Talking with Dr. Jhon Jairo Berrio about vascular disease and Prostaglandin E1


XXIX Congreso Latinoamericano de cirugia vascular y angiologia

Santa Cruz de la Sierra, Bolivia

Dr. Berrio, Vascular Surgeon, Tulua, Colombia

Dr. Jhon Jairo Berrio is  the Chief of Vascular Surgery at the Clinica San Francisco, Tulua, Colombia, which is a small community outside of Cali.  He attended medical school in Colombia, completing his general surgery residency at Hospital clinics for Carlos.  He completed additional training at New York University and he completed his vascular surgery residency in Bogota at the Hospital de Kennedy  and trained under the instruction of Dr. Albert Munoz, the current president of the Association of Latin American Vascular Surgery and Angiography (ALCVA) .  He does a range of vascular procedures such as aortic aneurysm repair, fistula creation as well as endovascular surgery but his favorite procedures are limb salvage procedures such as aorto-femoral bypass, femoral-popliteal bypass and other treatments designed to prevent amputation.

He is here in Bolivia giving a presentation on the use of Prostaglandin E1 for critical ischemia / and last chance limb salvage.

Today we are talking to Dr. Berrio about the use of prostaglandin E1 (Iloprost/ iprostadil) for peripheral vascular disease (PAD).  In the past, we have used a myriad of treatments including statins, pentoxifylline, clopidogrel and even quinine for the prevention and relief of claudication symptoms.  However, all of these previous agents are designed for early PAD and are only minimally effective at treating later stages of disease.  Treatment of severe disease (rest pain or ulceration/ ischemia wounds) has been limited to stenting (angioplasty) and surgical revascularization – but this strategy often fails for patients with microvascular disease (or disease that affects vessels that can not be operated on.)

Last effort at Limb Salvage in critical ischemia

No – Prostaglandin E is not some magic ‘panacea’ for peripheral vascular disease.  There is no such thing – but it is a medication in the treatment arsenal for vascular surgeons – and it has shown some promising results particularly in treating limb-threatening ischemia.  In fact, the data goes back over 20 years – even though most people in the United States have never heard of it.  That’s because prostaglandin E1 is more commonly used for other reasons in the USA.  It is a potent vasodilator, and in the US, this medication is often used in a different (aerosolized form) for primary pulmonary hypertension.  It is also used for erectile dysfunction.  Despite a wealth of literature supporting its use for critical ischemia it is not currently marketed for such use in the United States – and thus – must be individually compounded in a hospital pharmacy for IV use.  Supplies of this medication in this form are often limited and costly.

Intravenous Prostaglandin E1

This medication offers a desparately needed strategy for patients with critical ischemia who (for multiple reasons) may not be surgical candidates for revascularization and is a last-ditch attempt to treat ‘dry’ gangrene and prevent amputation and limb loss.  Since more than 25% of all diabetes will undergo amputation due to this condition – this is a critical development that potentially affects millions of people.  (Amputations also lead to high mortality for a variety of reasons not discussed here.)

What is Prostaglandin E1?

As mentioned above, prostaglandin E1 is a potent vasodilator – meaning it opens up blood vessels by forced the vessels to dilate.  This brings much-needed blood to ischemia tissue (areas of tissue dying due to lack of blood.)

Treatment details:

A full course of treatment is 28 days.  Patients receive 60 micrograms per day by IV.

Patients must be admitted to the hospital for observation for the first intravenous administration of prostaglandin E1.  While side effects such as allergic reactions, rash or tachycardia are rare – since this medication is given as an IV infusion, doctors will want to observe you for the first few treatments. The most common side effect is IV irritation.  If this occurs the doctors will stop the infusion and dilute it further to prevent discomfort.  Once your treatment has been established, doctors may arrange for you to have either out-patient therapy at an infusion center, or home health – where a nurse comes to your house to give you the medication.

The surgeons will evaluate your legs before, during and after treatment.  If the ischemia or rest pain are not improving, or worsen during treatment – doctors may discontinue therapy.

Prostaglandin E1 therapy is compatible with other medications for PAD such as clopidogrel, aspirin, pentoxifylline and statins, so you can continue your other medications for PAD while receiving this treatment.  However, if you are taking nitrates such as nitroglycerin, (Nitro-dur, Nitropaste) or medications for pulmonary hypertension or erectile dysfunction – please tell your surgeon.

In Colombia, the average cost of the entire course of treatment (4 weeks of daily therapy) is 12 million Colombian pesos.  At today’s exchange rate – that is  a little under $ 7000.00  (seven thousand dollars, USD).

While this is a hefty price tag – it beats amputation.  In some cases, arrangements can be made with insurance companies to cover some of the costs.  (Insurance companies know that amputation-related costs are higher over the long run, since amputation often leads to a lot of other problems due to decreased mobility).

Additional Information about Dr. Berrio:

Dr. Jhon Jairo Berrio, MD

Vascular surgeon

Calle 414 – 30

Buga, Colombia

Tele: 236 9449

Email: vascular@colombia.com

Speaks fluent English, Espanol.

References/ Additional information about peripheral arterial disease (PAD) and prostaglandin e1

Pharmacotherapy for critical limb ischemia  Journal of Vascular Surgery, Volume 31, Issue 1, Supplement 1, January 2000, Pages S197-S203

de Donato G, Gussoni G, de Donato G, Andreozzi GM, Bonizzoni E, Mazzone A, Odero A, Paroni G, Setacci C, Settembrini P, Veglia F, Martini R, Setacci F, Palombo D. (2006).  The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery.  Ann Surg. 2006 Aug;244(2):185-93.  An excellent read – even for novices.

S Duthois, N Cailleux, B Benosman, H Lévesque (2003).   Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases .  Diabetes & MetabolismVolume 29, Issue 1February 2003Pages 36-43

Katziioannou A, Dalakidis A, Katsenis K, Koutoulidis V, Mourikis D. (2012).  Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results.  Scientific World Journal. 2012;2012:803678. Epub 2012 Mar 12.e Note extremely small study size (ten patients).

Strecker EP, Ostheim-Dzerowycz W, Boos IB. (1998).  Intraarterial infusion therapy via a subcutaneous port for limb-threatening ischemia: a pilot study.  Cardiovasc Intervent Radiol. 1998 Mar-Apr;21(2):109-15.

Ruffolo AJ, Romano M, Ciapponi A. (2010).  Prostanoids for critical limb ischaemia.  Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006544.

Volteas N, Leon M, Labropoulos N, Christopoulos D, Boxer D, Nicolaides A. (1993).  The effect of iloprost in patients with rest pain.  Eur J Vasc Surg. 1993 Nov;7(6):654-8.

In the operating room with Dr. Martin Juzaino


This post is a little overdue since I was out of town for a few days.. I missed the 115 degree temps and I missed Mexicali too..

Dr. Juzaino (left) and Dr. Rivera

Usually, I go to surgery after I’ve spoken to the surgeon, and talked to them for a while but in this case – I had heard of Dr. Juzaino (after all – he practices at Hospital General de Mexicali) but couldn’t find a way to contact him – he’s not in the yellow pages, and no one seemed to have his number..

So I just hung out and waited for him when I saw his name on the surgery schedule. He was supernice, and invited me to stay and watch his femoral – popliteal bypass surgery.  Case went beautifully – leg fully revascularized at the end of the case.   Patient was awake during the case but appeared very comfortable.

intern during surgery

There was a beautiful intern in the surgery – her face was just luminous so I couldn’t resist taking a picture.  Unfortunately, I didn’t get her name, and no one recognizes her because of the mask – so I am hoping some one from the OR recognizes her here.. I’d like to send her a copy of the picture.. (and get permission to post it..)

Saw Lupita Dominguez – who in the role of nursing instructor that day.  She is always so delightful – I need to get a picture of her with out the mask so all of you can see her -besides being an outstanding nurse, and nursing instructor,  she is just the friendliest, sweetest person with cute freckles to boot.. (I am very envious of people with freckles..)

On another note entirely, here’s some more information about the ethical implications of transplant tourism for my interested readers as follow up to my Examiner.com article.  It’s a video of lectures by one of the leading ethicists and transplant surgeons, Dr. Delmonico.. (yes, like the steak.)

Dr. Palaez, same surgeon, new role


Attended the monthly thoracic surgery meeting this morning to discuss cases.

The rest of the morning was spent with Dr. Palaez, rounding and seeing patients.  It was an interesting contrast – at Cardioinfantil, we saw consults and patients in his role as Vascular Surgery fellow before proceeding to Clinica del Country to see patients in his role as the attending Thoracic Surgeon.  It was a different perspective for me and I asked Dr. Palaez about it.

He explained that while many of his colleagues thought it was interesting that he would return to training at this stage in his life (he is 49 and has been a practicing thoracic surgeon for many years), that he was really enjoying his training.  He believes strongly in lifelong learning but is very pleased to be close to the completion of his vascular surgery training.  He has enjoyed the experience but is looking forwards to being a practicing vascular surgeon.  (He is currently training with Dr. Jaime Camacho, who is himself, a hybrid surgeon with training in both vascular and cardiac surgery.

During rounds, we saw several post-operative patients as well as consultations in the emergency room with a wide variety of vascular disease.

Dr. Beltran and Dr. Renteria, Thoracic Surgeons


Spent a fascinating morning over at the National Cancer Insitute with Dr. Rafael Beltran, the Chief of Thoracic Surgery.  Since the cancer institute is the biggest hospital specializing in cancer treatment – Dr. Beltran sees most of the rare and unusual cancers affecting the chest.  He also have a keen interest in tracheal surgery, and has published (in collaboration with Dr. Barrios) several articles on the topic recently.  (Guess we’ll have to tap into his expertise for a guest publication over at CirugiadeTorax.org)

Hoping to follow him to the OR next week.

Then I spent the afternoon over at Hospital de Kennedy with Dr. Nelson Renteria.

Dr. Nelson Renteria, Thoracic & Vascular Surgeon

Today he performed a VATs decortication for a stage III empyema (which is one of my favorite cases – but that’s another discussion entirely.)  Going back tomorrow to see some of his vascular cases.

Dr. Renteria in the operating room

Dr. Nelson Renteria, Thoracic and Vascular Surgeon


What a delightful afternoon with Dr. Renteria and Dr. Cecilia Villasante (Radiology)!  Dr. Renteria works at the Centro Vascular del Country, which led me to suspect that he may no longer practice thoracic surgery.. But, happily, I was wrong.

While I enjoy meeting all the wonderful and interesting people from all surgical specialties (like the orthopedic surgeons I met with today), I can never deny how much I enjoy talking to people from my home specialties.  Maybe it makes me a little less homesick for my patients because it’s all so familiar.. And it’s always thrilling to meet people who find empyemas,  VATS and all these other things thoracic as interesting and engrossing as I do, especially when you meet people like Dr. Renteria, who still loves what he does as much as I do.  He still enjoys discussing cases, and has a real enthusiasm for his patients.

And – He does esophagectomies!  (Not many thoracic surgeons in Colombia perform esophageal surgery which is kind of like the ‘open heart’ surgery of thoracics*.)  He completed his fellowship training in esophageal surgery at Toronto General Hospital with Dr. Pearson (Dr. F. Griffith Pearson of Pearson’s Thoracic and Esophageal Surgery) and currently does esophagectomies here in Bogota.  (This is much bigger news than it sounds – finding qualified thoracic surgeons that perform an adequate number of esophagectomies can be difficult even in large centers.  Currently, in my home state of Virginia  – University of Virginia is home to the largest esophageal surgery center with three dedicated thoracic surgeons.  Even my beloved Duke only does about 75-76 cases a year.)

So, I admit I lost a bit of my professional cool (if I ever had any).  I was like a kid in a candy store – talking about pre-operative optimization, Ivor -Lewis versus Transhiatal approaches, node dissection and other minutiae that I enjoy.

I must say – I am looking forward to following him to the operating room soon!

** Studies show a significant decrease in morbidity and mortality when esophagectomies are performed by thoracic surgeons (versus general surgeons).

Does it get any better than this?


Going to heart surgery tomorrow – with one of the nicest people I’ve met since I’ve been here.. (Don’t worry, I’ll tell you all about it.)

Then, later this week, I have an appointment for an interview with a thoracic and vascular surgeon – I always said those two specialties combined are like dynamite..

Does it get any better than this? I’ll let you know.

(Cartagena Surgery News) But it certainly gets worse: over at our sister site we are talking about the financial and emotional burdens placed on Americans due to our failing healthcare system..

(Thoracic Surgery News) We’re discussing robotic surgery at our new Thoracic Surgery Portal:
Saw this on a neighboring blog, talking about robotic lung surgery – but my readers here know that Dr. Buitrago has been training with an American surgeon to offer that treatment here – at Clinica de Marly.

Dr. Jairo Ramirez and Dra. Stella Martinez


My early morning surgery plan fell apart – so I will try again next week. Met with Dr. Jairo Ramirez, MD, FACS over at Santa Fe de Bogota this morning. Dr. Ramirez is a vascular and thoracic surgeon, and the Chief of Vascular Surgery (at SF de B) but he reports the majority of his practice is the treatment of venous disease such as varicosities and venous stasis ulcers.

This afternoon, I met with Dra. Stella Martinez Jaramillo, (thoracic surgeon) and she is a fascinating lady. We had a great chat – and scheduled a day for me to see her in action..I am definitely looking forward to it.

Spoke with Dr. Javier Maldonado, cardiac surgeon on the phone today to set up an appointment next week over at Clinica Colombia. Now, I thought he completed some of his training in the USA but I could swear I heard soft traces of a southern accent – and Cleveland is a far cry from my native Virginia.. There must be a story there – or my overactive imagination.. I’ll keep you posted.

Writing, writing, writing


Spending the day (and much of the weekend) writing, transcribing notes from recent interviews, and working on an upcoming article. The article is a bit of a departure from my previous work, being a bit more light-hearted, and less academic than my previous writing. Hopefully, this will give it a broader appeal.   It’s also a nice way to call attention to some of the newer technologies, and techniques I’ve seen, and share a bit of the spotlight with the people doing all the hard work. (These guys don’t blow their own horns much – even when it’s well-deserved.) 

I have a few more interviews to conduct next week before I can finish it.. I am enjoying the change of style, but I will be happy to revert back to my usual writing.

Hoping to catch up with some more orthopedic surgeons, neurosurgeons, vascular surgeons, and just a few more thoracic surgeons in the next few weeks..(see my ‘Chasing Thoracics’ blog for more information).

Looks like the book cover is pretty much done – you can see it under the ‘book’ tab.  I find that completing the artwork helps keep me focused on the book, especially once I’ve past the mid-point..