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Robert A. Schwartz - One of the best experts on this subject based on the ideXlab platform.
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endovascular stent graft exclusion of thoracic arteriovenous malformation in a patient with Cobb Syndrome
Journal of Vascular Surgery, 2014Co-Authors: Cindy Huynh, Vivian Gahtan, Robert A. SchwartzAbstract:this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. Methods: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual, and outcomes were expressed in quality-adjusted life years (QALYs). The base case is a 60-year-old man with a filter placed within 3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base-case and sensitivity analyses, we used utilities and probabilities derived from the literature. Results: In the base-case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval might be preferable if the utility of living with a filter is <0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. Conclusions: Leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient. This decision is sensitive to the utility of living with the IVC filter and underlying PE risk.
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Endovascular Stent Graft Exclusion of Thoracic Arteriovenous Malformation in a Patient With Cobb Syndrome
Journal of Vascular Surgery, 2014Co-Authors: Cindy Huynh, Vivian Gahtan, Robert A. SchwartzAbstract:this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. Methods: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual, and outcomes were expressed in quality-adjusted life years (QALYs). The base case is a 60-year-old man with a filter placed within 3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base-case and sensitivity analyses, we used utilities and probabilities derived from the literature. Results: In the base-case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval might be preferable if the utility of living with a filter is
Cindy Huynh - One of the best experts on this subject based on the ideXlab platform.
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endovascular stent graft exclusion of thoracic arteriovenous malformation in a patient with Cobb Syndrome
Journal of Vascular Surgery, 2014Co-Authors: Cindy Huynh, Vivian Gahtan, Robert A. SchwartzAbstract:this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. Methods: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual, and outcomes were expressed in quality-adjusted life years (QALYs). The base case is a 60-year-old man with a filter placed within 3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base-case and sensitivity analyses, we used utilities and probabilities derived from the literature. Results: In the base-case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval might be preferable if the utility of living with a filter is <0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. Conclusions: Leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient. This decision is sensitive to the utility of living with the IVC filter and underlying PE risk.
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Endovascular Stent Graft Exclusion of Thoracic Arteriovenous Malformation in a Patient With Cobb Syndrome
Journal of Vascular Surgery, 2014Co-Authors: Cindy Huynh, Vivian Gahtan, Robert A. SchwartzAbstract:this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. Methods: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual, and outcomes were expressed in quality-adjusted life years (QALYs). The base case is a 60-year-old man with a filter placed within 3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base-case and sensitivity analyses, we used utilities and probabilities derived from the literature. Results: In the base-case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval might be preferable if the utility of living with a filter is
Ajit A. Krishnaney - One of the best experts on this subject based on the ideXlab platform.
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Combined endovascular and surgical resection of a giant lumbosacral arteriovenous malformation in a patient with Cobb Syndrome
Journal of neurointerventional surgery, 2011Co-Authors: Alejandro M Spiotta, Muhammad S. Hussain, Thomas J. Masaryk, Ajit A. KrishnaneyAbstract:Objective and importance Cobb Syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a progressively symptomatic massive lumbosacral arteriovenous malformation (AVM) in a patient with Cobb9s Syndrome requiring a multimodality approach including staged preoperative transarterial and transvenous endovascular embolization followed by surgical excision and wound reconstruction. Clinical presentation The patient presented with a massive lumbosacral AVM with symptoms of congestive heart failure. Angiography demonstrated arterial feeders predominantly from internal iliac, median sacral and lumbar segmental arteries. Intervention The patient underwent staged transarterial and transvenous endovascular embolization resulting in 90% reduction in the AVM size, followed by surgical resection of the lesion. The patient made an excellent recovery with improvement in his symptoms of congestive heart failure. Conclusion The treatment algorithm for massive AVMs must be individualized. A combination of staged embolization and subsequent surgery may be required to obtain a good result. Through this carefully planned multidisciplinary approach a previously incurable lesion in this patient with Cobb Syndrome was able to be treated successfully.
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E-041 Combined endovascular embolization and surgical resection of a massive lumbosacral arteriovenous malformation in a patient with Cobb Syndrome
Journal of NeuroInterventional Surgery, 2010Co-Authors: Alejandro M Spiotta, Muhammad S. Hussain, Thomas J. Masaryk, Thinesh Sivapatham, Ajit A. KrishnaneyAbstract:Objective and importance Cobb Syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a progressively symptomatic massive lumbosacral arteriovenous malformations (AVM) in a patient with Cobb9s Syndrome requiring a multimodality approach, including staged preoperative transarterial and transvenous endovascular embolization followed by surgical excision and wound reconstruction. Clinical presentation The patient is a 25-year-old man with a massive lumbosacral AVM with symptoms of congestive heart failure. Angiography demonstrated arterial feeders predominantly from the internal iliac, median sacral and lumbar segmental arteries. Intervention The patient underwent staged transarterial and transvenous endovascular embolization resulting in 90% reduction in the AVM size, followed by surgical resection of the lesion. The patient made an excellent recovery with improvement in his symptoms of congestive heart failure. Conclusion The treatment algorithm for massive AVMs must be individualized. A combination of staged embolization and subsequent surgery may be required to obtain a good result. Through this carefully planned multidisciplinary approach, a previously incurable lesion in this patient with Cobb Syndrome was able to be treated successfully.
Pierre Lasjaunias - One of the best experts on this subject based on the ideXlab platform.
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Segmental neurovascular Syndromes in children.
Neuroimaging clinics of North America, 2007Co-Authors: Timo Krings, Sasikhan Geibprasert, Chao-bao Luo, J. J. Bhattacharya, H. Alvarez, Pierre LasjauniasAbstract:The concept of segmental vascular Syndromes with different, seemingly unrelated, diseases is based on the embryology of the neural crest and the mesoderm migration of cells that share the same metameric origin. Migrating patterns of these cells link the brain, the cranial bones, and the face on the same side. A somatic mutation developing in the region of the neural crest or the adjacent cephalic mesoderm before migration can, therefore, be postulated to produce arterial or venous metameric Syndromes, including PHACES, CAMS, Cobb Syndrome, and Sturge-Weber Syndrome. Although these diseases may be rare, their relationships among each other and their postulated linkage with the development of the neural crest and the cephalic mesoderm may shed light on the complex pathology and etiology of various cerebral vascular disorders.
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Diagnosis and endovascular treatment of pediatric spinal arteriovenous shunts.
Neuroimaging clinics of North America, 2007Co-Authors: Sean P. Cullen, Timo Krings, H. Alvarez, Augustin Ozanne, G. Rodesch, Pierre LasjauniasAbstract:Spinal arteriovenous shunts (SAVSs) are rarely diagnosed in infants and children, but they are important clinically because morbidity can be significant. Although these lesions do not form a distinct pathologic group separate from the SAVSs seen in older patients, experience with these malformations in the pediatric population has led to the identification of several important features that are characteristic of this group of SAVSs. Association with genetic abnormalities, heritable (hereditary hemorrhagic telangiectasia) and nonheritable somatic (spinal arteriovenous metameric Syndrome or Cobb Syndrome), is relatively common and likely underrecognized. Male predominance is more pronounced than in the adult population. Hemorrhagic presentation is more frequent than in adults, except in extremely young children. The natural history seems to be better than previously thought, with early rehemorrhage uncommon. Despite early presentation and severe symptoms, these lesions are frequently amenable to endovascular treatment, often with anatomic cure achieved and with improvement or stabilization of symptoms after partial targeted treatment.
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Classification of spinal cord arteriovenous shunts: proposal for a reappraisal--the Bicêtre experience with 155 consecutive patients treated between 1981 and 1999.
Neurosurgery, 2002Co-Authors: Georges Rodesch, M. Hurth, Hortensia Alvarez, Marc Tadié, Pierre LasjauniasAbstract:OBJECTIVE: Spinal cord arteriovenous shunts (SCAVSs) are currently classified according to their morphological features. Certain shunts cannot be fully integrated into the predetermined categories that are usually described, however. Can these classifications be reevaluated on the basis of recent anatomic, biological, and genetic advances? METHODS: We reviewed the clinical and radiological files for 155 SCAVSs that were treated at Hopital Bicetre between 1981 and 1999. The lesions were examined with respect to their number (single or multiple), their primary architectural type (nidus or fistula), and their possible links with associated metameric lesions. RESULTS: All SCAVSs were either arteriovenous malformations or fistulae, with the latter being either micro- or macrofistulae. All SCAVSs corresponded to three categories, i.e., genetic hereditary lesions (macrofistulae and hereditary hemorrhagic telangiectasia), genetic nonhereditary lesions (all of which were multiple lesions with metameric or myelomeric associations), and single lesions (which could represent incomplete presentations of one of the previous groups). Of the SCAVSs in our series, 81% were single lesions and 19% were multiple; among these, 59% were true intradural shunts with metameric features. Ten cases of Cobb Syndrome, three cases of Klippel-Trenaunay Syndrome, and two cases of Parkes-Weber Syndrome, all with associated cord lesions, were observed. Nineteen percent of SCAVSs were fistulae; 23% of those were macrofistulae, of which 83% were related to Rendu-Osler-Weber disease. CONCLUSION: It seems legitimate to propose a categorization that takes into consideration a primary malformation (nidus or fistula) that evolves with time and in which angioarchitectural changes occur. Recognition of the factors originally responsible for the shunt (e.g., genetic hereditary or genetic nonhereditary) allows a different classification of SCAVSs.
Fernando Delgado Acosta - One of the best experts on this subject based on the ideXlab platform.
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Cobbs Syndrome: A case of spinal arteriovenous malformation treated with endovascular embolization
European Journal of Radiology Extra, 2011Co-Authors: Elvira Jiménez Gómez, Rafael Oteros Fernández, Fernando Delgado AcostaAbstract:Abstract Cobb Syndrome is a rare illness that combines vascular skin nevus and spinal vascular malformation at the same metamere. We report the case of a 34-year old man that presented a light low back pain, a slowly progressive paraparesis and abnormal urinary sphincter functioning. MR imaging of the thoracic spine depicted an intramedular arteriovenous malformation. Spinal angiography confirmed these findings. The arteriovenous malformation also affected the chestwall bones and muscles with the same metameric distribution as the intramedular lesion. Due to these findings Cobb Syndrome was suspected and in a second physical examination a skin angioma was noted on the patient's back. He was treated with corticosteroids and endovascular coiling and his symptoms rapidly improved. Although pathophysiology of this Syndrome is poorly understood and the correct management remains unknown, endovascular treatment has become the first choice for spinal arteriovenous malformations. We believe that combined treatment with corticosteroids and endovascular embolization is an effective procedure to alleviate symptoms and to minimize morbidity.