John D Hughes

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Journals/Publications

• Aziz, H., Branco, B. C., Braun, J., Hughes, J. D., Goshima, K. R., Trinidad-Hernandez, M., Hunter, G., & Mills, J. L. (2015). The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations. Journal of vascular surgery, 61(6), 1538-42.
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  Do-not-resuscitate (DNR) orders allow patients to communicate their wishes regarding cardiopulmonary resuscitation. Although DNR status may influence physician decision making regarding resuscitation, the effect of DNR status on outcomes of patients undergoing emergency vascular operation remains unknown. The aim of this study was to analyze the effect of DNR status on the outcomes of emergency vascular surgery.
• Branco, B. C., DuBose, J. J., Zhan, L. X., Hughes, J. D., Goshima, K. R., Rhee, P., & Mills, J. L. (2014). Trends and outcomes of endovascular therapy in the management of civilian vascular injuries. Journal of vascular surgery, 60(5), 1297-307, 1307.e1.
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  The rapid evolution of endovascular surgery has greatly expanded management options for a wide variety of vascular diseases. Endovascular therapy provides a less invasive alternative to open surgery for critically ill patients who have sustained arterial injuries. The purpose of this study was to evaluate recent trends in the management of arterial injuries in the United States with specific reference to the use of endovascular strategies and to examine the outcomes of endovascular vs open therapy for the treatment of civilian arterial traumatic injuries.
• Chavez, L. A., Leon, L. R., Hughes, J., & Mills, J. L. (2014). Aneurysmal degeneration of deep lower extremity vein conduits used for vascular reconstruction. Vascular and endovascular surgery, 48(3), 193-200.
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  Successful outcomes have been reported with the use of femoropopliteal vein (FPV) grafts as arterial conduits. We identified 2 patients with a rare complication, true, nonanastomotic aneurysmal degeneration.
• Echeverria, A. B., Branco, B. C., Goshima, K. R., Hughes, J. D., & Mills, J. L. (2014). Outcomes of endovascular management of acute thoracic aortic emergencies in an academic level 1 trauma center. American journal of surgery, 208(6), 974-80; discussion 979-80.
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  Thoracic aortic emergencies account for 10% of thoracic-related admissions in the United States and remain associated with high morbidity and mortality rates. Open repair has declined owing to the emergence of thoracic endovascular aortic repair (TEVAR), but data on emergency TEVAR use for acute aortic pathology remain limited. We therefore reviewed our experience.
• Armstrong, D. G., Bharara, M., White, M., Lepow, B., Bhatnagar, S., Fisher, T., Kimbriel, H. R., Walters, J., Goshima, K. R., Hughes, J., & Mills, J. L. (2012). The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot. Diabetes/metabolism research and reviews, 28(6), 514-8.
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  This study aimed to quantify the impact of an integrated diabetic foot surgical service on outcomes and changes in surgical volume and focus.
• Bui, T. D., Mills, J. L., Ihnat, D. M., Gruessner, A. C., Goshima, K. R., & Hughes, J. D. (2012). The natural history of duplex-detected stenosis after femoropopliteal endovascular therapy suggests questionable clinical utility of routine duplex surveillance. Journal of vascular surgery, 55(2), 346-52.
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  Duplex ultrasound (DU) surveillance (DUS) criteria for vein graft stenosis and thresholds for reintervention are well established. The natural history of DU-detected stenosis and the threshold criteria for reintervention in patients undergoing endovascular therapy (EVT) of the femoropopliteal system have yet to be determined. We report an analysis of routine DUS after infrainguinal EVT.
• Hughes, J. D., Leon, L. R., & Goshima, K. R. (2009). Aortic stent-graft explantation in a kidney transplant recipient. Annals of vascular surgery, 23(4), 535.e21-6.
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  AAA repair in renal transplant recipients has generated a variety of methods of managing the allograft. Endovascular techniques have been successfully employed in this patient population. Due to inherent limitations of present endovascular methods, occasional stent-graft excision must be performed. We present a case of aortic stent-graft excision in a renal transplant recipient using a pump-oxygenator to maintain allograft perfusion.
• Leon, L. R., Glazer, E. S., Hughes, J. D., Bui, T. D., Psalms, S. B., & Goshima, K. R. (2009). Aortoiliac aneurysm repair in kidney transplant recipients. Vascular and endovascular surgery, 43(1), 30-45.
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  A potential problem during endovascular aortic aneurysm repair (EVAR) or open repair in renal allograft patients is ischemia of the transplanted kidney. In this study, kidney transplant patients who underwent aortic aneurysm repair in our institution were added to similar cases extracted from the literature to represent the basis of this work. Comparisons between patients treated with open surgery versus EVAR were performed in terms of renal function. In the EVAR group, most aneurysms were infrarenal, and 84% were treated with modular bifurcated devices. Protective kidney allograft perfusion measures were not used. The pre- and postoperative Cr was 1.69 and 1.73 mg/dL, respectively (P = .412). All EVAR patients had good outcomes. Complications included 8 endoleaks and 1 limb ischemia case. Three patients died from aortic repair-unrelated reasons. In the open group, the pre-and postoperative Cr was 1.45 and 1.37 mg/dL, respectively (P = .055). Most cases were infrarenal and mostly treated by aortobiiliac bypasses. In 16%, no adjuvant allograft perfusion was provided. In the rest, temporary axillofemoral bypasses were used most often. Most outcomes were favorable (57%). Reported procedural-related complications included arterial embolism, wound infection, and pneumonia. Deaths were reported in 5 occasions (none allograft failure dependent). No differences in Cr between EVAR and open techniques (P = .13) were seen. Aneurysm repair in kidney transplant recipients is associated with excellent renal preservation. Adverse outcomes were all allograft failure independent in both groups. EVAR without special allograft protection measures seems to be equally effective as open surgery with or without adjuvant kidney transplant perfusion.
• Goshima, K. R., Mills, J. L., Awari, K., Pike, S. L., & Hughes, J. D. (2008). Measure what matters: institutional outcome data are superior to the use of surrogate markers to define "center of excellence" for abdominal aortic aneurysm repair. Annals of vascular surgery, 22(3), 328-34.
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  Outcome analysis is increasingly being used to develop health-care policy and direct patient referral. For example, the Leapfrog Group health-care quality initiative has proposed "evidence-based hospital" referral criteria for specific procedures including elective abdominal aortic aneurysm repair (AAA-R). These criteria include an annual hospital AAA operative volume exceeding 50 cases and provision of intensive care unit (ICU) care by board-certified intensivists. Outcomes after AAA-R are reportedly influenced by presentation (intact vs. ruptured), operative approach (endovascular vs. open, transperitoneal vs. retroperitoneal), surgeon subspecialty, case volume (hospital and surgeon), and provision of postoperative care by an intensivist. The purpose of this study was to compare our single-center results with those of high-volume centers to assess the validity of the concept that surrogate markers, such as case volume or intensivist involvement, can be used to estimate procedural outcome. A retrospective review was performed of AAA-Rs at one low-volume academic medical center from January 1994 to March 2005. Demographic data, aneurysm diameter and location, operative indications, and repair approach were documented. Postoperative complications, mortality rates, and hospital and ICU length of stay (LOS) were noted and compared to established benchmarks. During the study period, 270 patients underwent AAA-R (annual mean = 27 hospital cases and 13.4 cases/attending vascular surgeon). ICU care was provided by a dedicated vascular surgery service without routine intensivist involvement. Open, elective, infrarenal AAA-R was performed in 161 patients (60%), with a 2.5% hospital mortality rate (30-day, 3.1%). Thirty-three (12%) patients underwent elective endovascular aneurysm repair (EVAR), with no mortality. Both ICU (3.7 vs. 1.4 days, p = 0.03) and hospital (9.2 vs. 2.8 days, p = 0.002) LOS were significantly reduced after EVAR compared to open repair. Hospital LOS was significantly lower after open retroperitoneal repair compared to transperitoneal repair (6.1 vs. 10.3 days, p = 0.001). Thirty-five patients (13%) underwent ruptured AAA-R, with only 34.3% mortality (in-hospital and 30-day). Forty-one patients (15%) underwent repair of complex aortic aneurysms, with 14.1% mortality. There are increasing societal and economic pressures to direct patient referrals to "centers of excellence" for specific surgical procedures. Although our institution meets neither of the Leapfrog Group's proposed criteria, our mortality and LOS for both intact and ruptured infrarenal AAA-R are equivalent or superior to published benchmarks for high-volume hospitals. Individual institutional outcome results such as these suggest that patient referral and care should be based upon actual, carefully verified outcome data rather than utilization of surrogate markers such as case volume and subspecialist involvement in postoperative care.
• Lauvao, L. S., Goshima, K. R., Leon, L. R., Nolan, P. E., & Hughes, J. D. (2008). Superficial femoral artery thrombosis as a cause for distal embolism in primary antiphospholipid syndrome. Journal of vascular surgery, 48(2), 472-7.
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  Antiphospholipid syndrome is a diagnosis with the clinical manifestations of thromboses in the presence of an antiphospholipid antibody. A 25-year-old man with a history of deep venous thrombosis, pulmonary emboli, and myocardial infarction, and receiving long-term anticoagulation with warfarin, all due to primary antiphospholipid syndrome, presented with blue toe syndrome from a primary superficial femoral artery thrombus. He was anticoagulated with fondaparinux in addition to dipyridamole and aspirin perioperatively. The area of thrombus was resected and reconstructed using a cephalic vein interposition graft. This report reviews antiphospholipid syndrome and identifies potential questions and problems relating to a rare clinical presentation.
• Leon, L. R., Hughes, J. D., Psalms, S. B., Guerra, R., Biswas, A., Prasad, A., & Krouse, R. S. (2008). Portomesenteric reconstruction during Whipple procedures: review and report of a case. Vascular and endovascular surgery, 41(6), 537-46.
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  A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.
• Gonzales, A. J., Hughes, J. D., & Leon, L. R. (2007). Probable zoonotic aortitis due to group C streptococcal infection. Journal of vascular surgery, 46(5), 1039-43.
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  Human infections due to group C streptococcus (SGC) are unusual. Among them, vascular compromise, especially aortic involvement, is extremely rare. A case of microbial aortitis with aneurysm formation, likely secondary to a SGC soft tissue infection, in a 61-year-old patient who was caring for a purulent leg wound of his horse, is presented. He was successfully treated with antibiotics and in situ aortic replacement with a prosthetic graft and an omental wrap. He remains well almost 2 years after surgical intervention. Aortic infection caused by SGC is a rare condition that can be successfully treated with in situ prosthetic graft replacement.
• Patel, S. T., Mills, J. L., Tynan-Cuisinier, G., Goshima, K. R., Westerband, A., & Hughes, J. D. (2005). The limitations of magnetic resonance angiography in the diagnosis of renal artery stenosis: comparative analysis with conventional arteriography. Journal of vascular surgery, 41(3), 462-8.
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  Gadolinium-enhanced magnetic resonance angiography (MRA) is commonly used as a screening modality for the detection of renal artery stenosis. However, evidence supporting its utility in clinical practice is lacking; few rigorous studies have compared MRA with contrast arteriography (CA). After making anecdotal clinical observations that MRA sometimes overestimated the degree of renal artery stenosis, we decided to determine the interobserver variability, sensitivity, specificity, and diagnostic accuracy of MRA compared with CA.
• Dixit, M. P., Hughes, J. D., Theodorou, A., & Dixit, N. M. (2004). Hyponatremic hypertensive syndrome (HHS) in an 18-month old-child presenting as malignant hypertension: a case report. BMC nephrology, 5, 5.
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  The combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome (HHS). Malignant hypertension as a presentation has been reported in adults with HHS but is rare in children.
• Goshima, K. R., Mills, J. L., & Hughes, J. D. (2004). A new look at outcomes after infrainguinal bypass surgery: traditional reporting standards systematically underestimate the expenditure of effort required to attain limb salvage. Journal of vascular surgery, 39(2), 330-5.
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  Graft patency, limb salvage, and mortality are the traditional means of assessing the outcome of infrainguinal bypass surgery (IBS). However, these measures underestimate patient morbidity and fail to consider the entire spectrum of treatment required to restore the patients to their premorbid state. The aim of this study was to quantify the efforts required to achieve limb salvage by assessing three nontraditional outcomes: (1). index limb reoperation rate in 3 months, (2). hospital readmission rate in the first 6 months after IBS, and (3). wound-healing time.
• Ferris, B. L., Mills, J. L., Hughes, J. D., Durrani, T., & Knox, R. (2003). Is early postoperative duplex scan surveillance of leg bypass grafts clinically important?. Journal of vascular surgery, 37(3), 495-500.
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  The typical leg bypass surveillance program begins with a duplex scan evaluation of the vein graft 3 months after surgery; studies are repeated every 3 months during the first year of follow-up and are fully reimbursed by our Medicare carrier. Some authors have recommended early (before discharge or first postoperative visit) duplex scanning to identify high-risk grafts. However, the natural history of velocity disturbances detected with early scans is unclear, and furthermore, such studies are not reimbursed by Medicare.
• Knox, R. C., Berman, S. S., Hughes, J. D., Gentile, A. T., & Mills, J. L. (2002). Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access. Journal of vascular surgery, 36(2), 250-5; discussion 256.
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  The treatment of hemodialysis access-induced ischemic steal syndrome is challenging. Despite promising early results with the distal revascularization-interval ligation (DRIL) procedure, the operation has not been widely adopted because of concerns about its complexity and long-term efficacy. The purpose of this report was to determine the efficacy and durability of the DRIL procedure in relieving hand ischemia and in maintaining access patency in the setting of hemodialysis access-induced ischemia.

Proceedings Publications

• Khan, R., Choudhary, G., Goshima, K. R., Hughes, J. D., & Winegar, B. (2016, October). Time-Resolved MRA and MR Perfusion Findings Following Carotid Revascularization: Ipsilateral MCA Hyperperfusion Manifesting as Contralateral MCA Hypoperfusion. Case. In Western Neuroradiological Society 48th Annual Meeting, Austin, Texas.