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Donald T Baril

Publications and source records attributed to Donald T Baril.

14 recordsLinked to original sources
PubMed2007

Endovascular repair of a traumatic arteriovenous fistula 34 years after the injury: report of a case.

Penetrating extremity injuries can result in the development of arteriovenous fistulas (AVFs), whereby normal blood flow through the capillary bed is bypassed. Late complications of untreated AVFs include proximal arterial dilatation, venous congestion, congestive heart failure, and distal ischemia. We report the case of a 57-year-old man who was referred to us for treatment of a traumatic AVF with multiple sequelae, 34 years after he sustained a shrapnel injury to his right lower leg. We performed successful endovascular repair of this AVF with the patient under spinal anesthesia. Computed tomographic angiography (CTA) done 1 month and 6 months later confirmed AVF exclusion. Patients may present with sequelae of traumatic AVFs many years after their initial injury. Endovascular repair of AVFs offers several advantages over conventional repair and can be performed successfully even in the presence of complex anatomic abnormalities.

Arteriovenous Fistula↗
PubMed2006

Endovascular treatment of complicated aortic aneurysms in patients with underlying arteriopathies.

Patients with arteriopathies including giant cell arteritis, Marfan syndrome, and Takayasu's disease are at risk for aneurysmal degeneration of the aorta. Aortic repair has been recommended for these patients to prevent rupture. The purpose of this study was to examine outcomes following endovascular stent graft (EVSG) repair of aortic aneurysms in this patient population. Over an 8-year period, 11 patients (six men, five women) with arteriopathies underwent endovascular aortic repair. The mean age was 50 (range 15-81). Diseases included Marfan syndrome (n = 6), Takayasu's disease (n = 3), and giant cell arteritis (n = 2). Success of EVSG repair was evaluated per the reporting standards of the Society for Vascular Surgery/American Association for Vascular Surgery. Follow-up was a mean of 28.9 months (range 3-68). Six patients underwent EVSG repair of the thoracic aorta, four underwent EVSG repair of the abdominal aorta, and one underwent a staged repair of the thoracic and subsequently the abdominal aorta. Six true aneurysms and six pseudoaneurysms were repaired. Eight patients had previous aortic surgery, including four with multiple aortic operations. For the 12 aneurysms treated, technical success was achieved in 11 (91.7%). One technical failure occurred due to a small iliac access vessel, requiring an eventual iliac conduit for insertion. Early complications (<30 days) occurred in three patients. Type I or III endoleak developed following two repairs (16.7%). Aneurysm expansion occurred following one repair (8.3%). No aneurysm-related deaths occurred during follow-up. EVSG repair of aortic aneurysms is feasible and can be safely performed in patients with arteriopathies. Long-term durability in this younger group of patients who carry an ongoing risk of arterial degeneration remains to be determined.

Adolescent↗
PubMed2006

Endovascular repair of a saccular infrarenal aortic aneurysm in a liver transplant patient.

Saccular infrarenal aortic aneurysms are rare lesions that usually require prompt surgical repair. In clinical situations where morbidity and mortality associated with open aortic surgery appear to be prohibitively high, an endovascular approach may serve as a life-saving alternative. We report successful endovascular repair of a symptomatic saccular infrarenal aortic aneurysm in a complicated liver transplant patient.

Angioplasty↗
PubMed2006

Endovascular thoracic aortic repair and previous or concomitant abdominal aortic repair: is the increased risk of spinal cord ischemia real?

Spinal cord ischemia after endovascular thoracic aortic repair remains a significant risk. Previous or concomitant abdominal aortic repair may increase this risk. This investigation reviews the occurrence of spinal cord ischemia after endovascular repair of the descending thoracic aorta in patients with previous or concomitant abdominal aortic repair. Over an 8-year period, 125 patients underwent endovascular exclusion of the thoracic aorta at the Mount Sinai Medical Center. Twenty-eight of these patients had previous or concomitant abdominal aortic repair. The 27 patients who underwent staged repairs all had cerebrospinal fluid (CSF) drainage during and following repair. This population was analyzed for the complication of spinal cord ischemia and factors related to its occurrence. Mean follow-up was 19.3 months (range 1-61). Spinal cord ischemia developed in four of the 28 patients (14.3%) who underwent endovascular thoracic aortic repair with previous or concomitant abdominal aortic repair, while one of 97 patients (1.0%) developed ischemia among the remaining thoracic endograft population. One patient with concomitant abdominal aortic repair developed cord ischemia that manifested 12 hr following the procedure. The remaining three patients with previous abdominal aortic repair developed more delayed-onset paralysis ranging from the third postoperative day to 7 weeks following repair. Irreversible cord ischemia occurred in three patients, with full recovery in one patient. Major complications from CSF drainage occurred in one patient (3.7%). Spinal cord ischemia occurred at a markedly higher rate in patients with previous or concomitant abdominal aortic repair. This risk continued beyond the immediate postoperative period. The benefit of perioperative and salvage CSF drainage remains to be determined.

Angioplasty↗
PubMed2006

The management of 38 anastomotic leaks after 1,684 intestinal resections.

PURPOSE: This study was designed to evaluate the management of anastomotic leaks and assess the impact of outpatient leak presentation on clinical outcome. METHODS: Thirty-eight patients with clinical anastomotic leaks from 1,684 adult patients undergoing large and small intestinal anastomosis in a tertiary referral center between January 1, 2003 and September 1, 2005 were studied. All pediatric patients and adult patients with esophageal and gastric leaks were excluded. Charts were reviewed for information on anastomotic leak management, discharge status before leak presentation, length of stay, readmissions, and mortality. RESULTS: The overall leak rate was 2.3 percent. Eighty-seven percent of patients (n = 33) were managed operatively. Forty-two percent of patients (n = 16) were discharged after initial operation and presented as outpatients with anastomotic leak. The discharge and inpatient groups were comparable in respect to total length of stay (26.9 vs. 33.4 days) and number of readmissions (2 vs. 1.5). The overall mortality of 5 percent (n = 2) originated from the discharge group. A greater percentage of discharge patients required intensive care unit stays for more than two weeks (25 vs. 14 percent) and very long hospital admissions lasting more than two months (31 vs. 9 percent). A smaller percentage of the discharge group patients had their ostomies reversed (31 vs. 50 percent). CONCLUSIONS: The primary management of clinical anastomotic leak remains intestinal diversion. Although length of stay was shorter in the discharge group, the number of patients who experienced significant intensive care unit stays and very long hospital stays was greater. Within the discharge group, mortality was higher and fewer patients had their ostomies reversed.

Anastomosis, Surgical↗
PubMed2006

Evolving strategies for the treatment of aortoenteric fistulas.

BACKGROUND: Aortoenteric fistulas (AEFs) are a rare but often fatal cause of gastrointestinal bleeding. Operative repair of AEF has been historically associated with extremely high morbidity and mortality. We reviewed our experience of open surgical and endovascular treatment of AEF to compare outcomes over a contemporaneous time period. METHODS: Over a 9-year period between January 1997 and January 2006, 16 patients (11 men and 5 women) were diagnosed with and treated for AEFs. Seven patients underwent open surgical repair, and nine, with anatomically suitable lesions, underwent endovascular repair. The outcome after treatment of these patients was investigated for survival, perioperative complications, length of hospital stay, and long-term disposition. RESULTS: Three primary and 13 secondary AEFs were treated. The mean time from the initial aortic operation until AEF diagnosis was 5.9 years (range, 0.7-12.2 years) for patients with secondary AEFs. The overall 30-day mortality rate was 18.8%. One intraoperative death and one in-hospital death secondary to multisystem organ failure occurred in patients undergoing open repair. One in-hospital death related to persistent sepsis occurred in the endovascular group. The overall perioperative complication rate was 50.0%. Complications in the open group included sepsis, renal failure, bowel obstruction, and pancreatitis. Complications in the endovascular group were related to persistent sepsis. The mean in-hospital length of stay was significantly longer for patients undergoing open repair compared with endovascular repair (44.0 vs 19.4 days; P = .04). Four (80%) of five patients who were discharged from the hospital in the open group were placed in skilled nursing facilities, and seven (87.5%) of eight patients discharged in the endovascular group returned home. The median overall survival after hospital discharge was 23.1 months. There were no late aneurysm-related deaths or late deaths related to septic complications. CONCLUSIONS: Patients with AEFs have limited overall survival. Endovascular therapy offers an alternative to open surgical repair, seems to be associated with decreased perioperative morbidity and mortality and a shorter in-hospital stay, and allows for acceptable survival given the presence of coexisting medical comorbidities. Furthermore, endovascular repair provides a therapeutic option to control bleeding and allow for continued intervention in a stabilized setting.

Aged↗
PubMed2006

An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.

OBJECTIVE: The treatment of type II endoleaks remains controversial because little is known about their long-term natural history and impact on changes in aneurysm morphology. This study reviews type II endoleaks occurring in patients after endovascular abdominal aortic aneurysm repair (EVAR) at a single-institution over an 8-year period. METHODS: All patients undergoing EVAR who had type II endoleaks documented on follow-up imaging studies at our institution between January 1997 and March 2005 were reviewed. Data regarding patient demographics in addition to aneurysm size, device type, operative complications, and secondary interventions were reviewed. Outcomes evaluated included the rate of spontaneous sealing, freedom from secondary intervention, and aneurysm enlargement, rupture, or conversion. RESULTS: Type II endoleaks were present in 154 of 965 patients (16.0%) undergoing EVAR. Mean follow-up time was 22.0 months (range, 1 to 72 months). Fifty-five patients (35.7%) with type II endoleaks sealed spontaneously in a mean time of 14.5 months. According to Kaplan-Meier analysis, approximately 75% of type II endoleaks sealed spontaneously within a 5-year period. Nineteen patients (12.3%) with type II endoleaks were treated at a mean time of 19.9 months at the operating surgeon's discretion, including 13 with sac enlargement >5 mm. Kaplan-Meier analysis estimated that approximately 65% of the patients remained free of intervention after a period of 4 years. Thirteen patients (8.4%) experienced aneurysm sac enlargement >5 mm. Kaplan-Meier analysis estimated that approximately 80% of patients with type II endoleaks remained free of sac enlargement >5 mm over a 4-year period. No patients with type II endoleaks experienced rupture or required conversion to open repair during their follow-up. Cox regression analysis showed that cancer, coronary artery disease, and chronic obstructive pulmonary disease were associated with earlier spontaneous closure of the type II endoleaks (P < .05). CONCLUSIONS: We observed that type II endoleaks have a relatively benign course, and in the absence of sac expansion, can be followed for a prolonged course of time without the need for intervention. The rate of spontaneous seal continues to increase with time and, therefore, close follow-up of patients with type II endoleaks who show no signs of aneurysm expansion is a safe approach. For patients in whom the exact etiology of their endoleak is in question, dynamic imaging should be used to exclude the presence of a type I endoleak.

Adult↗
PubMed2006

Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy.

OBJECTIVE: Aneurysms involving branches of the superior mesenteric and celiac arteries are uncommon and require proper management to prevent rupture and death. This study compares surgical and endovascular treatment of these aneurysms and analyzes outcome. METHODS: Patients at the Mount Sinai Medical Center in New York who were treated for aneurysms in the branches of the celiac artery and superior mesenteric artery were identified through a search of the institution's medical records and endovascular database. Patient demographics, history, clinical presentation, aneurysm characteristics, treatments, and follow-up outcome were retrospectively recorded. Significant differences between patients treated by surgical or endovascular therapy were determined by using Student's t test and chi2 analysis. RESULTS: Between January 1, 1991, and July 1, 2005, 59 patients with 61 aneurysms were treated at a single institution. Twenty-four patients had surgical repair, and 35 underwent endovascular treatment, which included coil embolization and stent-graft therapy. Splenic (28) and hepatic (22) artery aneurysms predominated. Eighty-nine percent of splenic artery aneurysms were true aneurysms and were treated by endovascular and surgical procedures in near equal numbers (14 and 11, respectively). Pseudoaneurysms were significantly more likely to be treated by endovascular means (P < .01). The technical success rate of endovascular treatment for aneurysms was 89%, and failures were successfully treated by repeat coil embolization in all patients who presented for retreatment. Patients treated by endovascular techniques had a significantly higher incidence of malignancy than patients treated with open surgical techniques (P = .03). Furthermore, patients treated by endovascular means had a shorter in-hospital length of stay (2.4 vs 6.6 days, P < .001). CONCLUSION: Endovascular management of visceral aneurysms is an effective means of treating aneurysms involving branches of the celiac and superior mesenteric arteries and is particularly useful in patients with comorbidities, including cancer. It is associated with a decreased length of stay in the elective setting, and failure of primary treatment can often be successfully managed percutaneously.

Aneurysm↗
PubMed2006

Experience with endovascular abdominal aortic aneurysm repair in nonagenarians.

PURPOSE: To report a single-institution experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in nonagenarians. METHODS: A retrospective review was performed of all patients >90 years old undergoing EVAR over an 8-year period at a major academic medical center. The patient population was investigated for the presence of various comorbidities, initial aneurysm size, successful aneurysm exclusion, perioperative complications, disposition, endoleaks, secondary interventions, and overall survival. RESULTS: EVAR was performed in 18 male nonagenarians (mean age 92.4 years, range 90- 95). Mean aneurysm diameter was 7.3 cm (range 5.5-9.8). The cohort had an average of 3.2 comorbid conditions. Sixteen patients were treated electively, while 2 patients underwent emergent repair for contained rupture and bleeding aortoenteric fistula, respectively. Immediate technical success was 100%. Perioperative local/vascular complications occurred in 4 (22%) patients. Perioperative systemic complications occurred in 3 (17%) patients. There were 2 (11%) perioperative (<30 days) deaths. Three (17%) patients required secondary interventions. Mean survival in patients who expired during the follow-up period beyond the first 30 days was 34 months (range 8-78). Mean survival in 8 patients who are still alive is 17.4 months (range 9-39). CONCLUSION: Endovascular AAA repair in nonagenarians is associated with a high rate of technical success and relatively low morbidity rate. Survival times following successful hospital discharge are significant. Suitable patients over 90 years of age may benefit from an endovascular AAA repair.

Age Factors↗
PubMed2006

[Endovascular repair of abdominal aortic aneurysms].

Abdominal aortic aneurysms (AAA) continue to be a major source of morbidity and mortality. The transfemoral placement of endoluminal stent-grafts for the treatment of AAAs, first described in 1991, offers a minimally invasive technique for the treatment of AAAs. The technology of endovascular repair of AAAs has progressed rapidly and the approach has proven to be safe and effective in the short- to mid-term. The spectrum of patients who are candidates for endovascular repair and the devices available continue to expand. However, endovascular repair of AAAs remains a relatively novel technique, and there is still much to be learned about its long-term durability.

Aortic Aneurysm, Abdominal↗
PubMed2005

Branched endografts for treatment of complex aortic aneurysms.

Aortic aneurysms continue to be a major source of morbidity and mortality despite advances in operative and perioperative technology. Endovascular stent graft repair of abdominal aortic aneurysms has been widely adopted since its initial report in 1991. Improvements in device delivery systems and development of modular bifurcated stent grafts have greatly facilitated repair, and broadened the applicability of these techniques. However, aneurysmal involvement of critical branch vessels can be problematic. Experience is growing with custom-made branched endografts to maintain antegrade perfusion to critical arteries in treatment of thoracoabdominal and complex aortoiliac aneurysms. The use of branched devices allows for extension of the sealing and fixation portions of the graft into more stable aorta, while simultaneously maintaining branch vessel patency. Much remains to be learned regarding the long-term durability of these repairs; however, as additional devices are developed, it is evident that the limitations of endovascular aortic aneurysm repair will continue to diminish.

Aortic Aneurysm, Abdominal↗
PubMed2004

Endovascular repair of an infected carotid artery pseudoaneurysm.

Pseudoaneurysm formation after carotid endarterectomy is a rare but potentially lethal complication. The risks for embolization and continued expansion necessitate repair. Traditional surgical repair of carotid pseudoaneurysms is often technically demanding, and is associated with relatively high morbidity and mortality. Endovascular stent grafts have been used to treat both posttraumatic and postoperative carotid pseudoaneurysms. An endovascular approach to these pseudoaneurysms limits the risks for operative damage to surrounding structures and the potential for substantial blood loss. We present the case of an infected carotid pseudoaneurysm that was successfully treated with a covered stent graft.

Aged↗
PubMed2004

Endovascular therapy for aortic disease.

Minimally invasive repair of thoracic and abdominal aortic aneurysms (AAAs) is rapidly becoming a vital tool in the arsenal of the vascular specialist. Historically, surgical replacement of the aorta has been the "gold standard" for treatment of aortic aneurysms. However, transfemoral placement of an endovascular stent graft, first described by Dr. Parodi and colleagues in 1991, marked the beginning of a new era in treatment of aortic aneurysms. This approach has evolved, allowing success with significantly less morbidity. Over time, if the long-term results continue to prove favorable, endovascular stent graft repair of aortic aneurysms may become the most effective means to treat this life-threatening disease.

Angiography↗