• The effects of normalizing hyperhomocysteinemia on clinical and operative outcomes in patients with critical limb ischemia.

      Waters, Peadar S; Fennessey, Paul J; Hynes, Niamh; Heneghan, Helen M; Tawfick, Wael; Sultan, Sherif; Western Vascular Institute, University College Hospital Galway, Ireland. (Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, 2012-12)
      To assess the outcome of patients with medically treated hyperhomocysteinemia (HHC) requiring intervention for critical limb ischemia (CLI).
    • Five-year Irish trial of CLI patients with TASC II type C/D lesions undergoing subintimal angioplasty or bypass surgery based on plaque echolucency.

      Sultan, Sherif; Hynes, Niamh; Western Vascular Institute, Department of Vascular & Endovascular Surgery, University College Hospital, and The Galway Clinic, Galway, Ireland. mrsherif.sultan@gmail.com (Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, 2009-06)
      To report a 5-year observational parallel group study comparing the effectiveness of subintimal angioplasty (SIA) to bypass grafting (BG) for treatment of TASC II type C/D lesions in the lower limb arteries of patients with critical limb ischemia (CLI).
    • Homocysteine, the cholesterol of the 21st century. Impact of hyperhomocysteinemia on patency and amputation-free survival after intervention for critical limb ischemia.

      Heneghan, Helen M; Sultan, Sherif; Western Vascular Institute, Department of Vascular & Endovascular Surgery, University College Hospital, Galway, Ireland. (Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, 2008-08)
      To assess the prevalence of hyperhomocysteinemia and determine any correlation to the clinical and technical outcome of peripheral arterial revascularization for critical limb ischemia (CLI).
    • Nonoperative active management of critical limb ischemia: initial experience using a sequential compression biomechanical device for limb salvage.

      Sultan, Sherif; Esan, Olubunmi; Fahy, Anne; Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital Galway, Galway, Ireland. sherifsultan@esatclear.ie (Vascular, 2008)
      Critical limb ischemia (CLI) patients are at high risk of primary amputation. Using a sequential compression biomechanical device (SCBD) represents a nonoperative option in threatened limbs. We aimed to determine the outcome of using SCBD in amputation-bound nonreconstructable CLI patients regarding limb salvage and 90-day mortality. Thirty-five patients with 39 critically ischemic limbs (rest pain = 12, tissue loss = 27) presented over 24 months. Thirty patients had nonreconstructable arterial outflow vessels, and five were inoperable owing to severe comorbidity scores. All were Rutherford classification 4 or 5 with multilevel disease. All underwent a 12-week treatment protocol and received the best medical treatment. The mean follow-up was 10 months (SD +/- 6 months). There were four amputations, with an 18-month cumulative limb salvage rate of 88% (standard error [SE] +/- 7.62%). Ninety-day mortality was zero. Mean toe pressures increased from 38.2 to 67 mm Hg (SD +/- 33.7, 95% confidence interval [CI] 55-79). Popliteal artery flow velocity increased from 45 to 47.9 cm/s (95% CI 35.9-59.7). Cumulative survival at 12 months was 81.2% (SE +/- 11.1) for SCBD, compared with 69.2% in the control group (SE +/- 12.8%) (p = .4, hazards ratio = 0.58, 95% CI 0.15-2.32). The mean total cost of primary amputation per patient is euro29,815 ($44,000) in comparison with euro13,900 ($20,515) for SCBD patients. SCBD enhances limb salvage and reduces length of hospital stay, nonoperatively, in patients with nonreconstructable vessels.
    • Prospective evaluation of outcome measures in free-flap surgery.

      Kelly, John L; Eadie, Patricia A; Orr, David; Al-Rawi, Mogdad; O'Donnell, Margaret; Lawlor, Denis; Department of Plastic Surgery, University College Hospital, Galway, Newcastle, Ireland. (2004-08)
      Free-flap failure is usually caused by venous or arterial thrombosis. In many cases, lack of experience and surgical delay also contribute to flap loss. The authors prospectively analyzed the outcome of 57 free flaps over a 28-month period (January, 1999 to April, 2001). The setting was a university hospital tertiary referral center. Anastomotic technique, ischemia time, choice of anticoagulant, and the grade of surgeon were recorded. The type of flap, medications, and co-morbidities, including preoperative radiotherapy, were also documented. Ten flaps were re-explored (17 percent). There were four cases of complete flap failure (6.7 percent) and five cases of partial failure (8.5 percent). In patients who received perioperative systemic heparin or dextran, there was no evidence of flap failure (p = .08). The mean ischemia time was similar in flaps that failed (95 +/- 29 min) and in those that survived (92 +/- 34 min). Also, the number of anastomoses performed by trainees in flaps that failed (22 percent), was similar to the number in flaps that survived (28 percent). Nine patients received preoperative radiotherapy, and there was complete flap survival in each case. This study reveals that closely supervised anastomoses performed by trainees may have a similar outcome to those performed by more senior surgeons. There was no adverse effect from radiotherapy or increased ischemia time on flap survival.
    • Salvage of critical limb ischemia with the "trellis reserve'' of subintimal superficial femoral-popliteal artery occlusion: a new modality in managing critical limb ischemia--a case report.

      Sultan, Sherif; Heskin, Leonie; Hynes, Niamh; Akhtar, Yousaf; Cough, Val; Manning, Brian; Aremu, M; Courtney, D; Western Vascular Institute, Department of Vascular and Endovascular Surgery, University College Hospital Galway, Ireland. sherifsultan@esatclear.ie (Vascular and endovascular surgery, 2005)
      Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The ;;Trellis'' percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the ;;Trellis'' allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The ;;Trellis'' system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.
    • Sequential compression biomechanical device in patients with critical limb ischemia and nonreconstructible peripheral vascular disease.

      Sultan, Sherif; Hamada, Nader; Soylu, Esraa; Fahy, Anne; Hynes, Niamh; Tawfick, Wael; Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital, Galway, Ireland. sherif.sultan@hse.ie (Journal of vascular surgery, 2011-08)
      Critical limb ischemia (CLI) patients who are unsuitable for intervention face the dire prospect of primary amputation. Sequential compression biomechanical device (SCBD) therapy provides a limb salvage option for these patients. This study assessed the outcome of SCBD in severe CLI patients who otherwise would face an amputation. Primary end points were limb salvage and 30-day mortality. Secondary end points were hemodynamic outcomes (increase in popliteal artery flow and toe pressure), ulcer healing, quality-adjusted time without symptoms of disease or toxicity of treatment (Q-TwiST), and cost-effectiveness.
    • Six years' experience with prostaglandin I2 infusion in elective open repair of abdominal aortic aneurysm: a parallel group observational study in a tertiary referral vascular center.

      Beirne, Chris; Hynes, Niamh; Sultan, Sherif; Department of Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospitals, Galway, Ireland. (Annals of vascular surgery, 2008-11)
      The prostaglandin I(2) (PGI(2)) analogue iloprost, a potent vasodilator and inhibitor of platelet activation, has traditionally been utilized in pulmonary hypertension and off-label use for revascularization of chronic critical lower limb ischemia. This study was designed to assess the effect of 72 hr iloprost infusion on systemic ischemia post-open elective abdominal aortic aneurysm (EAAA) surgery. Between January 2000 and 2007, 104 patients undergoing open EAAA were identified: 36 had juxtarenal, 15 had suprarenal, and 53 had infrarenal aneurysms, with a mean maximal diameter of 6.9 cm. The male-to-female ratio was 2.5:1, with a mean age of 71.9 years. No statistically significant difference was seen between the study groups with regard to age, sex, risk factors, American Society of Anesthesiologists (ASA) grade, or diameter of aneurysm repaired. All emergency, urgent, and endovascular procedures for aneurysms were excluded. Fifty-seven patients received iloprost infusion for 72 hr in the immediate postoperative period compared with 47 patients who did not. Patients were monitored for signs of pulmonary, renal, cardiac, systemic ischemia, and postoperative intensive care unit (ICU) morbidity. Statistically significantly increased ventilation rates (p=0.0048), pulmonary complication rates (p=0.0019), and myocardial ischemia (p=0.0446) were noted in those patients not receiving iloprost. These patients also had significantly higher renal indices including estimate glomerular filtration rate changes (p=0.041) and postoperative urea level rises (p=0.0286). Peripheral limb trashing was noted in five patients (11.6%) in the non-iloprost group compared with no patients who received iloprost. Increased rates of transfusion requirements and bowel complications were noted in those who did not receive iloprost, with their ICU stay greater than twice that of iloprost patients. All-cause morbidity affected 67% of patients not receiving iloprost compared to 40% who did. Survival rates were significantly better with iloprost than without in both 30-day (p=0.009) and 5-year cumulative (p=0.0187) survival. Iloprost infusion for 72 hr after open AAA repair was associated with improved systemic perfusion and decreased systemic ischemia. Patients had a significant survival benefit at 30 days and 5 years and significantly improved renal, cardiac, and respiratory function.
    • Ten-year technical and clinical outcomes in TransAtlantic Inter-Society Consensus II infrainguinal C/D lesions using duplex ultrasound arterial mapping as the sole imaging modality for critical lower limb ischemia.

      Sultan, Sherif; Tawfick, Wael; Hynes, Niamh; Western Vascular Institute, Department of Vascular and Endovascular Surgery, Galway University Hospital, Galway, Ireland. sherif.sultan@hse.ie (2013-04)
      The aim of this study was to evaluate duplex ultrasound arterial mapping (DUAM) as the sole imaging modality when planning for bypass surgery (BS) and endovascular revascularization (EvR) in patients with critical limb ischemia for TransAtlantic Inter-Society Consensus (TASC) II C/D infrainguinal lesions.