15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease

Kumakura H, et al. 15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease. JACC Cardiovasc Interv. 2015 Dec 21;8(14): 1893-901.

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Methods: EVT was performed for 507 lesions in 455 patients with PAD. The 15-year endpoints were primary, primary-assisted, and secondary patency; overall survival; freedom from major adverse cardiovascular events (MACE); and freedom from major adverse cardiovascular and limb events (MACLE).

Results: The 5-, 10-, and 15-year primary and secondary patencies were 89%, 83%, and 75%, respectively, and 92%, 91%, and 91%, respectively. There were no significant differences among TASC-II categories.

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Coronary-artery revascularization before elective major vascular surgery

McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004 Dec 30;351(27):2795-804.

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Results: Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs Medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37). Continue reading

Aortic stenosis and noncardiac surgery: risks and postoperative outcomes

Pislaru SV, et al. Aortic stenosis and noncardiac surgery: managing the risk. Curr Probl Cardiol. 2015 Nov;40(11):483-503.

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“In summary, the mortality risk at contemporary noncardiac surgery has followed the general trend of decreasing surgical mortality rate, and is currently at 1.5%-4% for elective procedures, significantly lower than those in the early reports (Fig 1). Presence of severe AS does not result in increased mortality rates, but rather in excess cardiovascular morbidity (most notably myocardial infarction [13] or new or worsening heart failure [14]). Symptomatic patients have worse outcomes.” (pg. 488) Continue reading

The safety of enteral and parenteral nutrition in ICU patients receiving vasopressors

Patel JJ, et al. Phase 3 Pilot Randomized Controlled Trial Comparing Early Trophic Enteral Nutrition With “No Enteral Nutrition” in Mechanically Ventilated Patients With Septic Shock. JPEN J Parenter Enteral Nutr. 2020 Jul;44(5):866-873.

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Results: One hundred thirty-one patients were eligible for enrollment, and 49 were available for consent. Thirty-one (86%) consented and were randomized and 100% of patients in the early EN arm and 94% in the “no EN” arm completed their protocols. While on vasopressors, early EN group received median 384 kcal, and the “no EN” group received median 0 kcal. Contamination rate was 0 in the early trophic EN arm and 6% in the “no EN” arm. The early EN group had median 25 intensive care unit-free days, as compared with 12 in the “no EN” arm (P = .014). The early EN arm had median 27 ventilator-free days, compared with 14 in “no EN” arm (P = .009).

Conclusion: Our protocol comparing early trophic EN with “no EN” in septic shock was feasible. Early trophic EN may be beneficial, but a larger multicenter trial is warranted to confirm the observed clinical benefits seen in this trial.

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Systemic Thrombolysis for Pulmonary Embolism

Tapson VF, Friedman O. Systemic Thrombolysis for Pulmonary Embolism: Who and How. Tech Vasc Interv Radiol. 2017 Sep;20(3):162-174.

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PE screenshot

“For several decades, clinicians and clinical trialists have worked toward a more aggressive, yet safe solution for patients with intermediate-risk PE. Standard-dose thrombolysis, low-dose systemic thrombolysis, and catheter-based therapy which includes a number of devices and techniques, with or without low-dose thrombolytic therapy, have offered potential solutions and this area has continued to evolve. On the basis of heterogeneity within the category of intermediate-risk as well as within the high-risk group of patients, we will focus on the use of systemic thrombolysis in carefully selected high- and intermediate-risk patients. In certain circumstances when the need for aggressive therapy is urgent and the bleeding risk is acceptable, this is an appropriate approach, and often the best one.”


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Phlegmasia alba dolens and phlegmasia cerulea dolens

Chinsakchai K, et al. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011 Jan;45(1):5-14.

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PCD screenshot

Phlegmasia cerulea dolens (PCD) is a fulminant condition of acute massive venous thrombosis that may result in major amputation or death unless treated in an early phase. Guidelines for treatment are still not clearly documented. As a consequence, physicians might have limited knowledge of this potential life-threatening condition and its clinical course. Therefore, the purpose of this review was to analyze and summarize clinical manifestations and proposed diagnostic approach, factors that affect the outcome of PCD, and the evolution of management and therapeutic options. Underlying malignancy, pulmonary embolism, and PCD severity are the vital factors that predict the outcome of PCD. In the last decades, treatment options have remained largely unchanged. Published evidence shows that advances in minimally invasive techniques have not yet resulted in outcome improvements compared with traditional surgical thrombectomy. Treatment seems to depend on grading the severity of this condition and experience of the surgeon.

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Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery.

Christopherson R, Beattie C, Frank SM, Norris EJ, Meinert CL, Gottlieb SO, Yates H, Rock P, Parker SD, Perler BA, et al. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993 Sep;79(3):422-34.

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Background: Perioperative morbidity may be modifiable in high risk patients by the anesthesiologist’s choice of either regional or general anesthesia. This clinical trial compared outcomes between epidural (EA) and general (GA) anesthesia/analgesia regimens in a group of patients at high risk for cardiac and other morbidity who were undergoing similarly stressful surgical procedures.

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The surgical management of purulent peritonitis from perforated diverticulitis

Oberkofler CE, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012 Nov; 256(5):819-26; discussion 826-7.

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Results: Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group.

Conclusions: This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.


Thornell A, et al. Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized Trial. Ann Intern Med. 2016 Feb 2;164(3):137-45.

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LL vs Hartmann

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Preoperative splenic artery embolization for massive splenomegaly

Wu Z, Zhou J, Pankaj P, Peng B. Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy. Surg Endosc. 2012 Oct;26(10):2758-66.

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Surg Endo screenshot

Results: Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period.

Conclusions: Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.


Reso A, et al. Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly. Surg Endosc. 2010 Aug;24(8):2008-12.

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Results: A total of 19 patients were identified. The median spleen length was 23 cm, and the median spleen weight was 1,740 g. Nine patients underwent LAS, and 10 underwent HALS. The median operative time was 130 min, and the median hospital stay was 6 days. There were no conversions to open laparotomy. The median estimated blood loss was 200 ml. One patient required reoperation 24 h after LAS due to bleeding, and PVT developed in three patients postoperatively.

Conclusions: In the setting of massive splenomegaly, LAS or HALS with preoperative SAE is safe and has a low conversion rate. Postoperative imaging surveillance for PVT should be performed routinely in this patient population.


Pandey SK, et al. Anatomical variations of the splenic artery and its clinical implications. Clin Anat. 2004 Sep;17(6):497-502.

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anatomy splenic artery

“The variations in origin, course, and terminal branching pattern of the splenic artery were studied in 320 cadavers. The artery originated from the coeliac trunk in the majority of cadavers (90.6%), followed by abdominal aorta (8.1%), and other sights (1.3%). A suprapancreatic course of the artery was commonly observed (74.1%) followed by enteropancreatic (18.5%), intrapancreatic (4.6%), and retropancreatic (2.8%) courses.

In two cases (0.63%) the proximal part of the splenic artery made a loop that was embedded in the substance of the pancreas, which is an interesting and rare finding. In five cases (1.5%) the proximal part of the artery divided into two or more branches that had suprapancreatic and enteropancreatic courses. The splenic artery divided into terminal branches in 311 (97%) cadavers. In nine (2.8%) cadavers it passed through the hilum of spleen without dividing. Two terminal branches were the most common (63.1%) followed by four (18.8%), six (9.7%), and more than six (5.6%) branches.

The present study clearly indicates that there is variation in origin, course, and terminal distribution pattern of the splenic artery. The knowledge of these variations are of significant importance during surgical and radiological procedure of upper abdominal region to avoid any catastrophic complications.”


More PubMed results on preop splenic artery embolization for massive splenomegaly and splenic arterial anatomy.