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Mani, Kevin
Publications (10 of 71) Show all publications
Högberg, D., Mani, K., Wanhainen, A. & Svensjö, S. (2018). Clinical effect and cost effectiveness of screening for asymptomatic carotid stenosis: A Markov model. European Journal of Vascular and Endovascular Surgery, 55(6), 819-827
Open this publication in new window or tab >>Clinical effect and cost effectiveness of screening for asymptomatic carotid stenosis: A Markov model
2018 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 55, no 6, p. 819-827Article in journal (Refereed) Published
Abstract [en]

Objectives:   Screening for asymptomatic carotid artery stenosis (ACAS) is controversial. The cost-effectiveness of screening depends on screening cost, ACAS prevalence, and the potential stroke reducing effect of best medical treatment (BMT). The aim of the study was to determine the threshold values for these parameters in order for screening for ACAS to be cost-effective.

Material and methods: The clinical effect and cost-effectiveness of ultrasound-screening for ACAS with subsequent initiation of BMT versus not screening, was assessed in a Markov model with a life-time perspective. Key parameters; including stroke risk, all-cause mortality, and costs were based on contemporary published data, population statistics and ongoing screening programs. Prevalence of ACAS and rate of ongoing BMT was based on data from a population recently screened for ACAS. Minimum required stroke-risk reduction from BMT, incremental cost-efficiency ratio (ICER), absolute risk reduction for stroke (ARR), number needed to screen (NNS) were calculated. 

Results: Screening was cost-effective at an ICER of €5744 per incremental quality adjusted life-year (QALY) gained. ARR was 135 per 100000 screened, NNS was 741 and QALYs gained were 6700 per 100000 invited. At a willingness-to-pay (WTP) threshold of €50,000 per QALY the minimum required stroke risk reduction from BMT was 22%. The assumed degree of stroke risk reduction was the most important determinant of cost-efficiency.  

Conclusion: A moderate (22%) reduction in the risk of stroke from BMT was required for an ACAS screening strategy to be cost-effective at WTP of €50,000/QALY. Targeting populations with higher prevalence of ACAS could improve cost-efficiency.

Keywords
cost-eefectiveness, carotid stenosis, screening, preventive treatment
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-328785 (URN)10.1016/j.ejvs.2018.02.029 (DOI)000434259600005 ()
Projects
Screening for asymptomatic carotid atherosclerosis
Funder
Swedish Research Council, K2013-64X-20406-07-3
Available from: 2017-08-31 Created: 2017-08-31 Last updated: 2018-08-30Bibliographically approved
Karthikesalingam, A., Grima, M. J., Holt, P. J., Vidal-Diez, A., Thompson, M. M., Wanhainen, A., . . . Mani, K. (2018). Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden. Paper presented at Annual Meeting of the British-Society-for-Endovascular-Therapy, JUN, 2017, Wotton under Edge, ENGLAND. British Journal of Surgery, 105(5), 520-528
Open this publication in new window or tab >>Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden
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2018 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 5, p. 520-528Article in journal (Refereed) Published
Abstract [en]

Background

There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non-operative factors influence risk-adjusted outcomes. This study compared 90-day and 5-year mortality for patients undergoing elective AAA repair in England and Sweden.

Methods

Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety-day mortality and 5-year survival were compared after adjustment for age and sex. Separate within-country analyses were performed to examine the impact of co-morbidity, hospital teaching status and hospital annual caseload.

Results

The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69–79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68–78) years, of whom 82·9 per cent were men. Ninety‐day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five‐year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates.

Conclusion

Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England. Improving in England

National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-354237 (URN)10.1002/bjs.10749 (DOI)000428846100009 ()29468657 (PubMedID)
Conference
Annual Meeting of the British-Society-for-Endovascular-Therapy, JUN, 2017, Wotton under Edge, ENGLAND
Available from: 2018-06-29 Created: 2018-06-29 Last updated: 2018-06-29Bibliographically approved
Baderkhan, H., Haller, O., Wanhainen, A., Björck, M. & Mani, K. (2018). Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging. British Journal of Surgery, 05(6), 709-718
Open this publication in new window or tab >>Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging
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2018 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 05, no 6, p. 709-718Article in journal (Refereed) Published
Abstract [en]

Background

Lifelong postoperative surveillance is recommended following endovascular aneurysm repair (EVAR). Although the purpose is to prevent and/or identify complications early, it also results in increased cost and workload. This study was designed to examine whether it may be possible to identify patients at low risk of complications based on their first postoperative CT angiogram (CTA).

Methods

All patients undergoing EVAR in two Swedish centres between 2001 and 2012 were identified retrospectively and categorized based on the first postoperative CTA as at low risk (proximal and distal sealing zone at least 10 mm and no endoleak) or high risk (sealing zone less than 10 mm and/or presence of any endoleak) of complications.

Results

Some 326 patients (273 men) with a CTA performed less than 1 year after EVAR were included (low risk 212, 65·0 per cent; high risk 114, 35·0 per cent). There was no difference between the groups in terms of sex, age, co‐morbidities, abdominal aortic aneurysm (AAA) diameter, preoperative AAA neck anatomy, stent‐graft type or duration of follow‐up (mean(s.d.) 4·8(3·2) years). Five‐year freedom from AAA‐related adverse events was 97·1 and 47·7 per cent in the low‐ and high‐risk groups respectively (P < 0·001). The corresponding freedom from AAA‐related reintervention was 96·2 and 54·1 per cent (P < 0·001). The method had a sensitivity of 88·3 per cent, specificity of 77·0 per cent and negative predictive value of 96·6 per cent to detect AAA‐related adverse events. The number of surveillance imaging per AAA‐related adverse event was 168 versus 11 for the low‐risk versus high‐risk group.

Conclusion

Two‐thirds of patients undergoing EVAR have an adequate seal and no endoleak on the first postoperative CTA, and a very low risk of AAA‐related events up to 5 years. Less vigilant follow‐up after EVAR may be considered for these patients.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-334332 (URN)10.1002/bjs.10766 (DOI)000430058000014 ()
Available from: 2017-11-22 Created: 2017-11-22 Last updated: 2018-08-08Bibliographically approved
Mani, K. (2018). Outcomes and challenges in modern AAA repair: an introduction. Journal of Cardiovascular Surgery, 59(2), 178-179
Open this publication in new window or tab >>Outcomes and challenges in modern AAA repair: an introduction
2018 (English)In: Journal of Cardiovascular Surgery, ISSN 0021-9509, E-ISSN 1827-191X, Vol. 59, no 2, p. 178-179Article in journal, Editorial material (Other academic) Published
National Category
Cardiac and Cardiovascular Systems Surgery
Identifiers
urn:nbn:se:uu:diva-336090 (URN)10.23736/S0021-9509.17.10330-7 (DOI)000432308200006 ()29206003 (PubMedID)
Available from: 2017-12-12 Created: 2017-12-12 Last updated: 2018-08-31Bibliographically approved
Budtz-Lilly, J., Wanhainen, A. & Mani, K. (2018). Outcomes of endovascular aortic repair in the modern era.. Journal of Cardiovascular Surgery, 59(2), 180-189
Open this publication in new window or tab >>Outcomes of endovascular aortic repair in the modern era.
2018 (English)In: Journal of Cardiovascular Surgery, ISSN 0021-9509, E-ISSN 1827-191X, Vol. 59, no 2, p. 180-189Article, review/survey (Refereed) Published
Abstract [en]

Monitoring outcomes following endovascular aortic repair (EVAR) is critical. Although evidence from randomized controlled trials has solidified the role of EVAR, the analysis of outcomes and "real-world" data has uncovered limitations, improved the selection of appropriate patients, and underscored the importance of instructions for use. Subsequent studies demonstrated the learning curve of EVAR and gradual improvement of outcomes over time. Outcomes analyses will continue to play an important role, particularly as technological growth of endovascular therapy has enabled treatment of more complex aneurysm pathologies and patients. The important analyses are herein reviewed, following the development of EVAR in the treatment of intact abdominal aortic aneurysms (AAA) to ruptured AAAs, and finally to complex aneurysms, including thoracoabdominal aortic aneurysms and mycotic aneurysms. This includes an overview of the more recent results from analyses of branched and fenestrated EVAR, as well as the use of chimney grafts. It is emphasized that the success of endovascular repair has paradoxically been hampered by its rapid growth and early achievements. Even the most advanced engineering developments cannot overcome the long-term effects of the progression of aortic disease. The long-term benefits thus require careful planning and considerations of the natural history of aneurysms and the life expectancy of the patient. Large and international data registry collaborations should continue to play a role in providing outcomes analyses to guide future improvements.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-336059 (URN)10.23736/S0021-9509.17.10332-0 (DOI)000432308200007 ()29206004 (PubMedID)
Available from: 2017-12-12 Created: 2017-12-12 Last updated: 2018-08-31Bibliographically approved
Liungman, K., Mani, K., Wanhainen, A., Bosaeus, L. & Lachat, M. (2018). Safety and Functionality of a Guidewire Fixator: Clinical Investigation of a New Endovascular Tool. Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, 13(1), 51-53
Open this publication in new window or tab >>Safety and Functionality of a Guidewire Fixator: Clinical Investigation of a New Endovascular Tool
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2018 (English)In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 13, no 1, p. 51-53Article in journal (Refereed) Published
Abstract [en]

Objective: A new endovascular tool, the Liungman Guidewire Fixator, has been developed to simplify endovascular treatment in complex aortic aneurysms. The device has been extensively tested in bench models and animal trials. To verify the safety and functionality demonstrated in the porcine model, the device was tested in ten patients undergoing endovascular aortic repair (EVAR) or fenestrated endovascular aortic repair (f-EVAR) treatment for abdominal aortic aneurysm.

Methods: The Liungman Guidewire Fixator consists of a braided stent-like, cylindrical structure with conical ends and a central channel for a 0.035 '' guidewire. When in use, it is slid along the guidewire and positioned in the target artery, where the Liungman Guidewire Fixator interacts with the arterial wall by anchoring the guidewire to the wall through a radial force. The Liungman Guidewire Fixator allows for uninterrupted blood flow passed the point of fixation. In this study, the Liungman Guidewire Fixator was tested in ten patients undergoing EVAR or f-EVAR treatment for abdominal aortic aneurysm. The device was deployed and retrieved crossover into the hypogastric artery, and the occurrence of thrombotic occlusion, arterial dissection, and vascular rupture or trauma was studied using angiography, as well as device ability to withstand guidewire tension.

Results: There were no instances of occlusion, dissection, or vascular trauma detected using angiography. In all cases, deployment and retrieval were successful, and the devices could withstand an applied tension of 3 N. In one instance, retrieval was challenging because of significant tortuosity, which was resolved by a coaxial catheterization.

Conclusions: Deployment was uneventful in all ten patients. Retrieval according to the intended instruction for use was performed in nine of the patients. In one patient, a coaxial catheterization was necessary. All devices withstood a retention force of 3 N.

Place, publisher, year, edition, pages
LIPPINCOTT WILLIAMS & WILKINS, 2018
Keywords
Guidewire fixator, Guidewire tension, Aortic aneurysm, Stent graft, Fenestration
National Category
Surgery Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-351769 (URN)10.1097/IMI.0000000000000468 (DOI)000429101200009 ()29465630 (PubMedID)
Funder
VINNOVA, 2012-00374
Available from: 2018-05-31 Created: 2018-05-31 Last updated: 2018-05-31Bibliographically approved
Bergqvist, D., Mani, K., Troëng, T. & Wanhainen, A. (2018). Treatment of aortic aneurysms registered in Swedvasc: Development reflected in a national vascular registry with an almost 100% coverage. Gefässchirurgie, 23(5), 340-345
Open this publication in new window or tab >>Treatment of aortic aneurysms registered in Swedvasc: Development reflected in a national vascular registry with an almost 100% coverage
2018 (English)In: Gefässchirurgie, ISSN 0948-7034, E-ISSN 1434-3932, Vol. 23, no 5, p. 340-345Article in journal (Refereed) Published
Abstract [en]

Swedvasc is a registry for vascular surgical procedures, both open and endovascular. It was started in 1987 and since 1994 the whole population of Sweden is covered, at present around 10 million inhabitants. In a recent external validation, it was found to be highly accurate with abdominal aortic aneurysm surgery correctly reported in > 96%. In this paper various factors explaining the almost 100% coverage are discussed, one important being that the registry has been developed and maintained within the profession of vascular surgery and not dictated by authorities. Another factor of importance is the possibility to use data in various research projects and so far 15 PhD theses have used Swedvasc data. To exemplify the practical use of the registry, the treatment of abdominal aortic aneurysms is scrutinized and among the various complications abdominal compartment syndrome is analyzed. Several significant temporal changes have been observed over the almost 25 years of Swedvasc: increasing use of endovascular surgery, treatment of aneurysms detected by screening , decreasing treatment for rupture, improved outcome, increasing treatment of older patients and patients with comorbid conditions. In conclusion, a high quality national vascular registry can be valid with high compliance and can be used to study population-based development of treatment and outcome. It can also be used to perform international comparisons with other registries, thereby getting an indication of the quality of care.

Place, publisher, year, edition, pages
SPRINGER HEIDELBERG, 2018
Keywords
Vascular surgery, Vascular surgical procedures, Sweden/epidemiology, Population surveillance, Treatment outcome
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-362106 (URN)10.1007/s00772-018-0414-8 (DOI)000442589200009 ()30237668 (PubMedID)
Available from: 2018-10-01 Created: 2018-10-01 Last updated: 2018-10-01Bibliographically approved
Lilja, F., Wanhainen, A. & Mani, K. (2017). Changes in abdominal aortic aneurysm epidemiology. Journal of Cardiovascular Surgery, 58(6), 848-853
Open this publication in new window or tab >>Changes in abdominal aortic aneurysm epidemiology
2017 (English)In: Journal of Cardiovascular Surgery, ISSN 0021-9509, E-ISSN 1827-191X, Vol. 58, no 6, p. 848-853Article, review/survey (Refereed) Published
Abstract [en]

The epidemiology and treatment of abdominal aortic aneurysms (AAA) has changed over the past 30 years. This review aims to give the reader an overview of these changes and current trends in AAA epidemiology, management and outcome. In the past decades there have been three changes in AAA management and epidemiology: 1) introduction of endovascular aortic repair (EVAR); 2) population screening; and 3) a markedly reduced prevalence of the disease. These developments have resulted in an increased incidence of intact AAA-repair and reduced incidence of ruptured AAA-repair. Overall, survival after both intact and ruptured AAA repair has improved, much thanks to the broad introduction of EVAR. Additionally, both elective and rupture repair in the elderly population has increased, with octogenarians constituting >20% of intact AAA repairs performed in several countries. International analyses of vascular registries indicate that important variations remain in AAA management and results. The changes in AAA epidemiology and management have led to a situation where most AAAs today are treated with EVAR electively. The incidence of ruptured AAA-repair continues to decrease. These changes are accompanied by improvements in both short- and long-term survival.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-336060 (URN)10.23736/S0021-9509.17.10064-9 (DOI)000413016100006 ()28633519 (PubMedID)
Available from: 2017-12-12 Created: 2017-12-12 Last updated: 2018-03-29Bibliographically approved
Budtz-Lilly, J., Venermo, M., Debus, S., Behrendt, C.-A. -., Altreuther, M., Belles, B., . . . Mani, K. (2017). Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years. European Journal of Vascular and Endovascular Surgery, 54(1), 13-20
Open this publication in new window or tab >>Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years
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2017 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 1, p. 13-20Article in journal (Refereed) Published
Abstract [en]

Background: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. Methods: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results: A total of 83,253 patients were included. Over the two periods, the proportion of patients >= 80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. Conclusions: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AM treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.

Keywords
Abdominal aortic aneurysm, Outcomes, Clinical practice, Vascular registries
National Category
Cardiac and Cardiovascular Systems Surgery
Identifiers
urn:nbn:se:uu:diva-330016 (URN)10.1016/j.ejvs.2017.03.003 (DOI)000405051200006 ()28416191 (PubMedID)
Available from: 2017-10-11 Created: 2017-10-11 Last updated: 2017-10-11Bibliographically approved
Gavali, H., Mani, K., Tegler, G., Kawati, R., Covaciu, L. & Wanhainen, A. (2017). Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome. European Journal of Vascular and Endovascular Surgery, 54(2), 157-163
Open this publication in new window or tab >>Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome
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2017 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 2, p. 157-163Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of the study was to investigate the frequency and outcome of prolonged intensive care unit (ICU) length of stay (LOS) after abdominal aortic aneurysm (AAA) repair in the endovascular era.

Methods: All patients operated on for AAA between 1999 and 2013 at Uppsala University hospital were identified. Data were retrieved from the Swedish Vascular registry, the Swedish Intensive Care registry, the National Population registry, and case records. Prolonged ICU LOS was defined as >= 48 h during the primary hospital stay. Patients surviving >= 48 h after AAA surgery were included in the analysis.

Results: A total of 725 patients were identified, of whom 707 (97.5%) survived >= 48 h; 563 (79.6%) underwent intact AAA repair and 144 (20.4%) ruptured AAA repair. A total of 548 patients (77.5%) required < 48 h of intensive care, 115 (16.3%) 2-6 days and 44 (6.2%) >= 7 days. The rate of prolonged ICU LOS declined considerably over time, from 41.4% of all AAA repairs in 1999 to 7.3% in 2013 (p < .001) whereas the use of endovascular aortic repair (EVAR) increased from 6.9% in 1999 to 78.0% in 2013 (p < .001). The 30 day survival rate was 98.2% for those with < 48 h ICU stay versus 93.0% for 2-6 days versus 81.8% for >= 7 days (p < .001); the corresponding 90 day survival was 97.1% versus 86.1% versus 63.6% (p < .001) respectively. For patients surviving 90 days after repair, there was no difference in long-term survival between the groups.

Conclusion: During the period of progressively increasing use of EVAR, a simultaneous significant reduction in frequency of prolonged ICU LOS occurred. Although prolonged ICU LOS was associated with a high short-term mortality, long-term outcome among those surviving the initial 90 days was less affected.

Keywords
Abdominal aortic aneurysm, Critical care, Length of stay, Outcome, Time trends
National Category
Surgery Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-334093 (URN)10.1016/j.ejvs.2017.05.014 (DOI)000407536300005 ()28648757 (PubMedID)
Available from: 2017-11-21 Created: 2017-11-21 Last updated: 2017-11-21Bibliographically approved
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