Objective/background National differences exist in the outcome of elective abdominal aortic aneurysm (AAA) repair. The role of case mix variation was assessed based on an international vascular ...registry collaboration. Methods All elective AAA repairs with aneurysm size data in the Vascunet database in the period 2005–09 were included. AAA size and peri-operative outcome (crude and age adjusted mortality) were analysed overall and in risk cohorts, as well as per country. Glasgow Aneurysm Score (GAS) was calculated as risk score, and patients were stratified in three equal sized risk cohorts based on GAS. Predictors of peri-operative mortality were analysed with multiple regression. Missing data were handled with multiple imputation. Results Patients from Australia, Finland, Hungary, Norway, Sweden and the UK ( n = 5,895) were analysed; mean age was 72.7 years and 54% had endovascular repair (EVAR). There were significant variations in GAS (lowest = Finland 75.7, highest = UK 79.4, p for comparison of all regions < .001), proportion of AAA < 5.5 cm (lowest = UK 6.4%, highest = Hungary 29.0%; p < .001), proportion undergoing EVAR (lowest = Finland 10.1%, highest = Australia 58.9%; p < .001), crude mortality (lowest = Norway 2.0%, highest = Finland 5.0%; p = .006), and age adjusted mortality (lowest = Norway 2.5%, highest = Finland 6.0%; p = .048). Both aneurysm size and peri-operative mortality were highest among patients with a GAS >82. Of those with a GAS >82, 8.4% of men and 20.8% of women had an AAA <5.5 cm. Conclusion Important regional differences exist in case selection for elective AAA repair, including variations in AAA size and patient risk profile. These differences partly explain the variations in peri-operative mortality. Further audit is warranted to assess the underlying reasons for the regional variation in case-mix.
Among the immunocompetent, infections with parvovirus B19 (B19V) and human bocavirus (HBoV) 1 range clinically from asymptomatic to severe, while following allogeneic hematopoietic SCT (HSCT) B19V ...can cause a persistent severe illness. The epidemiology and clinical impact of HBoV1 and the other emerging parvovirus 4 (PARV4) among immunocompromised patients have not been established. To determine the occurrence and clinical spectrum of B19V, PARV4 and HBoV1 infections, we performed a longitudinal molecular surveillance among 53 allogeneic HSCT recipients for pre- and post-HSCT DNAemias of these parvoviruses. Quantitative real-time PCR showed B19V DNA in sera of 16 (30%) patients, at mean levels of 4.6 × 10(3), 9.9 × 10(7), 1.1 × 10(10) and 1.6 × 10(2) B19V DNA copies/mL pre-HSCT (9/53), and at 1 (6/53), 2 (4/53) and 3 months (1/25) post HSCT, respectively. However, no clinical manifestation correlated with the presence of B19V viremia. All B19V sequences were of genotype 1. None of the sera investigated contained PARV4 or HBoV1 DNAs. Our data demonstrate B19V viremia to be frequent among pediatric allogeneic HSCT recipients, yet without apparent clinical correlates. PARV4 or HBoV1 viremias were not seen in these immunocompromised patients.
Objectives To assess the prevalence and clinical significance of elevated ankle-brachial index (ABI) in patients referred to vascular consultation. Design Retrospective clinical study. Material and ...methods In 1,762 patients referred with a suspicion of peripheral arterial disease (PAD), ABI and toe brachial index (TBI) were measured by photoplethysmography. ABI ≥ 1.3 was considered falsely elevated and TBI < 0.60 was the diagnostic criterion for PAD. Results The prevalence of elevated ABI was 8.4% and that of PAD among these patients 62.2%. PAD was significantly more prevalent among subjects with severe symptoms (rest pain, ulcers or gangrene) than in those with intermittent claudication (83.8% and 45.3%, respectively, p < 0.001). The risk of PAD diagnosis was ten-fold (OR 10.31, 95% CI 2.07–51.30) among those with chronic renal failure, five-fold among patients with a history of smoking (OR 5.63, 95% CI 1.22–26.00) and over three-fold (OR 3.44, 95% CI 1.46–8.12) among those with coronary heart disease. The specificities of elevated ABI threshold levels (1.3, 1.4 and 1.5) in identifying PAD were 86%, 94% and 96%, respectively, the sensitivities being 44%, 38% and 36%, respectively. Conclusions The prevalence of elevated ABI in patients referred to vascular consultation is 8.4% and that of PAD among these 62.2%. PAD is significantly more probable among those with chronic renal failure, a history of smoking and coronary heart disease. Furthermore, the specificity of elevated ABI (≥1.3) in recognizing PAD is good, whereas the sensitivity is only satisfactory.
Introduction:
Endovascular aneurysm sealing represents an alternative to advanced technology devices for compromised patients with abdominal aortic aneurysms. We report our results of 15 fragile ...patients with very low-quality infrarenal necks treated with endovascular aneurysm sealing.
Material and methods:
All patients treated with Nellix device in our hospital between June 2015 and October 2016 were retrospectively reviewed. The primary endpoints are the following: overall survival and freedom from reintervention rates. The secondary endpoints are the following: technical success; 30-day mortality; abdominal aortic aneurysm–related mortality; and freedom from endoleak rate, complications, and surgical conversion rate.
Results:
Nellix was used in 15 patients, median age 75.5 years, of which 67% were unfit for open surgery. Mean aneurysm diameter was 60 mm. One-third (5/15) of the patients were inside the Nellix instructions for use. Technical success rate was 93.3%. No perioperative complications existed, and 30-day mortality was 0%. Median follow-up was 35 (interquartile range: 11–37) months. Survival rates at 1 and 3 years were 80% and 59.3%. Abdominal aortic aneurysm–related mortality occurred in 3 of 15 cases. Freedom from rupture rates at 1 and 3 years were 92.9% and 66%. Freedom from endoleak rates at 1 and 3 years were 92.9% and 74.5%. Freedom from reintervention rates at 1 and 3 years were 86.7% and 70.6%, with a dramatic drop to 37.1% at 4 years of follow-up. Three open surgery conversions were needed. There were no statistically significant differences in results between patients treated inside and outside instructions for use.
Conclusion:
The endovascular aneurysm sealing has shown encouraging short-term results, but its safety and effectiveness during time is questionable, because this system still carries high rates of reintervention, conversions for type IA endoleaks, and secondary aneurysm ruptures.
Objective/Background Owing to the increased life expectancy of the population the number of very old patients referred to vascular surgical units has increased. Advanced age is a well known risk ...factor in patients undergoing surgical interventions for lower limb ischemia. However, amputation performed on an elderly person living independently will lead to permanent institutional care. The aim of this study was to evaluate the outcome of patients aged 90 years and older with lower limb ischemia undergoing surgical or endovascular revascularization. Methods Two hundred and thirty-three nonagenarians with either chronic critical limb ischemia (CLI) or acute limb ischemia (ALI) who underwent revascularization at the authors' institution between 2002 and 2013 were included in this retrospective study. Risk factors were evaluated and survival, limb salvage, and amputation free survival (AFS) assessed. Results The median age of the study population was 92 years (range 90–100 years). The majority (81.1%) of the patients were female. One in four (24.5%) patients had diabetes, and the incidence of coronary artery disease was 79.8%. Seventy-three percent of the patients had CLI and 27% of had ALI. Seventy percent of the patients underwent surgical revascularization and 30% were treated endovascularly. The majority (72.5%) of the patients maintained their independent living status; 27.5% ended up in institutional care post-operatively. Similarly, the majority (82.0%) of the patients maintained their walking ability, while 18% were not able to ambulate independently after revascularization. One year survival, limb salvage, and AFS rates were 50.9% versus 48.6% ( p = .505), 85.1% versus 87.0% ( p = .259), and 45.7% versus 44.4% ( p = .309) in the surgical versus endovascular group, respectively. Dementia was an independent risk factor of poor AFS (odds ratio: 1.56; 95% confidence interval: 1.077–2.272; p = .019). Conclusion Good limb salvage can be achieved by both surgical and endovascular revascularization, and independent living can be maintained in the majority of the patients. However, the benefit of revascularization is limited owing to high mortality, especially in patients with dementia.
Angiosome Theory: Fact or Fiction? Alexandrescu, V.; Söderström, M.; Venermo, M.
Scandinavian Journal of Surgery,
06/2012, Letnik:
101, Številka:
2
Book Review, Journal Article
Recenzirano
The angiosome concept delineates the human body into three-dimensional blocks of tissue fed by specific arterial and venous sources named “angiosomes.” Adjacent angiosomes are connected by a vast ...compensatory collateral web, or “choke vessels.” This concept may provide new information applicable to improving targeted revascularization of ischemic tissue lesions.
A few dedicated studies available seem to favor this strategy, as encouraging ulcer healing and limb preservation are reported in connection with both bypass and endovascular techniques based on these principles.
The theory on the angiosome model of revascularization (AMV) may help the clinician to better refine vessel selection, vascular access, and specific strategies in the revascularization of critically ischemic legs with tissue lesions. Specific applications of angiosome-guided revascularization were recently suggested for patients with diabetes or renal insufficiency, with ischemic tissue lesions of the lower limb, and extended large- and medium-size collateral network decay. For these cases, the concept may allow deliberate arterial reconstruction following individual wound topographies in specific ischemic areas, although deprived from “rescue-vessel” supply. The AMV theory may contribute to a shift in common reperfusion options.
However, the data available is suggestive and does not provide strong evidence as factors such as case mix and the severity of ischemia are unsatisfactorily controlled.
At present, the evidence is scarce as to the effect of the severity of the arterial disease. In all comparisons, the groups treated are likely to be dissimilar and mismatched. The angiosome concept is postulated to be valid especially in diabetics, whose ischemic lesions tend to heal worse than those of non-diabetics.
Objective/Background To analyse the impact of ischaemia and revascularisation strategies on the long-term outcome of patients undergoing free flap transfer (FFT) for large diabetic foot lesions ...penetrating to the tendon, bone, or joint. Methods Foot lesions of 63 patients with diabetes (median age 56 years; 70% male) were covered with a FTT in 1991–2003. Three groups were formed and followed until 2009: patients with a native in line artery to the ulcer area ( n = 19; group A), patients with correctable ischaemia requiring vascular bypass ( n = 32; group B), and patients with uncorrectable ischaemia lacking a recipient vessel in the ulcer area ( n = 12; group C). Results The respective 1, 5, and 10 year amputation free survival rates were 90%, 79%, and 63% in group A; 66%, 25%, and 18% in group B; and 50%, 42%, and 17%, in group C. The respective 1, 5, and 10 year leg salvage rates were 94%, 94%, and 87% in group A; 71%, 65%, and 65% in group B; and 50%, 50%, and 50% in group C. In 1 year, 43%, 45%, and 18% of the patients in groups A, B, and C, respectively, achieved stable epithelisation for at least 6 months. The overall amputation rate was associated with smoking (relative risk RR 3.09, 95% confidence interval CI 1.8–5.3), heel ulceration (RR 2.25, 95% CI 1.1–4.7), nephropathy (RR 2.24, 95% CI 1.04–4.82), and an ulcer diameter of >10 cm (RR 2.08, 95% CI 1.03–4.48). Conclusion Despite diabetic comorbidities, complicated foot defects may be covered by means of an FFT with excellent long-term amputation free survival, provided that a patent native artery feeds the ulcer area. Ischaemic limbs may also be salvaged with combined FFT and vascular reconstruction in non-smokers and in the absence of very extensive heel ulcers. Occasionally, amputation is avoidable with FFT, even without the possibility of direct revascularisation.
Recently a parvovirus called bufavirus (BuV) has been implicated as a causative agent of diarrhoea. To further reveal the epidemiology and genetic characteristics of BuV, this study was performed in ...Turkish children with diarrhoea. BuV was detected in 1.4% (8/583) of stool samples. All stool samples from healthy children (n = 148) were negative for BuV. Diarrhoea in BuV-positive patients was severe and occurred mainly during the colder months of the year. Complete genome sequences were generated from four BuVs. Only BuV3 was found, which was genetically and phylogenetically similar to Bhutanese BuV3, indicating that BuV3 is prevalent in Asian countries.
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