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Time-trends and management of acute aortic occlusion: a 21-years´ experience
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.ORCID iD: 0000-0001-6561-9734
(English)In: Article in journal (Other academic) Submitted
Abstract [en]

Background: Acute aortic occlusion (AAO) is a rare and potentially catastrophic event. The aim was to study epidemiology and outcome of surgical treatment of AAO in a population-based cohort.

Method: The Swedish nationwide vascular database (Swedvasc) was used to identify cases, and the Population Registry to study long-term survival.

Results: During the 21-year study-period (1994-2014), 715 cases of AAO were included with a yearly incidence of 3.8 per million inhabitants. Mean age was 69.7 years, 50.5% were women and mean follow-up was 5.2 years. Most patients presented with bilateral acute limb ischemia. The aetiology for AAO was in-situ thrombosis in 64.1%, saddle embolus in 21.3% and occluded graft/stent/stentgrafts in 14.7%. The proportion of occluded grafts/stent/stentgrafts increased during the study period with a simultaneous reduction in the proportion of in-situ thrombosis.

The most commonly used methods for revascularization were thromboembolectomy (32.0%), thrombolysis (22.4%), axillary-bifemoral bypass (18.9%) and aorto-biiliacal/bifemoral bypass (18.2%). The choice of revascularization technique depended on the aetiology of the occlusion.

Amputation was preformed in 8.6%, and 19.9% of the patients died within 30-days after surgery. The 30-days mortality rate was lower after occluded grafts/stents/stentgrafts (9.5%) and higher after saddle embolus (30.9%, p<0.001). There was a reduction in overall 30-days mortality over time (25.0% 1994-2000 versus 15.3% 2008-2014, p=0.008). Long-term survival revealed significant differences between the subgroups, although the difference occurred early after the event (log-rank, p<0.001).

Conclusion: Mortality after AAO is improving over time, but remains high. The proportion of AAO secondary to occluded grafts/stents/stentgrafts increased over time.

National Category
Medical and Health Sciences
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-363356OAI: oai:DiVA.org:uu-363356DiVA, id: diva2:1256584
Available from: 2018-10-17 Created: 2018-10-17 Last updated: 2018-10-24Bibliographically approved
In thesis
1. Acute limb ischaemia: Treatment, outcome and time trends
Open this publication in new window or tab >>Acute limb ischaemia: Treatment, outcome and time trends
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Acute limb ischaemia (ALI) is a frequent emergency associated with high rates of amputation and death. Traditionally, patients with ALI were treated with open surgical removal of the occlusion or bypass surgery. During the past few decades, new endovascular techniques developed.  

No larger studies have investigated the optimal contemporary treatment for patients with ALI. Today, there are no international consensus for recommendations for the treatment of ALI, leaving it open to every surgeon or department to decide the best treatment option. 

This thesis aimed to study patients with ALI as a means to extend the understanding of this group of patients, as well as to investigate treatment options. Data sources included hospital charts or information was gathered from the Swedish nationwide Vascular Registry (Swedvasc), the Swedish Population Registry for deaths and the Swedish Patient Registry for amputations.

Paper I compared the results from thrombolysis with and without continuous heparin infusion in 749 thrombolytic procedures, concluding that both treatment strategies were equally successful in achieving revascularisation, with acceptable complication rates for both strategies. Continuous heparin infusion during intra-arterial thrombolysis offered no advantage. Although the regime with continuous heparin infusion was associated with a higher frequency of bleeding complications (p<0.001), this difference disappeared after adjustment for confounders.

Paper II studied long-term outcome after thrombolysis and showed that thrombolytic therapy achieves good medium- and long-term clinical outcome, which reduces the need for open surgical treatment in most patients. More than half of the patients in paper II did not require any surgical reintervention or amputation in their remaining lifetime or during a mean of 6.2 years of follow-up. Long-term outcome differed between the aetiological groups. This information is valuable when deciding on the optimal treatment strategy for patients with ALI.

Paper III compared outcomes after open and endovascular revascularisation for the treatment of ALI in 16,229 patients treated in 1994-2014. The large propensity score-matched nationwide cohort study revealed that endovascular treatment of ALI was associated with significantly better short-term survival and amputation-free survival compared with open revascularisation.

Paper IV investigated acute aortic occlusion (AAO) and subsequent ALI. This study showed that mortality after AAO is high but has improved in the past 20 years. The proportion of AAO secondary to occluded graft/stent/stentgrafts increases over time as a result of the endovascular shift in treating aortic diseases and the proportion of AAO secondary to native artery thrombosis decreases.

Taken together, the main findings of this thesis demonstrate a gradual improvement in survival and that endovascular techniques are becoming more frequently used as a first- line treatment of patients with ALI.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 98
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1511
Keywords
Acute limb ischaemi, Treatment, Open revascularisation, Endovascular revascularisation, Outcome
National Category
Medical and Health Sciences
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-363357 (URN)978-91-513-0492-2 (ISBN)
Public defence
2018-12-15, Auditorium minus, Museum Gustavianum, Akademigatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2018-11-22 Created: 2018-10-24 Last updated: 2018-11-30

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Wanhainen, AndersBjörck, Martin

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