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Biomedical subjects

Samuel R Money

Publications and source records attributed to Samuel R Money.

At least 19 recordsLinked to original sources
PubMed2007

Endovascular repair of an iliac artery aneurysm in a patient with Ehlers-Danlos syndrome type IV.

Ehlers-Danlos type IV (EDS-IV) is an inherited condition most notable for its associated vascular complications. Patients are prone to aneurysm formation, arterial dissection, and spontaneous vessel rupture. Intervention for the vascular pathology of EDS-IV carries high morbidity and mortality. We describe a case of a 57-year-old man with EDS-IV and an expanding iliac aneurysm who underwent successful endovascular repair with a stent-graft. Endovascular aneurysm repair is feasible and should be considered for patients with EDS-IV.

Blood Vessel Prosthesis Implantation↗
PubMed2005

Mid- and long-term device migration after endovascular abdominal aortic aneurysm repair: a comparison of AneuRx and Zenith endografts.

BACKGROUND: Freedom from migration is key to the durability of endovascular aneurysm repair (EVAR). This study evaluates the mid- and long-term incidence of migration with two different endografts. METHODS: Between September 1997 and June 2004, 235 patients were scheduled for EVAR with an AneuRx (Medtronic/AVE Inc.) or Zenith (Cook) endograft. Patients with fusiform, infrarenal aneurysms and a minimum 12 months of follow-up were analyzed, for a final cohort of 130 patients. Migration was assessed on axial computed tomography (CT) (2.5 to 3 mm cuts) as the distance from the most caudal renal artery to the first slice containing endograft (AneuRx) or to the top of the bare suprarenal stent (Zenith). Aortic neck diameters were measured at the most caudal renal artery. The initial postoperative CT scan was the baseline. Migration was defined by caudal movement of the endograft at two thresholds, > or =5 mm and > or =10 mm, or any migration with a related clinical event. RESULTS: Life-table analysis demonstrated AneuRx freedom from migration (> or =10 mm or clinical event) was 96.1%, 89.5%, 78.0%, and 72.0% at 1, 2, 3, and 4 years, respectively. Zenith freedom from migration was 100%, 97.6%, 97.6%, and 97.6% at 1, 2, 3, and 4 years, respectively (P = .01, log-rank test). The stricter 5-mm migration threshold found 67.4% of AneuRx and 90.1% of Zenith patients free from migration at 4 years of follow-up. Twelve out of 14 (85.7%) AneuRx patients (12/14) with migration (> or =10 mm or clinical event) underwent 14 related secondary procedures (13 endovascular, 1 open conversion). The single Zenith patient with migration (> or =10 mm) has not required adjuvant treatment. Mean follow-up was 39.0 +/- 2.3 months (AneuRx) and 30.8 +/- 1.9 months (Zenith, P = .01). Patients with and without migration did not differ in age, gender ratio, aneurysm diameter, and neck diameter. However, initial neck length was shorter in patients with migration (22.1 +/- 2.1 mm vs 31.2 +/- 1.2 mm, P = .02). A subset of patients (21.6%) experienced significant (defined as > or =3 mm) maximum aortic neck dilation. Of the AneuRx patients, > or =3 mm aortic neck dilation affected 30.8% of migrators vs 13.0% of nonmigrators (P = .20). CONCLUSIONS: Endograft migration is a time-dependent phenomenon affected by both device choice and aortic neck length. A great majority of patients (85.7%) with migration of the AneuRx device ultimately required treatment. A minority of patients experienced aortic neck dilation that could be considered clinically significant. Careful surveillance for migration is an essential component of long-term follow-up after EVAR.

Aged↗
PubMed2004

Influence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: results from the Zenith Multicenter Trial.

BACKGROUND: Generous endograft oversizing has been associated with propensity for aortic neck dilation and subsequent device migration in endografts without suprarenal fixation. Effects of variable oversizing of endografts with suprarenal fixation have been poorly studied. METHODS: Three hundred fifty-one patients underwent endovascular AAA repair (EVAR) in a prospective multicenter trial using the Zenith AAA Endovascular Graft, a fully supported bifurcated 3-piece endograft with barb-enhanced suprarenal stent fixation. Blinded core-laboratory measurement of variables was prospectively recorded at predischarge and at 1, 6, 12, and 24 months after the procedure. Potential influence of endograft oversizing on subsequent aortic neck dilation (minor axis), aneurysm shrinkage (major axis), device migration, endoleak, rupture, open conversion, and death were retrospectively studied. Data are given as mean +/- SEM. RESULTS: Risk of endograft migration (>5mm) at 12 months was 2.3% (6/261). However, patients with endograft oversizing of >30% had a 14% (4/29) migration risk compared with those oversized < or =30% (0.9%, 2/232), P <.002. There was zero device migration by the SVS definition (>10 mm or clinical event). Device oversizing >30% was associated with decreased AAA sac shrinkage (48% vs 77%) and with increased sac enlargement (9.5% vs 0.6%) at 24 months when compared with oversizing of < or =30%, respectively (P =.001). Incidence rate of any endoleak at 12 and 24 months was 8.2% (21/256) and 7.1% (12/169), respectively. Oversizing of endografts by >30% was associated with an increased type II endoleak rate (11 vs 4.7%) that failed to reach statistical significance (P =.27). Aortic neck diameters increased significantly by 6 months (P <.001) but then stabilized through 24 months; the absolute changes at 1 (n = 298), 6 (n = 278), 12 (n = 264), and 24 months (n = 171) were 0.66 +/- 0.10 mm (3.0%), 1.32 +/- 0.11 mm (5.6%), 1.38 +/- 0.12 mm (5.9%), and 1.44 +/- 0.16 mm (6.1%), respectively. Linear regression analysis demonstrated no correlation between endograft oversizing and aortic neck dilation at 12 (P =.86) or 24 months (P =.64). CONCLUSIONS: Device migration and endoleaks were very infrequent after treatment with the Zenith AAA Endovascular Graft. However, endograft oversizing of >30% was associated with an approximately 14-fold increase in device migration (>5 mm) at 12 months and with a approximately 16-fold increased risk of AAA expansion at 24 months. Although further follow-up will be essential to assess whether these early associations continue, avoidance of excessive endograft oversizing is recommended.

Aorta, Abdominal↗
PubMed2004

Late problems at the proximal aortic neck: migration and dilation.

Migration is a late-term complication of endovascular aneurysm repair (EVAR) evidenced by downward slippage of the endograft. The etiology of migration may be inherent to problems with endograft fixation, although aortic neck dilation may also play a role. Devices with active fixation (ie, hooks and barbs) possess an additional mechanism of fixation and may better resist migration. Aortic neck dilation after EVAR is significant in a subset of patients and may be related to neck degeneration. Excessive oversizing of endografts may contribute to dilation and migration and is, therefore, not recommended. Migration should be treated when the overlap between the endograft and aortic neck is less than 10 mm or when associated with clinically significant events such as type I endoleak or aneurysm expansion. Failure to treat migration could lead to repressurization and subsequent rupture of the aneurysm.

Aortic Aneurysm, Abdominal↗
PubMed2004

Importance of access to fixed-imaging fluoroscopy: practice implications for the vascular surgeon.

PURPOSE: To examine the impact of unfettered access to high quality fixed-imaging fluoroscopy in a vascular surgery practice. METHODS: The case mix of 2 vascular surgeons was retrospectively examined for a 12-month period before (period A) and after (period B) routine access to fixed-imaging equipment was established. Operative and endovascular cases were identified by their CPT codes. Trends in procedure frequency and gross charges were assessed. RESULTS: Endovascular code usage increased 174% (p<0.001) following routine access to fixed imaging equipment. There was an overall 2.3-fold increase in angioplasty across all vascular beds (p<0.001), as well as a 2.1-fold increase in stent utilization (p<0.001). More complex diagnostic and interventional procedures were performed, as evidenced by a large increase in third-order catheterizations (p<0.001). Open surgical therapy decreased overall by 11.4% (p=0.051) in period B. Reductions in open surgery for peripheral arterial occlusive disease were most pronounced, decreasing 35.6% (p<0.001). Overall gross charges increased 6% in group B. Endovascular procedures accounted for 36.6% of gross charges in period B, doubling its contributions from period A (17.1%, p=0.01). Open major vascular case contributions to gross charges fell from 54.4% to 36.2%. CONCLUSIONS: A significant shift in case mix was observed after routine access to fixed imaging equipment was established, with a dramatic increase seen in percutaneous endovascular case volume and complexity. Corresponding contributions to gross charges for endovascular procedures became equivalent to that of all open major vascular cases combined. Routine access to fixed imaging fluoroscopy appeared to be the chronological fulcrum on which the balance of endovascular and open vascular cases has shifted, allowing the development of a fully integrated vascular and endovascular practice.

Angioplasty↗
PubMed2003

The effect of gender on early and intermediate results of endovascular aneurysm repair.

Results of endovascular aneurysm repair (EVAR) may be gender dependent. Between September 1997 and September 2001, 118 AneuRx aortic grafts were placed for aneurysmal disease. During this period, 17 females and 101 males were treated with this device. A prospective database was maintained and supplemented with retrospectively gathered information to evaluate early and mid-term end points. A total of 113 devices were deployed in 118 attempts. Length of procedure was greater for females (3.3 +/- 1.75 vs. 2.3 +/- 0.8 hr, p = 0.05) and they were more likely to have significant arterial dissections (12% vs. 1%, p = 0.05). The mortality rates at 1 month were 12% for females and 0% for males ( p = 0.02); the complication rates at 1 month were 41% for females and 15% for males ( p = 0.02). Although technical success was not significantly different between the sexes, assisted primary technical success (requiring endovascular assistance) and assisted secondary technical success (requiring open surgical assistance) were significantly different (71% vs. 96%, p = 0.003; and 76% vs. 98%, p = 0.004, respectively). Clinical success at 1 month was 59% for females and 84% for males ( p = 0.02). This difference was also significant when assessing 1-month assisted primary clinical success (59% vs. 90%, p = 0.003) and assisted secondary clinical success as well (71% vs. 96%, p = 0.003). Clinical success and assisted primary clinical success were not different at 6- or 12-month intervals, however, assisted secondary clinical successes differed at both time intervals (56% vs. 83%, p = 0.02; and 56% vs. 81%, p = 0.05, respectively). As-yet undetermined factors appear to predispose females to complications and technical difficulties in the short term. Endovascular and open procedures required to achieve ongoing clinical success in the following months appear to favor males to a greater degree than females.

Aged↗
PubMed2003

Aortic aneurysm sac shrinkage after endovascular repair is device-dependent: a comparison of Zenith and AneuRx endografts.

Aneurysm sac shrinkage after endovascular aneurysm repair (EAR) provides objective evidence of successful aneurysm exclusion and absence of endotension. Attainment of this outcome parameter may be device-dependent. In this study, 169 patients underwent EAR with an AneuRx (n = 118) or Zenith (n = 51) endograft at a single institution. A prospectively maintained database was examined for significant changes in aneurysm sac diameter (> or = 5 mm) on the basis of computed tomography (CT) measurements at 6 and 12 months follow-up. Significant aneurysm sac shrinkage (> or = 5 mm) occurred in 73.1 % (19/26) vs. 43.1% (28/65) of patients in the Zenith and AneuRx groups, respectively, at 12 months (p = 0.03). At 6 months follow-up, sac shrinkage rates were 51.4% (19/37) vs. 25.8% (16/62) in the Zenith and AneuRx groups, respectively (p = 0.04). Mean reduction of sac diameter at 12 months was -7.6 +/- 1.6 mm vs. -3.5 +/- 0.8 mm in the Zenith and AneuRx groups, respectively (p = 0.01). There was a trend toward fewer Type I and III endoleaks at 1 month in the Zenith group (0 vs. 8.3%) that did not achieve statistical significance (p = 0.067). The presence of any endoleak (> or = 1 month) was associated with reduced 12 month shrink rates from 47.1% (25/51) to 28% (4/14) in the AneuRx group (p = 0.35) and from 77.3% (17/22) to 50% (2/4) in the Zenith group (p = 0.25). Patients treated with the Zenith endograft demonstrated a significantly higher rate and amount of aneurysm sac shrinkage than patients treated with an AneuRx device. Endoleaks appeared to negatively influence shrink rates with both endografts.

Aortic Aneurysm, Abdominal↗
PubMed2003

Acute bilateral iliac artery occlusion secondary to blunt trauma: successful endovascular treatment.

INTRODUCTION: Endovascular treatment of blunt vascular trauma has been infrequently reported. PRESENTATION: A 27-year-old man was crushed between a fork-lift truck and a concrete platform. The physical examination was remarkable for hemodynamic stability, significant lower abdominal ecchymosis and tenderness, obvious pelvic fracture, and gross hematuria. Vascular examination revealed no femoral pulses, no pedal signals bilaterally, and minimal left leg and no right leg motor function. Arteriograms revealed right common iliac artery and external iliac artery occlusion and a 2-cm near occlusion of the left external iliac artery. TREATMENT: In the operating room, bilateral common femoral artery access was obtained, and retrograde arteriogram on the right side demonstrated free extravasation of contrast material at the level of the proximal external iliac artery. An angled glide wire was successfully traversed over the vascular injury, and two covered stents (Wallgraft, 10 x 50 mm and 8 x 30 mm) were deployed. The left iliac injury was similarly treated with an 8 x 30-mm covered stent. After calf fasciotomy, exploratory laparotomy revealed a severe sigmoid colon degloving injury, requiring resection and colostomy. A suprapubic catheter was placed because of bladder rupture, and an open-book pelvic fracture was treated with external fixation. Postoperatively the patient regained palpable bilateral pedal pulses and normal left leg function, but right leg paralysis persisted secondary to severe lumbar plexus nerve injury. CONCLUSION: Endovascular repair of blunt intra-abdominal arterial injuries is possible and should be particularly considered when fecal contamination, pelvic hematoma, or multiple associated injuries make conventional repair problematic.

Adult↗
PubMed2003

Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of type II endoleaks.

One of the complications of endovascular repair of abdominal aortic aneurysm is endoleak from a patent inferior mesenteric artery (IMA). Between 1995 and 2002, of 213 patients who had endografts placed for abdominal aortic aneurysm, 4 (1.8%) had enlarging aneurysms from type II endoleaks involving a patent IMA and underwent a secondary procedure. Two patients had endovascular embolizations through the superior mesenteric artery, and two patients underwent laparoscopic inferior mesenteric artery ligation. In the laparoscopic group, operative time was 85 minutes (range, 35-136 minutes). One laparoscopic procedure had to be redone due to a missed IMA branch. Length of stay was 0 and 3 days. At mean followup at 16 months (range, 2-42 months), all patients had had successful resolution of endoleaks. Laparoscopic ligation is a minimally invasive treatment for IMA-mediated type II endoleaks.

Aged↗
PubMed2002

Does ASA classification impact success rates of endovascular aneurysm repairs?

The purpose of this study was to evaluate the technical success, clinical success, postoperative complication rate, need for a secondary procedure, and mortality rate with endovascular aneurysm repair (EAR), based on the physical status classification scheme advocated by the American Society of Anesthesiologists (ASA). At a single institution 167 patients underwent attempted EAR. Query of a prospectively maintained database supplemented with a retrospective review of medical records was used to gather statistics pertaining to patient demographics and outcome. In patients selected for EAR on the basis of acceptable anatomy, technical and clinical success rates were not significantly different among the different ASA classifications. Importantly, postoperative complication and 30-day mortality rates do not appear to significantly differ among the different ASA classifications in this patient population.

Aged↗
PubMed2002

A decade of decline: an analysis of Medicare reimbursement for vascular surgical procedures.

Despite inflation and a robust economy, standard Medicare reimbursements for vascular surgical procedures have progressively declined. The objective of this analysis was to quantitatively and objectively evaluate the decline of vascular surgical reimbursement over the past decade. In this study, data for the analysis of specific vascular surgical procedures was obtained from the National Center for Health Statistics-National Hospital Discharge Survey (NCHS-NHDS) for all vascular procedures as reported by ICD-9-CM codes. The average Medicare reimbursement for each of the specified procedures for 1990 was compared to that of 2001 and the percent change in average reimbursement over this period was calculated. Comparisons between 1990 and 2001 dollar amounts were made after correction for inflation using the consumer price index. This correction factor allows for the calculation of the actual percentage reduction in "real dollars" that is reflected in buying power. We found significant decreases in Medicare reimbursement for each of the vascular procedures included in this analysis. Despite national economic prosperity, there was an average 41% decrease in the buying power per case for vascular surgical procedures over the past decade. We feel that these reductions in reimbursement are overzealous and need to be reexamined.

Aged↗
PubMed2002

Mid-term results of patients undergoing endovascular aortic aneurysm repair.

BACKGROUND: The utilization of endovascular aneurysm repair (EAR) is increasing significantly; however, few papers have outlined mid-term outcomes. METHODS: Patients undergoing EAR with an AneuRx endograft between September 1997 and May 2001 were evaluated. Mean follow-up was 20.7 +/- 11.9 (SD) months. RESULTS: In all, 101 EAR devices were successfully deployed in 105 attempts. Four open conversions (2 acute, 2 delayed) were performed for complications of EAR. Technical, clinical, and 1 to 3 year continuing success rates were 75%, 73%, and 78% to 83%. When divided by the median date, significantly fewer patients in the later group required secondary procedures compared with the early group. Vascular insufficiency occurred in 12 patients; 11 were treated with a secondary procedure. For 9 type I and 9 type II persistent endoleaks, secondary procedures were attempted and successful in 10 patients. Of successful EAR deployments, including secondary interventions, 85% demonstrated no persistent leak, rupture, increase in aneurysm size, or migration at most recent follow-up. CONCLUSIONS: EAR is successful in selected individuals; however, continuing follow-up is of paramount importance.

Aged↗
PubMed2002

Can claudication be improved with medication?

Intermittent claudication is a common disabling condition that affects approximately 5% to 15% of patients with atherosclerotic disease. Recommended treatment involves lifestyle modification and physical conditioning through the adoption of a regular exercise program. These methods of treatment often have been unsuccessful in the past because of noncompliance, in large part related to the relatively minor degree of improvement experienced by the patient. However, some recent trials have resulted in greater relative improvements in both pain-free and maximal walking distances in some patients treated with medication. Surgical and endovascular options offer greater degrees of improvement but also greater morbidity and should be reserved as treatment for severe claudication. The efficacies, as well as common adverse reactions associated with current medications used to treat patients with intermittent claudication are reviewed.

Carnitine↗