Clinical Focus

  • Vascular Surgery

Academic Appointments

Administrative Appointments

  • Program Director, Vascular Surgery Fellowship/Residency (2011 - Present)
  • Director of Endovascular Surgery, Stanford Hospital and Clinics (2007 - Present)
  • Curriculum Committee, Goodman Simulation Center (2006 - Present)

Professional Education

  • Residency:LA CO-Harbor-UCLA Medical Center (2004) CA
  • Board Certification: Vascular Surgery, American Board of Surgery (2007)
  • Fellowship:Stanford University Medical Center (2006) CA
  • Board Certification: General Surgery, American Board of Surgery (2005)
  • Internship:LA CO-Harbor-UCLA Medical Center (1999) CA
  • Medical Education:University of California San Diego (1998) CA
  • Fellowship, Stanford Univ. Medical Center, Vascular Surgery (2006)
  • Residency, Harbor-UCLA Medical Center, General Surgery (2004)
  • MD, UC San Diego School of Medicine (1998)

Research & Scholarship

Current Research and Scholarly Interests

Describe your current research interest and activities

Clinical Trials

  • Zenith(R) Low Profile AAA Endovascular Graft Clinical Study Recruiting

    The Zenith® Low Profile AAA Endovascular Graft Clinical Study is a clinical trial approved by US FDA to study the safety and effectiveness of the Zenith® Low Profile AAA Endovascular Graft used in conjunction with the Zenith® Spiral-Z® AAA Iliac Leg Graft to treat abdominal aortic, aorto-iliac, and iliac aneurysms.

    View full details

  • Prevention of Colon Ischemia During Aortic Aneurysm (AAA) Repair Not Recruiting

    Patients undergoing surgery on their Aorta can get ischemia, a lack of blood flow, to their intestines and colon. This is very serious, as 2 out of 3 patients who have this problem die before leaving the hospital. A device developed by Spectros, called T-Stat, is approved by the US FDA to detect ischemia, and has been reported to detect ischemia in AAA aneurysm surgery and stenting, allowing the surgeon or interventional radiologist to take action quickly, while the colon ischemia is still treatable. This purpose of this study is to establish how T-Stat can best be used to prevent deaths.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jason Lee, (650) 725 - 5227.

    View full details

  • Protected Carotid Artery Stenting in Subjects at High Risk for Carotid Endarterectomy (CEA) (PROTECT) Not Recruiting

    The purpose of this study is to evaluate the long-term safety and efficacy of the Xact™ Rapid Exchange Carotid Stent System used in conjunction with the Emboshield® Pro Rapid Exchange Embolic Protection System (Generation 5) and the Emboshield® BareWire™ Rapid Exchange Embolic Protection System (Generation 3), in the treatment of atherosclerotic carotid artery disease in high-surgical risk subjects.

    Stanford is currently not accepting patients for this trial. For more information, please contact Ronald Dalman, (650) 725 - 5227.

    View full details

  • Endovascular Repair of Descending Thoracic Aortic Aneurysms Not Recruiting

    The purpose of this study is to determine whether the system is safe and effective for the intended use of treating descending thoracic aortic aneurysms.

    Stanford is currently not accepting patients for this trial. For more information, please contact Christopher Zarins, (650) 725 - 5227.

    View full details

  • The (PIVOTAL) Study Not Recruiting

    The purpose of this study is to compare endovascular repair using any FDA approved Medtronic AAA Stent Graft System versus surveillance in subjects with smaller abdominal aortic aneurysms (AAA)(4-5CM), with respect to AAA rupture and AAA related deaths.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jason Lee, (650) 725 - 5227.

    View full details

  • CHOICE: Carotid Stenting For High Surgical-Risk Patients Not Recruiting

    The purposes of this study is to 1) Provide additional information that the commercially available Abbott Vascular Carotid Stent Systems and Embolic Protection Systems can be used successfully by a wide range of physicians under commercial use conditions. 2) Provide an ongoing post-market surveillance mechanism for documentation of clinical outcomes and for possible extension of the Centers for Medicare and Medicaid Services (CMS) coverage to a broader group of patients.

    Stanford is currently not accepting patients for this trial. For more information, please contact Ronald Dalman, (650) 725 - 5227.

    View full details

  • Plaque Removal Versus Open Bypass Surgery For Critical Limb Ischemia Not Recruiting

    To compare the outcome of bypass surgery and plaque excision for treatment of critical limb ischemia in the lower limbs

    Stanford is currently not accepting patients for this trial. For more information, please contact Jason Lee, (650) 725 - 5227.

    View full details

  • Endurant Bifurcated and Aorto-Uni-Iliac (AUI) Stent Graft System Not Recruiting

    To demonstrate safety and effectiveness of the Endurant Stent Graft in the treatment of Abdominal Aortic or Aorto-Uni-Iliac Aneurysms.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jason Lee, (650) 725 - 5227.

    View full details

  • PRESERVE-Zenith® Iliac Branch Clinical Study Recruiting

    The PRESERVE-Zenith® Iliac Branch Clinical Study is a clinical trial to study the safety and effectiveness of the Zenith® Branch Endovascular Graft-Iliac Bifurcation in combination with the Zenith® Connection Endovascular Stent/ConnectSX™/Atrium iCAST™ covered stent in the treatment of aorto-iliac and iliac aneurysms.

    View full details

  • Endurant Stent Graft System Post Approval Study Not Recruiting

    The purpose of the study is to demonstrate the long term safety and effectiveness of the Endurant Stent Graft System for the endovascular treatment of infrarenal abdominal aortic aneurysms in a post-approval environment, through the endpoints established in this protocol. The clinical objective of the study is to evaluate the long term safety and effectiveness of the Endurant Stent Graft System assessed at 5 years through freedom from Aneurysm-Related Mortality (ARM).

    Stanford is currently not accepting patients for this trial. For more information, please contact Ronald Dalman, (650) 725 - 5227.

    View full details

  • Prospective Aneurysm Trial: High Angle Aorfix™ Bifurcated Stent Graft Not Recruiting

    Purpose of this study: The purpose of the study is to evaluate the safety and effectiveness of the Lombard Medical endovascular Aorfix™ AAA bifurcated stent graft in the treatment of abdominal aortic, aorto-iliac and common iliac aneurysms with anatomies including angled aorta, angled aneurysmal body, or both, between 0° and 90°. Study hypothesis: The primary efficacy hypothesis is the proportion of grafts remaining free from endoleak, migration, and fracture at 12 months. Efficacy: The 12 month, all cause mortality rate in the Aorfix™ group will be non-inferior to the 12 month, all cause mortality rate in the Open Control group. Safety: The rates of early serious adverse events between 0 and 30 days post-operative in the Aorfix™ groups will be non-inferior to the early serious adverse event rates between 0 and 30 days post-operative in the Open Control group.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jason Lee, (650) 725 - 5227.

    View full details

  • Endovascular Repair of Abdominal Aortic Aneurysms Not Recruiting

    The purpose of this study is to determine if it is safe and effective to use the TALENT AAA Stent Graft System as a treatment for AAAs in patients who are also candidates for conventional surgical aneurysm repair.

    Stanford is currently not accepting patients for this trial. For more information, please contact Christopher Zarins, (650) 725 - 5227.

    View full details


2014-15 Courses


Journal Articles

  • Venous Thromboembolic Disease Clinical Practice Guidelines in Oncology JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Streiff, M. B., Bockenstedt, P. L., Cataland, S. R., Chesney, C., Eby, C., Fanikos, J., Fogerty, A. E., Gao, S., Goldhaber, S. Z., Hassoun, H., Hendrie, P., Holmstrom, B., Kuderer, N., Lee, J. T., Millenson, M. M., Neff, A. T., Ortel, T. L., Siddiqi, T., Smith, J. L., Yee, G. C., Zakarija, A., McMillian, N., Naganuma, M. 2013; 11 (11): 1402-1429


    Venous thromboembolism (VTE) remains a common and life-threatening complication among patients with cancer. Thromboprophylaxis can be used to prevent the occurrence of VTE in patients with cancer who are considered at high risk for developing this complication. Therefore, it is critical to recognize the various risk factors for VTE in patients with cancer. Risk assessment tools are available to help identify patients for whom discussions regarding the potential benefits and risks of thromboprophylaxis would be appropriate. The NCCN Clinical Practice Guidelines in Oncology for VTE provide recommendations on risk evaluation, diagnosis, prevention, and treatment of VTE in patients with cancer.

    View details for Web of Science ID 000327066800009

  • Factors impacting follow-up care after placement of temporary inferior vena cava filters JOURNAL OF VASCULAR SURGERY Gyang, E., Zayed, M., Harris, E. J., Lee, J. T., Dalman, R. L., Mell, M. W. 2013; 58 (2): 440-445


    OBJECTIVE: Rates of inferior vena cava (IVC) filter retrieval have remained suboptimal, in part because of poor follow-up. The goal of our study was to determine demographic and clinical factors predictive of IVC filter follow-up care in a university hospital setting. METHODS: We reviewed 250 consecutive patients who received an IVC filter placement with the intention of subsequent retrieval between March 2009 and October 2010. Patient demographics, clinical factors, and physician specialty were evaluated. Multivariate logistic regression analysis was performed to identify variables predicting follow-up care. RESULTS: In our cohort, 60.7% of patients received follow-up care; of those, 93% had IVC filter retrieval. Major indications for IVC filter placement were prophylaxis for high risk surgery (53%) and venous thromboembolic event with contraindication and/or failure of anticoagulation (39%). Follow-up care was less likely for patients discharged to acute rehabilitation or skilled nursing facilities (P < .0001), those with central nervous system pathology (eg, cerebral hemorrhage or spinal fracture; P < .0001), and for those who did not receive an IVC filter placement by a vascular surgeon (P < .0001). In a multivariate analysis, discharge home (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.99-8.2; P < .0001), central nervous system pathology (OR, 0.46; 95% CI, 0.22-0.95; P = .04), and IVC filter placement by the vascular surgery service (OR, 4.7; 95% CI, 2.3-9.6; P < .0001) remained independent predictors of follow-up care. Trauma status and distance of residence did not significantly impact likelihood of patient follow-up. CONCLUSIONS: Service-dependent practice paradigms play a critical role in patient follow-up and IVC filter retrieval rates. Nevertheless, specific patient populations are more prone to having poorer rates of follow-up. Such trends should be factored into institutional quality control goals and patient-centered care.

    View details for DOI 10.1016/j.jvs.2012.12.085

    View details for Web of Science ID 000322759500029

  • EVAR Deployment in Anatomically Challenging Necks Outside the IFU EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY Lee, J. T., Ullery, B. W., Zarins, C. K., Olcott, C., Harris, E. J., Dalman, R. L. 2013; 46 (1): 65-73


    Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points.A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU).IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all p < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs. 2.1%, p = .003), and needed increased fluoroscopy time (31 vs. 25 minutes, p = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, p = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05).EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.

    View details for DOI 10.1016/j.ejvs.2013.03.027

    View details for Web of Science ID 000321883200013

    View details for PubMedID 23628325

  • Differences in readmissions after open repair versus endovascular aneurysm repair JOURNAL OF VASCULAR SURGERY Casey, K., Hernandez-Boussard, T., Mell, M. W., Lee, J. T. 2013; 57 (1): 89-95


    Reintervention rates after repair of abdominal aortic aneurysm (AAA) are higher for endovascular repair (EVAR) than for open repair, mostly due to treatment for endoleaks, whereas open surgical operations for bowel obstruction and abdominal hernias are higher after open repair. However, readmission rates after EVAR or open repair for nonoperative conditions and complications that do not require an intervention are not well documented. We sought to determine reasons for all-cause readmissions within the first year after open repair and EVAR.Patients who underwent elective AAA repair in California during a 6-year period were identified from the Health Care and Utilization Project State Inpatient Database. All patients who had a readmission in California ≤1 year of their index procedure were included for evaluation. Readmission rates and primary and secondary diagnoses associated with each readmission were analyzed and recorded.From 2003 to 2008, there were 15,736 operations for elective AAA repair, comprising 9356 EVARs (60%) and 6380 open repairs (40%). At 1 year postoperatively, the readmission rate was 52.1% after open repair and 55.4% after EVAR (P=.0003). The three most common principle diagnoses associated with readmission after any type of AAA repair were failure to thrive, cardiac issues, and infection. When stratified by repair type, patients who underwent open repair were more likely to be readmitted with primary diagnoses associated with failure to thrive, cardiac complications, and infection compared with EVAR (all P<.001). Those who underwent EVAR were more likely, however, to be readmitted with primary diagnoses of device-related complications (P=.05), cardiac complications, and infection.Total readmission rates within 1 year after elective AAA repair are greater after EVAR than after open repair. Reasons for readmission vary between the two cohorts but are related to the magnitude of open surgery after open repair, device issues after EVAR, and the usual cardiac and infectious complications after either intervention. Systems-based analysis of these causes of readmission can potentially improve patient expectations and care after elective aneurysm repair.

    View details for DOI 10.1016/j.jvs.2012.07.005

    View details for Web of Science ID 000312833800016

  • A comparison of 0+5 versus 5+2 applicants to vascular surgery training programs JOURNAL OF VASCULAR SURGERY Zayed, M. A., Dalman, R. L., Lee, J. T. 2012; 56 (5): 1448-1452


    The new integrated 0 + 5 vascular surgery (VS) training paradigm introduced in 2007 required program directors and faculty to reconsider recruiting methods and exposure of medical students to VS. As a means to identify variables important for recruitment of 0 + 5 VS applicants, we sought to analyze national 0 + 5 VS residency application trends and to compare medical school demographics of applicants to both our 0 + 5 residency and 5 + 2 fellowship programs.Electronic Residency Application Service and National Resident Matching Program online public databases were queried to evaluate nationwide trends in the number of applicants to integrated VS residency programs between 2007 and 2010. Demographic data from Electronic Residency Application Service applications submitted to our institution's 0 + 5 and 5 + 2 VS training programs during the same time period were reviewed.From 2008 to 2011, there were 190 applicants to our 0 + 5 VS residency program and 161 applicants to our 5 + 2 fellowship program, with 127 (66.8%) and 122 (75.8%) being United States medical graduates, respectively. Annual application volume to our programs over these years remained stable for both training pathways (range, 39-49 for 0 + 5 integrated; range, 39-43 for 5 + 2 traditional). Nationally, applications to 0 + 5 programs increased sixfold over the same time period (52 in 2007 to 340 applicants in 2010; P < .001), far exceeding the available training positions. Compared with applicants to the 5 + 2 VS fellowships, medical students applying to the 0 + 5 programs are more likely to be female, be slightly older, have additional postgraduate degrees and publications, have higher United States Medical Licensure Examination test scores, and are more likely to be in the top quartile of their medical school class.Nationwide interest in the 0 + 5 vascular surgery residency training paradigm continues to significantly increase. Significant differences exist between the cohorts of 0 + 5 residency and 5 + 2 fellowship program applicants at the completion of medical school, suggesting that 0 + 5 VS residency programs are attracting a different medical student population to the VS specialty. VS program directors should continue to foster interest in this new applicant pool through early exposure, mentorship, and extracurricular research activities.

    View details for DOI 10.1016/j.jvs.2012.05.083

    View details for Web of Science ID 000310428200047

    View details for PubMedID 22857814

  • Could the endo-first strategy really be better? Archives of surgery Lee, J. T. 2012; 147 (9): 846-?

    View details for DOI 10.1001/archsurg.2012.2021

    View details for PubMedID 22987178

  • Transesophageal Echocardiography Guidance for Stent-Graft Repair of a Thoracic Aneurysm is Facilitated by the Ability of Partial Stent Deployment ANNALS OF VASCULAR SURGERY Crimi, E., Lee, J. T., Dake, M. D., van der Starre, P. J. 2012; 26 (6)


    Transesophageal echocardiography (TEE) is routinely used in our Institution for monitoring correct positioning of thoracic aortic stent grafts. We present a case of successful endovascular repair of three discrete thoracic aortic aneurysms with Zenith TX2 endovascular stent grafts in an 82-year-old female patient. Our focus is on the increased value of TEE guidance because of the ability of partial stent deployment and manipulation during insertion.

    View details for DOI 10.1016/j.avsg.2012.01.013

    View details for Web of Science ID 000306436700028

    View details for PubMedID 22794345

  • Fenestrate What You Can't Snorkel? ANNALS OF VASCULAR SURGERY Zayed, M. A., Chowdhury, M., Casey, K., Dalman, R. L., Lee, J. T. 2012; 26 (5)


    Although challenging proximal necks have limited the utility of standard endovascular aneurysm repair (EVAR) devices, sophisticated endovascular techniques have evolved in recent years for the repair of juxtarenal abdominal aortic aneurysms (AAAs). Among these techniques, snorkel or chimney EVAR (sn-EVAR) and fenestrated EVAR (f-EVAR) have emerged as options for repairing anatomic high-risk AAAs. Unfortunately, in the United States, except in the context of a clinical trial or physician-sponsored device exemption, limited long-term data exist on the treatment of juxta- and suprarenal AAAs with either sn-EVAR or f-EVAR. Owing to these limitations, comparison of these two techniques is challenging, and we sought to describe a case when one was favored over the other.A 72-year-old man presented with an enlarging, asymptomatic, juxtarenal fusiform AAA (5.9 cm), a moderately enlarged right common iliac artery (2.8 cm), a history of oxygen-dependent chronic obstructive pulmonary disease, and a previous right nephrectomy. An initial sn-EVAR was attempted but was unsuccessful owing to the inability to deliver the "snorkel" covered stent via a brachial approach because of renal ostial stenosis and cephalad angulation of the patient's left renal artery. A subsequent f-EVAR approach was successfully used to repair the juxtarenal AAA while preserving adequate renal artery blood flow. Two-year postoperative follow-up demonstrated a stable endovascular repair without endoleaks, a shrinking aneurysm sac, and stable renal function.The sn-EVAR configuration in this case report was precluded by cephalad renal angulation, and the AAA was instead repaired using an f-EVAR approach, with good 2-year follow-up outcomes. The sn-EVAR strategy requires downward pointing renal arteries in addition to adequate brachial/axillary artery access dimensions to facilitate successful repair. With improving techniques and technology for either approach, anatomic specifications and indications for these advanced EVAR strategies will need to be delineated.

    View details for DOI 10.1016/j.avsg.2011.08.027

    View details for Web of Science ID 000304901500027

    View details for PubMedID 22664290

  • Hybrid Treatment of Celiac Artery Compression (Median Arcuate Ligament) Syndrome DIGESTIVE DISEASES AND SCIENCES Palmer, O. P., Tedesco, M., Casey, K., Lee, J. T., Poultsides, G. A. 2012; 57 (7): 1782-1785

    View details for DOI 10.1007/s10620-011-2019-x

    View details for Web of Science ID 000305746100009

    View details for PubMedID 22212729



    Vascular ultrasound can provide quick and reliable diagnosis of arterial bleeding but it requires trained and experienced personnel. Development of automated sonographic bleed detection methods would potentially be valuable for trauma management in the field. We propose a detection method that (1) measures blood flow in a trauma victim, (2) determines the victim's expected normal limb arterial flow using a power law biofluid model where flow is proportional to the vessel diameter taken to a power of k and (3) quantifies the difference between measured and expected flow with a novel metric, flow split deviation (FSD). FSD was devised to give a quantitative value for the likelihood of arterial bleeding and validated in human upper extremities. We used ultrasound to demonstrate that the power law with k = 2.75 appropriately described the normal brachial artery bifurcation geometry and adequately determined the expected normal flows. Our metric was then applied to three-dimensional (3-D) computational models of forearm bleeding and on dialysis patients undergoing surgical construction of wrist arteriovenous fistulas. Computational models showed that larger sized arterial defects produced larger flow deviations. FSD values were statistically higher (paired t-test) for arms with fistulas than those without, with average FSDs of 0.41 ± 0.12 and 0.047 ± 0.021 (mean ± SD), respectively. The average of the differences was 0.36 ± 0.12 (mean ± SD).

    View details for DOI 10.1016/j.ultrasmedbio.2011.12.016

    View details for Web of Science ID 000301181300018

    View details for PubMedID 22341050

  • Delayed Hypogastric Artery Pseudoaneurysm Following Blunt Trauma Without Evidence of Pelvic Fracture ANNALS OF VASCULAR SURGERY Al-Khatib, W. K., Lee, G. K., Casey, K., Lee, J. T. 2012; 26 (3)


    Arterial pelvic bleeding caused by bony fragments is a common finding in patients with pelvic fractures after blunt trauma (Durkin et al., Am J Surg 2006;192:211-23). However, arterial injury in the absence of bony fracture is extremely rare, and in the event that it does occur, is immediately discovered on cross-sectional imaging. We present an unusual case of a 15-year-old boy who was involved in a bicycle accident, and who, a week after his injury, developed a delayed hypogastric branch artery pseudoaneurysm causing sciatic nerve compression with a right foot drop. Initial magnetic resonance imaging scan and pelvic X-ray at the time of the injury showed no evidence of pelvic fracture or vascular damage. The pseudoaneurysm was successfully treated with selective coil embolization and hematoma evacuation. This study represents only the second reported case of delayed pelvic pseudoaneurysm in the absence of pelvic fracture.

    View details for DOI 10.1016/j.avsg.2011.11.007

    View details for Web of Science ID 000301847700018

    View details for PubMedID 22326296

  • Invited commentary. Journal of vascular surgery Lee, J. T. 2012; 55 (3): 720-?

    View details for DOI 10.1016/j.jvs.2011.09.076

    View details for PubMedID 22370024

  • Development and Implementation of an Introductory Endovascular Training Course for Medical Students ANNALS OF VASCULAR SURGERY Aparajita, R., Zayed, M. A., Casey, K., Dayal, R., Lee, J. T. 2011; 25 (8): 1104-1112


    Endovascular simulation has been promoted as an educational tool for trainees to practice procedures in a safe environment and improve basic technical skills. We sought to determine whether an established endovascular training course for medical students could increase technical proficiency, enhance interest in vascular surgery, and be implemented at another academic institution.At Center A, medical students participated in an eight-week elective course with a structured curriculum comprised of weekly mentored simulator sessions and didactic teachings. A similar course was developed at Center B to train a similar cohort of students using the same high-fidelity simulator. Demographics and survey data, including interest in vascular surgery, were obtained, and pre- and postcourse graded simulator sessions on renal stent or iliac/superficial femoral artery stent modules were conducted. Performance was assessed by expert observers using a standardized global endovascular rating scale and objective procedural metrics collected from the simulator.Seventy-seven medical students (41 at Center A and 36 at Center B; 56 men and 21 women) completed the course from 2007 to 2009. Parameters measured on the standardized global endovascular rating scale, including angiography skills, wire handling, and interventional criteria as well as simulator-generated metrics, significantly improved from pre- to postcourse values for both groups of medical students at the two institutions (p < 0.05). More than 94% of the students agreed or strongly agreed that the simulation course increased their interest in vascular surgery.A simulation-based endovascular course provides an educational tool that improves basic technical performance and increases interest in vascular surgery among medical students. This simple educational module appears to be transferable and adaptable at another institution with minimal modification to produce similar results.

    View details for DOI 10.1016/j.avsg.2011.07.002

    View details for Web of Science ID 000296553100014

    View details for PubMedID 21945331

  • Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome DIGESTIVE DISEASES AND SCIENCES Magee, G., Slater, B. J., Lee, J. T., Poultsides, G. A. 2011; 56 (9): 2528-2531

    View details for DOI 10.1007/s10620-011-1757-0

    View details for Web of Science ID 000294800100005

    View details for PubMedID 21643740

  • Two Decades of Progress in Vascular Medicine AMERICAN JOURNAL OF MEDICINE Leeper, N. J., Lee, J. T., Cooke, J. P. 2011; 124 (9): 791-792

    View details for DOI 10.1016/j.amjmed.2011.03.017

    View details for Web of Science ID 000294043100016

    View details for PubMedID 21683936

  • Venous Thromboembolic Disease JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Streiff, M. B., Bockenstedt, P. L., Cataland, S. R., Chesney, C., Eby, C., Fanikos, J., Fogarty, P. F., Gao, S., Garcia-Aguilar, J., Goldhaber, S. Z., Hassoun, H., Hendrie, P., Holmstrom, B., Jones, K. A., Kuderer, N., Lee, J. T., Millenson, M. M., Neff, A. T., Ortel, T. L., Smith, J. L., Yee, G. C., Zakarija, A. 2011; 9 (7): 714-777

    View details for Web of Science ID 000292264200005

    View details for PubMedID 21715723

  • A survey of demographics, motivations, and backgrounds among applicants to the integrated 0+5 vascular surgery residency JOURNAL OF VASCULAR SURGERY Lee, J. T., Teshome, M., De Virgilio, C., Ishaque, B., Qiu, M., Dalman, R. L. 2010; 51 (2): 496-503


    The 0 + 5 integrated vascular surgery (VS) residency has altered the training paradigm for future vascular specialists. Rising interest in these novel programs highlights our need to better understand the applicant pool. We compared demographics and surveyed recent applicants to our integrated program to gain more insight into their background and motivation for accelerated vascular training.Demographics and objective parameters were determined from all 65 applicants to the integrated VS program at Stanford University Medical Center and compared to 58 applicants interviewed by the general surgery (GS) program at Harbor-UCLA Medical Center by querying the Electronic Residency Application System for the programs in 2009. There was no overlap of applicants between programs. An anonymous, voluntary Web-based survey was sent to these cohorts with a response rate of 82% for VS applicants and 60% for GS applicants. Subjects were queried regarding their background, personal experience, prior exposure to VS, and motivations for residency specialty selection.Applicants to integrated VS programs tended to be older, were less likely to be from a US medical school, had a higher number of publications, and a higher percentage of cardiovascular-related publications than the GS applicants. When stratified by the 27 VS applicants (41%) that were offered an interview, this highly selected and desirable group for training was nearly 40% female, more likely to have an additional degree (PhD, master's), just as likely to be in the top quartile of their medical school class (60%), and score equally well on standardized board examinations (90th percentile) than the top GS applicants offered interviews. Survey data revealed that the majority of career choices (65%) were made during the third and fourth years of medical school. Factors most strongly influencing the decision to choose VS as a career were endovascular technologies/devices, challenging open vascular operations, clinical rotations on vascular surgery, the aging patient population, and perceived need for vascular surgeons and vascular surgeon mentorship. The most common reasons cited for particularly pursuing an integrated 0 + 5 VS training program were (1) more focused training/integration of cardiovascular medicine, (2) interest in catheter-based endovascular therapies, and (3) shorter time in training. Of the GS applicants, 58% indicated they would be interested in applying to an integrated residency in their subspecialty of interest, and 45% listed vascular surgery as a potential fellowship option after general surgery.Applicants to 0 + 5 integrated vascular residencies were more likely to have rotated on a vascular surgery service, observed vascular cases, identified a vascular surgery mentor, and been actively involved in cardiovascular research. The quality of the top VS applicant based on class rank and test scores is comparable to the top GS applicants, yet the VS applicant has a higher percentage of advanced degrees, more publications, and more involvement in cardiovascular research. Institutional strategies to increase medical student exposure to vascular surgery clinically and via research programs will optimize our ability to attract and train the best candidates in these new training programs.

    View details for DOI 10.1016/j.jvs.2009.08.076

    View details for Web of Science ID 000274602800033

    View details for PubMedID 20022205

  • Thoracic outlet syndrome. PM & R : the journal of injury, function, and rehabilitation Lee, J., Laker, S., Fredericson, M. 2010; 2 (1): 64-70

    View details for DOI 10.1016/j.pmrj.2009.12.001

    View details for PubMedID 20129515

  • The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery. Journal of surgical education Lee, J. T., Qiu, M., Teshome, M., Raghavan, S. S., Tedesco, M. M., Dalman, R. L. 2009; 66 (6): 367-373


    New training paradigms in vascular surgery allow for early specialization out of medical school. Surgical simulation has emerged as an educational tool for trainees to practice procedures in a controlled environment allowing interested medical students to perform procedures without compromising patient safety. The purpose of this study is to assess the ability of a simulation-based curriculum to improve the technical performance and interest level of medical students in vascular surgery.Prospective observational cohort study of medical student performance.Academic medical center.Forty-one medical students (23 first year, 15 second year, 3 other) enrolled in a vascular surgery elective course. Students completed a survey of their interests and performed a renal stent procedure on an endovascular simulator (pretest). The curriculum consisted of didactic teaching and weekly mentored simulator sessions and concluded with a final renal stent procedure on the simulator (posttest). Objective procedural measures were determined during the pre- and posttest by the simulator, and subjective performance was graded by expert observers utilizing a structured global assessment scale. After the course, the students were surveyed as to their opinions about vascular surgery as a career option. Finally, 1 year after the course, all students were again surveyed to determine continued interest in vascular surgery.The objective and subjective criteria measured on the simulator and structured global assessment scale significantly improved from pre- to posttest in terms of performer technical skill, patient safety measures, and structured global assessments. Before beginning the course, 8.5% of the students expressed high interest in vascular surgery, and after completing the course 70% were seriously considering vascular surgery as a career option (p = 0.0001). More than 95% of the students responded that endovascular simulation increased their knowledge and interest in vascular surgery. In the 1-year follow-up survey (n = 23 medical students), 35% had already entered their clinical years. Seventy percent of the students were still considering vascular surgery, while several other career options were still popular including the surgical subspecialties (70%), interventional cardiology (57%), and interventional radiology (48%). Most respondents indicated the major reasons for continued interest in vascular surgery were the ability to practice endovascular procedures on the simulator (100%) and mentorship from vascular surgery faculty (78%).The use of high fidelity endovascular simulation within an introductory vascular surgery course improves medical student performance with respect to technical skill, patient safety parameters, and global performance assessment. Mentored exposure to endovascular procedures on the simulator positively impacts long term medical student attitudes towards vascular surgery. Simulator-based courses may have the potential to be an important component in the assessment and recruitment of medical students for future surgical training programs.

    View details for DOI 10.1016/j.jsurg.2009.06.002

    View details for PubMedID 20142137

  • Preoperative Thrombus Volume Predicts Sac Regression After Endovascular Aneurysm Repair JOURNAL OF ENDOVASCULAR THERAPY Yeung, J. J., Hernandez-Boussard, T. M., Song, T. K., Dalman, R. L., Lee, J. T. 2009; 16 (3): 380-388


    To examine whether preoperative aneurysm thrombus volume correlated with abdominal aortic aneurysm (AAA) sac regression following endovascular aneurysm repair (EVAR).Clinical records and computed tomographic angiograms (CTAs) from patients undergoing EVAR from 2003 to 2008 were reviewed. Inclusion criteria for this study were available preoperative CTA images, >or=12-month follow-up with surveillance imaging, lack of re-intervention at 12 months, and treatment with commercially available devices. Patients with ruptured AAAs, those requiring an aortomonoiliac stent-graft, and clinical trial cases were excluded. Based on these criteria, satisfactory images and clinical follow-up were available in 100 patients (90 men; mean age 76.8 years, range 55-95). Preoperative CTAs were categorized as demonstrating "minimal," "moderate," or "severe" aneurysm thrombus load by 2 independent examiners blinded to clinical outcome. Percentage of the aortic cross-sectional area occluded by clot (% clot area) was calculated as [(total area) - (luminal area)]/(total area). Multivariate logistic regression analysis was performed to determine predictors of sac shrinkage at long-term follow-up.AAA thrombus was classified as minimal in 24%, moderate in 23%, and severe in 53%. Thrombus area averaged 11%+/-13%, 41%+/-14%, and 72+/-12% in each group, respectively. By multivariate analysis, minimal thrombus (OR = 1.47) and greater AAA diameter (OR = 1.3) were independent predictors of sac regression at 1, 6, and 12 months (all p<0.05). Presence of neck plaque and endoleak were also independent predictors of sac expansion (p<0.05). Patients with severe preoperative thrombus were less likely to demonstrate sac regression even in the absence of endoleak. Thrombus judgment (subjective) and percent clot area (objective) were strongly correlated (R = 0.82, p<0.05). Interobserver agreement on thrombus judgment was 86%.Thrombus burden on preoperative CTA is a strong independent predictor of sac regression following EVAR. If validated by prospective studies, relative thrombus burden should be incorporated into postoperative surveillance algorithms to define procedural success and optimize the timing and cost-effectiveness of cross-sectional imaging.

    View details for Web of Science ID 000268117500019

    View details for PubMedID 19642793

  • Reduction of postprocedure microemboli following retrospective quality assessment and practice improvement measures for carotid angioplasty and stenting JOURNAL OF VASCULAR SURGERY Tedesco, M. M., Dalman, R. L., Zhou, W., Coogan, S. M., Lane, B., Lee, J. T. 2009; 49 (3): 607-612


    We have previously demonstrated a 70% incidence of microemboli on diffusion weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS). The purpose of this study is to compare the incidence of microemboli in two distinct time periods when procedural modifications were implemented into a CAS program.Following a retrospective quality review of our CAS cohort (n = 27) from November 2004 through April 2006 (period 1), we enrolled patients (n = 20) from May 2006 through February 2008 (period 2) undergoing CAS into a prospective cohort that included obtaining pre- and postprocedure DW-MRI exams. Procedural modifications during period 2 included the preferential use of closed-cell systems (60% vs 0% in period 1), early heparinization at the initiation of arterial access, and elimination of an arch angiogram. The hospital records of these 47 patients were reviewed; symptoms, comorbidities, lesion characteristics, periprocedural information, and postoperative outcomes were collected. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs.Twenty (74%) CAS patients from period 1 and seven (35%) patients from period 2 demonstrated acute microemboli on postprocedural DW-MRI (P = .02). The mean number of microemboli in period 1 was 4.1 +/- 5.3 vs 1.5 +/- 2.7 during period 2 (P = .04). Two of the 27 patients (7.4%) during period 1 experienced temporary neurologic changes that resolved within 36 hours. None of the patients during period 2 exhibited any neurologic changes. Patient demographics, comorbidities, and presenting symptoms were similar between the two groups except for smoking prevalence, female presence, and obesity (BMI > 30). Period 2 patients when compared with period 1 had more technically challenging anatomy with more calcified lesions (68% vs 27%), longer lesions (15.9 mm vs 8.2 mm), and higher incidence of ulceration (55% vs 27%) (all P < .04).Despite successful performance of 47 consecutive CAS procedures without permanent neurologic sequelae, significant reductions in periprocedural embolic events as identified via DW-MRI lesions may be achieved through implementation of quality improvement measures identified through continuous outcome analysis. The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined.

    View details for DOI 10.1016/j.jvs.2008.10.031

    View details for Web of Science ID 000263802000015

    View details for PubMedID 19135833

  • Anatomic Suitability of Ruptured Abdominal Aortic Aneurysms for Endovascular Repair ANNALS OF VASCULAR SURGERY Slater, B. J., Harris, E. J., Lee, J. T. 2008; 22 (6): 716-722


    Mortality from ruptured abdominal aortic aneurysms (rAAAs) remains high despite improvements in anesthesia, postoperative intensive care, and surgical techniques. Recent small series and single-center experiences suggest that endovascular aneurysm repair (EVAR) for rAAAs is feasible and may improve short-term survival. However, the applicability of EVAR to all cases of rAAA is unknown. The purpose of this study was to investigate the anatomical suitability of ruptured aneurysms for EVAR as determined by preoperative cross-sectional imaging. A contemporary consecutive series of rAAAs presenting to a tertiary academic center was retrospectively reviewed. Preoperative radiographic imaging was reviewed and assessed for endovascular compatibility based on currently available EVAR devices. Patients with aneurysm morphology demonstrating neck diameter >32 mm, neck length <10 mm, neck angulation >60 degrees, severe iliac tortuosity, or external iliac diameter <6 mm were deemed noncandidates for EVAR. Forty-seven rAAAs were treated over a 10-year period, with 47% of patients presenting with free rupture and 60% of patients transferred from outside hospitals. Five (11%) patients were treated with EVAR, all over the past 2 years, while the remaining 42 patients underwent open repair. Preoperative imaging was available for review in 43 (91%) patients, and morphological measurements indicated that 49% would have been candidates for EVAR with currently available devices. Criteria precluding EVAR in this cohort were inadequate neck length in 73%, unsuitable iliac access in 23%, large neck diameter in 18%, and severe neck angulation in 14%. Overall 30-day mortality was 34%, and 1-year mortality was 42%. Candidates for EVAR were more likely than non-EVAR candidates to be male (95% vs. 68%, p = 0.046) and to have smaller sac diameters (7.0 vs. 8.5 cm, p = 0.02) and longer neck lengths (24.1 vs. 8.6 mm, p < 0.0001); less likely to have a >60 degree angulated neck (10% vs. 45%, p = 0.0002), larger external iliac diameter (8.9 vs. 7.3 mm, p = 0.015), and less blood loss during surgical repair (2.4 vs. 6.0 L, p = 0.02); and more likely to be discharged home (71% vs. 25%, p = 0.05). There were no differences in 30-day, 1-year, or overall mortality between candidates for EVAR and noncandidates. Only 49% of patients with rAAAs in this consecutive series were found to be candidates for EVAR with conventional stent-graft devices. Differences in demographics, aneurysm morphology, and outcomes between candidates and noncandidates undergoing open repair suggest that differential risks apply to ruptured aneurysm patients. Protocols and future reports of EVAR for rAAAs should be tailored to these results. Device and technique modifications are necessary to increase the applicability of EVAR for rAAAs.

    View details for DOI 10.1016/j.avsg.2008.06.001

    View details for Web of Science ID 000260722100003

    View details for PubMedID 18657385

  • Venous thromboembolic disease. NCCN. Clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network Wagman, L. D., Baird, M. F., Bennett, C. L., Bockenstedt, P. L., Cataland, S. R., Fanikos, J., Fogarty, P. F., Goldhaber, S. Z., Grover, T. S., Haire, W., Hassoun, H., Hutchinson, S., Jahanzeb, M., Lee, J., Linenberger, M. L., Millenson, M. M., Ortel, T. L., Salem, R., Smith, J. L., Streiff, M. B., Vedantham, S. 2008; 6 (8): 716-753

    View details for PubMedID 18926086

  • Treating superficial venous thrombophlebitis. Journal of the National Comprehensive Cancer Network Lee, J. T., Kalani, M. A. 2008; 6 (8): 760-765


    Superficial venous thrombophlebitis (SVT) is characterized as a localized inflammatory condition of the venous vessels underlying the skin. It arises from thrombosis of a superficial vein, and clinical presentation usually involves pain, erythema, and tenderness at the sites of inflammation. Although the condition is usually self-limited and not serious or fatal, symptomatic superficial thrombophlebitis can be debilitating, limit movement and certain capabilities, or progress to involve the deep venous system and cause pulmonary embolism. SVT is typically associated with venous valvular insufficiency, pregnancy, infection, and prothrombotic conditions, including malignancy. Currently, medical therapies comprising bedrest, elastic stockings, compression bandages, nonsteroidal anti-inflammatory drugs, and low molecular weight heparins are used to reduce the extension of inflammation and recurrence of thrombotic events in patients experiencing SVT. In patients refractory to conservative measures, surgical interventions such as phlebectomy, sclerotherapy, saphenous junction ligation, or saphenous vein stripping are potential treatments.

    View details for PubMedID 18926088

  • Simulation-based endovascular skills assessment: The future of credentialing? JOURNAL OF VASCULAR SURGERY Tedesco, M. M., Pak, J. J., Harris, E. J., Krummel, T. M., Dalman, R. L., Lee, J. T. 2008; 47 (5): 1008-1014


    Simulator-based endovascular skills training measurably improves performance in catheter-based image-guided interventions. The purpose of this study was to determine whether structured global performance assessment during endovascular simulation correlated well with trainee-reported procedural skill and prior experience level.Fourth-year and fifth-year general surgery residents interviewing for vascular fellowship training provided detailed information regarding prior open vascular and endovascular operative experience. The pretest questionnaire responses were used to separate subjects into low (<20 cases) and moderate (20 to 100) endovascular experience groups. Subjects were then asked to perform a renal angioplasty/stent procedure on the Procedicus Vascular Intervention System Trainer (VIST) endovascular simulator (Mentice Corporation, Gothenburg, Sweden). The subjects' performance was supervised and evaluated by a blinded expert interventionalist using a structured global assessment scale based on angiography setup, target vessel catheterization, and the interventional procedure. Objective measures determined by the simulator were also collected for each subject. A postsimulation questionnaire was administered to determine the subjects' self-assessment of their performance.Seventeen surgical residents from 15 training programs completed questionnaires before and after the exercise and performed a renal angioplasty/stent procedure on the endovascular simulator. The beginner group (n = 8) reported prior experience of a median of eight endovascular cases (interquartile range [IQR], 6.5-17.8; range, 4-20), and intermediate group (n = 9) had previously completed a median of 42 cases (IQR, 31-44; range, 25-89, P = .01). The two groups had similar prior open vascular experience (79 cases vs 75, P = .60). The mean score on the structured global assessment scale for the low experience group was 2.68 of 5.0 possible compared with 3.60 for the intermediate group (P = .03). Scores for subcategories of the global assessment score for target vessel catheterization (P = .02) and the interventional procedure (P = .05) contributed more to the differentiation between the two experience groups. Total procedure time, fluoroscopy time, average contrast used, percentage of lesion covered by the stent, placement accuracy, residual stenosis rates, and number of cine loops utilized were similar between the two groups (P > .05).Structured endovascular skills assessment correlates well with prior procedural experience within a high-fidelity simulation environment. In addition to improving endovascular training, simulators may prove useful in determining procedural competency and credentialing standards for endovascular surgeons.

    View details for DOI 10.1016/j.jvs.2008.01.007

    View details for Web of Science ID 000255294700019

    View details for PubMedID 18372149

  • Developing an Arterial Bleed Detection Algorithm for Diagnostic Ultrasound 2008 IEEE ULTRASONICS SYMPOSIUM, VOLS 1-4 AND APPENDIX Wang, A. S., Bech, F., Lee, J., Taylor, C. A., Liang, D. H. 2008: 1627-1630
  • Risk factors for developing postprocedural microemboli following carotid interventions JOURNAL OF ENDOVASCULAR THERAPY Tedesco, M. M., Coogan, S. M., Dalman, R. L., Haukoos, J. S., Lane, B., Loh, C., Penkar, T. S., Lee, J. T. 2007; 14 (4): 561-567


    To determine risk factors predictive of microemboli found on diffusion-weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS) with distal protection and carotid endarterectomy (CEA).A retrospective review was conducted of all carotid interventions at a single institution between 2004 and 2006. In that time frame, 64 carotid interventions (34 CAS, 30 CEA) were performed in 63 male patients (mean age 69.5 years, range 52 to 91) with DW-MRI scans available for review. Patient characteristics, including age, gender, smoking history, diabetes mellitus, hypertension, hyperlipidemia, obesity (body mass index >30), coronary artery disease (CAD), chronic obstructive pulmonary disease, peripheral vascular disease, and atrial fibrillation, were documented. For the CAS patients, anatomical and procedural characteristics, including fluoroscopy time, contrast volume, performance of an arch angiogram, and lesion anatomy, were recorded. Bivariate analyses were performed to determine which parameters were associated with the occurrence of acute postprocedural microemboli found on DW-MRI by 2 blinded neuroradiologists.Twenty-four (71%) of the 34 CAS patients and 1 (3%) of the 30 CEA patients demonstrated new cerebral microemboli postoperatively. In the bivariate analyses of all patient, anatomical, and procedural characteristics, only a history of CAD was associated with an increased risk of microemboli; 20 (80%) of the 25 patients who had postprocedure microemboli had CAD compared to 18 (46%) of 39 patients without microemboli (p=0.007). Twenty (53%) of the 38 (59%) patients with CAD developed microemboli compared to 5 (19%) of the 26 patients without CAD (p=0.007). All other patient, procedural, and anatomical characteristics were not found to be independent risk factors predictive of postprocedure microemboli.CAS with distal protection carries a significantly greater risk for developing new microemboli compared to CEA. Of all the risk factors analyzed, only a history of CAD emerged as an independent risk factor for the development of microemboli following carotid intervention. This finding may influence the decision to perform CAS in patients deemed high risk solely due to the presence of CAD.

    View details for Web of Science ID 000248794300019

    View details for PubMedID 17696633

  • Postprocedural microembolic events following carotid surgery and carotid angioplasty and stenting JOURNAL OF VASCULAR SURGERY Tedesco, M. M., Lee, J. T., Dalman, R. L., Lane, B., Loh, C., Haukoos, J. S., Rapp, J. H., Coogan, S. M. 2007; 46 (2): 244-250


    The relative safety of percutaneous carotid interventions remains controversial. Few studies have used diffusion-weighted magnetic resonance imaging (DW-MRI) to evaluate the safety of these interventions. We compared the incidence and distribution of cerebral microembolic events after carotid angioplasty and stenting (CAS) with distal protection to standard open carotid endarterectomy (CEA) using DW-MRI.From November 2004 through August 2006, 69 carotid interventions (27 CAS, and 42 CEA) were performed in 68 males at a single institution. Pre- and postprocedure DW-MRI exams were obtained on each patient undergoing CAS and the 20 most recent CEA operations. These 46 patients (47 procedures as one patient underwent bilateral CEAs in a staged fashion) constitute our study sample, and the hospital records of these patients (27 CAS and 20 CEA) were retrospectively reviewed. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs and assessed independently by two neuroradiologists without knowledge of the subjects' specific procedure.Nineteen CAS patients (70%, 95% confidence interval [CI]: 42%-81%) demonstrated evidence of postoperative, acute, cerebral microemboli by DW-MRI vs none of the CEA patients (0%, 95% CI: 0%-17%) (P < .0001). Of the 19 CAS patients with postoperative emboli, nine (47%) were ipsilateral to the index carotid lesion, three (16%) contralateral, and seven (36%) bilateral. The median number of ipsilateral microemboli identified in the CAS group was 1 (interquartile ranges [IQR]: 0-2, range 0-21). The median number of contralateral microemboli identified in the CAS group was 0 (IQR: 0-1, range 0-5). Three (11%) CAS patients experienced temporary neurologic sequelae lasting less than 36 hours. These patients suffered 12 (six ipsilateral and six contralateral), 20 (19 ipsilateral and one contralateral), and zero microemboli, respectively. By univariate analysis, performing an arch angiogram prior to CAS was associated with a higher risk of microemboli (median microemboli 5 vs none, P =.04)Although our early experience suggests that CAS may be performed safely (no permanent neurologic deficits following 27 consecutive procedures), cerebral microembolic events occurred in over two-thirds of the procedures despite the uniform use of distal protection. Open carotid surgery in this series seems to offer a lower risk of periprocedural microembolic events detected by DW-MRI.

    View details for DOI 10.1016/j.j.jvs.2007.04.049

    View details for Web of Science ID 000248395600014

    View details for PubMedID 17600657

  • Iliac fixation inhibits migration of both suprarenal and infrarenal aortic endografts JOURNAL OF VASCULAR SURGERY Benharash, P., Lee, J. T., Abilez, O. J., Crabtree, T., Bloch, D. A., Zarins, C. K. 2007; 45 (2): 250-257


    To evaluate the role of iliac fixation in preventing migration of suprarenal and infrarenal aortic endografts.Quantitative image analysis was performed in 92 patients with infrarenal aortic aneurysms (76 men and 16 women) treated with suprarenal (n = 36) or infrarenal (n = 56) aortic endografts from 2000 to 2004. The longitudinal centerline distance from the superior mesenteric artery to the top of the stent graft was measured on preoperative, postimplantation, and 1-year three-dimensional computed tomographic scans, with movement more than 5 mm considered to be significant. Aortic diameters were measured perpendicular to the centerline axis. Proximal and distal fixation lengths were defined as the lengths of stent-graft apposition to the aortic neck and the common iliac arteries, respectively.There were no significant differences in age, comorbidities, or preoperative aneurysm size (suprarenal, 6.0 cm; infrarenal, 5.7 cm) between the suprarenal and infrarenal groups. However, the suprarenal group had less favorable aortic necks with a shorter length (13 vs 25 mm; P < .0001), a larger diameter (27 vs 24 mm; P < .0001), and greater angulation (19 degrees vs 11 degrees ; P = .007) compared with the infrarenal group. The proximal aortic fixation length was greater in the suprarenal than in the infrarenal group (22 vs 16 mm; P < .0001), with the top of the device closer to the superior mesenteric artery (8 vs 21 mm; P < .0001) as a result of the 15-mm uncovered suprarenal stent. There was no difference in iliac fixation length between the suprarenal and infrarenal groups (26 vs 25 mm; P = .8). Longitudinal centerline stent graft movement at 1 year was similar in the suprarenal and infrarenal groups (4.3 +/- 4.4 mm vs 4.8 +/- 4.3 mm; P = .6). Patients with longitudinal centerline movement of more than 5 mm at 1 year or clinical evidence of migration at any time during the follow-up period comprised the respective migrator groups. Suprarenal migrators had a shorter iliac fixation length (17 vs 29 mm; P = .006) and a similar aortic fixation length (23 vs 22 mm; P > .999) compared with suprarenal nonmigrators. Infrarenal migrators had a shorter iliac fixation length (18 vs 30 mm; P < .0001) and a similar aortic fixation length (14 vs 17 mm; P = .1) compared with infrarenal nonmigrators. Nonmigrators had closer device proximity to the hypogastric arteries in both the suprarenal (7 vs 17 mm; P = .009) and infrarenal (8 vs 24 mm; P < .0001) groups. No migration occurred in either group in patients with good iliac fixation. Multivariate logistic regression analysis revealed that iliac fixation, as evidenced by iliac fixation length (P = .004) and the device to hypogastric artery distance (P = .002), was a significant independent predictor of migration, whereas suprarenal or infrarenal treatment was not a significant predictor of migration. During a clinical follow-up period of 45 +/- 22 months (range, 12-70 months), there have been no aneurysm ruptures, abdominal aortic aneurysm-related deaths, or surgical conversions in either group.Distal iliac fixation is important in preventing migration of both suprarenal and infrarenal aortic endografts that have longitudinal columnar support. Secure iliac fixation minimizes the risk of migration despite suboptimal proximal aortic neck anatomy. Extension of both iliac limbs to cover the entire common iliac artery to the iliac bifurcation seems to prevent endograft migration.

    View details for DOI 10.1016/j.jvs.2006.09.061

    View details for Web of Science ID 000243987200006

    View details for PubMedID 17263997

  • Applications of Intravascular Ultrasound in the Treatment of Peripheral Occlusive Disease SEMINARS IN VASCULAR SURGERY Lee, J. T., Fang, T. D., White, R. A. 2006; 19 (3): 139-144


    Intravascular ultrasound (IVUS) has emerged as a useful and often necessary adjunct in a rising number of catheter-based peripheral interventions. IVUS catheters enable luminal and transmural cross-sectional imaging of peripheral vessels with high dimensional accuracy and provide detailed information about lesion morphology. IVUS is able to guide the optimal choice of appropriate angioplasty technique, guide the delivery of endovascular devices, and assess the immediate outcome of an intervention. In this review we discuss the role of IVUS for peripheral occlusive diseases, specifically the application of IVUS technology during percutaneous transluminal angioplasty (PTA), intravascular stent placement, crossing total occlusions, and venous obstructive disease.

    View details for DOI 10.1053/j.semvascsurg.2006.06.004

    View details for Web of Science ID 000208018000004

    View details for PubMedID 16996415

  • Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome JOURNAL OF VASCULAR SURGERY Lee, J. T., Karwowski, J. K., Harris, E. J., Haukoos, J. S., Olcott, C. 2006; 43 (6): 1236-1243


    The purpose of this study was to determine the clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with nonoperative management of patients with primary subclavian vein thrombosis.Sixty-four patients treated for Paget-Schroetter syndrome from 1996 to 2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First-rib resection was performed in 29 patients (45%) within the first 3 months, with a success rate of 93%. The remaining 35 patients (55%) were treated nonoperatively and constitute this study's population.Of the 35 patients with successful nonoperative management, 8 (23%) developed recurrent thrombotic events of the same extremity at a mean follow-up time of 13 months after thrombolysis (range, 6-33 months). These eight patients subsequently underwent first-rib resection with a 100% success rate without further sequelae at a mean follow-up time of 51 months (range, 2-103 months). The other 27 patients remained symptom free at a mean follow-up interval of 55 months (range, 10-110 months). Bivariate analyses determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P = .05). The recurrence group was also significantly younger than the asymptomatic group (22 vs 36 years; P = .01). Sex, being a competitive athlete, a history of trauma, whether the dominant arm was affected, time of delay to lysis, initial clot burden, response to original lysis, use of adjunctive balloons or mechanical thrombectomy devices, residual stenosis on venography, length of time on warfarin, and patency of the vein on follow-up duplex examination were all characteristics not associated with long-term recurrence after nonoperative management.Conservative nonoperative management of primary subclavian vein thrombosis can be successfully used with acceptable long-term results. A younger age (<28 years old) and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.

    View details for DOI 10.1016/j.jvs.2006.02.005

    View details for Web of Science ID 000238046700034

    View details for PubMedID 16765247

  • Colonic histoplasmosis presenting as colon cancer in the nonimmunocompromised patient: Report of a case and review of the literature AMERICAN SURGEON Lee, J. T., Dixon, M. R., Murrell, Z., Konyalian, V., Agbunag, R., Rostami, S., French, S., Kumar, R. R. 2004; 70 (11): 959-963


    Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn's disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic anti-fungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.

    View details for Web of Science ID 000225229400005

    View details for PubMedID 15586505

  • Current status of thoracic aortic endograft repair SURGICAL CLINICS OF NORTH AMERICA Lee, J. T., White, R. A. 2004; 84 (5): 1295-?


    The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections,penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality.Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy.

    View details for DOI 10.1016/j.suc.2004.04.012

    View details for Web of Science ID 000224296400007

    View details for PubMedID 15364556

  • Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections JOURNAL OF VASCULAR SURGERY Hansen, C. J., Bui, H., Donayre, C. E., Aziz, I., Kim, B., Kopchok, G., Walot, I., Lee, J., Lippmann, M., White, R. A. 2004; 40 (2): 228-234


    The advent of endovascular prostheses to treat descending thoracic aortic lesions offers an alternative approach in patients who are poor candidates for surgery. The development of this approach includes complications that are common to the endovascular treatment of abdominal aortic aneurysms and some that are unique to thoracic endografting.We conducted a retrospective review of 60 emergent and high-risk patients with thoracic aortic aneurysms (TAAs) and dissections treated with endovascular prostheses over 4 years under existing investigational protocols or on an emergent compassionate use basis.Fifty-nine of the 60 patients received treatment, with one access failure. Thirty-five patients received treatment of TAAs. Four of these procedures were performed emergently because of active hemorrhage. Twenty-four patients with aortic dissections (16 acute, 8 chronic) also received treatment. Eight of the patients with acute dissection had active hemorrhage at the time of treatment. Three devices were used: AneuRx (Medtronic; n = 31), Talent (Medtronic; n = 27), and Excluder (Gore; n = 1). Nineteen secondary endovascular procedures were performed in 14 patients. Most were secondary to endoleak (14 of 19), most commonly caused by modular separation of overlapping devices (n = 8). Other endoleaks included 4 proximal or distal type I leaks and 2 undefined endoleaks. The remaining secondary procedures were performed to treat recurrent dissection (n = 1), pseudoaneurysm enlargement (n = 3), and endovascular abdominal aortic aneurysm repair (n = 1). One patient underwent surgical repair of a retrograde ascending aortic dissection after endograft placement. Procedure-related mortality was 17% in the TAA group and 13% in the dissection group, including 2 acute retrograde dissections that resulted in death from cardiac tamponade. Overall mortality was 28% at 2-year follow-up.Although significant morbidity and mortality remain, endovascular repair of descending TAAs and dissections in patients at high-risk patients can be accomplished with acceptable outcomes compared with traditional open repair. The major cause for repeat intervention in these patients was endoleak, most commonly caused by device separation. Improved understanding of these complications may result in a decrease in secondary procedures, morbidity, and mortality in these patients. The need for secondary interventions in a significant number of patients underscores the necessity for continued surveillance.

    View details for DOI 10.1016/j.jvs.2004.03.051

    View details for Web of Science ID 000227388100006

    View details for PubMedID 15297815

  • Basics of intravascular ultrasound: an essential tool for the endovascular surgeon. Seminars in vascular surgery Lee, J. T., White, R. A. 2004; 17 (2): 110-118


    The concept of catheter-based ultrasound imaging was first introduced in the early 1970s. Since its inception, intravascular ultrasound (IVUS) technology has become more user-friendly because of improvements in both the catheters and computer-driven imaging platforms. IVUS catheters enable luminal and transmural cross-sectional imaging of coronary and peripheral blood vessels with high-dimensional accuracy and detailed information about lesion morphology. With the advent of endovascular techniques in both the coronary and peripheral vasculature, IVUS has emerged as a useful and necessary adjunct. In addition to providing diagnostic information, IVUS enables optimal choice of appropriate angioplasty technique, endovascular device guidance, and controlled assessment of the efficacy of interventions. In this review we discuss the design and function of available IVUS catheters, imaging techniques and interpretation, and the present and future clinical utility in peripheral endovascular interventions.

    View details for PubMedID 15185176

  • Volume regression of abdominal aortic aneurysms and its relation to successful endoluminal exclusion JOURNAL OF VASCULAR SURGERY Lee, J. T., Aziz, I. N., Lee, J. T., Haukoos, J. S., Donayre, C. E., Walot, I., Kopchok, G. E., Lippmann, M., White, R. A. 2003; 38 (6): 1254-1263


    Evaluating the success of endoluminal repair of abdominal aortic aneurysms (AAAs) is frequently based on diameter measurements and determining the presence of endoleaks. The use of three-dimensional volumetric data and observation of morphologic changes in the aneurysm and device have been proposed to be more appropriate for postdeployment surveillance. The purpose of this study was to analyze the long-term volumetric and morphologic data of 161 patients who underwent endovascular AAA exclusion and to assess the utility of volume measurements for determining successful AAA repair.Patients with spiral computed tomography scans obtained preoperatively, within the first postoperative month, at 6 months, and annually thereafter, were included in this analysis. Computerized interactive three-dimensional reconstruction of each AAA scan was performed. Total aneurysm sac volume was measured at each time interval (mean preoperative volume 169.0 +/- 78.5 mL), and the significance of volume changes was determined by mixed linear modeling, a form of repeated measures analysis, to account for longitudinal data clustered at the individual level. Sixty-two patients (38%) developed endoleaks at some time during follow-up-15 type I leaks, 45 type II leaks, and 2 type III leaks. The patients with type I and type III leaks were treated with cuffs, and the type II leaks were treated either with observation, side-branch embolization, or required open conversion.Aneurysm sac volume increased slightly at 1-month follow-up (+3.3%), and then decreased steadily to -12.9% at 5 years (P <.0001). This effect remained unchanged after controlling for the three device types used in our study population. Patients who did not exhibit an endoleak (n = 99) showed a significant decrease in aneurysm volume across the entire follow-up duration when compared with those who did exhibit an endoleak (n = 62) (P <.0001). The presence of a 10% or greater decrease in volume at 6 months demonstrated a sensitivity of 64%, a specificity of 95%, a positive predictive value of 95%, a negative predictive value of 62%, and an accuracy of 75% for predicting primary clinical success defined by successful deployment of the device; freedom from aneurysm- or procedure-related death; freedom from endoleak, rupture, migration, or device malfunction; or conversion to open repair.Volumetric analysis may be used to predict successful endoluminal exclusion of AAAs. Volume regression appears to be device-independent and should be expected in most clinically successful cases. The presence of volume increases in the first 6 months is suspicious for an endoleak that is pressurizing the aneurysm sac and heralds the need for closer evaluation and possible intervention. A volume decrease of 10% or greater at 6 months and continuing regression over time is associated with successful endovascular repair.

    View details for DOI 10.1016/S0741-5214(03)00924-8

    View details for Web of Science ID 000186955400027

    View details for PubMedID 14681624

  • Validation of an updated approach to preoperative cardiac risk assessment in vascular surgery AMERICAN SURGEON Bui, H., Lee, J. T., Greenway, S., Donayre, C., De Virgilio, C. 2003; 69 (11): 923-926


    To validate a more selective approach to cardiac assessment which consisted of limiting stress testing and coronary revascularization to highly selected patients and limiting coronary revascularization to patients with severe cardiac symptoms, we compared two time periods (1994-1995 and 2000-2001) with respect to cardiac work-up and cardiac morbidity and mortality. Our method involved a retrospective review of patients undergoing vascular procedures from 2000 to 2001 at a single institution. In group 1 (2000-2001), 139 operations were performed on 120 patients. In group 2 (1994-1995), 145 procedures were performed on 109 patients. Preoperative stress testing was reduced from 42 patients (29%) in group 2 to 20 patients (14%) in group 1 (P < 0.01), and preoperative coronary artery bypass grafting was reduced from six (4.1%) to two (1.4%) (P < 0.28), respectively. Coronary angiography was unchanged: 8 (5.8%) patients in group 1 versus 11 (7.9%) patients in group 2 (P = NS). Two (1.4%) patients underwent percutaneous transluminal coronary angioplasty in group 1 and group 2. Cardiac event rates were similar: seven (5%) patients in both groups. Cardiac death was not significantly different: two (1.4%) in group 1 versus one (0.7%) in group 2. Cardiac morbidity and mortality after major vascular surgery remain the same despite using a more selective cardiac stress protocol.

    View details for Web of Science ID 000186440000001

    View details for PubMedID 14627248

  • An alternative anesthetic technique for the morbidly obese patient undergoing endovascular repair of an abdominal aortic aneurysm ANESTHESIA AND ANALGESIA Lippmann, M., Rubin, S., Ginsburg, R., White, R. A., Lee, J., Lee, J., Aziz, I. 2003; 97 (4): 981-983


    Abdominal aortic aneurysms have been treated by open operative repair for many years. A frequent rate of morbidity is associated with the natural history of abdominal aortic aneurysms in combination with open surgical repair. Recently a new technique that is less surgically invasive has been developed as an alternative to open repair. The present case report outlines a less invasive anesthetic technique for the morbidly obese patient.This case report discusses a minimally invasive anesthetic approach towards the morbidly obese patient undergoing endovascular abdominal aortic aneurysm repair. It demonstrates a safe and cost-effective means of managing a patient with numerous comorbidities. We also discuss an anesthetic/surgical approach on how to provide maximum analgesia with minimal anesthesia.

    View details for DOI 10.1213/01.ANE.0000081791.02404.F7

    View details for Web of Science ID 000185492300011

    View details for PubMedID 14500144

  • Cardiac risk stratification in patients undergoing endoluminal graft repair of abdominal aortic aneurysm: A single-institution experience with 365 patients JOURNAL OF VASCULAR SURGERY Aziz, I. N., Lee, J. T., Kopchok, G. E., Donayre, C. E., White, R. A., de Virgilio, C. 2003; 38 (1): 56-60


    Patients undergoing abdominal aortic aneurysm repair have a high incidence of coexisting cardiac disease. The traditional cardiac risk stratification for open abdominal aortic aneurysm surgery may not apply to patients undergoing endoluminal graft exclusion. The purpose of this study was to examine predictive risk factors for perioperative cardiac events.As part of multiple prospective endograft trials approved by the US Food and Drug Administration, data for 365 patients who underwent endoluminal graft repair from 1996 to 2001 were collected. Variables included for analysis were age and sex; history of smoking; presence of hypertension, diabetes mellitus, or renal insufficiency; Eagle clinical cardiac risk factors; American Society of Anesthesiologists index; type of anesthesia administered; estimated blood loss; preoperative hemoglobin level; preoperative use of beta-blocker therapy; duration of surgery; need for iliac artery conduit; and concomitant other vascular procedures. Univariate and multivariate logistic regression analysis were used to determine which variables were predictive of an adverse perioperative cardiac event, eg, Q wave and non-Q wave myocardial infarction (MI), congestive heart failure (CHF), severe arrhythmia, and unstable angina.The study cohort included 322 men and 43 women (mean age, 74.2 years). Fifty-two (14.2%) postoperative cardiac events occurred: severe dysrhythmia in 15 patients (4.1%), MI in 14 patients (3.8%), non-Q wave MI in 8 patients (2.2%), CHF in 8 patients (2.2%), and unstable angina in 7 patients (1.9%). Univariate analysis demonstrated that age 70 years or older (P =.034), history of MI (P =.018), angina (P =.004), history of CHF (P <.001), two or more Eagle risk factors (P <.001), and lack of use of preoperative beta-blocker therapy (P =.005) were predictors of perioperative cardiac events. Multivariate analysis identified only age 70 years or older (P =.026), history of MI (P =.024) or CHF (P =.001), and lack of use of preoperative beta-blocker therapy (P =.007) as independent risk factors for an adverse cardiac event.Age 70 years or older, history of MI or CHF, and lack of use of preoperative beta-blocker therapy are independent risk factors for perioperative cardiac events in patients undergoing endoluminal graft repair.

    View details for DOI 10.1016/S0741-5214(03)00475-0

    View details for Web of Science ID 000183985900009

    View details for PubMedID 12844089

  • Accuracy of three-dimensional simulation in the sizing of aortic endoluminal devices ANNALS OF VASCULAR SURGERY Aziz, I., Lee, J., Lee, J. T., Donayre, C. E., Walot, I., Kopchok, G., Mirahashemi, S., Esmailzadeh, H., White, R. A. 2003; 17 (2): 129-136


    The purpose of this study is to examine the accuracy of a 3D simulation generated by inclusion of various intensity-selected portions of spiral CT data into a proprietary software program (Preview, Medical Media Systems, MMS) in preoperative and postoperative assessment of the anatomical features of abdominal aortic aneurysm (AAA). The accuracy of this software was measured against two other modalities-intravascular ultrasound (IVUS) and axial CT scan-using the IVUS as the reference. Eighty-five patients were included; 43 underwent AAA endovascular exclusion with Talent devices, and 42 with Aneurx devices. Measurement of proximal neck diameter was performed using IVUS, Preview software, and axial CT scan with manual calipers. Measurement of the AAA maximum diameter was performed using Preview software and axial CT scan; 253 measurements in the 85 patients were included. These measurements were compared by means of both linear regression and Bland-Altman agreement analysis. Our results showed that the 95% confidence interval between the Preview software and mean IVUS measurement of proximal AAA neck (3.1 and 2.5) is narrow enough for the software to be used in sizing AAA. This would be especially important for having the properly sized devices available preoperatively. The Preview software tended to be more accurate than CT scans although it was not statistically significant.

    View details for DOI 10.1007/s10016-001-0398-8

    View details for Web of Science ID 000182424700003

    View details for PubMedID 12616351

  • Stent-graft migration following endovascular repair of aneurysms with large proximal necks: Anatomical risk factors and long-term sequelae JOURNAL OF ENDOVASCULAR THERAPY Lee, J. T., Lee, J., Aziz, I., Donayre, C. E., Walot, I., Kopchok, G. E., Heilbron, M., Lippmann, M., White, R. A. 2002; 9 (5): 652-664


    To evaluate the outcome of aortic endografts deployed in large infrarenal necks and to identify any association of preoperative aneurysm characteristics and postoperative morphological changes with the incidence of neck dilatation and device migration in this patient subset.The records of 47 patients (41 men; mean age 74, range 55-84) with large aortic neck diameters treated with Talent stent-grafts from 1998 to 2001 were reviewed. Patients with anatomical criteria that precluded aneurysm exclusion with currently available devices were preferentially selected. Mean baseline aneurysm morphology included 27.6-mm (range 18-33.4) suprarenal and 28.1-mm (range 24-34) infrarenal neck diameters; the infrarenal neck length was 26 +/- 16 mm with angulation of 37 degrees +/- 18 degrees. Computed tomographic (CT) angiograms up to 3 years were analyzed using specialized interactive software; migration was defined as >1-cm change in the distance from the lower renal artery to the top of the device. Pre- and postoperative morphological characteristics of the aneurysm were compared between patients with and without migration.Of the 45 patients successfully treated, 40 had complete CT data for analysis. During a mean 17-month follow-up, 7 (17.5%) of the 40 devices exhibited distal migration. Six patients required secondary procedures; 5 were in the migration cohort. No preoperative anatomical characteristic or degree of neck dilatation over time was predictive of stent-graft migration. Aneurysm sac regression was significant at 1 (-0.09 +/- 4.90 mm) and 2 (-1.48 +/- 2.56 mm) years in endografts without migration (p<0.001). Distal endograft migration >1 cm predicted the need for secondary interventions (p<0.001), with 83% sensitivity and 94% specificity.Endovascular repair is successful in patients with large infrarenal necks and complex neck morphology. Changes in aneurysm remodeling over time were similar to reported observations in patients with more favorable neck criteria. Although no anatomical factor associated with migration could be identified from this analysis, distal displacement >1 cm correlated with the need for a secondary intervention.

    View details for Web of Science ID 000179638100018

    View details for PubMedID 12431151

  • Regression of a descending thoracoabdominal aortic dissection following staged deployment of thoracic and abdominal aortic endografts JOURNAL OF ENDOVASCULAR THERAPY White, R. A., Donayre, C., Walot, I., Lee, J., Kopchok, G. E. 2002; 9: 92-97
  • Regression of a descending thoracoabdominal aortic dissection following staged deployment of thoracic and abdominal aortic endografts. Journal of endovascular therapy White, R. A., Donayre, C., Walot, I., Lee, J., Kopchok, G. E. 2002; 9: II92-7


    To describe the successful endovascular repair and regression of an extensive descending thoracoabdominal aortic dissection associated with thoracic and abdominal aortic aneurysms.An 83-year-old man presented with acute chest pain and shortness of breath. A descending thoracoabdominal aortic dissection that extended from near the left subclavian artery (LSA) to the right common iliac artery was found on computed tomography. Separate aneurysms in the thoracic and abdominal aorta were also identified. Staged endovascular procedures were undertaken to (1) close the single entry site and exclude the aneurysm in the thoracic aorta with an AneuRx thoracic stent-graft, (2) exclude the abdominal aneurysm and distal re-entry site with a bifurcated AneuRx endograft, and (3) treat a newly dilated thoracic segment between the LSA and first thoracic stent-graft. At 1 year, the false lumen had completely disappeared, the thoracic aneurysm had collapsed onto the endograft, and the abdominal aneurysm had shrunk by 30%.The potential to treat extensive aortic dissections with the hope that they might regress is promising, but repair of highly complex lesions involving one or more aneurysms in addition to the dissection requires meticulous imaging studies both preoperatively and intraprocedurally.

    View details for PubMedID 12166848

Conference Proceedings

  • Ethnic differences in arm vein diameter and arteriovenous fistula creation rates in men undergoing hemodialysis access Ishaque, B., Zayed, M. A., Miller, J., Nguyen, D., Kaji, A. H., Lee, J. T., O'Connell, J., de Virgilio, C. MOSBY-ELSEVIER. 2012: 424-432


    The National Kidney Foundation recommends that arteriovenous fistulas (AVFs) be placed in at least 65% of hemodialysis patients. Some studies suggest that African American patients are less likely to receive a first-time AVF than patients of other ethnicities, although the reason for this disparity is unclear. The purpose of our study is to determine (1) whether there are ethnic differences in AVF creation, (2) whether this may be related to differences in vein diameters, and (3) whether AVF patency rates are similar between African American and non-African American male patients.Consecutive male patients undergoing first-time hemodialysis access from 2006 to 2010 at two institutions were retrospectively reviewed. Data collected included age, ethnicity, weight, height, body mass index, diabetes, hypertension, congestive heart failure, smoking history, intravenous drug abuse, need for temporary access placement, and preoperative venous ultrasound measurements. Categoric variables were compared using ?(2) analysis, and the Wilcoxon rank-sum test was used to compare continuous variables.Of 249 male patients identified, 95 were African American. Median age in African American and non-African American patients was 63 years. Hypertension and hyperlipidemia were statistically significantly greater in African American patients. The need for temporary access before hemoaccess was similar between the cohorts. African American patients demonstrated significantly smaller median basilic and cephalic vein diameters at most measured sites. Overall, 221 of 249 (88.8%) underwent AVF first. An AV graft was created in 17.9% of African American patients vs in only 7.1% of non-African Americans (odds ratio, 2.8; 95% confidence interval, 1.3-6.4; P = .009). The difference between median vein diameters used for autologous fistula creation in African American and non-African American patients was not significant. There was no significant difference in the primary patency (80.8% vs 76.2%; P = .4), primary functional patency (73.1% vs 69.2%; P = .5), or secondary functional patency rates (91.0% vs 96.5%; P = .1). Average primary fistula survival time was 257 days in African American and 256 in non-African American patients (P = .2).African American patients are less likely than non-African American patients to undergo AVF during first-time hemodialysis access surgery. This ethnic discrepancy appears to be due to smaller arm vein diameters in African American patients. In African American patients with appropriate vein diameters who do undergo AVF, primary and functional patencies are equivalent to non-African American patients.

    View details for DOI 10.1016/j.jvs.2012.01.029

    View details for Web of Science ID 000307160400020

    View details for PubMedID 22551911

  • Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair Greenberg, J. I., Dorsey, C., Dalman, R. L., Lee, J. T., Harris, E. J., Hernandez-Boussard, T., Mell, M. W. MOSBY-ELSEVIER. 2012: 291-297


    Current information regarding coverage of accessory renal arteries (ARAs) during endovascular aneurysm repair (EVAR) is based on small case series with limited follow-up. This study evaluates the outcomes of ARA coverage in a large contemporary cohort.Consecutive EVAR data from January 2004 to August 2010 were collected in a prospective database at a University Hospital. Patient and aneurysm-related characteristics, imaging studies, and ARA coverage versus preservation were analyzed. Volumetric analysis of three-dimensional reconstruction computed tomography scans was used to assess renal infarction volume extent. Long-term renal function and overall technical success of aneurysm exclusion were compared.A cohort of 426 EVARs was identified. ARAs were present in 69 patients with a mean follow-up of 27 months (range, 1 to 60 months). Forty-five ARAs were covered in 40 patients; 29 patients had intentional ARA preservation. Patient and anatomic characteristics were similar between groups except that ARA coverage patients had shorter aneurysm necks (P = .03). Renal infarctions occurred in 84% of kidneys with covered ARAs. There was no significant deterioration in long-term glomerular filtration rate when compared with patients in the control group. No difference in the rate of endoleak, secondary procedures, or the requirement for antihypertensive medications was found.This study is the largest to date with the longest follow-up relating to ARA coverage. Contrary to previous reports, renal infarction after ARA coverage is common. Nevertheless, coverage is well tolerated based upon preservation of renal function without additional morbidity. These results support the long-term safety of ARA coverage for EVAR when necessary.

    View details for DOI 10.1016/j.jvs.2012.01.049

    View details for Web of Science ID 000307160400002

    View details for PubMedID 22480767

  • Selective Use of Percutaneous Endovascular Aneurysm Repair in Women Leads to Fewer Groin Complications Al-Khatib, W. K., Zayed, M. A., Harris, E. J., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012: 476-482


    Endovascular aneurysm repair (EVAR) in women is often technically limited by smaller access vessel anatomy, particularly at the femoral and iliac artery levels. Percutaneous femoral artery access and closure using the "Preclose" technique (PERC) is a less invasive alternative to open surgical femoral arterial exposure and has been reported to be technically feasible, particularly in male cohorts. The purpose of this study was to evaluate the efficacy and access-related outcomes of PERC in women undergoing EVAR.We identified female patients in a prospectively maintained EVAR database from 2000 to 2009. An all-percutaneous approach was adopted in 2007 if technically feasible, based on preoperative computed tomography angiogram criteria including a femoral diameter >7 mm, <25% posterior plaque and lack of circumferential calcification/disease. All percutaneous EVAR procedures were performed using two Perclose Proglide devices in a standardized manner for sheath sizes ranging between 12F and 26F.In period 1 (2000-2006), most cases were performed with open femoral exposure. In period 2 (2007-2009), our group adopted a percutaneous-first approach. Of 736 EVARs performed during the study period, 120 (16.3%) were in women, leading to 178 femoral arteries requiring large sheath access. Period 1 included 90 women and period 2 included 30 women who were evaluated for percutaneous access. During period 2, of the 47 eligible femoral arteries for possible PERC, 24 (51%) met appropriate criteria, and the Preclose technique was employed. The remaining 23 femoral arteries during period 2 were accessed with surgical exposure (OPEN). Technical success rate of PERC in period 2 was 96%, with one device pulling through a thin anterior arterial wall requiring open femoral conversion. During period 2, the OPEN cohort had a higher rate of total wound complications compared with PERC (34.8% vs. 8.3%, P = 0.02), including hematomas (8.7% vs. 0%), wound breakdowns (8.7% vs. 0%), and pseudoaneurysms (4.3% vs. 0%). There were two cases of femoral artery thrombosis in the PERC group requiring repair in the immediate postoperative period; however, this was not significantly different compared with the OPEN group (8.7% vs. 8.3%).Selective percutaneous access of the femoral arteries for EVAR is safe and effective in the female population, with fewer wound complications than open exposure. Approximately one-half of femoral arteries in women are eligible for PERC access, and complications can be limited with careful selection based on preoperative imaging.

    View details for DOI 10.1016/j.avsg.2011.11.026

    View details for Web of Science ID 000303110300005

    View details for PubMedID 22437069

  • Early experience with the snorkel technique for juxtarenal aneurysms Lee, J. T., Greenberg, J. I., Dalman, R. L. MOSBY-ELSEVIER. 2012: 935-946


    The lack of readily available branched and fenestrated endovascular aneurysm repair (EVAR) options has created an opportunity for creative deployment of endograft components to treat juxtarenal aneurysms. We present our early experience with "snorkel" or "chimney" techniques in the endovascular management of complex aortic aneurysms.We retrospectively reviewed planned snorkel procedures for juxtarenal aneurysms performed from September 2009 to August 2011. Our standardized technique included axillary or brachial cutdown for delivery of covered snorkel stents and mostly percutaneous femoral access for the main body endograft.Fifty-six snorkel grafts were successfully placed in 28 consecutive patients (mean age, 75 years) with juxtarenal aneurysms. Mean aneurysm size was 64.8 mm (range, 53-87 mm). The snorkel configuration extended the proximal seal zone from an unsuitable infrarenal neck for standard EVAR (median diameter, 33.5 mm; length, 0.0 mm) to a median neck diameter of 24.5 mm and length of 18.0 mm. Five patients had unilateral renal snorkels, 17 had bilateral renal snorkels, and six had celiac/superior mesenteric artery/renal combinations. Technical success of snorkel placements was 98.2%, with loss of wire access leading to one renal stent deployment failure. Thirty-day mortality was 7.1%: one patient was readmitted 1 week postoperatively with pneumonia and died of sepsis; one patient died at 1 week of a right hemispheric stroke. Other major complications included perinephric hematomas, 7.1%; permanent hemodialysis, 3.6%; iliac artery injury requiring endoconduit placement, 3.6%; and brachial plexus nerve injury, 3.6%. Cardiac complications included self-limited arrhythmias (14.3%) and one non-Q-wave myocardial infarction (3.6%), with all recovering without coronary intervention. Mean follow-up was 10.7 months (range, 3-25 months). One patient died of nonaneurysmal-related causes at 3 months (89.3% survival). Postoperative imaging revealed one renal snorkel graft occlusion occurring at 3 months (98.2% overall primary patency). Seven (25%) early endoleaks were noted on the first follow-up computed tomography angiography: two type I, three type II, and two type III (25%), leading to one secondary intervention (3.6%) with bridging cuff placement (type III). The small type Ia endoleaks and other type III endoleak resolved at the 6-month scan. Mean sac regression at the latest follow-up was 7.3 mm. No aneurysm has enlarged on postoperative imaging.Early success with the snorkel technique for juxtarenal aneurysms has made it our procedure of choice for complex short-neck to no-neck EVAR. Although long-term follow-up is needed, the flexibility of the snorkel technique and lack of requirement for custom-built devices may make this approach more attractive than branched or fenestrated stent grafts.

    View details for DOI 10.1016/j.jvs.2011.11.041

    View details for Web of Science ID 000302145700006

    View details for PubMedID 22244859

  • Endovascular Repair of Bilateral Iliac Artery Aneurysms in a Patient With Loeys-Dietz Syndrome Casey, K., Zayed, M., Greenberg, J. I., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012


    Loeys-Dietz syndrome (LDS) is a rare congenital connective tissue disorder (CTD) caused by mutations in the gene encoding for transforming growth factor-? receptors I and II. This recently described syndrome is characterized by aortic aneurysms and dissections, arterial tortuosity, and spontaneous organ perforation. The technical feasibility of endovascular interventions, particularly endovascular aneurysm repair (EVAR), in CTDs is relatively unknown.A 38-year-old man presented with asymptomatic bilateral common iliac artery aneurysms measuring 5.3 cm on the right and 4.3 cm on the left. The patient had an extensive surgical and medical history, including a recently repaired Stanford type-A aortic dissection, total colectomy with end ileostomy for a colonic perforation, splenectomy for rupture, and cirrhosis secondary to chronic hepatitis C. The patient's CTD, multiple abdominal surgeries performed in the past, and ileostomy made him a poor candidate for open repair. We elected to offer him a complex endovascular repair and hoped to preserve his pelvic circulation by using "double-barrel" configuration of stent-grafts in the right iliac artery system. Successful deployment of the devices and repair of femoral access allowed routine discharge on postoperative day 2. At 6-month follow-up, the patient's pelvic circulation has been maintained, the aneurysms are excluded without endoleak, and sac regression has been shown.LDS is a rare connective tissue disorder characterized by vascular aneurysms and arterial tortuosity. When vascular reconstruction is necessary, open techniques are often preferred given the lack of data on endovascular procedures. In the present case, we report the first successful abdominal EVAR in a high-risk patient with LDS, providing excellent short-term results.

    View details for DOI 10.1016/j.avsg.2011.06.005

    View details for Web of Science ID 000298325900015

    View details for PubMedID 21835579

  • Cost Impact of Extension Cuff Utilization During Endovascular Aneurysm Repair Chandra, V., Greenberg, J. I., Al-Khatib, W. K., Harris, E. J., Dalman, R. L., Lee, J. T. ELSEVIER SCIENCE INC. 2012: 86-92


    Modular stent-graft systems for endovascular aneurysm repair (EVAR) most often require two to three components, depending on the device. Differences in path lengths and availability of main body systems often require additional extensions for appropriate aneurysm exclusion. These additional devices usually result in added expenses and can affect the financial viability of an EVAR program within a hospital. The purpose of this study was to analyze the use of extensions during EVAR, focusing on incidence, clinical impact, and financial impact, as well as determining the associated cost differences between two- and three-component EVAR device systems.We reviewed available clinical data, images, and follow-up of 218 patients (203 males and 15 females, mean age: 74 ± 9 years) who underwent elective EVAR at a single academic center from 2004 to 2007. Patients were divided into two groups: patients undergoing EVAR using the standard number of pieces, that is, no extensions used (group A, n = 98), and those needing proximal or distal extensions during the index procedure (group B, n = 120).Both groups were similar in terms of demographics; preoperative characteristics, including aneurysm morphology; as well as intraoperative, postoperative, and midterm outcomes. Overall, 30-day operative mortality was 1.4%, with a mean follow-up of 24 months. Group A patients underwent repair with two-piece modular devices 41% of the time and three-piece systems 59% of the time, whereas group B patients underwent repair with two-piece modular systems 82% of the time and three-piece modular systems 18% of the time. The number of additional extensions per patient ranged from one to four (median: one piece). There was a 30% cost increase in overall mean device-related cost when using extensions versus the standard number of pieces (group A: $13,220 vs. group B: $17,107, p < 0.01).Clinical midterm aneurysm-related outcomes after EVAR in patients who required additional extensions was comparable with those treated with the standard number of pieces. An increased number of extensions led to increased costs and could have potentially been minimized with appropriate preoperative planning or device selection. Consideration should be made toward per-case pricing instead of per-piece pricing to further improve cost efficiency without compromising long-term patient outcomes.

    View details for DOI 10.1016/j.avsg.2011.10.003

    View details for Web of Science ID 000298325900011

    View details for PubMedID 22176878

  • Early results of a highly selective algorithm for surgery on patients with neurogenic thoracic outlet syndrome Chandra, V., Olcott, C., Lee, J. T. MOSBY-ELSEVIER. 2011: 1698-1705


    Neurogenic thoracic outlet syndrome (nTOS) encompasses a wide spectrum of disabling symptoms that are often vague and difficult to diagnose and treat. We developed and prospectively analyzed a treatment algorithm for nTOS utilizing objective disability criteria, thoracic outlet syndrome (TOS)-specific physical therapy, radiographic evaluation of the thoracic outlet, and selective surgical decompression.Patients treated for nTOS from 2000-2009 were reviewed (n = 93). In period 1, most patients were offered surgery with documentation of appropriate symptoms. A prospective observational study began in 2007 (period 2) and was aimed at determining which patients benefited most from surgical intervention. Evaluation began with a validated mini-QuickDASH (QD) quality-of-life scale (0-100, 100 = worse) and duplex imaging of the thoracic outlet. Patients then participated in TOS-specific physical therapy (PT) for 2 to 4 months and were offered surgery based on response to PT and improvement in symptoms.Thirty-four patients underwent first rib resection in period 1 (68% female, mean age 39, 18% athletes, 15% workers comp). In operated patients undergoing duplex imaging, 47% showed compression of their thoracic outlet arterial flow on provocative positioning. Based on subjective improvement of symptoms, 56% of patients at 1 year had a positive outcome. In period 2 during the prospective cohort, 59 consecutive patients were evaluated for nTOS (64% female, mean age 36, 32% athletes, 12% workers comp) with a mean pre-PT QD disability score of 55.1. All patients were prescribed PT, and 24 (41%) were eventually offered surgical decompression based on compliance with PT, interval improvement on QD score, and duplex compression of the thoracic outlet. Twenty-one patients underwent surgery (SURG group) consisting of first rib resection, middle and anterior scalenectomy, and brachial plexus neurolysis. There were significant differences between the SURG and non-SURG cohorts with respect to age, participation in competitive athletics, history of trauma, and symptom improvement with PT. At 1-year follow-up, 90% of patients expressed symptomatic improvement with the mean post-op QD disability score decreasing to 24.9 (P = .005) and 1-year QD scores improving down to 20.5 (P = .014).This highly-selective algorithm for nTOS surgery leads to improvement in overall success rates documented subjectively and objectively. Compliance with TOS-specific PT, improvement in QD scores after PT, young age, and competitive athletics are associated with improved surgical outcomes. Long-term follow-up will be necessary to document sustained symptom relief and to determine who the optimal surgical candidates are.

    View details for DOI 10.1016/j.jvs.2011.05.105

    View details for Web of Science ID 000297823400022

    View details for PubMedID 21803527

  • Long-term impact of a preclinical endovascular skills course on medical student career choices Lee, J. T., Son, J. H., Chandra, V., Lilo, E., Dalman, R. L. MOSBY-ELSEVIER. 2011: 1193-1200


    Surging interest in the 0 + 5 integrated vascular surgery (VS) residency and successful recruitment of the top students in medical school requires early exposure to the field. We sought to determine the impact of a high-fidelity simulation-based preclinical endovascular skills course on medical student performance and ultimate career specialty choices.Fifty-two preclinical medical students enrolled in an 8-week VS elective course from 2007 to 2009. Students completed a baseline and postcourse survey and performed a renal angioplasty/stent procedure on an endovascular simulator (pretest). A curriculum consisting of didactic teaching covering peripheral vascular disease and weekly mentored simulator sessions concluded with a final graded procedure (posttest). Long-term follow-up surveys 1 to 3 years after course completion were administered to determine ultimate career paths of participants as well as motivating factors for career choice.Objective and subjective performance measured on the simulator and through structured global assessment scales improved in all students from pre- to posttest, particularly with regard to technical skill and overall procedural competency (P < .001). Prior to enrolling in the course, 9% of the students expressed high interest in VS, and after completing the course, this response nearly tripled in terms of seriously considering VS as a career option (P = .03). Overall interest postcourse in VS and procedural-based surgical specialties was nearly 90%. In long-term follow-up, 25% were still strongly considering integrated VS residencies, with other top career choices including surgical subspecialties (64%), radiology (10%), and cardiology (6%). Most respondents indicated major reasons for continued interest in VS were the ability to practice endovascular procedures on the simulator (92%) and mentorship from VS faculty (70%).Basic endovascular skills can be efficiently introduced through a simulation-based curriculum and lead to improved novice performance. Early exposure of preclinical medical students provides an effective teaching and recruitment tool for procedural-based fields, particularly surgical subspecialties. Mentored exposure to endovascular procedures on the simulator positively impacts long-term medical student attitudes toward vascular surgery and ultimate career choices.

    View details for DOI 10.1016/j.jvs.2011.04.052

    View details for Web of Science ID 000295562800042

    View details for PubMedID 21723068

  • A comparison between one- and two-stage brachiobasilic arteriovenous fistulas Reynolds, T. S., Zayed, M., Kim, K. M., Lee, J. T., Ishaque, B., Dukkipati, R. B., Kaji, A. H., de Virgilio, C. MOSBY-ELSEVIER. 2011: 1632-1638


    Brachiobasilic arteriovenous fistulas (BBAVF) can be performed in one or two stages. We compared primary failure rates, as well as primary and secondary patency rates of one- and two-stage BBAVF at two institutions.Patients undergoing one- and two-stage BBAVF at two institutions were compared retrospectively with respect to age, sex, body mass index, use of preoperative venous duplex ultrasound, diabetes, hypertension, and cause of end-stage renal disease. Categorical variables were compared using chi-square and Fisher's exact test, whereas the Wilcoxon rank-sum test was used to compare continuous variables. Patency rates were assessed using the Kaplan-Meier survival analysis and the Cox proportional hazards model with propensity analysis to determine hazard ratios.Ninety patients (60 one-stage and 30 two-stage) were identified. Mean follow-up was 14.2 months and the mean time interval between the first and second stage was 11.2 weeks. Although no significant difference in early failure existed (one-stage, 22.9% vs two-stage, 9.1%; P = .20), the two-stage BBAVF showed significantly improved primary functional patency at 1 year at 88% vs 61% (P = .047) (hazard ratio, 0.2 (95% confidence interval [CI], .04-.80; P = .03). Patency for one-stage BBAVF markedly decreased to 34% at 2 years compared with 88% for the two-stage procedure (P = .047). Median primary functional patency for one-stage BBAVF was 31 weeks (interquartile range [IQR], 11-54) vs 79 weeks (IQR, 29-131 weeks) for the two-stage procedure, respectively (P = .0015). Two-year secondary functional patency for one- and two-stage procedures were 41% and 94%, respectively (P = .015).Primary and secondary patency at 1 and 2 years as well as functional patency is improved with the two-stage BBAVF when compared with the one-stage procedure. Lower primary failure rates prior to dialysis with the two-stage procedure approached, but did not reach statistical significance. While reasons for these finding are unclear, certain technical aspects of the procedure may play a role.

    View details for DOI 10.1016/j.jvs.2011.01.064

    View details for Web of Science ID 000291410600026

    View details for PubMedID 21531530

Stanford Medicine Resources: