Recent Clinical Projects – Vascular

Below are a few of our publications on vascular surgery. A more comprehensive list can be found on our Clinical Publications webpage.

Anomalous origin of the right coronary artery: right internal thoracic artery to right coronary artery bypass is not the answer. Fedoruk LM, Kern JA, Peeler BB, Kron IL. J Thorac Cardiovasc Surg. 133(2):456-60, 2007.

OBJECTIVE: Anomalous origin of the right coronary artery from the opposite sinus of Valsalva can be a lethal congenital anomaly. Right internal thoracic artery grafting to the right coronary artery is prone to fail in this circumstance. We sought to describe alternative surgical techniques.  METHODS: Retrospective analysis identified 5 adult and pediatric patients in our database. We reviewed the surgical techniques used to repair this anomaly. On the basis of our experience, we describe our management technique.  RESULTS: There were no operative deaths, and postoperative computed tomographic scans demonstrated widely patent repairs in all patients. Two patients with previous right internal thoracic artery to right coronary artery grafts presented with occlusion of the right internal thoracic artery. Short-term follow-up demonstrated continued patency.  CONCLUSION: Right internal thoracic artery grafting fails in this circumstance, and alternative surgical options provide a good outcome.

Early repair of complete atrioventricular septal defect is safe and effective.  Singh RR, Warren PS, Reece TB, Ellman P, Peeler BB, Kron IL.  Ann Thorac Surg. 82(5):1598-601, 2006.

BACKGROUND: Surgical repair of complete atrioventricular septal defect (CAVSD) is a well-established procedure performed on young children. Our hypothesis is that with modern techniques, the current risks of CAVSD repair in children aged younger than 3 months and in children older than 3 months are equal.  METHODS: This was a retrospective review of 65 infants and children with a mean age of 10.9 months (range, 1 month to 15.5 years) who underwent CAVSD repair from 1990 to 2004. Twenty-six repairs (40%) were done on or before 3 months of age (group A) and 39 repairs (60%) were done after 3 months of age (group B). In all patients, the ventricular septal defect was repaired with an individualized approach according to each patient's specific anatomy: direct suturing without a patch, interposition of a small pericardial patch with a running suture, or both. The atrioventricular commissure was closed with interrupted sutures, and all atrial defects were closed with a pericardial patch. Data were analyzed using the chi2 analysis and the Fisher exact test.  RESULTS: Three hospital deaths occurred (<30 days), 2 in group A and 1 in group B (7.7% vs 2.6%, respectively, p = 0.33). One death in group A occurred during another noncardiac surgery. Early reoperation (<1 year of initial surgery) for residual ventricular septal defect or significant mitral regurgitation, or both, occurred in 3 group A patients and in 4 group B patients (11.5% versus 10.3% respectively, p = 0.68).  CONCLUSIONS: These results suggest that repair of CAVSD defects in children 3 months of age or younger had similar outcomes compared with those who underwent surgical repair after 3 months of age.

Coarctation of a right aortic arch. Maxey TS, Bradner MW, Reece TB, Keeling WB, Kron IL. J Card Surg. 21(3):261-3, 2006.

Right-sided aortic arch with a concomitant coarctation is an exceedingly rare congenital cardiac anomaly. We report of a 4-year-old boy who presented with a history of a stenotic bicuspid aortic valve who upon further evaluation was found to have a coarctation of a right-sided aortic arch. The frequency with which other anomalies exist in either of the above conditions requires thorough cardiac evaluation and detailed imaging. Surgical repair of this anomaly can safely be undertaken through a right thoracotomy.

Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft. Gazoni LM, Carty R, Skinner J, Cherry KJ, Harthun NL, Kron IL, Tribble CG, and Kern JA. J Vasc Surg 44:282-287, 2006.

BACKGROUND: Although the use of endoscopic vein harvest (EVH) in coronary artery bypass grafting is accepted, few studies have documented the implementation of EVH in peripheral vascular disease surgery. We hypothesized that EVH improves outcomes compared with open vein harvest (OVH) in patients undergoing femoral to below the knee arterial bypass surgery. METHODS: The charts of 144 consecutive patients undergoing infrainguinal bypass surgery over the course of 27 months were reviewed. A femoral to below the knee arterial bypass with saphenous vein was done in 88 patients (29 had EVH, 59 had OVH). The preoperative characteristics evaluated were age, gender, renal function, history of diabetes, hypertension, tobacco use, and previous infrainguinal bypass surgery on the affected side. End points included wound complications, length of hospital stay, operative time, angiographic and operative interventions for graft occlusion, patency rates, limb salvage, acute renal failure, myocardial infarction, and death. RESULTS: Patient characteristics and demographics were similar in the EVH and OVH groups. No operative intervention for occlusion was required in the EVH group (0/29) compared with 13.4% in the OVH group (8/59) (P = .03). At the mean follow-up time of 21 months, primary patency rate was 92.8% in the EVH group and 80.6% in the OVH group (P = .12). No significant differences were found between the EVH and OVH groups in postoperative complications, length of hospital stay, operative time, patency rates, limb salvage, and death. CONCLUSION: Despite our initial concerns of damaging the venous conduit with a minimally invasive approach to saphenous vein harvest, EVH in our experience has resulted in a trend toward improved patency rates and decreased infectious wound complications while affording the benefit of improved cosmesis. An endoscopic approach results in smaller incisions, decreased interventions for occlusion, and improved outcomes compared with OVH. EVH is the procedure of choice for harvesting saphenous vein for femoral to below the knee arterial bypass surgery.

Thoracic aortic endografting is the treatment of choice for elderly patients with thoracic aortic disease. Kern JA, Matsumoto AH, Tribble CG, Gazoni LM, Peeler BB, Harthun NL, Chong T, Cherry KJ, Dake MD, Angle JS, Kron IL. Ann Surg 243:815-820, 2006.

OBJECTIVE: To assess the effect of age on outcomes following thoracic aortic endografting. BACKGROUND: Endograft therapy for thoracic aortic disease is rapidly evolving. This therapy is less invasive, and elderly patients with significant medical comorbidities are more frequently referred for endografting. We hypothesized that elderly patients over the age of 75 have worse outcomes after thoracic endografting than patients under the age of 75. METHODS: We retrospectively reviewed the charts of the first 42 patients who underwent endografting for thoracic aortic pathology. Charts were reviewed for demographics, comorbid conditions, perioperative complications and death, endoleaks, and results at 3, 6, and 12 months. Preexisting medical conditions were also evaluated to determine if any patient characteristics were associated with adverse outcomes. Perioperative morbidity included cardiac, pulmonary, renal, hemorrhagic, and neurologic (stroke and spinal cord injury) complications. RESULTS: Twenty-four patients were under the age of 75, and 18 patients were 75 or older. Baseline demographics and comorbidities were similar between the 2 groups. There were no differences in operative time, length of stay, perioperative mortality, or the incidence of significant complications between the 2 age groups. Gender, however, was associated with a statistically significant difference between the occurrence of complications, with more women experiencing complications than men (P = 0.026, relative risk = 2.36). One patient (age >75 years) in the entire cohort of 42 (2.4%) suffered a spinal cord injury. At 3 months, endoleaks were more common in the older age group (P = 0.059). CONCLUSION: Endograft therapy for thoracic aortic disease can be performed safely in elderly patients with no significant increase in perioperative morbidity or mortality compared with younger patients. Female gender is associated with a higher likelihood of perioperative complications, regardless of age. The overall incidence of spinal cord injury is very low. Endograft therapy, when anatomically possible, is the treatment of choice for thoracic aortic disease in elderly patients.

Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft. Gazoni LM, Carty R, Skinner J, Cherry KJ, Harthun NL, Kron IL, Tribble CG, and Kern JA. J Vasc Surg 44:282-287, 2006.

BACKGROUND: Although the use of endoscopic vein harvest (EVH) in coronary artery bypass grafting is accepted, few studies have documented the implementation of EVH in peripheral vascular disease surgery. We hypothesized that EVH improves outcomes compared with open vein harvest (OVH) in patients undergoing femoral to below the knee arterial bypass surgery. METHODS: The charts of 144 consecutive patients undergoing infrainguinal bypass surgery over the course of 27 months were reviewed. A femoral to below the knee arterial bypass with saphenous vein was done in 88 patients (29 had EVH, 59 had OVH). The preoperative characteristics evaluated were age, gender, renal function, history of diabetes, hypertension, tobacco use, and previous infrainguinal bypass surgery on the affected side. End points included wound complications, length of hospital stay, operative time, angiographic and operative interventions for graft occlusion, patency rates, limb salvage, acute renal failure, myocardial infarction, and death. RESULTS: Patient characteristics and demographics were similar in the EVH and OVH groups. No operative intervention for occlusion was required in the EVH group (0/29) compared with 13.4% in the OVH group (8/59) (P = .03). At the mean follow-up time of 21 months, primary patency rate was 92.8% in the EVH group and 80.6% in the OVH group (P = .12). No significant differences were found between the EVH and OVH groups in postoperative complications, length of hospital stay, operative time, patency rates, limb salvage, and death. CONCLUSION: Despite our initial concerns of damaging the venous conduit with a minimally invasive approach to saphenous vein harvest, EVH in our experience has resulted in a trend toward improved patency rates and decreased infectious wound complications while affording the benefit of improved cosmesis. An endoscopic approach results in smaller incisions, decreased interventions for occlusion, and improved outcomes compared with OVH. EVH is the procedure of choice for harvesting saphenous vein for femoral to below the knee arterial bypass surgery.

Preoperative shock determines outcome for acute type A aortic dissection. Long SM, Tribble CG, Raymond DP, Fiser SM, Kaza AK, Kern JA, and Kron IL. Ann Thorac Surg 75:520-524, 2003.

BACKGROUND: Acute type A aortic dissection is a life-threatening catastrophe. Surgical results have not improved. METHODS: The charts of all 70 patients surgically treated for acute type A primary aortic dissection during the period of January 1988 through April 2001 were reviewed. RESULTS: Average age was 59 +/- 2 years. Comorbidities included hypertension (66%), coronary artery disease (17%), and Marfan's syndrome (11%). At presentation, 23% were in shock, 17% had neurologic dysfunction, and 36% had coronary ischemia. The aortic valve was preserved in 55. Distal aortic anastomosis was performed under aortic cross-clamp ("closed") in 32 and "open" under circulatory arrest in 38 patients. Operative mortality was 18.6% (13 of 70 patients). Patients in shock had an operative mortality of 50% compared with stable patients of 9% (p = 0.0002). Mortality was similar regardless of technique. Univariate analysis revealed preoperative shock (p = 0.0002), tamponade (p = 0.003), and neurologic deficit (p = 0.02) to be associated with mortality. Multivariate analysis revealed hemodynamic stability (odds ratio = 0.10, p = 0.04) and outside transfer (odds ratio = 0.12, p = 0.03) to be negative predictors of mortality. Of 57 survivors, follow-up was 93% complete for an average of 46 +/- 6 months. The overall late reoperation rate was 24.6% (14 of 57 patients) at 50.3 +/- 12.3 months. Twelve patients (21%) underwent future aortic aneurysmal repair. No difference in reoperation rate was seen comparing "closed" (26%) with "open" (18%; p = 0.46). Of 42 preserved native valves, only 3 (7.1%) needed future valve replacement. CONCLUSIONS: In our experience, operative mortality was determined by preoperative hemodynamic instability. Technique did not impact survival or late reoperation. Early diagnosis and repair is critical to improving survival.