Jeffrey Indes MD, FACS
Assistant Professor of Surgery (Vascular); Associate Program Director, Vascular Surgery Residency/Fellowship
Clinical outcomes of endovascular and open surgery; Limb salvage in diabetic patients; Open and Endovascular Surgical Education; Aortoiliac Occlusive Disease; Peripheral Artery Disease (PAD)
Current ProjectsClinical Outcomes in Chronic Mesenteric Ischemia
Clinical Outcomes in Thoracic Aortic Aneurysms, and Aortic Transection
Clinical and Economic Outcomes in Peripheral Artery Disease (PAD)
Clinical Outcomes in Carotid Artery Disease
His research currently focuses on outcomes in patients undergoing various open and endovascular treatment modalities for vascular disease. By better characterizing statewide and national trends in the treatment of these disease processes and documenting morbidities, costs incurred and mortality associated with each, these treatments can be applied to the appropriate patients with the greatest benefit.
Extensive Research Description
Jeffrey E. Indes M.D. is assistant professor of surgery and interventional radiology at Yale University School of Medicine. He completed his undergraduate degree in Microbiology and Molecular Genetics from the University of California Los Angeles. He then went on to receive his medical degree with distinction in research from the Mount Sinai School of Medicine. His surgical training was completed at Temple University Hospital followed by his fellowship training in vascular and endovascular surgery at the Albert Einstein College of Medicine/Montefiore Medical Center. He is a registered physician in vascular interpretation (RPVI), and currently the associate program director for the vascular residency program, as well as the founder and director of the Yale Vein Center and the Yale Vascular Laboratory. His clinical interests include all facets of vascular and endovascular surgery with a special interest in surgical education. His research currently focuses on outcomes in patients undergoing various open and endovascular treatment modalities for vascular disease.
Routine administrative databases are increasingly utilized to monitor outcomes in the healthcare system within the United States at statewide and national levels. These databases have been shown to be accurate at predicting the risks associated with certain surgical procedures. 1 The aim of our current work is to provide insight into the outcomes associated with endovascular procedures when comparing them to open procedures for specific disease processes, by utilizing both the New York State health department statewide planning and research cooperative system (SPARCS), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the Medicare databases respectively. 2,3 We are focusing on specific anatomical patterns of atherosclerotic disease such as chronic mesenteric ischemia (CMI), aortoiliac occlusive disease, renovascular disease, femoro-popliteal occlusive disease and carotid artery occlusive disease, and compare the outcomes related to endovascular vs. open treatment within each disease category.
By better characterizing the statewide and national trends in treatment of these disease processes and documenting morbidity and mortality associated with each, as well as the costs incurred with endovascular and open procedures, these treatments can be applied to the appropriate patients. In addition, although many prospective randomized control trials comparing open and endovascular treatment for carotid artery disease have been completed or are underway, 4-16 there are deficiencies in the performance of trials for: CMI, renovascular disease, aortoiliac occlusive disease and femoro-popliteal occlusive disease. Our results may provide solid support that these trials need to be performed. Finally, our results at the statewide and national levels with regards to the open and endovascular treatment of carotid artery disease can be compared to published data from multicenter trials and provide important information on the outcomes of these patients.
Our preliminary work studying outcomes associated with CMI using the SPARKS database for the years 2000-2006 have yielded interesting results. We identified 6549 patients with CMI in New York State during the study period 2000 to 2006. Of these patients with CMI, 666 received an intervention and underwent either open (280) or endovascular (347) repair. Thirty nine patients underwent both treatments. Statistically significant comorbidities included a higher incidence of diabetes, coronary artery disease, peripheral vascular disease, hyperlipidemia, renal insufficiency and hypertension among endovascular patients, while gender and history of emphysema was constant between the two groups. During the 7 year study period; there was a continuous increase in the number of endovascular procedures, while the number of open procedures fluctuated. Twenty eight percent of the procedures done in 2000 for CMI were endovascular where as 75% of the procedures done in 2006 were endovascular. In addition, there was a 2 fold increase in the total number of interventions, when those done in 2000 were compared to those done in 2006.
The overall mortality rate for the 7 year period was significantly lower for endovascular vs. open repair (10.95% vs. 20.36%, p = 0.0011). Endovascular repair was associated with a significantly lower rate of ischemic complications of the mesentery when compared to open repair (6.92% vs. 17.14% p < 0.0001). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of cardiac, pulmonary and infectious complications. Within the open repair group 36.8%, compared to 55% of the endovascular repair patients, were discharged to home during the seven year study period (p < 0.0001). The number of patients treated with an intervention for CMI continues to increase, due primarily, to the increase in the number endovascular procedures. Patients undergoing endovascular treatment experience improved morbidity, mortality and frequency of discharge to home. These data support the need for prospective randomized studies comparing clinical outcomes in patients treated surgically for CMI. (Published in JEVT).
Future directions include utilizing our administrative databases to examine specific cost and institutional analyses related to open and endovascular treatments for CMI, renovascular disease, aortoiliac occlusive disease, femoral popliteal occlusive disease, carotid disease, vascular trauma, aortic aneurysms and venous disease. By analyzing cost effectiveness as well as outcomes related to the type of institution a patient was treated in (high volume vs. low volume), results can help guide patient care, provide input on healthcare policy and suggest specific treatment strategies which are in need of further investigation through randomized controlled trials.
Our current projects include outcomes in Traumatic Aortic Transection as well as Thoracic Aortic Aneurysms in New York State. Under the tutelage of Julie Ann Sosa M.D. in the Department of Surgery we are currently studying clinical and economic outcomes in patients with peripheral artery disease (PAD) utilizing the HCUP-NIS database. We are also interested in forming new research studying surgical education with focus on surgical skills utilizing simulation and measures of knowledge base.
1. Aylin, P, Bottle A, Majeed, A, Use of administrative data or clinical databases as predictors of risk of death in hospital: comparison of models, BMJ, 2007 May 19;334(7602):1044.
2. New York State Health Department, Statewide Planning and Research Cooperative System, (http://www.health.state.ny.us/nysdoh/sparcs/sparcs.htm#general)
3. Healthcare Cost, Utilization Project (HCUP-6). Nationwide Inpatient Sample, Rockville MD. Agency for Health Care Research and Quality.
4. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415–25.
5. European Carotid Surgery Trialists’ Collaborative Group. MRCEuropean Carotid Surgery trial: interim results for symptomaticpatients with severe (70–99%) or with mild (0–29%) carotid stenosis.Lancet 1991;337:1235– 43
6. MRC European Carotid Surgery Trialists. Randomized trial of endarterectomyfor recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379–87.
7. Executive Committee for the Asymptomatic Carotid AtherosclerosisStudy. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421– 8.
8. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004;363:1491–502.
9. CAVATAS Investigators. Endovascular versus surgical treatment inpatients with carotid stenosis in the CArotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial. Lancet 2001;357:1729 –37.
10. Alberts MJ, McCann R, Smith TP, et al., for the Schneider Wallstent Endoprosthesis Clinical Investigators. A randomized trial of carotid stenting vs. endarterectomy in patients with symptomatic carotid stenosis: study design. J Neurovasc Dis 1997;2:228 –34.
11. CaRESS Steering Committee. Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg 2005;42:213–9.
12. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004;351:1493–501. 13. Ringleb PA, Allenberg J, Bruckmann H, et al. 30 day results from the SPACE trial of in symptomatic patients: a randomized non-inferiority trial. Lancet 2006;368:1239–47.
14. Hobson RW II, Howard VJ, Roubin GS, et al. Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase. J Vasc Surg 2004;40:1106 –11.
15. Featherstone RL, Brown MM, Coward LJ, for the ICSS Investigators. International carotid stenting study: protocol for a randomized clinical trial comparing carotid stenting with endarterectomy in symptomatic carotid artery stenosis. Cerebrovasc Dis 2004;18:69 –74.
16. Carotid Stenting vs. Surgery of Severe Carotid Artery Disease and Stroke Prevention in Asymptomatic Patients (ACT I). Available at: http://www.clinicaltrials.gov/ct/show/NCT00106938?order_1. Accessed October 21, 2007