Manuel Garcia Toca

All Publications

• Arteriovenous Fistula and Graft Construction in Patients with Implantable Cardiac Devices: Does Side Matter? Annals of vascular surgery Sgroi, M. D., McFarland, G., Itoga, N. K., Sorial, E., Garcia-Toca, M. 2018

  Abstract

  BACKGROUND: Limited reports have documented the effect cardiac implantable electronic devices (CIEDs) have on arteriovenous (AV) access patency. Current recommendations suggest placing the access on the contralateral side of the CIEDs, as there is concern for increased central venous stenosis and access failure. The goal of this study is to review our single-center AV access patency rates for dialysis patients with an ipsilateral or contralateral side CIED.METHODS: A retrospective review was performed from 2008 to 2016 at a single institution identifying all patients who have received a CIED and the diagnosis of end-stage renal disease (ESRD). Medical records were queried to identify each patient's dialysis access and whether it was ipsilateral or contralateral to the CIED. Primary outcomes of study were primary and secondary patency rates.RESULTS: A total of 44 patients were identified to have ESRD and CIED. Of these patients, 28 patients with fistulas or grafts (13 ipsilateral and 15 contralateral) had follow-up with regards to their AV access. There were 3 primary failures in both groups. For patients who had the CIED placed after already starting the dialysis, patency was based on when the cardiac device was implanted. Primary patency for ipsilateral and contralateral access was 20.2 and 22.2months, respectively. With secondary interventions, ipsilateral and contralateral mean patency was 39 and 48.8months, respectively. Six-month and 1-year primary patency for arteriovenous fistula or arteriovenous graft on patients with ipsilateral access was 69.2% and 53.8%, respectively. Ipsilateral 1-year cumulative patency was 39months.CONCLUSIONS: CIED may lead to stenosis or occlusion to one's AV access; however, primary assisted and secondary patency rates are still acceptable at 6months and 1year compared to Kidney Disease Outcomes Quality Initiative guidelines. Despite a CIED, a surgeon's algorithm should not lead to the abandonment of an ipsilateral access if the central venous system is patent.

  View details for DOI 10.1016/j.avsg.2018.10.003

  View details for PubMedID 30339901

• Secondary Interventions in Patients With Implantable Cardiac Devices and Ipsilateral Arteriovenous Access Dua, A., Sgroi, M., Lavingia, K., Rothenberg, K. A., Mikkineni, K., Sorial, E., Garcia-Toca, M. MOSBY-ELSEVIER. 2018: E6–E7

  View details for Web of Science ID 000439318700008

• Comparison of Secondary Intervention Rates in Patients With Implantable Cardiac Devices and Ipsilateral Versus Contralateral Arteriovenous Access Dua, A., Sgroi, M., Lavingia, K., Rothenberg, K. A., Sorial, E., Garcia-Toca, M. MOSBY-ELSEVIER. 2018: E125

  View details for Web of Science ID 000433036700148

• Mycotic Renal Artery Aneurysm Presenting as Critical Limb Ischemia in Culture-Negative Endocarditis CASE REPORTS IN SURGERY Vy Thuy Ho, Itoga, N. K., Wu, T., Sorial, E., Garcia-Toca, M. 2018: 7080813

  Abstract

  Mycotic renal artery aneurysms are rare and can be difficult to diagnose. Classic symptoms such as hematuria, hypertension, or abdominal pain can be vague or nonexistent. We report a case of a 53-year-old woman with a history of intravenous drug abuse presenting with critical limb ischemia, in which CT angiography identified a mycotic renal aneurysm. This aneurysm tripled in size from 0.46 cm to 1.65 cm in a 3-week interval. Echocardiography demonstrated aortic valve vegetations leading to a diagnosis of culture-negative endocarditis. The patient underwent primary resection and repair of the aneurysm, aortic valve replacement, and left below-knee amputation after bilateral common iliac and left superficial femoral artery stenting. At 1-year follow-up, her serum creatinine is stable and repaired artery remains patent.

  View details for DOI 10.1155/2018/7080813

  View details for Web of Science ID 000432960100001

  View details for PubMedID 29854544

  View details for PubMedCentralID PMC5964565

• Post-operative infections are associated with increased risk of cardiac events in vascular patients. Annals of vascular surgery Chun, T. T., Garcia-Toca, M., Eng, J. F., Slaiby, J., Marcaccio, E. J., Cioffi, W. G., Heffernan, D. S. 2017

  Abstract

  Despite advances in perioperative care, the rate of cardiac events in vascular patients remains high. We have previously shown that infections in trauma patients are associated with higher rates of subsequent cardiac complications, likely due to the additive effect of a second hit of an infection following the trauma. The aim of this study was to investigate whether there is an association between postoperative infections and subsequent cardiac events in vascular patients.A 5-year retrospective review of demographics, comorbidities, operative interventions, infectious, and cardiac events in all vascular patients who underwent an operative intervention at a single tertiary referral center was performed. In patients with clinical suspicion of myocardial injury, myocardial damage was defined as troponin >0.15 ng/mL and myocardial infarction (MI) as troponin >1 ng/mL. Pneumonia was diagnosed using bronchoalveolar lavage (BAL) and considered positive if BAL fluid culture contained >10,000 colony-forming units (cfu). Urinary tract infection (UTI) was diagnosed if the urine culture contained >100,000 cfu. All other infections were diagnosed by culture data. Regression analysis was performed to assess risk of cardiac events as a function of infections adjusting for age, gender, and comorbidities.We analyzed 1,835 vascular operative interventions with the mean age of the cohort 65.5 years (65.9% male). The overall infection rate was 13.2%, with UTI being the most common (60.3%). The overall rate of myocardial damage was 8.1% and the rate of MI 3.8%. Rates of both myocardial damage (15.5 vs. 7.7%; P = 0.0015) and MI (7.1 vs. 3.4%; P = 0.018) were significantly higher in patients with infections, compared to those without infections. Adjusting for age, gender, medical comorbidities, open versus endovascular cases as well as statin and steroid use, patients with UTI were more likely to subsequently develop either myocardial damage (odds ratio [OR] = 3.57 [95% confidence interval = 1.51-8.45]) or MI (OR = 4.20 [1.23-14.3]). A similar association was noted between any infections and either myocardial damage (OR = 2.97 [1.32-6.65]) or MI (OR = 4.31 [1.44-12.94]).We herein describe an association between postoperative infections, most commonly UTI, and subsequent cardiac events. Efforts should be made to minimize the risk of developing infections to ensure cardioprotection in vascular patients during perioperative period.

  View details for DOI 10.1016/j.avsg.2016.09.026

  View details for PubMedID 28238924

• Open Revascularization Procedures Are More Likely to Influence Smoking Reduction Than Percutaneous Procedures ANNALS OF VASCULAR SURGERY Rajaee, S., Cherkassky, L., Marcaccio, E. J., Carney, W. I., Chong, T. T., Garcia-Toca, M., Slaiby, J. M. 2014; 28 (4): 990-998

  Abstract

  Among patients with peripheral arterial disease (PAD), smokers have a higher incidence of life- and limb-threatening complications, including lower extremity ischemic rest pain, myocardial infarction, and cardiac death, highlighting the need for smoking reduction. Several studies have previously investigated the perioperative period as a teachable moment for smoking cessation. The purpose of this study is to determine whether the type of revascularization for PAD (percutaneous versus open) is associated with smoking reduction.Study participants included patients seen at a tertiary academic medical center in Providence, RI, between 2005 and 2010 and assigned International Classification of Diseases, Ninth Revision code diagnoses indicative of PAD. This study uses patient-answered surveys and retrospective chart review to assess changes in smoking habits after medical, percutaneous, or open revascularization. Surveys also assessed patient perceptions regarding the influence of intervention on smoking reduction and how strongly patients associate PAD with their smoking habits.Of 54 patients who were active smokers at the time of intervention, 8 (67%) in the medical management group, 12 (50%) in the percutaneous group, and 15 (83%) in the open intervention group reduced smoking by 50% after intervention. After controlling for several confounders, open revascularization was independently associated with smoking reduction when compared with percutaneous intervention (odds ratio, 8.26; 95% confidence interval, 1.18, 76.7; P = 0.043). Surveys revealed that 94% of the patients believed that smoking was a significant contributor to their PAD.Patients with PAD who undergo open revascularization are more likely to reduce smoking than those who undergo percutaneous revascularization. The perioperative period provides an opportunity to improve rates of smoking reduction.

  View details for DOI 10.1016/j.avsg.2013.05.017

  View details for Web of Science ID 000335655700029

  View details for PubMedID 24556178

• A 14-year experience with blunt thoracic aortic injury. Journal of vascular surgery Watson, J., Slaiby, J., Garcia Toca, M., Marcaccio, E. J., Chong, T. T. 2013; 58 (2): 380-385

  Abstract

  This study reviewed the natural history of blunt thoracic aortic trauma (BTAT) over a 14-year period at our level 1 trauma center and compared open vs endovascular treatment.All patients with BTAT presenting to a level 1 trauma center from 1998 to 2011 were included in a retrospective analysis. Multiple data points and short-term and midterm outcomes were ascertained through a retrospective record review.We identified 129 patients with BTAT. Of these, 32 (25%) were dead on arrival, 38 (29%) underwent a resuscitative thoracotomy and died, 33 (26%) underwent open repair, 14 (11%) underwent endovascular repair, 9 (7%) underwent simultaneous procedures, and 3 (2%) were managed nonoperatively. Mean Injury Severity Scores and Revised Trauma Scores were similar (P = .484, P = .551) between the open repair group (n = 36) and the endovascular repair group (n = 14). In the open repair group, there were 14 deaths (42%) ≤ 30 days of injury, 3 strokes (9%), 2 patients (6%) with paralysis, 2 myocardial infarctions (MIs; 6%), and 3 patients (9%) who required hemodialysis. In the endovascular group, there was 1 death (7%) ≤ 30 days of injury, 1 (7%) stroke, and 1 (7%) stent collapse. No paralysis, MI, or renal failure requiring hemodialysis was noted in the endovascular group. The average length of stay was 15 days for patients treated with endovascular repair vs 24 days for those treated with open repair (P = .003).The incidence of BTAT is low but the mortality associated with it is significant. During the 14-year period studied, there was a clear change in management preference from open repair to endovascular repair at our level 1 trauma center. Outcomes, including stroke, MI, renal failure, paralysis, length of stay, and death, appear to be reduced in the endovascular group.

  View details for DOI 10.1016/j.jvs.2013.01.045

  View details for PubMedID 23756339

• Primary Extracranial Vertebral Artery Aneurysms ANNALS OF VASCULAR SURGERY Morasch, M. D., Phade, S. V., Naughton, P., Garcia-Toca, M., Escobar, G., Berguer, R. 2013; 27 (4): 418-423

  Abstract

  Extracranial vertebral artery aneurysms are uncommon and are usually associated with trauma or dissection. Primary cervical vertebral aneurysms are even rarer and are not well described. The presentation and natural history are unknown and operative management can be difficult. Accessing aneurysms at the skull base can be difficult and, because the frail arteries are often afflicted with connective tissue abnormalities, direct repair can be particularly challenging. We describe the presentation and surgical management of patients with primary extracranial vertebral artery aneurysms.In this study we performed a retrospective, multi-institutional review of patients with primary aneurysms within the extracranial vertebral artery.Between January 2000 and January 2011, 7 patients, aged 12-56 years, were noted to have 9 primary extracranial vertebral artery aneurysms. All had underlying connective tissue or another hereditary disorder, including Ehler-Danlos syndrome (n=3), Marfan's disease (n=2), neurofibromatosis (n=1), and an unspecified connective tissue abnormality (n=1). Eight of 9 aneurysms were managed operatively, including an attempted bypass that ultimately required vertebral ligation; the contralateral aneurysm on this patient has not been treated. Open interventions included vertebral bypass with vein, external carotid autograft, and vertebral transposition to the internal carotid artery. Special techniques were used for handling the anastomoses in patients with Ehler-Danlos syndrome. Although endovascular exclusion was not performed in isolation, 2 hybrid procedures were performed. There were no instances of perioperative stroke or death.Primary extracranial vertebral artery aneurysms are rare and occur in patients with hereditary disorders. Operative intervention is warranted in symptomatic patients. Exclusion and reconstruction may be performed with open and hybrid techniques with low morbidity and mortality.

  View details for DOI 10.1016/j.avsg.2012.08.002

  View details for Web of Science ID 000318464700004

  View details for PubMedID 23540677

• Endovascular Repair of Mycotic Aneurysm of the Descending Thoracic Aorta ANNALS OF VASCULAR SURGERY Johnstone, J. K., Slaiby, J. M., Marcaccio, E. J., Chong, T. T., Garcia-Toca, M. 2013; 27 (1): 23-28

  Abstract

  Mycotic thoracic aortic aneurysms (MTAAs) are a rare yet life-threatening disease. The current standard of care consists of surgical resection, in situ or extra-anatomic revascularization, and antibiotic therapy. Despite this treatment, mortality remains high (range, 5-40%). The endovascular repair of degenerative thoracic aortic aneurysms has been shown to be safe and effective, but its use in the treatment of MTAAs is still controversial. The purpose of this study is to review the use of endovascular repair for MTAAs.A 10-year retrospective chart review was conducted of patients who underwent endovascular repair of MTAAs between March 2001 and March 2011. The surgical results of this single-institution review are reported.Seven patients underwent endovascular repair of MTAAs. One patient died 2 days postoperatively, which gave an in-hospital survival rate of 85.7%. The 1-year survival rate was 71.4%. The mean follow-up time was 25 months (range, 0-72 months), with a survival rate at that time of 57.1%. All patients were free of infection during their follow-up period.In this single-center case series, endovascular repair of MTAAs was associated with favorable perioperative and short-term mortality and morbidity.

  View details for DOI 10.1016/j.avsg.2012.06.004

  View details for Web of Science ID 000312530800004

  View details for PubMedID 23084733

• Escherichia coli primary aortitis presenting as sequelae of incompletely treated urinary tract infection JOURNAL OF VASCULAR SURGERY Johnstone, J. K., Garcia-Toca, M., Slaiby, J. M., Marcaccio, E. J., Chong, T. T. 2012; 55 (6): 1779-1781

  Abstract

  We report a rare case of nonaneurysmal infectious aortitis (IA) with the causative microorganism being Escherichia coli. The patient was a 78-year-old man who presented with a 3-week history of abdominal pain, fevers, and anorexia after treatment for a urinary tract infection. The patient had positive blood cultures and a computed tomography scan that had signs of IA. He was treated with intravenous antibiotics and extra-anatomic revascularization with excision and debridement of the infected aortic segment with a good outcome. IA is an uncommon condition with a high mortality rate; however, if diagnosed early, it can be successfully treated.

  View details for DOI 10.1016/j.jvs.2011.12.074

  View details for Web of Science ID 000304206000036

  View details for PubMedID 22386143

• Are Carotid Stent Fractures Clinically Significant? CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Garcia-Toca, M., Rodriguez, H. E., Naughton, P. A., Keeling, A., Phade, S. V., Morasch, M. D., Kibbe, M. R., Eskandari, M. K. 2012; 35 (2): 263-267

  Abstract

  Late stent fatigue is a known complication after carotid artery stenting (CAS) for cervical carotid occlusive disease. The purpose of this study was to determine the prevalence and clinical significance of carotid stent fractures.A single-center retrospective review of 253 carotid bifurcation lesions treated with CAS and mechanical embolic protection from April 2001 to December 2009 was performed. Stent integrity was analyzed by two independent observers using multiplanar cervical plain radiographs with fractures classified into the following types: type I = single strut fracture; type II = multiple strut fractures; type III = transverse fracture; and type IV = transverse fracture with dislocation. Mean follow-up was 32 months.Follow-up imaging was completed on 106 self-expanding nitinol stents (26 closed-cell and 80 open-cell stents). Eight fractures (7.5%) were detected (type I n = 1, type II n = 6, and type III n = 1). Seven fractures were found in open-cell stents (Precise n = 3, ViVEXX n = 2, and Acculink n = 2), and 1 fracture was found in a closed-cell stent (Xact n = 1) (p = 0.67). Only a previous history of external beam neck irradiation was associated with fractures (p = 0.048). No associated clinical sequelae were observed among the patients with fractures, and only 1 patient had an associated significant restenosis (≥ 80%) requiring reintervention.Late stent fatigue after CAS is an uncommon event and rarely clinically relevant. Although cell design does not appear to influence the occurrence of fractures, lesion characteristics may be associated risk factors.

  View details for DOI 10.1007/s00270-011-0149-3

  View details for Web of Science ID 000304162400007

  View details for PubMedID 21431966

• Emergent Repair of Acute Thoracic Aortic Catastrophes A Comparative Analysis ARCHIVES OF SURGERY Naughton, P. A., Park, M. S., Morasch, M. D., Rodriguez, H. E., Garcia-Toca, M., Wang, C. E., Eskandari, M. K. 2012; 147 (3): 243-249

  Abstract

  To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR).Single-center retrospective review (April 2001-January 2010).Academic medical center.One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2).Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months.Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001).Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

  View details for Web of Science ID 000301637200009

  View details for PubMedID 22430904

  View details for PubMedCentralID PMC3978207

• Does a Contralateral Carotid Occlusion Adversely Impact Carotid Artery Stenting Outcomes? ANNALS OF VASCULAR SURGERY Keldahl, M. L., Park, M. S., Garcia-Toca, M., Wang, C. E., Kibbe, M. R., Rodriguez, H. E., Morasch, M. D., Eskandari, M. K. 2012; 26 (1): 40-45

  Abstract

  Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood.A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years).Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant).A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.

  View details for DOI 10.1016/j.avsg.2011.07.005

  View details for Web of Science ID 000298325900006

  View details for PubMedID 21963325

  View details for PubMedCentralID PMC3242852

• Endovascular Treatment of Delayed Type 1 and 3 Endoleaks CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Naughton, P. A., Garcia-Toca, M., Rodriguez, H. E., Keeling, A. N., Resnick, S. A., Eskandari, M. K. 2011; 34 (4): 751-757

  Abstract

  Endovascular aortic aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. Type I and III endoleaks require prompt, definitive repair or explantation. We review a single center experience of endovascular treatment of type I and III endoleaks.Retrospective review of 22 patients who underwent endovascular intervention for remediation of proximal or distal seal zone endoleaks.Median age was 77 years. Median time interval from EVAR to reintervention was 4 years (range, 1 month-11 years). Sixteen patients (73%) had radiological evidence of endoleak and/or expanding sac size and 6 (27%) had contained rupture. Nine patients underwent a total of 12 endovascular reinterventions before this salvage procedure. Stent grafts used at the original procedure were: AneuRx (n = 10), Excluder (n = 7), Ancure (n = 3), Zenith (n = 1), and custom made (n = 1). Endoleaks treated were type Ia (n = 11), Ib (n = 12), and type III (n = 3). Interventions included: proximal cuff insertion with or without Palmaz stent insertion (n = 8), distal limb extension (n = 2), stent graft relining (n = 6), embolization of hypogastric artery and iliac limb extension (ILE) (n = 5), and aorto-uni-iliac stent graft (AUI) with femoral-femoral crossover (n = 1). One patient who had a rupture died of multiorgan failure. Two patients needed additional reinterventions for endoleaks. Median length of hospital stay was 1 day.Lifelong surveillance after EVAR is advocated because of the potential of delayed type I or III endoleaks, which mandate definitive treatment. Fortunately, most delayed type I and III endoleaks can be successfully corrected with endoluminal interventions rather than resorting to explantation of the endograft.

  View details for DOI 10.1007/s00270-010-0020-y

  View details for Web of Science ID 000294815400009

  View details for PubMedID 21107984

• Complicated Acute Type B Thoracic Aortic Dissections: Endovascular Treatment For Visceral Malperfusion And Pseudoaneurysms VASCULAR AND ENDOVASCULAR SURGERY Naughton, P. A., Garcia-Toca, M., Matsumura, J. S., Rodriguez, H. E., Morasch, M. D., Resnick, S. A., Eskandari, M. K. 2011; 45 (3): 219-226

  Abstract

  Morbidity and mortality of acute type B thoracic aortic dissections remain alarmingly high. Endoluminal options are promising.A single-center 5-year review of 17 acute type B aortic dissections complicated by visceral malperfusion (11) or pseudoaneurysm formation (6) treated with endovascular intervention. Interventional techniques included endografting (15) and/or percutaneous fenestration (4). Median follow-up is 28 months (range 0-76 months).Median age was 55 years; 30-day death, stroke, and paraplegia rates were 0%, 17.6%, and 5.9%. Success reversing visceral ischemia or sealing a pseudoaneurysm was 100%. Cross-sectional imaging demonstrated that the false lumen was thrombosed in 9 patients, partially thrombosed in 6 patients. Late events include 1 delayed proximal type I endoleak, 1 delayed rupture of the thoracic aorta requiring successful emergent open surgical repair, and 2 unrelated late deaths.Endovascular approaches to type B dissections presenting with visceral malperfusion and/or pseudoaneurysm can achieve acceptable early results.

  View details for DOI 10.1177/1538574410395039

  View details for Web of Science ID 000288827400001

  View details for PubMedID 21478244

• Intimal angiosarcoma causing abdominal aortic rupture JOURNAL OF VASCULAR SURGERY Naughton, P. A., Wandling, M., Phade, S., Garcia-Toca, M., Carr, J. C., Rodriguez, H. E. 2011; 53 (3): 818-821

  Abstract

  Intimal angiosarcomas are rare and difficult to diagnose preoperatively. Complete surgical resection is essential, but long-term survival is unlikely. We report a patient who presented with a contained ruptured infrarenal aorta with clinical and radiologic findings suggestive of infectious aortitis. Surgical resection, regional debridement, and reconstruction were completed using a cadaveric arterial homograft. However, pathologic evaluation revealed a high-grade intimal sarcoma.

  View details for DOI 10.1016/j.jvs.2010.10.090

  View details for Web of Science ID 000287788200046

  View details for PubMedID 21215575

• Techniques in endovascular aneurysm repair. International journal of vascular medicine Phade, S. V., Garcia-Toca, M., Kibbe, M. R. 2011; 2011: 964250-?

  Abstract

  Endovascular repair of infrarenal abdominal aortic aneurysms (EVARs) has revolutionized the treatment of aortic aneurysms, with over half of elective abdominal aortic aneurysm repairs performed endoluminally each year. Since the first endografts were placed two decades ago, many changes have been made in graft design, operative technique, and management of complications. This paper summarizes modern endovascular grafts, considerations in preoperative planning, and EVAR techniques. Specific areas that are addressed include endograft selection, arterial access, sheath delivery, aortic branch management, graft deployment, intravascular ultrasonography, pressure sensors, management of endoleaks and compressed limbs, and exit strategies.

  View details for DOI 10.1155/2011/964250

  View details for PubMedID 22121487

  View details for PubMedCentralID PMC3202090

• Regulatory TEVAR clinical trials JOURNAL OF VASCULAR SURGERY Garcia-Toca, M., Eskandari, M. K. 2010; 52: 22S-25S

  View details for DOI 10.1016/j.jvs.2010.06.140

  View details for Web of Science ID 000282660400005

  View details for PubMedID 20732780

• Carotid Artery Reconstruction for Infected Carotid Patches EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY Naughton, P. A., Garcia-Toca, M., Rodriguez, H. E., Pearce, W. H., Eskandari, M. K., Morasch, M. D. 2010; 40 (4): 492-498

  Abstract

  Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP.Single-center retrospective study.10-year review of the surgical treatment of ICPP.Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery (n = 6), cadaveric homograft (n = 3), long saphenous vein (n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus (n = 3), Corynebacterium propionibacterium (n = 1) and Streptococcus anginous (n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3-108 months).Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.

  View details for DOI 10.1016/j.ejvs.2010.07.005

  View details for Web of Science ID 000284683600016

  View details for PubMedID 20705492

• Zone I Gunshot Neck Injury Treated with Common Carotid and Esophageal Stent Grafts JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Garcia-Toca, M., Hayman, A., Naughton, P., Blum, M. G., Eskandari, M. K. 2010; 21 (9): 1448-1451

  Abstract

  Management of zone I gunshot injuries to the neck is controversial. Endovascular and endoscopic therapies are appealing minimally invasive alternatives, but they are still evolving. This case report demonstrates effective stent grafting of an arterial and an esophageal zone I neck injury after a civilian gunshot.

  View details for DOI 10.1016/j.jvir.2010.05.014

  View details for Web of Science ID 000281620600021

  View details for PubMedID 20691609

• Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries Seven-Year Single-Center Experience ARCHIVES OF SURGERY Garcia-Toca, M., Naughton, P. A., Matsumura, J. S., Morasch, M. D., Kibbe, M. R., Rodriguez, H. E., Pearce, W. H., Eskandari, M. K. 2010; 145 (7): 679-683

  Abstract

  Thoracic endovascular aortic repair (TEVAR) for acute blunt thoracic aortic injury has good early and mid-term results.Single-center retrospective 7-year review from January 2001 to December 2008.Urban tertiary care hospital.Twenty-four consecutive patients with acute blunt thoracic aortic injury treated with TEVAR.Procedure-related mortality, stroke, or paraplegia; injury severity score; and complications.Among the 24 treated patients (mean age, 41 years; range, 20-71 years), the mean injury severity score was 43 (range, 25-66). Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedure-related death, stroke, or paraplegia. Access to the aorta was obtained through an open femoral/iliac approach (n = 7) or an entirely percutaneous groin approach (n = 17). Systemic heparin was not used in 84% of cases. Two access complications (8%) occurred, requiring an iliofemoral bypass in one patient and a thrombectomy in another. One patient required secondary intervention for device collapse, which was treated successfully with repeat endografting. There have been no delayed device failures or complications among the entire cohort at mid-term follow-up.Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity.

  View details for Web of Science ID 000279994200010

  View details for PubMedID 20644131

• Eight-year institutional review of carotid artery stenting JOURNAL OF VASCULAR SURGERY Eskandari, M. K., Usman, A. A., Garcia-Toca, M., Matsumura, J. S., Kibbe, M. R., Morasch, M. D., Rodriguez, H. E., Pearce, W. H. 2010; 51 (5): 1145-1151

  Abstract

  Vascular surgeons have increasingly become proficient in carotid artery stenting (CAS) as an alternative treatment modality for cervical carotid artery occlusive disease. We analyzed our early and late outcomes of CAS over the last 8 years.We report a single-center retrospective review of 388 carotid bifurcation lesions treated with CAS using cerebral embolic protection from May 2001 to July 2009. Data analysis includes demographics, procedural records, duplex exams, arteriograms, and two-view plain radiographs over a mean follow-up time of 23.0 months (interquartile range, 10.9-35.4).At the time of treatment, the mean age of the entire cohort (76% men and 24% women) is 71 years; 13% were >/=80 years of age, and 31% had a prior history of either carotid endarterectomy (CEA) and/or external beam neck irradiation (XRT). The mean carotid stenosis is 80%, and asymptomatic lesions represent 69% of the group. Overall 30-day rates of death, stroke, and myocardial infarction are 0.5%, 1.8%, and 0.8%, respectively. The combined death/stroke rate at 30 days is 2.3%. The 30-day major/minor stroke rates for analyzed subgroups are statistically significant only for XRT/recurrent stenosis vs de novo lesions, 0% and 2.6% (P = .03), but not for asymptomatic vs symptomatic patients, 1.9% and 1.7% (P = .91) and age <80 vs >/=80, 2.0% and 1.8% (P = .52), respectively. At long-term, the freedom from all strokes at 12, 24, 36, and 48 months was 99.2%, 97.6%, 96.7%, and 96.7%, respectively. At late follow-up, the restenosis rate is 3.5%. Restenosis rates for recurrent stenosis/XRT vs de novo lesions are 2.7% and 3.4% (P = .39). Among the restenotic lesions were two associated type III stent fractures in de novo lesions, both of which were closed-cell stents. An additional two other type I fractures have been identified, yielding a stent fracture rate of 5.5%. The late death rate for the entire group is 16.8%, with one stent-related death secondary to ipsilateral stroke at 20 months (0.3% death rate).Vascular surgeons performing CAS with embolic protection can achieve good early and late outcomes that are comparable to CEA benchmarks. Late stent failures (stroke, restenosis, and/or stent fatigue), while uncommon, are a recognized delayed problem.

  View details for DOI 10.1016/j.jvs.2009.12.025

  View details for Web of Science ID 000277216000011

  View details for PubMedID 20304594

• Endovascular Repair of Complicated Type B Aortic Dissection Following Coronary Artery Bypass Grafting JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Naughton, P. A., Garcia-Toca, M., Eskandari, M. K. 2010; 21 (3): 403-405

  View details for DOI 10.1016/j.jvir.2009.10.039

  View details for Web of Science ID 000277367700016

  View details for PubMedID 20097093

• Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring JOURNAL OF VASCULAR SURGERY Tan, T., Garcia-Toca, M., Marcaccio, E. J., Carney, W. I., Machan, J. T., Slaiby, J. M. 2009; 49 (6): 1374-1378

  Abstract

  The routine use of intraoperative electroencephalography (EEG) monitoring with selective shunt placement during carotid endarterectomy (CEA) has been shown to be safe and effective. We attempt to identify the anatomic and clinical factors associated with significant EEG changes requiring shunt placement during CEA.Between January 2005 and June 2007, 242 CEAs were performed with selective shunt placement for significant EEG changes. Risk factors assessed include severity of both ipsilateral and contralateral disease, presence of ipsilateral preoperative symptoms, hypertension, coronary artery disease, diabetes, age, gender, and preemptive intraoperative blood pressure manipulation to >or=20% above baseline before cross-clamping. Data were analyzed with the chi(2) test (P < .05 was significant).CEA was performed for asymptomatic disease in 177 of 242 patients (73.1%). The perioperative stroke rate was 0.8% (2 of 242), and the overall morbidity rate was 4.5%. No patients died. Significant EEG changes requiring shunt occurred in 35 patients (14.46%). Factors associated with carotid shunt placement were moderate ipsilateral carotid artery stenosis (50% to 79%) compared with severe (>or=80%) disease (30.6% vs 11.7%, P = .003) and degree of contralateral carotid stenosis (0% to 49%, 10.8%; 50% to 79%, 10.9%; 80% to 99%, 23.2%; occlusion, 50%; P = .0003). Presence of symptoms, gender, age, hypertension, diabetes, or coronary artery disease, and preemptive intraoperative manipulation of blood pressure were not significant predictors of shunt placement.CEA performed with routine EEG monitoring and selective shunt placement is associated with a low risk of perioperative stroke. Identified predictors of significant EEG changes were anatomic factors including degree of contralateral carotid artery disease and moderate ipsilateral carotid artery stenosis (50% to 79%). Although contralateral carotid occlusion has been accepted as indication for shunt placement in the absence of cerebral monitoring, this study suggests that high-grade contralateral disease and moderate ipsilateral carotid stenosis are associated with cerebral ischemia resulting in EEG changes and should prompt consideration for nonselective shunting.

  View details for DOI 10.1016/j.jvs.2009.02.206

  View details for Web of Science ID 000266681000002

  View details for PubMedID 19497494

• Relative adrenal insufficiency in the adult burn intensive care unit: A report of four cases BURNS Goverman, J., Garcia-Toca, M., Sheridan, R. L., Ryan, C. M. 2008; 34 (3): 421-424

  View details for DOI 10.1016/j.burns.2007.01.013

  View details for Web of Science ID 000255098300020

  View details for PubMedID 17618053