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Thomas T Terramani

Publications and source records attributed to Thomas T Terramani.

At least 19 recordsLinked to original sources
PubMed2006

In situ reconstruction with cryopreserved arterial allografts for management of mycotic aneurysms or aortic prosthetic graft infections: a multi-institutional experience.

We designed this study to evaluate a multi-institutional experience regarding the efficacy of cryopreserved aortic allografts in the treatment of infected aortic prosthetic grafts or mycotic aneurysms. We reviewed clinical data of all patients from 4 institutions who underwent in situ aortic reconstruction with cryopreserved allografts for either infected aortic prosthetic graft or mycotic aneurysms from during a 6-year period. Relevant clinical variables and treatment outcomes were analyzed. A total of 42 patients (37 men; overall mean age 63 +/- 13 years, range 41-74 years) were identified during this study period. Treatment indications included 34 primary aortic graft infections (81%), 6 mycotic aneurysms (22%), and 2 aortoenteric erosions (5%). Transabdominal and thoracoabdominal approaches were used in 38 (90%) and 4 patients (10%), respectively. Staphylococcus aureus was the most commonly identified organism (n=27, 64%). Although there was no intraoperative death, the 30-day operative mortality was 17% (n=7). There were 21 (50%) nonfatal complications, including local wound infection (n=8), lower-extremity deep venous thrombosis (n=5), amputation (n=6), and renal failure requiring hemodialysis (n=2). The average length of hospital stay was 16.4 +/- 7 days. During a mean follow-up period of 12.5 months, reoperation for allograft revision was necessary in 1 patient due to graft thrombosis (6%). The overall treatment mortality rate was 21% (n=9). In situ aortic reconstruction with cryopreserved allografts is an acceptable treatment method in patients with infected aortic prosthetic graft or mycotic aneurysms. Our study showed that mid-term graft-related complications such as reinfection or aneurysmal degeneration were uncommon.

Adult↗
PubMed2004

Endovascular abdominal aortic aneurysm repair in the octogenarian.

The aim of this study was to analyze patient outcomes following endovascular repair of infrarenal abdominal aortic aneurysms (EAR) among patients 80 years of age or older. In this study, reporting standards of the Ad Hoc Committee for Standardized Reporting Practices for Endovascular Aortic Aneurysm Repair of the Society of Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) were followed. Between August 8, 1996 and February 12, 2001 EAR was performed in 31 patients (29 male and 2 female) with an average age of 83 +/- 3 years and an average maximum aneurysm diameter of 59 +/- 7 mm. Overall technical success was 90% (28/31) with a single acute conversion and a 6% (2/32) incidence of major morbidity. There were no in-hospital deaths, but two patients (6%) died within 30 days of intervention. Four endoleaks, two type I and two type II, were observed within the first 30 days after endograft implantation and three new type II endoleaks were noted after implant periods that exceeded 1 month. Average follow-up was 16 months, with a single aneurysm-related death that occurred after late conversion to open repair, 2 years following initial endovascular treatment. Kaplan-Meier analysis revealed 3-, 12-, and 24-month estimated survivals of 93% (+/-5), 75% (+/-8), and 68% (+/-10), respectively. Clinical success rates were 90% (+/-5), 90% (+/-5), and 72% (+/-17) at 12, 24, and 36 months, respectively. We conclude that, in the octogenarian with mild to moderate medical comorbidities, endovascular aneurysm repair provides an alternative to open AAA repair with low operative morbidity and good clinical success rates. Elevated SVS/AAVS medical comorbidity scores were not associated with increased operative mortality rates, but they did show a trend toward decreased mid-term survival. Careful consideration of life expectancy and the probability of rupture, as with traditional AAA repair, should dictate necessity for intervention.

Aged↗
PubMed2003

Impact of an endovascular program on the operative experience of abdominal aortic aneurysm in vascular fellowship and general surgery residency.

BACKGROUND: This study was performed to determine the impact of an endovascular program (EVP) on open and endovascular abdominal aortic aneurysm (AAA) operations in a residency training institution. METHODS: Over an 8-year period ending in September 2001, hospital records of all patients undergoing open or endovascular AAA repair were retrospectively reviewed. Data were analyzed to determine the changing patterns of case volume, type of operative repair, and complexity of open repair with regards to the training of both general surgical chief residents and vascular fellows. RESULTS: A total of 849 AAA operations were performed during the study period. The initiation of the EVP in 1997 resulted in a steady increase in the total annual AAA cases (P < 0.05), due in part to an increase in endovascular AAA operations despite a decrease in the annual open AAA volume. EVP had a positive impact on the overall operative experience of vascular fellows owing to the large increase in their endovascular AAA experience (annual mean pre-EVP 3 +/- 0.8 versus post-EVP 47 +/- 9.6, P < 0.01). A significant reduction occurred in the vascular fellows' open AAA experience (annual mean pre-EVP 40 +/- 12.7 versus post-EVP 19 +/- 9.4, P < 0.05). EVP did not affect the endovascular AAA experience of general surgery chief residents (annual mean pre-EVP 1 +/- 0.8 versus post-EVP 3 +/- 1.5, not significant). A significant reduction occurred in chief residents' open AAA experience (annual mean pre-EVP 39 +/- 9.7 versus post-EVP 18 +/- 7.4, P < 0.05). EVP did not affect the operative experience of complex open AAA operations in either vascular fellows or general surgery residents. CONCLUSIONS: An endovascular program has a positive impact on the aortic aneurysm practice in an academic institution, as evidenced by the significant increase in annual endovascular AAA cases despite a decrease in open AAA operations. Although vascular fellows continued to maintain sufficient experience in both open and endovascular AAA operations, general surgery chief residents suffered a significant decrease in their open AAA experience. Further evaluation of the residency system is warranted to better optimize the training paradigm of both vascular fellowship and general surgery residency.

Aortic Aneurysm, Abdominal↗
PubMed2003

Concomitant intraoperative renal artery embolization and resection of complex renal carcinoma.

BACKGROUND: Renal cell carcinoma, which has the propensity for rapid enlargement and local invasion, may present a surgical challenge, in part because of extensive vascularity. Conventional treatment typically involves staged preoperative renal artery embolization followed by nephrectomy after 1 or 2 days. We evaluated the clinical outcome of concomitant intraoperative embolization and nephrectomy. METHODS: Over 7 years, eight patients with renal cell carcinoma underwent combined intraoperative renal artery coil embolization and nephrectomy. A cohort of 14 patients who underwent staged renal embolization and nephrectomy during the same period served as the control group. Renal tumor embolization was achieved via percutaneous femoral artery approach, followed by coil placement in the distal portion of the main renal artery. Complete renal artery embolization was confirmed with intraoperative angiography. Nephrectomy was performed either concomitantly or after renal artery embolization, dependent on treatment group. Intraoperative data, clinical outcome, and hospital cost were compared between the two groups. RESULTS: Renal artery embolization and nephrectomy were successfully performed in all patients. There was no perioperative mortality. Mean hospital length of stay in the combined and staged treatment groups was 5.6 +/- 1.3 days and 10.2 +/- 3.2 days, respectively. Post-infarction syndrome developed in four patients (36%) in the staged group, compared with no patients in the combined treatment group. Decreased room cost and radiology cost was noted in the combined treatment group compared with the staged group. Mean total hospital cost was significantly less in patients who underwent the combined treatment compared with the staged treatment approach (mean difference, US dollars 9214; P =.02) During mean follow-up of 36 months, six patients (27%) died of unrelated causes. There was no evidence of tumor recurrence in surviving patients. DISCUSSION: In patients with renal cell carcinoma, combined renal embolization and nephrectomy minimizes patient discomfort and post-infarction syndrome associated with traditional staged treatment. Moreover, it is associated with reduced hospital costs, due in part to decreased hospital length of stay. Vascular surgeons with endovascular skills are well suited to perform intraoperative renal artery embolization. Use of adjunctive endovascular techniques to facilitate large open procedures is a growing role for the endovascular-competent vascular surgeon.

Aged↗
PubMed2003

The LifeSite Hemodialysis Access System in patients with limited access.

OBJECTIVE: The LifeSite Hemodialysis Access System was recently introduced as a completely subcutaneous device with reported advantages of improved patient comfort and reduced catheter-related infection. The performance of the LifeSite catheter at a single, tertiary-care university medical center was reviewed. METHODS: We retrospectively reviewed all patients who underwent placement of the LifeSite catheter between February 2001 and March 2002. Kaplan-Meier analysis was used to determine the probability of patient survival, freedom from catheter-related infection, and freedom from device failure necessitating catheter removal. RESULTS: Thirty-six patients who had previously received dialysis for an average of 6.1 years underwent placement of 37 LifeSite catheters. Most patients (95%) were referred for LifeSite placement because they had exhausted all available arteriovenous fistula and graft sites. Mean follow-up was 6.8 months, with a patient survival rate of 81% at 8 months. Primary and secondary patency rates were 62% and 87% at 8 months, respectively. Two patients died from infectious device-related complications. Twelve of 17 patients (71%) with device-related infection did not manifest any signs or symptoms at the valve site. There were 2.4 catheter-related infections and 2.6 device failures requiring removal per 1000 patient-catheter days. Freedom from infection and device removal at 8 months was 46% and 49%, respectively. CONCLUSIONS: The LifeSite demonstrated acceptable patency, infection, and device failure rates; however, in patients with limited access, unrecognized infection and death may occur. The LifeSite should not be used as a substitute for a more permanent form of hemodialysis access.

Bacterial Infections↗
PubMed2003

Simple technique to ensure coaxial guidewire positioning for placement of iliac limb of modular aortic endograft.

Endovascular abdominal aortic aneurysm repair using a modular bifurcated stent-graft requires the initial placement of the main component in the infrarenal aorta, followed by insertion of additional iliac stent-graft(s) to exclude aneurysm and to securely affix the device. Placement of the contralateral iliac component within the main bifurcated device is critical in this endovascular procedure, as malpositioning of the contralateral iliac limb can require conversion to open aneurysm repair. A simple adjunctive technique utilizing a rotational maneuver of a pigtail catheter is described. This maneuver reliably confirms the proper placement of the contralateral iliac stent-graft within the main bifurcated device.

Aorta, Abdominal↗
PubMed2003

Transluminal stent graft repair with Wallgraft endoprosthesis in a porcine arteriovenous graft pseudoaneurysm model.

PURPOSE: Pseudoaneurysm is a known complication of arteriovenous grafts in chronic hemodialysis and can result in graft disruption or thrombosis if left untreated. This study evaluated the safety and efficacy of endovascular repair with Wallgraft endoprosthesis (Boston Scientific, Inc, Watertown, Mass) in a porcine arteriovenous graft (AVG) pseudoaneurysm model. MATERIALS AND METHODS: Bilateral groin AVG pseudoaneurysms (n = 18) were created with an oversized Dacron interposition graft within a polytetrafluoroethylene femoral AVG in nine domestic swine and allowed to mature 28 +/- 4 days (standard deviation). Transluminal placement of Wallgraft was performed to exclude the pseudoaneurysm from the AVG circulation. Hemodialysis was performed (400 mL/min x 1 hour, with intravenous heparin 30 units/kg) every 4 days for a total of 6 weeks via 15-gauge needles in the treated AVG pseudoaneurysm site. Arteriography and duplex ultrasound scan were performed to determine AVG patency and pseudoaneurysm flow. Histologic evaluation was performed to determine Wallgraft morphology. In vitro pulsatile flow chamber was used to determine maximal flow volume without peri-Wallgraft endoleak. RESULTS: All AVG pseudoaneurysms were successfully excluded with the Wallgrafts. Twelve AVG (67%) remained patent at the completion of the study. No Wallgraft migration occurred from hemodialysis. Transient peri-Wallgraft endoleak (<2 hours after hemodialysis) was present in 13 of 18 (72%) and four of 12 (33%) AVG pseudoaneurysms by weeks 1 and 6, respectively. With maintenance of an intraluminal pressure of 80, 100, 120, 140, and 160 mm Hg in the pulsatile flow chamber, the maximal flow rates without peri-Wallgraft endoleak were 625 +/- 120, 650 +/- 145, 620 +/- 95, 425 +/- 110, and 262 +/- 86 mL/min. Scanning electron microscopy showed a neointimal layer covered with thrombus on the Wallgraft surface. CONCLUSION: Endoluminal placement of Wallgraft endoprosthesis provides adequate structural support for continuous hemodialysis after AVG pseudoaneurysm exclusion. Transient blood flow in the pseudoaneurysm cavity may occur immediately after the hemodialysis, which may represent the effect of heparin used during hemodialysis. This study suggests Wallgraft is a safe and effective treatment for AVG pseudoaneurysm and permits continuous hemodialysis.

Aneurysm, False↗
PubMed2002

Intraaortic stabilization of the AneuRx stent-graft system: a useful adjunct to minimize device migration.

The deployment of a Medtronic AneuRx stent-graft system for endovascular abdominal aortic aneurysm repair requires a series of precise maneuvers that include positioning the primary delivery catheter in the infrarenal aorta, retracting the graft-covering sheath, and withdrawing the stainless steel runners. The last step allows the stent-graft to fully expand and attach to the non-aneurysmal aorta and iliac arteries. Such maneuvers may cause the stent-graft to move caudally if the device is placed in a severely angulated aortic neck. We describe a simple, coaxial, stabilization technique utilizing the contralateral introducer sheath which minimizes potential caudal migration of the stent-graft in angulated aortic necks during runner withdrawal.

Aortic Aneurysm, Abdominal↗
PubMed2002

Endovascular aortic aneurysm repair in patients with renal dysfunction or severe contrast allergy: utility of imaging modalities without iodinated contrast.

Contrast-enhanced imaging studies are required for preoperative evaluation in patients undergoing endovascular aortic aneurysm repair; however, the use of iodinated contrast agents may not be suitable in patients with renal dysfunction or severe contrast allergy. The objective of this study was to evaluate the utility of imaging modalities without iodinated contrast in patients undergoing endovascular aortic aneurysm repair. A total of 297 patients underwent endo vascular repair of abdominal aortic aneurysms during a 6-year period ending in August 2001. Among them, 20 patients (6.2%), who underwent imaging studies without iodinated contrast because of either renal dysfunction or severe contrast allergy formed the basis of this study. Multiple non-iodinated contrast imaging studies were used, including gadolinium-enhanced magnetic resonance angiography (MRA), non-contrast computed tomography (CT), gadolinium or carbon dioxide (CO2) aortography, and intravascular ultrasound (IVUS). Hospital records were reviewed to evaluate the imaging study, renal function, perioperative morbidity, and clinical outcome of endo vascular aortic aneurysm repair. From the results of our study we concluded that endovascular aortic aneurysm repair can be performed safely in patients with renal dysfunction or severe contrast allergy utilizing non-iodinated contrast-based imaging modalities. IVUS is a useful intraoperative imaging modality, and postoperative endoleak surveillance can be performed using duplex ultrasound scanning to avoid risk of iodinated contrast exposure.

Aged↗
PubMed2002

The utility of preoperative routine carotid artery duplex scanning in patients undergoing aortic valve replacement.

Patients with aortic valve disease (AVD) typically have a cardiac murmur that radiates to the neck and may be indistinguishable from a cervical bruit secondary to carotid artery occlusive disease. The purpose of this report was to determine the prevalence of significant asymptomatic carotid artery occlusive disease in patients undergoing aortic valve replacement (AVR). All patients scheduled for AVR were prospectively studied. Preoperative carotid artery color-flow duplex was performed in all patients. A total of 204 patients were included in the study and significant carotid disease (>50% stenosis of the internal carotid artery) was found in 17 (8%). In patients with isolated aortic valve disease, 4/129 (3%) had significant stenosis. Of the patients with concurrent aortic valve and coronary artery disease, 13/75 (17%) had significant stenosis. The incidence of significant carotid stenosis in patients with aortic valve disease was over five fold higher in patients with concurrent coronary artery disease (3% vs. 17%, p <0.001). The yield of routine carotid duplex scanning for patients undergoing isolated AVR is low. However, in the subset of patients with concurrent coronary disease, the yield is higher. This finding supports the use of routine carotid duplex scanning in patients with coexistent aortic valve and coronary artery disease.

Adult↗
PubMed2002

Ex vivo repair of a large renal artery aneurysm and associated arteriovenous fistula.

The development of a renal artery to vein arteriovenous fistula due to a large extraparenchymal renal artery aneurysm is uncommon. Previous surgical experience with this entity is limited. Based on the existing surgical literature, nephrectomy has been the treatment of choice. We report preservation of the kidney by surgical correction of this entity using ex vivo "bench" repair in a middle-aged female with fibromuscular dysplasia of the renal artery. The technique, results, and recommendations for surgical management are discussed.

Aneurysm↗
PubMed2002

Endovascular aortic aneurysm operations.

Options for the treatment of abdominal and thoracic aortic aneurysms are in a state of evolutionary change. The development and continued refinement of the endoluminal approaches has decreased the need for open aortic aneurysm surgery. Endovascular stent graft technology is an area of active research in which both the delivery systems and the endografts are undergoing continued improvement so that patients with what was previously thought to be unfavorable anatomy may be treated by these means. The design and deployment techniques of the currently available endografts, as well as those in clinical trials, are presented.

Aortic Aneurysm↗
PubMed2002

Covered stent exclusion of dialysis access pseudoaneurysms.

BACKGROUND: The traditional repair of hemodialysis graft pseudoaneurysms has been to surgically replace that segment of involved PTFE graft material or autogenous vein. We report a novel approach to these lesions, employing a covered stent (Wallgraft) for exclusion of arteriovenous graft (AVG) and arteriovenous fistula (AVF) pseudoaneurysms. METHODS: Ten patients with AVG or AVF pseudoaneurysms were treated endoluminally by covered stent exclusion. Wallgraft implantations were performed in the operating room with interventional capabilities under local anesthesia through a percutaneous access. Follow-up included physical examination at 2 weeks and duplex ultrasound of AVG/ AVF at 6 months after surgery. RESULTS: Ten patients with pseudoaneurysmal degeneration of their AVG/AVF were identified. The mean diameter of the pseudoaneurysmal segment was 3 cm (range, 1.5-5 cm). Immediately following covered stent implantation all the patients had palpable pulses in the pseudoaneurysms despite adequate coverage by angiography. At the 2-week follow-up visit all had lost the palpable pseudoaneurysm pulsation while the AVGs remained functional in nine patients. One patient had early thrombosis of the AVG. The follow-up duplex scans at 6 months showed complete exclusion of the pseudoaneurysms in seven patients. Two patients had thrombosis of their dialysis access, at 3 weeks (n = 1) and 3 months (n = 1) post-implantation. CONCLUSION: Endovascular covered stent exclusion of AV dialysis access pseudoaneurysms is safe and technically feasible in eliminating flow through dialysis access pseudoaneurysms and represents a novel and simple approach to this common problem, prolonging the functional life of the access site.

Adult↗
PubMed2002

Management of infected hemodialysis access grafts using cryopreserved human vein allografts.

BACKGROUND: One of the most feared complications of dialysis access is prosthetic arteriovenous (AV) graft infection, which is typically treated with AV graft removal followed by a staged dialysis graft placement elsewhere. Such a treatment approach often presents a challenge since many hemodialysis-dependent patients have limited venous access that may preclude a new AV graft or dialysis catheter placement. In this article, we review the management of AV graft infection using in situ cryopreserved human vein allografts. DATA SOURCES: Functional and antigenic characteristics as well as the clinical experience of cryopreserved human vein allograft in dialysis access are reviewed. Surgical technique of in situ cryopreserved human allograft placement for infected prosthetic AV graft is also described. CONCLUSIONS: Cryopreserved vein allograft is an acceptable graft conduit in difficult hemodialysis access situations. It offers surgeons the ability to deal with the infected graft in one operative procedure with low incidence reinfection and graft patency similar to conventional prosthetic graft replacement.

Adult↗
PubMed2002

Injury induced neointima formation and its inhibition by retrovirus-mediated transfer of nitride oxide synthase gene in an in-vitro human saphenous vein culture model.

Human saphenous veins were cultured to characterize neointima formation and feasibility of gene transfer to inhibit the intimal proliferative response to injury. Mechanical injury was introduced by abrading the luminal surface of the vein patch with a sterile cotton bud. Both injured and non-injured vein patches were cultured and transduced with retroviral vectors carrying marker or therapeutic genes. After a 14-day culture, the thickness of the intimal layer of non-injured vein patches reached 90+/-28 microm at the edge and 61+/-22 microm at the center (n=29) from the original 22+/-12 microm at harvest (n=6, P=0.02). Mechanical injury to the intimal surface prior to culture resulted in an exaggerated proliferative response. The intimal thickness of injured vein patches increased from 3.4+/-1 microm right after injury to 128+/-23 microm (n=12, P<0.001) at the edge after 14-day culture. Genes were transduced efficiently into a luminal layer of cultured veins using a pseudotyped murine leukemia viral vector. Transduction of gene encoding nitric oxide synthase resulted in reduction of neointima formation to 33+/-7 microm (n=12) at the edge after 14-day culture compared to 90 microm (P<0.01) seen in untransduced non-injured vein patches. Marker gene transduction did not alter intimal proliferative response or its immunohistochemical profile. The data suggest that cultured vein can be used as a model for studying the effects of injury to blood vessels and to evaluate the effects of candidate therapeutic genes.

Cells, Cultured↗
PubMed2002

Iliac artery kinking with endovascular therapies: technical considerations.

Iliac artery tortuosity should be considered when planning endovascular interventions from a femoral approach. Stiff guide wires across tortuous iliac segments can introduce foreshortening and temporary kinking. Recognition of this phenomenon and its implications is important when making anatomic measurements before endovascular device placement, when assessing iliac runoff, and when considering adjunctive procedures after aortoiliac interventions. Two illustrative cases of external iliac artery kinking are presented, one during an abdominal aortic aneurysm endograft procedure and another encountered during stent placement in an external iliac artery dissection. In both cases, the temporary nature of the deformity was recognized, avoiding unnecessary additional intervention.

Aged↗