Introduction Aortic prosthetic graft infection (AGI) is a major challenge in vascular surgery. Eradicating the infection requires prosthetic material removal, debridement, and lower limb ...revascularization. For the past 15 years, we have used femoral veins for aorto-iliac reconstruction and tensor fascia lata to strengthen the upper anastomosis. Objective The purpose of this single institution retrospective study is to present results regarding in situ replacement of infected aortic grafts with autologous femoral veins (FVs). Methods From October 2000 to March 2013, patients treated for AGI with graft removal and autologous FV reconstruction at Helsinki University Hospital were included. Primary outcome measures were 30 day mortality, long-term treatment related mortality, and re-infection rate. Secondary outcome measures were long-term all cause mortality and event free survival (graft rupture, re-intervention, major amputation). Results During a 13 year period 55 patients (42 male, 13 female) were operated on using a venous neo-aorto-iliac system for AGI. The mean follow up was 32 months (1–157 months). The 30 day mortality rate was 9% (5) and overall treatment related mortality 18% (10). All cause mortality during follow up was 22 (40%) and overall Kaplan–Meier survival was 90.7% at 30 days, 81.5% at 1 year, and 59.3% at 5 years. Graft rupture occurred in three (5%) cases, two of which were caused by graft re-infection (4%). Four patients required major amputation, one of them on arrival and three (5%) during the post-operative period. Nine (16%) patients needed interventions for the vein graft, and two graft limbs occluded during follow up. Conclusion In situ reconstruction for aortic graft infection with autologous FV presents acceptable rates of morbidity and mortality, and remains the treatment of choice for AGI at Helsinki University Hospital.
Background
A variety of minimally invasive techniques are available for the treatment of varicose great saphenous vein (GSVs). Non‐tumescent, non‐thermal ablation methods have been developed. This ...study compared mechanochemical ablation (MOCA), a non‐tumescent, non‐thermal ablation technique, with two endovenous thermal ablation methods requiring tumescence in an RCT.
Methods
Patients with GSV reflux were randomized to undergo MOCA, or thermal ablation with endovenous laser (EVLA) or radiofrequency (RFA). The primary outcome measure was the occlusion rate of the GSV at 1 year.
Results
The study finally included 125 patients, of whom 117 (93·6 per cent) attended 1‐year follow‐up. At 1 year, the treated part of the GSV was fully occluded in all patients in the EVLA and RFA groups, and in 45 of 55 in the MOCA group (occlusion rates 100, 100 and 82 per cent respectively; P = 0·002). The preoperative GSV diameter was associated with the recanalization rate of the proximal GSV in the MOCA group. At 1 year after treatment, disease‐specific life quality was similar in the three groups.
Conclusion
The GSV occlusion rate 1 year after treatment was significantly higher after EVLA and RFA than after MOCA. Quality of life was similar between interventions. Registration number: NCT03722134 (http://www.clinicaltrials.gov).
This study reports the 1‐year results of an RCT comparing mechanochemical ablation with either endovenous laser ablation or radiofrequency ablation in the treatment of great saphenous vein (GSV) insufficiency. At 1 year, the occlusion rate of the GSV was significantly higher after endovenous laser and radiofrequency ablation than after mechanochemical ablation.
Thermal ablation superior occlusion rates
Introduction This study aimed to evaluate the impact of angiosome targeted (direct) revascularisation according to revascularisation method in patients with diabetes. Materials and methods This ...retrospective study cohort comprised 545 diabetic patients with critical limb ischaemia and tissue loss (Rutherford 5, 6). All patients underwent infrapopliteal endovascular (PTA) or open surgical revascularisation between January 2008 and December 2013. Differences in the outcome after direct revascularisation, bypass surgery, and PTA were investigated by means of Cox proportional hazards analysis. The endpoints were wound healing, leg salvage, and amputation free survival. Results Overall, 60.3% of the ischaemic wounds healed during 1 year of follow-up. The highest wound healing rate was achieved after direct bypass (77%) and the worst after indirect PTA (52%). The Cox proportional hazards analysis showed that the number of affected angiosomes <3 (HR 1.37, 95% CI 1.01–1.84) was associated with improved wound healing, whereas wound healing was poorest after indirect PTA ( p = .001). When Cox proportional hazard analysis was adjusted for the number of affected angiosomes, direct bypass gave the best wound healing (p = 0.003). The overall amputation rate was 25.1% at 1 year of follow-up, and the Cox proportional hazards analysis indicated that haemodialysis compared with patients with no haemodialysis (HR 2.55, 95% CI 1.49–4.38), C-reactive protein ≥10 mg/dL (HR 2.05, 95% CI 1.45–2.90), atrial fibrillation (HR 1.54, 95% CI 1.05–2.26), and number of affected angiosomes >3 (HR 1.75, 95% CI 1.24–2.46) were significantly associated with poor leg salvage. Direct PTA was associated with a lower rate of major amputation compared with indirect PTA (HR 0.57 95% CI 0.37–0.89). Conclusion In diabetics, indirect endovascular revascularisation leads to significantly worse wound healing and leg salvage rates compared with direct revascularisation. Therefore, endovascular procedures should be targeted according to the angiosome concept. In bypass surgery, however, the concept is of less value and the artery with the best runoff should be selected as the outflow artery.
Human parvovirus B19 (B19) has been, for decades, the only parvovirus known to be pathogenic in humans. Another pathogenic human parvovirus, human bocavirus (HBoV), was recently identified in ...respiratory samples from children with acute lower respiratory tract symptoms. Both B19 and HBoV are transmitted by the respiratory route. The vast majority of adults are IgG seropositive for HBoV, whereas the HBoV-specific Th-cell immunity has not much been studied. The aim of this study was to increase our knowledge on HBoV-specific Th-cell immunity by examining HBoV-specific T-cell proliferation, Interferon-gamma (IFN-γ), IL-10 and IL-13 responses in 36 asymptomatic adults. Recombinant HBoV VP2 virus-like particles (VLP) were used as antigen. HBoV-specific responses were compared with those elicited by B19 VP2 VLP. Proliferation, IFN-γ and IL-10 responses with HBoV and B19 antigens among B19-seropositive subjects were statistically similar in magnitude, but the cytokine and proliferation responses were much more closely correlated in HBoV than in B19. Therefore, at the collective level, B19-specific Th-cell immunity appears to be more divergent than the HBoV-specific one.
Objective To test various indicators for comparing the outcomes of diabetic foot care. Design All 396,317 patients treated with hypoglycaemic medication in Finland were followed up based on ...nationwide registers on hospital discharges and causes of death during 1997–2007. Materials and methods The crude and standardized incidences of lower extremity amputations (LEAs), the minor–major ratio of the first LEA and 2-year survival with a preserved leg after the first minor LEA were used as indicators for regional and temporal variation in diabetic foot care. Results A total of 13,469 LEAs were recorded in 1997–2007. The standardized population-corrected rate of first major LEA per 100,000 person-years declined from 10.0 (95% CI 9.6–10.5) to 7.3 (6.9–7.6) ( p < .001), while the minor–major LEA ratio progressed from 0.86 (0.80–0.92) to 1.35 (1.26–1.46) ( p < .001). By using these indicators, variation was observed between the university hospital catchment areas. Nationwide, the 2-year survival with a preserved leg after the first minor LEA increased statistically insignificantly from 50.8% (47.3–54.6%) to 55.4% (51.9–59.0%) ( p = .08). Conclusions The standardized, population-corrected incidence of major LEA, the minor–major LEA ratio, and major-amputation-free survival proved useful as indicators in comparing the outcomes of diabetic foot care.
Objectives The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR). Methods Data ...from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country. Results Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0–72%), Hungary (5–55%), and the United States (0–100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4–7.7). Conclusions Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world.
Background and Aims:
Stenosis due to intimal hyperplasia and restenosis after initially successful percutaneous angioplasty are common reasons for failing arteriovenous fistulas. The aim of this ...study was to evaluate the effect of drug-coated balloons in the treatment of arteriovenous fistula stenosis.
Design:
Single-center, parallel group, randomized controlled trial. Block randomized by sealed envelope 1:1.
Materials and Methods:
A total of 39 patients with primary or recurrent stenosis in a failing native arteriovenous fistulas were randomized to drug-coated balloon (n = 19) or standard balloon angioplasty (n = 20). Follow-up was 1 year. Primary outcome measure was target lesion revascularization.
Results:
In all, 36 stenoses were analyzed; three patients were excluded due to technical failure after randomization. A total of 88.9% (16/18) in the drug-coated balloon group was revascularized or occluded within 1 year, compared to 22.2% (4/18) of the stenoses in the balloon angioplasty group (relative risk for drug-coated balloon 7.09). Mean time-to- target lesion revascularization was 110 and 193 days after the drug-coated balloon and balloon angioplasty, respectively (p = 0.06).
Conclusions:
With 1-year follow-up, the target lesion revascularization-free survival after drug-coated balloon-treatment was clearly worse. The reason for this remains unknown, but it may be due to differences in the biological response to paclitaxel in the venous arteriovenous fistula-wall compared to its antiproliferative effect in the arterial wall after drug-coated balloon treatment of atherosclerotic occlusive lesions. Trial registration: ClinicalTrials.gov NCT03036241
Background
Clinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended ...lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture‐preventing reintervention) to enable the development of personalized surveillance intervals.
Methods
Baseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR‐1 and EVAR‐2 trials were used to develop the model, with external validation in a cohort from a single‐centre vascular database. Longitudinal mixed‐effects models were fitted to trajectories of sac diameter, and model‐predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models.
Results
Some 785 patients from the EVAR trials were included, of whom 155 (19·7 per cent) experienced at least one rupture or required a rupture‐preventing reintervention during follow‐up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2 years (C‐index 0·68), 3 years (C‐index 0·72) and 5 years (C‐index 0·75) after operation and had excellent external validation (C‐index 0·76–0·79). More than 5 years after operation, growth rates above 1 mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2 years.
Conclusion
Secondary sac growth is an important predictor of rupture or rupture‐preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow‐up.
Potential to tailor surveillance
Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical ...registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy‐related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large‐scale data over longer periods of time, the importance of centralization of care to high‐volume centres was shown, particularly for open repair. Additionally, large‐scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.
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