CIAR were older (P =.03) and had more extensive and multifocal iliac artery occlusive disease, with more TASC (TransAtlantic Inter-Society Consensus) type C lesions (P =.03), compared with patients undergoing IAS alone. No other significant differences in risk factors were noted. Runoff scores between patients undergoing IAS with CIAR and those undergoing IAS alone were not significantly different (median runoff scores, 6 [range, 5-8] and 7 [range, 5-9], respectively; P =.77). Primary stent patency rate at 1, 3, and 5 years was 87%, 54%, and 42%, respectively, for patients undergoing IAS with CIAR, and was 76%, 66%, and 55%, respectively, for patients undergoing IAS. Univariate analysis revealed that primary stent patency rate was not significantly different between the 2 groups (K-M, log-rank test, P =.81). Primary graft patency rate for CIAR was 81%, 52%, and 46% at 1, 3, and 5 years, respectively. Performing CIAR did not affect primary iliac stent patency (relative risk, 1.1; 95% confidence interval, 0.49-2.47; P =.81). Overall, there was a trend toward improved limb salvage in patients undergoing IAS with CIAR, compared with those undergoing IAS alone (K-M, log rank test, P =.07). CONCLUSION: In patients undergoing IAS with poor distal runoff, CIAR does not improve iliac artery stent patency. Infrainguinal bypass procedures should therefore be reserved for patients who do not demonstrate clinical improvement and possibly for those with limb-threatening ischemia.

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PubMed2003

Does transrenal fixation of aortic endografts impair renal function?

OBJECTIVES: Transrenal fixation (TFX) of aortic endografts is thought to increase the risk for renal infarction and impaired renal function. We studied the late effects of TFX on renal function and perfusion. METHODS: Of 189 patients with commercial aortic endografts, which we inserted between 1995 and 2002, we reviewed data for 130 patients (112 men, 18 women) with available creatinine (Cr) concentration and contrast enhanced computed tomography (CT) scans preoperatively and 1 to 97 months after the procedure. Of the 130 patients, 69 patients had TFX and 61 patients had infrarenal fixation (IFX). Both groups were physiologically comparable. Average age was 76 +/- 8 years for patients with TFX and 75 +/- 8 years for patients with IFX. Presence of renal infarct or renal artery occlusion was determined by nephrograms on serial contrast-enhanced CT scans. RESULTS: Mean follow-up was 17 +/- 16 months (range, 1-54 months) for TFX and 21 +/- 21 months (range, 1-97 months) for IFX. Mean serum Cr concentration increased significantly during long-term follow-up in both groups (TFX, 1.3 +/- 0.5 mg/dL to 1.5 +/- 0.8 mg/dL, P <.01; IFX, 1.3 +/- 0.7 mg/dL to 1.4 +/- 0.8 mg/dL, P <.03). Creatinine clearance (CrCl) similarly decreased over long-term follow-up in both groups (TFX, 53.3 +/- 17.7 mL/min/1.73 m(2) to 47.9 +/- 16.2 mL/min/1.73 m(2), P <.01; IFX, 58.1 +/- 22.7 mL/min/1.73 m(2) to 53.1 +/- 23.4 mL/min/1.73 m(2), P <.02). There were no significant differences in the increase in Cr concentration (P =.19) or decrease in CrCl (P =.68) between TFX and IFX groups. Small renal infarcts were noted in four patients (5.8%) in the TFX group and one patient (1.6%) in the IFX group. No increase in Cr concentration or decrease in CrCl was noted in any patient with a renal infarct. Postoperative renal dysfunction developed in 7 of 69 patients (10.1%) in the TFX group and 7 of 61 patients (11.5%) in the IFX group. There were no statistically significant differences between groups with respect to number of patients with new renal infarcts (P =.37) or postoperative renal dysfunction (P =.81). CONCLUSION: There is a slight increase in serum Cr concentration and decrease in CrCl after aortic endografting. However, there was no significant difference in these changes between patients with TFX and IFX. Although TFX may produce a higher incidence of small renal infarcts, these do not impair renal function. Thus our midterm results suggest that TFX can be performed safely, with no greater change in renal function than observed after IFX.

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PubMed2003

Endovascular abdominal aortic aneurysm repair to prevent rupture in a patient requiring lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) for urolithiasis may result in rupture of a coexistent abdominal aortic aneurysm (AAA). We report a patient who required ESWL and who had an AAA. Open surgery was precluded by morbid obesity and persisting incisional hernias after mesh repair. Endovascular AAA repair (EVAR) with bifurcated grafts was precluded by an 11-mm distal aorta. EVAR with stacked tubular AneuRx components was performed, followed by ESWL. The AAA was excluded, and the integrity and position of the endografts were not altered by ESWL.

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PubMed2003

Intra-abdominal aortic graft infection: complete or partial graft preservation in patients at very high risk.

BACKGROUND: Total graft excision with in situ or extra-anatomic revascularization is considered mandatory to treat infection involving the body of aortic grafts. We present a series of nine patients with this complication and such severe comorbid medical illnesses or markedly hostile abdomens that traditional treatments were precluded. In these patients selective complete or partial graft preservation was used. METHODS: Over the past 20 years we have treated nine infected infrarenal aortic prosthetic grafts with complete or partial graft preservation, because excision of the graft body was not feasible. In all nine patients infection of the main body of the aortic graft was documented at computed tomography or surgery. Essential adjuncts included percutaneous or operative drain placement into retroperitoneal abscess cavities and along the graft, with instillation of antibiotics three times daily, repeated debridement of infected groin wounds, and intravenous antibiotic therapy for at least 6 weeks. RESULTS: One patient with purulent groin drainage treated with complete graft preservation died of sepsis. One patient with groin infection treated with complete graft preservation initially did well, but ultimately required total graft excision 5 months later, after clinical improvement. In four patients complete graft preservation was successful; two patients required excision of an occluded infected limb of the graft; and one patient underwent subtotal graft excision, leaving a graft remnant on the aorta, and axillopopliteal bypass. In summary, seven of nine patients survived hospitalization after complete or partial graft preservation; amputation was avoided in all but one patient; and no recurrent infection developed over mean follow-up of 7.6 years (range, 2-15 years). CONCLUSIONS: Although contrary to conventional concepts, partial or complete graft preservation combined with aggressive drainage and groin wound debridement is an acceptable option for treatment of infection involving an entire aortic graft in selected patients with prohibitive risks for total graft excision. This treatment may be compatible with long-term survival and protracted absence of signs or symptoms of infection.

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PubMed2003

Patency rates of femorofemoral bypasses associated with endovascular aneurysm repair surpass those performed for occlusive disease.

PURPOSE: To evaluate the patency rates of femorofemoral grafts performed in conjunction with aortomonoiliac or aortomonofemoral (AMI/F) endografts. METHODS: Over the past 8 years, 110 patients (98 men; mean age 77+/-7 years, range 57-90) underwent aortoiliac aneurysm repair with an AMI/F endograft. Follow-up data in these patients were prospectively collected for a mean 2.3 years (range 1-68 months). RESULTS: There were 2 early (<7 days) AMI/F endograft thromboses with secondary femorofemoral graft occlusion. In both patients, patency of all grafts was restored by thrombectomy plus stenting of the endograft. Three late (4, 5, and 10 months) AMI/F endograft thromboses led to femorofemoral graft failure; 2 were successfully treated, but the third patient refused further intervention. No femorofemoral bypass failed in the absence of AMI/F endograft thrombosis. There were no femorofemoral graft infections. Four-year life-table primary and secondary patency rates were 95% and 99%, respectively. CONCLUSIONS: Femorofemoral bypasses with AMI/F endografts for aneurysmal disease are durable procedures and have better patency than femorofemoral grafts used to treat occlusive disease. Femorofemoral bypass patency rates alone are not a disadvantage of aortomonoiliac endografts.

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PubMed2002

Spontaneous recanalization of arterial occlusions: an unusual mechanism for symptomatic improvement.

OBJECTIVE: Patients with infrainguinal occlusive disease may experience spontaneous symptomatic improvement. This is generally thought to be from augmented collateral circulation. This study reports another mechanism. METHODS: Over a 20-year period, 4123 patients underwent lower extremity arteriography for limb ischemia. For a variety of reasons, 451 patients had repeat arteriography. RESULTS: Five patients were identified as having conclusive arteriographic evidence of spontaneous recanalization of occluded arterial segments without having undergone any surgical or thrombolytic interventions. Repeat contrast arteriography was performed on these patients for failing grafts (n = 2) or contralateral lower extremity ischemia (n = 3). Three other patients had magnetic resonance arteriographic or duplex arteriographic evidence of spontaneous arterial recanalization. Spontaneous recanalizaton occurred in ileofemoral (n = 2), superficial femoral (n = 2), popliteal (n = 3), and peroneal (n = 1) arterial segments. The average time interval of occlusion to recanalization was 21 weeks (2 weeks to 2 years). Two of the eight patients had failed revascularization procedures before spontaneous recanalization. All eight patients had restoration of pulses distal to the recanalized segments and significant symptomatic improvement as defined with the Society for Vascular Surgery/American Association for Vascular Surgery categories for limb ischemia. CONCLUSION: Spontaneous recanalization of arterial segments can occur and must be considered when evaluating other proposed treatments of critical limb ischemia, including cilostazol, lytic agents, and angiogenic agents, such as vascular endothelial growth factor. Although its true incidence is unknown, this represents another mechanism for spontaneous symptomatic improvement without treatment in patients with severe limb ischemia.

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