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  • 1.
    Baderkhan, Hassan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Gonçalves, Frederico M. Bastos
    Erasmus Univ, Dept Vasc Surg, Med Ctr, Rotterdam, Netherlands; Hosp Santa Marta, Dept Angiol & Vasc Surg, Ctr Hosp Lisboa Cent, Lisbon, Portugal.
    Oliveira, Nelson Gomes
    Erasmus Univ, Dept Vasc Surg, Med Ctr, Rotterdam, Netherlands; Hosp Divino Espirito Santo Ponta Delgada, Dept Angiol & Vasc Surg, Azores, Portugal.
    Verhagen, Hence J. M.
    Erasmus Univ, Dept Vasc Surg, Med Ctr, Rotterdam, Netherlands.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm2016In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 23, no 6, p. 919-927Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To analyze the effects of aortic anatomy and endovascular aneurysm repair (EVAR) inside and outside the instructions for use (IFU) on outcomes in patients treated for ruptured abdominal aortic aneurysms (rAAA).

    METHODS: All 112 patients (mean age 73 years; 102 men) treated with standard EVAR for rAAA between 2000 and 2012 in 3 European centers were included in the retrospective analysis. Patients were grouped based on aortic anatomy and whether EVAR was performed inside or outside the IFU. Data on complications, secondary interventions, and mortality were extracted from the patient records. Cox regression analysis was performed to assess predictors of mortality and complications; results are presented as the hazard ratio (HR) with 95% confidence interval (CI). Survival was analyzed using the Kaplan-Meier method.

    RESULTS: Of the 112 patients examined, 61 (54%) were treated inside the IFU, 43 (38%) outside the IFU, and 8 patients lacked adequate preoperative computed tomography scans for determination. Median follow-up of those surviving 30 days was 2.5 years. Mortality at 30 days was 15% (95% CI 6% to 24%) inside the IFU vs 30% (95% CI 16% to 45%) outside (p=0.087). Three-year mortality estimates were 33.8% (95% CI 20.0% to 47.5%) inside the IFU vs 56% (95% CI 39.7% to 72.2%) outside (p=0.016). At 5 years, mortality was 48% (95% CI 30% to 66%) inside the IFU vs 74% (95% CI 54% to 93%) outside (p=0.015). Graft-related complications occurred in 6% (95% CI 0% to 13%) inside the IFU and 30% (95% CI 14% to 42%) outside (p=0.015). The rate of graft-related secondary interventions was 14% (95% CI 4% to 22%) inside the IFU vs 35% (95% CI 14% to 42%) outside (p=0.072). In the multivariate analysis, neck length <15 mm (HR 8.1, 95% CI 3.0 to 21.9, p<0.001) and angulation >60° (HR 3.1, 95% CI 1.0 to 9.3, p=0.045) were independent predictors of late graft-related complications. Aneurysm neck diameter >29 mm (HR 2.5, 95% CI 1.1 to 5.9, p=0.035) was an independent predictor of overall mortality.

    CONCLUSION: Long-term mortality and complications after rEVAR are associated with aneurysm anatomy. The role of adjunct endovascular techniques and the outcome of open repair in cases with challenging anatomy warrant further study.

  • 2. Baird, D L H
    et al.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Sabharwal, T
    Taylor, P R
    Zayed, H A
    Endovascular treatment of isolated iliac artery aneurysms using a custom-made stent graft with proximal barb fixation: early outcome2013In: Vascular, ISSN 1708-5381, Vol. 21, no 2, p. 92-96Article in journal (Refereed)
    Abstract [en]

    Current endovascular treatments for isolated iliac artery aneurysms (IIAAs) include the use of aortoiliac stent grafts with coverage of the distal aorta or stent grafts confined to the iliac artery without active proximal fixation. We report our experience in the use of custom-made Cook ZenithTM iliac limb stent grafts with proximal barb fixation. Patients treated from July 2009 to February 2011 were included. All imaging and patient records were assessed for perioperative and early outcomes. Nine IIAAs (seven patients) were treated. The mean patient age was 80 years (range 58–91 years). The mean aneurysm size was 48 mm (35–80 mm), and the mean length of the proximal landing zone (PLZ) was 29 mm (10–50 mm). The distal landing zone was in the external iliac artery after coil embolization of the internal iliac artery. The Mean diameter of the PLZ was 21 mm (20–24 mm). Technical success was achieved in eight cases. Perioperative complications included reoperation in one patient for groin bleeding and ischemia. On follow-up (mean 12 months, range 1–26), all aneurysms were successfully excluded from the circulation and there was no stent graft migration or thrombosis. Use of custom-made stent grafts with proximal barb fixation in treatment of IIAAs is a feasible option which may reduce the risk of migration when compared with stent grafts with lack of proximal fixation.

  • 3.
    Bergqvist, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Epidemiological aspects on abdominal aortic aneurysm (AAA)2010In: Pan Arab Angiology Journal, ISSN 2000-6535, Vol. 1, p. 1-Article in journal (Refereed)
    Abstract [en]

    In this overview, the present day knowledge on the epidemiology of abdominal aortic aneurysms (AAA) is summarized based on a review of the current literature. The prevalence of AAA and incidence of rupture is analyzed, and the natural history of the disease is illustrated both concerning the AAA as such and the survival of the patient. This knowledge is important when contemplating on screening for AAA, which is being implemented in several countries worldwide.

  • 4.
    Björck, Martin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Improving outcomes for ruptured abdominal aortic aneurysm2014In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 383, no 9921, p. 933-934Article in journal (Refereed)
  • 5.
    Bosaeus, Linus
    et al.
    Endovasc Dev Ltd, Vasagatan 5B, S-75313 Uppsala, Sweden.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Liungman, Krister
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Precannulated Fenestrated Endovascular Aneurysm Repair Using Guidewire Fixator: A Novel Method Using the Liungman Guidewire Fixator2017In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 12, no 4, p. 265-268Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: By using a guidewire fixator, the distal guidewire position can be secured in an artery. This new principle enables a method for fenestrated endovascular aortic repair where the connection between the aortic branches and the stent graft fenestrations is made before inserting and deploying the stent graft.

    METHODS: This is conducted using a fenestrated stent graft with preloaded catheters, through which the prepositioned and distally secured guidewires from the branches are inserted.

    RESULTS: This report covers the method when implementing a single fenestration stent graft in pig.

    CONCLUSIONS: Successful tests with single and dual fenestrated grafts have been conducted in pigs.

  • 6. Bosaeus, Linus
    et al.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Ljungman, Krister
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Novel device, a temporary guidewire fixator2016In: Vascular, ISSN 1708-5381, E-ISSN 1708-539X, Vol. 24, no 6, p. 604-609Article in journal (Refereed)
    Abstract [en]

    A novel device for distal fixation of a guidewire was tested in regards to deployment and retrieval, deposition in the blood stream and force of fixation in a pig model. Eleven pigs were subjected to full anaesthesia and heparinized to active clotting time 250-350 s. Uninterrupted blood flow during 4 h deposition was assessed by angiography and inspected for thrombus deposition upon retrieval. The force of fixation was investigated up to the level of loss of fixation (displacement force). The device was successfully deployed and retrieved in over 40 cases. In one case, an alternative method for bailout retrieval was used. Deposition for 4 h was performed, and uninterrupted blood flow was verified by angiography. No instances of arterial occlusion or thrombosis were detected. The median dislocation force was 7.6 N. No arterial rupture or dissection was detected following the loss of fixation. As a conclusion, the device was considered safe and functional in this animal test model.

  • 7.
    Budtz-Lilly, Jacob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Aarhus Univ Hosp, Dept Cardiothorac & Vasc Surg, Aarhus, Denmark..
    Venermo, M.
    Helsinki Univ Hosp, Dept Vasc Surg, Helsinki, Finland..
    Debus, S.
    Univ Heart Ctr Hamburg Eppendorf, Dept Vasc Med, Hamburg, Germany..
    Behrendt, C. -A
    Altreuther, M.
    St Olavs Hosp, Dept Vasc Surg, Trondheim, Norway..
    Belles, B.
    Australian & New Zealand Soc Vasc Surg, Melbourne, Vic, Australia..
    Szeberin, Z.
    Semmelweis Univ, Dept Vasc Surg, Budapest, Hungary..
    Eldrup, N.
    Aarhus Univ Hosp, Dept Cardiothorac & Vasc Surg, Aarhus, Denmark.;Natl Univ Hosp Iceland, Dept Surg, Reykjavik, Iceland..
    Danielsson, G.
    Thomson, I.
    Dunedin Publ Hosp, Dunedin Sch Med, Dept Vasc Surg, Dunedin, New Zealand..
    Wigger, P.
    Kantonsspital Winterthur, Dept Cardiovasc Surg, Winterthur, Switzerland..
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Loftus, I.
    St Georges Univ London, Dept Vasc Surg, London, England..
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 1, p. 13-20Article in journal (Refereed)
    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.

  • 8. Clough, R
    et al.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Taylor, P
    Thoratic aortic pathology is key to choice of treatment2012In: 34th Symposium Book: Vascular and Endovascular Controversies Update / [ed] Roger M Greenhalgh, London: BIBA Medical , 2012Chapter in book (Other academic)
  • 9. Clough, Rachel E
    et al.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lyons, Oliver T
    Bell, Rachel E
    Zayed, Hany A
    Waltham, Matthew
    Carrell, Tom W
    Taylor, Peter R
    Endovascular treatment of acute aortic syndrome2011In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 54, no 6, p. 1580-1587Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The term acute aortic syndrome (AAS) encompasses a range of conditions that have a risk of imminent aortic rupture and where delays in treatment result in increased mortality. Endovascular treatment offers an attractive alternative to open surgery but little is known about the durability of the repair and the factors that predict mortality.

    METHODS: Prospective data were collected for a cohort of 110 consecutive patients with endovascular treatment for AAS. Patient and procedural characteristics were related to short- and midterm outcome using multivariate logistic regression analysis.

    RESULTS: There were 75 men and 35 women with a median age of 68 (range 57-76) years. The pathologies treated were acute dissection (35), symptomatic aneurysm (32), infected aneurysm (18), transection (12), chronic dissection (9), penetrating ulcer (3), and intramural hematoma (1). Thirty-day mortality was 12.7% and this was associated with hypotension (odds ratio [OR], 5.25), use of general anesthetic (OR, 5.23), long procedure duration (OR, 2.03), and increasing age (OR, 1.07). The causes of death were aortic rupture (4), myocardial infarction (4), stroke (3), and multisystem organ failure (3). The stroke and paraplegia rates were 7.3% and 6.4%, respectively. The 1-year survival was 81% and the 5-year survival 63%. Secondary procedures were required in 13 (11.8%) patients. Factors associated with death at 1 year were presence of an aortic fistula (OR, 9.78), perioperative stroke (OR, 5.87), and use of general anesthetic (OR, 3.76); and at 5 years were aortic fistula (OR, 12.31) and increasing age (OR, 1.06).

    CONCLUSIONS: Acute aortic syndrome carries significant early and late mortality. Emergency endovascular repair offers a minimally invasive treatment option associated with acceptable short and midterm results. Continued surveillance is important as secondary procedures and aortic-related deaths continue to occur throughout the follow-up period.

  • 10.
    Dahlberg, Matz
    et al.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics. IBF.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Öhman, Mattias
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Health Information and Well-Being: Evidence from an Asymptomatic Disease2016Report (Other academic)
    Abstract [en]

    We examine how health information affects individuals' subjective well-being using a regression discontinuity design on data from a screening program for an asymptomatic disease, abdominal aortic aneurysm (AAA). The information provided to the individuals is guided by the measured aorta size and its relation to pre-determined levels. When comparing individuals that receive information that they are healthy with those that receive information that they are in the risk zone for AAA, we find no effects. However, when comparing those that receive information that they have a small AAA, and will be under increased surveillance, with those who receive information that they are in the risk zone, we find a weak positive effect on well-being. This indicates that the information about increased surveillance (positive) may outweigh the information about worse health (negative).

  • 11.
    Dellagrammaticas, Demos
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Baderkhan, Hassan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Management of Aortic Sac Enlargement Following Successful EVAR in a Frail Patient2016In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 51, no 2, p. 302-308Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: An enlarging aneurysm after endovascular aneurysm repair (EVAR) without clear endoleak is a clinical challenge. Management of this problem is guided by the current evidence for adequate EVAR follow up and recommended thresholds for re-intervention. In a frail patient, careful risk assessment of aneurysm related mortality against the risks associated with examinations and interventions is required.

    METHODS: The literature was reviewed for imaging modalities for EVAR follow up and their advantages and disadvantages. The current evidence and guideline recommendations regarding follow up and re-intervention after EVAR were assessed in relation to the presented case.

    RESULTS: To detect sac expansion after EVAR, repeated examinations with the same imaging modality are needed. Verified expansion must be above the inter-observer variation of the method used. Although duplex ultrasound is an excellent modality for EVAR follow up, the finding of a significant expansion on duplex requires further examination, primarily with computed tomography angiography to assess sealing, stent graft integrity, and presence of endoleak. A frail patient should be assessed thoroughly before any kind of surgical intervention, the extent of which is related to the identified or suspected cause of expansion.

    CONCLUSION: Failure to totally exclude the aneurysm from continuing circulation, pressure and endoleak remains a potential shortcoming of EVAR. Significant sac expansion is an indication of EVAR failure. Decisions regarding further examinations or intervention are guided by the stability of the initial EVAR performed, the cause and extent of expansion, and the patient's comorbidities.

  • 12.
    Fahlström, Markus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Nyman, Rickard
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Åberg, Karin
    Bjerner, Tomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Morell, Arvid
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Aortastentgraft ingen kontra­indikation för undersökning med MR: Men undersökningskvaliteten kan påverkas, visar litteraturstudie2014In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 111, no 27-28, p. 1184-1187Article in journal (Refereed)
    Abstract [en]

    Endovascular implantation of stent grafts is currently considered the preferred treatment for many aortic pathologies. In Sweden, approximately 900 patients are treated with an aortic stent graft. Stent grafts consists of a metal stent which is manufactured in stainless steel or nitinol covered by a prosthetic graft material. The possibility to perform successful magnetic resonance imaging (MRI) of a patient depends on the metal composition of and the localisation of the stent graft. This article presents the most common types of stent grafts and how they affect patients’ possibility to undergo an MRI examination successfully.

  • 13.
    Gavali, Hamid
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Tegler, Gustaf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Kawati, Rafael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Covaciu, Lucian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 2, p. 157-163Article in journal (Refereed)
    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.

  • 14. Goncalves, F. Bastos
    et al.
    Baderkhan, Hassan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Verhagen, H. J. M.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Stolker, R. J.
    Hoeks, S. E.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 7, p. 802-810Article in journal (Refereed)
    Abstract [en]

    Background: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods: Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results: Some 597 EVARs (71.1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47.6 per cent), moderate shrinkage (5-9mm) in 142 (23.8 per cent) and major shrinkage (at least 10mm) in 171 patients (28.6 per cent). Four years after the index imaging, the rate of freedom from complications was 84.3 (95 per cent confidence interval 78.7 to 89.8), 88.1 (80.6 to 95.5) and 94.4 (90.1 to 98.7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3.11; P < 0.001). Moderate compared with major shrinkage (HR 2.10; P = 0.022), early postoperative complications (HR 3.34; P < 0.001) and increasing abdominal aortic aneurysm baseline diameter (HR 1.02; P = 0.001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion: Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.

  • 15.
    Gunnarsson, Kim
    et al.
    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, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Djavani Gidlund, Khatereh
    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, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Endovascular Versus Open Repair as Primary Strategy for Ruptured Abdominal Aortic Aneurysm: A National Population-based Study2016In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 51, no 1, p. 22-28Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE/BACKGROUND: In randomized trials, no peri-operative survival benefit has been shown for endovascular (EVAR) repair of ruptured abdominal aortic aneurysm (rAAA) when compared with open repair. The aim of this study was to investigate the effect of primary repair strategy on early and midterm survival in a non-selected population based study.

    METHODS: The Swedish Vascular Registry was consulted to identify all rAAA repairs performed in Sweden in the period 2008-12. Centers with a primary EVAR strategy (treating > 50% of rAAA with EVAR) were compared with centers with a primary open repair strategy. Peri-operative outcome, midterm survival, and incidence of rAAA repair/100,000 inhabitants aged > 50 years were assessed.

    RESULTS: In total, 1,304 patients were identified. Three primary EVAR centers (pEVARc) operated on 236 patients (74.6% EVAR). Twenty-six primary open repair centers (pORc) operated 1,068 patients (15.6% EVAR). Patients treated at pEVARc were more often referrals (28.0% vs. 5.3%; p < .01), had a higher rate of respiratory comorbidity (36.5% vs. 21.9%; p < .01), and higher pre-operative systolic blood pressure (84.3 vs. 72.3 mmHg; p < .01). There was no difference in mortality based on primary treatment strategy at 30 days (pEVARc 28.0%, n = 66; pORc 27.4%, n = 296 [p = .87]), 1 year (pEVARc 39.9%, n = 93; pORc 34.7%, n = 366 [p = .19]), or 2 years (42.1%, n = 94; 38.3%, n = 394 [p = .28]), either overall or in subgroups based on age or referral status. Overall, patients treated with EVAR were older (mean age 76.4 vs. 74.0 years; p < .01), and had a lower 30 day mortality (EVAR 21.6%, n = 74; odds ratio 29.6%, n = 288 [p = < .01]). Incidence of rAAA repair was lower in pEVARc regions (6.07, 95% confidence interval [CI] 5.01-7.13) when compared with pORc regions (8.15, 95% CI 7.64-8.66).

    CONCLUSION: There was no difference in mortality after rAAA repair among centers with a primary EVAR approach when compared with a primary open repair strategy, either peri-operatively or in the midterm. The study supports the early findings of the randomized controlled trials in a national population based setting.

  • 16.
    Hellgren, Tina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Long-term Survival after TEVAR depends on Indication for Surgery: and is Shorter than Expected after Ruptured Thoracic Aneurysm2015In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, European Society for Vascular Surgery, Vol. 50, no 3, p. 395-Article in journal (Refereed)
  • 17.
    Hellgren, Tina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Sunderby Hospital, Luleå.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Steuer, Johnny
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Outcome of endovascular repair for intact and ruptured thoracic aortic aneurysms2017In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 66, no 1, p. 21-28Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The objective of this study was to assess long-term outcome after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA).

    METHODS: All patients who underwent TEVAR for TAA at Uppsala University Hospital from December 1999 to December 2014 were included. Characteristics of the patients and outcome data were collected from medical records, national population registry, and cause of death registry. Perioperative survival was analyzed with the χ(2) test, and 5-year survival was estimated with Kaplan-Meier analysis. Predictors of long-term survival were assessed with Cox regression.

    RESULTS: There were 77 patients included in the study, 49 with intact TAAs (iTAAs) and 28 with ruptured TAAs (rTAAs). Mean follow-up was 83.7 months for iTAA patients and 82.0 months for rTAA patients (P = .853). Mean age was 71.5 years for iTAA patients and 74.8 years for rTAA patients (P = .04). Survival after iTAA repair was 95.9% at 30 days, 91.8% at 90 days, and 62.5% at 5 years. After rTAA repair, survival was 71.4% at 30 days and decreased to 57.1% at 90 days (P < .01), with most deaths after 30 days being related to the aortic event. The 3-year survival rate after rTAA repair was 27.8%, and only one rTAA patient with 5 years of follow-up remained alive. Six aorta-related deaths occurred after 90 days (three iTAA patients, three rTAA patients); five were due to rupture of nontreated aortic segments. The 5-year reintervention rate was 13.2% for iTAA patients and 17.9% for rTAA patients (P = .682). All reinterventions occurred within 14 months of TEVAR. The age-adjusted hazard ratio for long-term mortality was 4.4 after rTAA repair compared with iTAA repair.

    CONCLUSIONS: TEVAR for iTAA was associated with low perioperative mortality and acceptable 5-year survival at 62.5%. Results were more pessimistic after rTAA repair, however, for which two-thirds of the patients were deceased at 3-year follow-up. Improved selection of patients is necessary to identify patients who are likely to truly benefit from rTAA repair.

  • 18.
    Karkamanis, Achilleas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Venermo, M
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Abdominal Aortic Aneurysm: Threshold for elective intervention2015In: Vascular and Endovascular Controversies Update / [ed] Greenhalgh R, London: BIBA Publishing , 2015, p. 185-192Chapter in book (Other academic)
  • 19.
    Karthikesalingam, A.
    et al.
    St Georges Univ London, St Georges Vasc Inst, Room 0-231, London SW17 0RE, England.;St Georges Univ Hosp NHS Fdn Bust, London, England..
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Holt, P. J.
    St Georges Univ London, St Georges Vasc Inst, Room 0-231, London SW17 0RE, England.;St Georges Univ Hosp NHS Fdn Bust, London, England..
    Vidal-Diez, A.
    St Georges Univ London, St Georges Vasc Inst, Room 0-231, London SW17 0RE, England.;St Georges Univ Hosp NHS Fdn Bust, London, England..
    Brownrigg, J. R. W.
    St Georges Univ London, St Georges Vasc Inst, Room 0-231, London SW17 0RE, England.;St Georges Univ Hosp NHS Fdn Bust, London, England..
    Shpitser, I.
    Univ Southampton, Dept Math Sci, Southampton, Hants, England..
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Thompson, M. M.
    St Georges Univ London, St Georges Vasc Inst, Room 0-231, London SW17 0RE, England.;St Georges Univ Hosp NHS Fdn Bust, London, England..
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Comparison of long-term mortality after ruptured abdominal aortic aneurysm in England and Sweden2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, no 3, p. 199-206Article in journal (Refereed)
    Abstract [en]

    Background: Concern has been raised regarding international discrepancies in perioperative mortality after repair of ruptured abdominal aortic aneurysm (rAAA). The variation in in-hospital mortality is difficult to interpret, owing to international differences in discharge strategies. This study compared 90-day and 5-year mortality in patients who had a rAAA in England and Sweden. Methods: Patients undergoing rAAA repair were identified from English Hospital Episode Statistics and the Swedish Vascular Registry (Swedvasc) between 2003 and 2012. Ninety-day and 5-year mortality were compared after matching for age and sex. Within-country analyses examined the impact of co-morbidity, teaching hospital status or hospital annual caseload, adjusted with causal inference techniques. Results: Some 12 467 patients underwent rAAA repair in England, of whom 83.2 per cent were men; the median (i.q.r.) age was 75 (70-80) years. A total of 2829 Swedish patients underwent rAAA repair, of whom 81.3 per cent were men; their median (i.q.r.) age was 75 (69-80) years. The 90-day mortality rate was worse in England (44.0 per cent versus 33.4 per cent in Sweden; P < 0.001), as was 5-year mortality (freedom from mortality 38.6 versus 46.3 per cent respectively; P < 0.001). In England, lower mortality was seen in teaching hospitals with larger bed capacity, higher annual caseloads and greater use of endovascular aneurysm repair (EVAR). In Sweden, lower mortality was associated with EVAR, high annual caseload, or surgery on weekdays compared with weekends. Conclusion: Short-and long-term mortality after rAAA repair was higher in England. In both countries, mortality was lowest in centres performing greater numbers of AAA repairs per annum, and more EVAR procedures.

  • 20. Laine, M
    et al.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Beiles, B
    Szeberin, Z
    Thomson, I
    Altreuther, M
    Debus, S
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Menyhei, G
    Venermo, M
    Few Internal Iliac artery Aneurysms Rupture under 4 cm2017In: Journal of Vascular Research, ISSN 1018-1172, E-ISSN 1423-0135, Vol. 65, no 1, p. 76-81Article in journal (Refereed)
    Abstract [en]

    Objective

    This study investigated the diameter of internal iliac artery (IIA) aneurysms (IIAAs) at the time of rupture to evaluate whether the current threshold diameter for elective repair of 3 cm is reasonable. The prevalence of concomitant aneurysms and results of surgical treatment were also investigated.

    Methods

    This was a retrospective analysis of patients with ruptured IIAA from seven countries. The patients were collected from vascular registries and patient records of 28 vascular centers. Computed tomography images taken at the time of rupture were analyzed, and maximal diameters of the ruptured IIA and other aortoiliac arteries were measured. Data on the type of surgical treatment, mortality at 30 days, and follow-up were collected.

    Results

    Sixty-three patients (55 men and 8 women) were identified, operated on from 2002 to 2015. The patients were a mean age of 76.6 years (standard deviation, 9.0; range 48-93 years). A concomitant common iliac artery aneurysm was present in 65.0%, 41.7% had a concomitant abdominal aortic aneurysm, and 36.7% had both. IIAA was isolated in 30.0%. The mean maximal diameter of the ruptured artery was 68.4 mm (standard deviation, 20.5 mm; median, 67.0 mm; range, 25-116 mm). One rupture occurred at <3 cm and four at <4 cm (6.3% of all ruptures). All patients were treated, 73.0% by open repair and 27.0% by endovascular repair. The 30-day mortality was 12.7%. Median follow-up was 18.3 months (interquartile range, 2.0-48.3 months). The 1-year Kaplan-Meier estimate for survival was 74.5% (standard error, 5.7%).

    Conclusions

    IIAA is an uncommon condition and mostly coexists with other aortoiliac aneurysms. Follow-up until a diameter of 4 cm seems justified, at least in elderly men, although lack of surveillance data precludes firm conclusions. The mortality was low compared with previously published figures and lower than mortality in patients with ruptured abdominal aortic aneurysm.

    Abdominal aortic aneurysm (AAA) is the most common and studied aneurysm. Aneurysms of the iliac arteries are found considerably less often, and epidemiologic data on these do not exist. In many cases iliac artery aneurysms coexist with aortic aneurysms: ∼10% to 20% of patients with AAA also have a concomitant aneurysm in the iliac arteries.1 The artery most often affected is the common iliac artery (CIA), followed by the internal iliac artery (IIA), also called the hypogastric artery. In the case of isolated aneurysms in the iliac arteries, without involvement of the aorta, the most common location is the IIA.2 Aneurysms of the external iliac artery are extremely rare, possibly because these arteries originate later in development from a different cell population than the distal aorta and the CIA and IIA. Studies on IIA aneurysms (IIAAs) are scarce owing to the rarity of the condition. The existing literature consists primarily of case reports and small patient series. No prospective studies on IAAs exist.

    According to the literature, IAAs have a high rupture and mortality rate even in elective cases, possibly because of their deep location in the pelvis.3 The etiology and risk factors of IAA seem to be the same as AAA.4 Iliac aneurysms are mostly degenerative but can also be mycotic or caused by genetic disorders such as Marfan or Ehlers-Danlos syndromes. Traumatic aneurysms in the iliac arteries have also been described; for example, caused by iatrogenic trauma from hip, lumbar, or gynecologic operations. A mainly historical subpopulation of young women with IIAA caused by trauma from pregnancy and delivery has been described.5 and 6

    IAAs cause symptoms more often than AAA because of compression of pelvic structures such as ureters, bladder, veins, or lumbar nerves. Wilhelm et al7 reported that 53% of published isolated IIAA cases were symptomatic, not including the ruptured ones (31%). The high proportion of symptomatic patients in these older reports may partly be explained, however, by the fact that most of these cases were from time before widespread use of modern imaging. IIAA are not easily discovered with clinical examination because of their location8 but are detected increasingly often as a result of imaging and screening programs.

    Because the studies on IIAAs are scarce, the natural history is virtually unknown. A widely used threshold for elective repair is 3 cm, originally suggested by McCready et al9 because their series did not include any ruptures under that diameter. However, only seven ruptures were included in that report. The reference list of this article illustrates that most of the papers on this subject were published when open repair was the only treatment option. Nowadays endovascular treatment is the first option in many centers.10

    The aim of this study was to investigate at what diameter IIAAs tend to rupture and whether the current operative threshold of 3 cm is rational. Secondary aims were to assess the prevalence of concomitant aortoiliac aneurysms, treatment patterns, and the results of treatment.

  • 21.
    Lilja, Fredrik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Editor's Choice – Trend-break in Abdominal Aortic Aneurysm Repair With Decreasing Surgical Workload2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 53, no 6, p. 811-819Article in journal (Refereed)
    Abstract [en]

    Background: The epidemiology and management of abdominal aortic aneurysms (AAAs) has changed drastically in the past decades, with implementation of nationwide screening programs, introduction of endovascular repair (EVAR), and reduced prevalence of the disease. This report aims to assess recent trends in AAA repair epidemiology in Sweden in this context.

    Methods: Primary AAA repairs registered in the nationwide Swedish Vascular Registry (Swedvasc) 1994-2014 were analyzed regarding patient characteristics, repair incidence, technique, and outcome. Four time periods were compared: 1994-1999, 2000-2004, 2005-2009, and 2010-2014.

    Result: The incidence of intact AAA repair increased (18.4/100,000 1994-1999, 27.3/100,000 2010-2014, p < .001) predominantly among octogenarians (12.7/100,000 1994-1999, 36.0/100,000 2010-2014, p < .001). The utilization of EVAR increased (58% of all intact AAA repairs 2010-2014), especially among octogenarians (80% 2010-2014). During the last time period, however, the incidence of intact AAA repair stabilized, despite an increasing number of screening-detected AAAs operated on (19% in 2010-2014). Short-and long-term outcome after intact AAA repair continued to improve, most pronounced among octogenarians (30-day mortality 9% 1994-1999, 2% 2010-2014, p < .001). The incidence of ruptured AAA repair steadily decreased (9.2/100,000 1994-1999, 6.9/100,000 2010-2014, p < .001) and the use of EVAR for ruptures increased (30% in 2010-2014). The previously observed improvement of short-and long-term outcome after ruptured AAA repair (30-day mortality 38% 1994-1999, 28% 2010-2014, p < .001) stalled during the last time period. The overall 30-day mortality after ruptured AAA repair was 22% after EVAR versus 31% after open repair in 2010-2014. The corresponding mortality for octogenarians was 28% versus 42%.

    Conclusions: For the first time, a halt in intact AAA repair workload could be identified. This trend-break occurred despite continued increase in treatment of octogenarians and screening-detected aneurysms. Additionally, the ruptured AAA repair incidence continued to decrease. These findings, together with the sustained improvement in survival after AAA repair, may have important impact on planning of vascular surgical services.

  • 22.
    Lilja, Fredrik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Changes in abdominal aortic aneurysm epidemiology2017In: Journal of Cardiovascular Surgery, ISSN 0021-9509, E-ISSN 1827-191X, Vol. 58, no 6, p. 848-853Article, review/survey (Refereed)
    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.

  • 23.
    Linder, Fredrik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Juhlin, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Eklöf, Hampus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Routine whole body CT of high energy trauma patients leads to excessive radiation exposure2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 24, no 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Whole body computed tomography (WBCT) is an important adjunct in trauma care, which is often part of standard protocol in initial management of trauma patients. However, WBCT exposes patients to a significant dose of radiation. The use of WBCT was assessed in a modern trauma cohort in Sweden.

    METHODS: A two-center retrospective cohort study was performed. All consecutive trauma alert patients at a university hospital (July-December 2008), and a rural county hospital (January 2009- December 2010) were included. Patients were stratified into three groups (high, intermediate and low risk) based on documented suspected injuries at primary survey at the site of accident or at the emergency department. Injury severity score (ISS) was calculated. Case records were reviewed for clinical and radiological findings at the time of trauma, and during a ≥36 months of follow-up period to identify possible missed injuries.

    RESULTS: A total of 523 patients were included in the study (university hospital n = 273; rural county hospital n = 250), out of which 475 patients (91.0 %) underwent radiological examinations, 290 patients (55.4 %) underwent WBCT, which identified trauma related findings in 125 patients (43.1 % of those examined). The high-risk group (n = 62) had a mean age of 38.5 years (21.1 SD). Mean ISS was 16.48 (18.14 SD). In this group, WBCT resulted in a positive finding in 38 (74.5 %) patients. In the intermediate-risk group (n = 322; mean age 37.66, 20.24 SD) ISS was 4.42 (6.30 SD). A positive finding on WBCT was found in 87 of the intermediate group patients (44.8 %). The low-risk group (n = 139; mean age 32.5 years; 21.4 SD) had a mean ISS of 0.84 (1.57 SD) with no positive findings on WBCT and no missed injuries in medical records at ≥36 months.

    DISCUSSION: The risk of developing radiation induced cancer is significant for young people if exposed to relatively high dose radiation as is the case in WBCT. WBCT in high-energy trauma is important for planning of treatment in severely injured patients while it can be questioned in the seemingly not injured where it is used mainly to permit early discharge from the ED.

    CONCLUSIONS: Risk stratification criteria could in this retrospective study identify high energy trauma patients not in need of radiological imaging. WBCT in high-energy trauma does not affect patient care if the patient is mentally alert, not intoxicated nor shows signs of other than minor injuries when evaluated by a trauma-team. The risk of missing important traumatic findings in these patients is very low. Observation of the patient with reexamination instead of imaging may be considered in this group of often young patients where radiation dose is an issue.

  • 24.
    Liungman, Krister
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Bosaeus, Linus
    Endovasc Dev Ltd, Vasagatan 5B, S-75313 Uppsala, Sweden..
    Lachat, Mario
    Univ Krankenhaus Zurich, Zurich, Switzerland..
    Safety and Functionality of a Guidewire Fixator: Clinical Investigation of a New Endovascular Tool2018In: 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)
    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.

  • 25.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Abdominal Aortic Aneurysm: Epidemiological and Health Economic Aspects2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Abdominal aortic aneurysm (AAA) is a common disease that is life threatening when rupture occurs. The aims of this thesis were to study (I) the long-term survival after AAA repair, (II) the cost of repair with open (OR) and endovascular (EVAR) technique, (III) the effect of different statistical methods on interpretation of cost data, (IV) the prevalence of the disease among patients with suspected arterial disease referred to the vascular laboratory, and (V) the cost-effectiveness of selective high-risk screening. Analyses of data from the Swedish vascular registry (Swedvasc), local patient registries, patient records and hospital cost registries form the basis of this thesis.

    Short- and long-term survival after intact AAA repair improved over the past two decades, despite increasing patient age and rate of comorbidities over time. Compared to a general population adjusted for age, sex and calendar year, the relative 5-year survival was 90% among those surviving repair. While short-term survival improved over time after ruptured repair, relative long-term survival was stable. Despite differences in patient selection and cost structure, the total cost of AAA repair with EVAR and OR was similar in a population based setting (€28,193). There was lack of consistency in the methods used in cost-analysis in the current literature, and p-values were highly dependent on test method.

    The practice of selective (non-population-based) screening for AAA among patients referred to the vascular laboratory was studied. The prevalence of AAA was 4.2% among male and 1.5% among female patients. AAA was associated with high age and prevalence of arterial stenosis. Of AAAs detected through selective screening, 21.5% had undergone elective repair at 7.5 years follow-up. In a health-economic evaluation, the incremental cost-effectiveness ratio of selective screening was €11,084 per life year gained.

    In conclusion, survival after intact AAA repair has improved over time, despite changes in case-mix. Results of health economic reports on cost of AAA repair can be highly dependent on patient selection as well as presentation of data and the statistical methods used. Selective screening for AAA among patients referred to the vascular laboratory is cost-effective.

    List of papers
    1. Improved long-term survival after abdominal aortic aneurysm repair
    Open this publication in new window or tab >>Improved long-term survival after abdominal aortic aneurysm repair
    2009 (English)In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 120, no 3, p. 201-11Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Treatment of abdominal aortic aneurysm (AAA) has changed significantly over the past 2 decades. In this perspective, time trends in long-term survival were studied. METHODS AND RESULTS: We identified 8663 primary intact and 4171 ruptured AAA repairs in the Swedish Vascular Registry from 1987 to 2005. Mortality was obtained from the national population registry. Crude survival was analyzed, including all mortality. To analyze the long-term outcome among those surviving the AAA repair, relative survival, which denotes the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, was calculated, excluding 90-day mortality. In a comparison of AAA repairs from 1987 to 1999 and 2000 to 2005, age (71.4 versus 72.5 years; P<0.001), patients with comorbidities (65.0% versus 68.5%; P<0.001), and endovascular repair (1.6% versus 17.0%; P<0.001) increased. After intact AAA repair, crude 5-year survival was 69.0% (99% confidence interval [CI], 67.7 to 70.4), and relative 5-year survival excluding 90-day mortality was 90.3% (99% CI, 88.6 to 92.0). Relative 5-year survival was better for those operated on from 2000 to 2005 compared with 1987 to 1999 (difference, 4.7%; 99% CI, 1.3 to 8.1), for men versus women (4.6%; 99% CI, 0.4 to 8.8), and for octogenarians versus patients <80 years of age (10.2%; 99% CI, 1.5 to 18.8); no difference was observed between open and endovascular repair (6.0%; 99% CI, -1.5 to 13.4). After ruptured AAA repair, crude 5-year survival was 41.7% (99% CI, 39.6 to 43.7) and relative 5-year survival was 87.1% (99% CI, 83.9 to 90.3). No significant differences in relative 5-year survival were observed between time periods, sex, or age groups. CONCLUSIONS: Long-term survival improved over time after intact AAA repair despite a change in case mix toward older patients with more comorbidities. Long-term survival was stable after ruptured AAA repair.

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    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-108642 (URN)10.1161/CIRCULATIONAHA.108.832774 (DOI)000268110900005 ()19581497 (PubMedID)
    Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2017-12-13Bibliographically approved
    2. Similar cost for elective open and endovascular AAA repair in a population-based setting
    Open this publication in new window or tab >>Similar cost for elective open and endovascular AAA repair in a population-based setting
    2008 (English)In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 15, no 1, p. 1-11Article in journal (Refereed) Published
    Abstract [en]

    PURPOSE: To compare cost differences between elective open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm in a population-based setting. METHODS: Clinical data and hospital-related costs (pre-, peri-, and postoperative) were analyzed for 109 consecutive AAA procedures (98 men; mean age 73 years, range 48-95; mean aneurysm diameter 61 mm, range 42-120) performed from 2001 to 2005 (58 OR, 51 EVAR) in our primary catchment area. Data were obtained through case records and hospital accounting systems. Nonparametric bootstrap was used for cost comparison. RESULTS: EVAR patients were older (76 versus 70 years, p<0.001) and had more comorbidities (ASA class 2.6 versus 2.3, p = 0.025). OR patients more often had anatomically complex aneurysms (52% versus 14%, p<0.001). Comparison of data with diagnosis-based reimbursement levels nationally and internationally indicated adequate cost level in the study. No difference was observed in total cost between OR and EVAR (euro29,786 versus euro26,382; p = 0.336). Preoperative cost was lower for OR compared to EVAR (euro661 versus euro1494, p = 0.002). OR patients had higher cost of intensive care [36% (euro8921) of perioperative cost versus 7% (euro1460), p = 0.001], while EVAR had higher implant cost [36% (euro7468) versus 2% (euro448), p<0.001]. Mean follow-up was 2.5 years (range 0.5-5.4). Mean postoperative cost was similar (OR euro4613 versus EVAR euro4403, p = 0.209; 16% and 17% of total cost, respectively). Postoperative cost after OR was high early on, with lower cost thereafter. Postoperative cost after EVAR was more homogeneously distributed, leveling off at euro500 to euro1000 annually over 5 years. CONCLUSION: In a population-based setting, total cost was similar for OR and EVAR. There were, however, important differences in patient characteristics and cost structure.

    Keywords
    abdominal aortic aneurysm, surgery, endovascular aneurysm repair, hospital costs, cost-benefit analysis
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-108646 (URN)10.1583/07-2258.1 (DOI)000253060300001 ()18254676 (PubMedID)
    Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2017-12-13Bibliographically approved
    3. Challenges in analysis and interpretation of cost data in vascular surgery
    Open this publication in new window or tab >>Challenges in analysis and interpretation of cost data in vascular surgery
    2010 (English)In: Journal of vascular surgery, ISSN 0741-5214, Vol. 51, no 1, p. 148-154Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE: Health economic arguments have become increasingly important in clinical decision making, especially when new treatment modalities are introduced. This study reviews the methods used in health economic reports of abdominal aortic aneurysm (AAA) repair and uses original cost data to study how different methods affect interpretation of results in terms of cost differences and economic efficiency. DESIGN: Publications referenced in PubMed from 2003 to 2008 studying cost of AAA repair were reviewed. Original population-based cost data of AAA repair were analyzed, comparing open (OR) and endovascular repair (EVAR). Means, medians, and cost distributions were calculated, and differences were analyzed with four different statistical methods. RESULTS: The review showed a mixture of statistical methods used in AAA treatment cost-comparison studies. Presentation of cost data and inclusion criteria varied between studies. The analysis of original data showed skewed distribution of cost data, with large differences between mean and median cost. Although mean values indicated a lower total, perioperative, and postoperative cost for EVAR, the median values indicated OR was the least costly method. Exclusion of extreme values lowered mean perioperative cost of OR by 10%, while cost of EVAR was unaffected. Inferential testing of cost differences by means of four statistical methods showed that P values were highly dependent on test methodology. CONCLUSIONS: Conclusions of health economic reports can be highly dependent on how the data are presented and the statistical methods that are used. We recommend that cost data be presented as mean values with distributions. Exclusion of outliers and focus on P values should be avoided.

    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-110809 (URN)10.1016/j.jvs.2009.08.042 (DOI)000273708500027 ()19889511 (PubMedID)
    Available from: 2009-11-25 Created: 2009-11-25 Last updated: 2011-12-19Bibliographically approved
    4. Selective screening for abdominal aortic aneurysm among patients referred to the vascular laboratory
    Open this publication in new window or tab >>Selective screening for abdominal aortic aneurysm among patients referred to the vascular laboratory
    2008 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 35, no 6, p. 669-74Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Patients examined for peripheral arterial disease at the vascular laboratory, Uppsala University Hospital, are since 1993 screened for abdominal aortic aneurysm (AAA). The objective of this study was to study the prevalence of AAA found at this selective high-risk screening. METHODS: All files in the vascular laboratory were retrospectively reviewed. Of 9296 persons examined with arterial duplex between 1993 and October 2005, 5924 were screened for AAA. The primary target vessel was the carotid arteries in 3772 subjects, the renal arteries in 1529 subjects and the lower extremity arteries in 1457 subjects. An AAA was defined as an infrarenal aortic diameter >/=30mm. RESULTS: 179 subjects were found to have an AAA. In a logistic regression model male gender, age and duplex-verified arterial stenosis were independently associated with AAA (odds ratio 3.2, 2.0/20 years and 2.0, respectively, p<0.001). In men <60 years the AAA prevalence was 0.9% (95% confidence interval 0.2-1.6%) when arterial stenosis was absent and 1.5% (0.0-3.2%) when present. In men >/=60 years the AAA prevalence was 4.0% (3.0-5.1%) when no arterial stenosis was found and 7.3% (5.7-8.9%) when found. The corresponding prevalences in women were 0%, 0%, 1.2% (0.5-1.8%), and 3.1% (1.9-4.3%), respectively. CONCLUSIONS: Men >/=60 years referred for arterial examination have a significant risk of having an AAA while only women >/=65 years with a duplex verified arterial stenosis have a sufficient risk of having an AAA. Studies to evaluate the benefit of selective high-risk screening are warranted.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-108645 (URN)10.1016/j.ejvs.2007.12.014 (DOI)000257044700006 ()18258461 (PubMedID)
    Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2017-12-13Bibliographically approved
    5. Screening for Abdominal Aortic Aneurysm among Patients Referred to the Vascular Laboratory is Cost-effective
    Open this publication in new window or tab >>Screening for Abdominal Aortic Aneurysm among Patients Referred to the Vascular Laboratory is Cost-effective
    Show others...
    2010 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 39, no 2, p. 208-216Article in journal (Refereed) Published
    Abstract [en]

    Screening for abdominal aortic aneurysm (AAA) in high-risk groups has been recommended based on a high prevalence of disease, while being questioned due to a high frequency of co-morbidities and inferior life-expectancy. We evaluated the long-term outcome and the cost-effectiveness of selective AAA screening among patients referred to the vascular laboratory for arterial examination. METHODS: A total of 5924 patients, referred to the vascular laboratory of a university hospital, were screened for AAA with ultrasound (definition: slashed circle>/=30mm), 1993-2005. Outcome data were gathered through hospital records and the national population registry. A Markov model was used for health-economic evaluation. RESULTS: An AAA was detected in 181 patients (mean age 72.8 years), of whom 21.5% underwent elective repair (perioperative mortality 5.1%) after 7.5 years of follow-up. Four of six patients diagnosed with AAA rupture were operated upon. Relative 5-year survival compared with the general Swedish population, controlled for age and sex, was 80.4% (95% confidence interval (CI): 70.8-88.8). The cost-effectiveness was robust in base-case (11 084 Euro/life year gained) and in sensitivity analyses of prevalence, cost and survival. CONCLUSIONS: Patients in whom AAA was detected at selective screening had inferior long-term survival and were operated on less frequently, compared with AAA patients described in previous studies. Yet, selective screening at the vascular laboratory was cost-effective.

    Keywords
    Abdominal aortic aneurysms, Screening, Cost-benefit analysis
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-108639 (URN)10.1016/j.ejvs.2009.11.004 (DOI)000275985900014 ()19942460 (PubMedID)
    Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2017-12-13Bibliographically approved
  • 26.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Aortic Remodeling After TEVAR for Type B Dissection: Time for Consensus Definition2014In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 21, no 4, p. 526-528Article in journal (Refereed)
  • 27.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Endovascular Aneurysm Repair - To Avoid Rupture or to Improve Quality of Life?2011In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 41, no 3, p. 332-333Article in journal (Other academic)
  • 28.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Open repair for chronic type B dissection2015In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 50, no 6, p. 744-744Article in journal (Refereed)
  • 29.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    The Importance of Re-interventions After Ruptured EVAR2015In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 49, no 6, p. 669-669Article in journal (Refereed)
  • 30.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lundkvist, Jonas
    Medical management centre, Karolinska institutet.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Improved long-term survival after abdominal aortic aneurysm repair2009In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 120, no 3, p. 201-11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Treatment of abdominal aortic aneurysm (AAA) has changed significantly over the past 2 decades. In this perspective, time trends in long-term survival were studied. METHODS AND RESULTS: We identified 8663 primary intact and 4171 ruptured AAA repairs in the Swedish Vascular Registry from 1987 to 2005. Mortality was obtained from the national population registry. Crude survival was analyzed, including all mortality. To analyze the long-term outcome among those surviving the AAA repair, relative survival, which denotes the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, was calculated, excluding 90-day mortality. In a comparison of AAA repairs from 1987 to 1999 and 2000 to 2005, age (71.4 versus 72.5 years; P<0.001), patients with comorbidities (65.0% versus 68.5%; P<0.001), and endovascular repair (1.6% versus 17.0%; P<0.001) increased. After intact AAA repair, crude 5-year survival was 69.0% (99% confidence interval [CI], 67.7 to 70.4), and relative 5-year survival excluding 90-day mortality was 90.3% (99% CI, 88.6 to 92.0). Relative 5-year survival was better for those operated on from 2000 to 2005 compared with 1987 to 1999 (difference, 4.7%; 99% CI, 1.3 to 8.1), for men versus women (4.6%; 99% CI, 0.4 to 8.8), and for octogenarians versus patients <80 years of age (10.2%; 99% CI, 1.5 to 18.8); no difference was observed between open and endovascular repair (6.0%; 99% CI, -1.5 to 13.4). After ruptured AAA repair, crude 5-year survival was 41.7% (99% CI, 39.6 to 43.7) and relative 5-year survival was 87.1% (99% CI, 83.9 to 90.3). No significant differences in relative 5-year survival were observed between time periods, sex, or age groups. CONCLUSIONS: Long-term survival improved over time after intact AAA repair despite a change in case mix toward older patients with more comorbidities. Long-term survival was stable after ruptured AAA repair.

  • 31.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lundkvist, Jonas
    Medical management centre, Karolinska institutet.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Similar cost for elective open and endovascular AAA repair in a population-based setting2008In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 15, no 1, p. 1-11Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To compare cost differences between elective open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm in a population-based setting. METHODS: Clinical data and hospital-related costs (pre-, peri-, and postoperative) were analyzed for 109 consecutive AAA procedures (98 men; mean age 73 years, range 48-95; mean aneurysm diameter 61 mm, range 42-120) performed from 2001 to 2005 (58 OR, 51 EVAR) in our primary catchment area. Data were obtained through case records and hospital accounting systems. Nonparametric bootstrap was used for cost comparison. RESULTS: EVAR patients were older (76 versus 70 years, p<0.001) and had more comorbidities (ASA class 2.6 versus 2.3, p = 0.025). OR patients more often had anatomically complex aneurysms (52% versus 14%, p<0.001). Comparison of data with diagnosis-based reimbursement levels nationally and internationally indicated adequate cost level in the study. No difference was observed in total cost between OR and EVAR (euro29,786 versus euro26,382; p = 0.336). Preoperative cost was lower for OR compared to EVAR (euro661 versus euro1494, p = 0.002). OR patients had higher cost of intensive care [36% (euro8921) of perioperative cost versus 7% (euro1460), p = 0.001], while EVAR had higher implant cost [36% (euro7468) versus 2% (euro448), p<0.001]. Mean follow-up was 2.5 years (range 0.5-5.4). Mean postoperative cost was similar (OR euro4613 versus EVAR euro4403, p = 0.209; 16% and 17% of total cost, respectively). Postoperative cost after OR was high early on, with lower cost thereafter. Postoperative cost after EVAR was more homogeneously distributed, leveling off at euro500 to euro1000 annually over 5 years. CONCLUSION: In a population-based setting, total cost was similar for OR and EVAR. There were, however, important differences in patient characteristics and cost structure.

  • 32.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Changes in the management of infrarenal abdominal aortic aneurysm disease in Sweden2013In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 100, no 5, p. 638-644Article in journal (Refereed)
    Abstract [en]

    Background Treatment of abdominal aortic aneurysm (AAA) has changed over time, with endovascular repair (EVAR) being the main technical revolution. This study assessed the effect of this change on outcome on a national basis over a 17-year interval. Methods Primary infrarenal AAA repairs in Swedish residents aged 50 years and older, in the Swedish Vascular Registry (Swedvasc) 19942010, were analysed. The rate per 100 000 population, patient characteristics, operative technique and outcome were assessed for the intervals 19941999, 20002005 and 20062010. Results Some 11 336 intact aneurysm repairs were performed. The overall rate per 100 000 increased (18 center dot 4 in 19941999, 19 center dot 4 in 20002005 and 24 center dot 0 in 20062010; P < 0 center dot 001), most noticeably among older people (18 per cent increase among those aged 5064 years, P = 0 center dot 004; 27 per cent in 6579-year-olds, P < 0 center dot 001; 128 per cent in those aged at least 80 years, P < 0 center dot 001). The use of EVAR increased rapidly after 2005 (rate: 0 center dot 6 in 19941999, 4 center dot 4 in 20002005 and 11 center dot 8 in 20062010; P < 0 center dot 001). The 30-day mortality rate decreased after open repair (4 center dot 7, 3 center dot 4 and 2 center dot 7 per cent respectively; P < 0 center dot 001), but was stable after EVAR (2 center dot 6, 2 center dot 2 and 1 center dot 6 per cent; P = 0 center dot 227). Some 4972 ruptured aneurysm (rAAA) repairs were performed. The rate decreased after 2005 (9 center dot 3 in 19931999, 9 center dot 3 in 20002005 and 8 center dot 4 in 20062010; P = 0 center dot 006). The use of EVAR for rAAA increased over time (rate: 0, 0 center dot 5 and 1 center dot 6 respectively; P < 0 center dot 001), whereas open repair decreased (9 center dot 3, 8 center dot 8 and 6 center dot 8; P < 0 center dot 001). Thirty-day mortality decreased over time (38 center dot 3, 32 center dot 8 and 28 center dot 4 per cent; P < 0 center dot 001). Conclusion The introduction of EVAR has been associated with an increased number of intact AAA repairs, which has accelerated recently, whereas the rate of rAAA repair has started to decline. Simultaneously, outcomes have improved.

  • 33.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Campbell, A
    Fitzpatrick, J
    Modarai, B
    Carrell, T
    Rashid, H
    Zayed, H
    A Novel Reverse Thermosensitive Polymer to Achieve Temporary Atraumatic Vessel Occlusion in Infra-popliteal Bypasses2013In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 1, p. 51-56Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The study aims to assess a novel thermosensitive polymer (LeGoo(®)) for distal vessel control during infra-popliteal (crural/pedal) bypass surgery in severe leg ischaemia. METHOD: Retrospective analysis of all distal bypasses from October 2009 to February 2012. Technical success, patency, limb salvage and amputation-free survival rates were analysed. RESULTS: Fifty-four infra-popliteal bypasses using the polymer were performed in 46 patients. The distal anastomosis was at the anterior tibial (n = 15, 28%), posterior tibial (n = 12, 22%), peroneal (n = 8, 15%), tibio-peroneal trunk (n = 8, 15%) and dorsalis pedis arteries (n = 11, 20%). Technical success was achieved in 51/54 (94.4%; failures: two inadequate haemostasis, one un-dissolved polymer). In-hospital duplex of the distal anastomosis showed a significant stenosis in two cases (4.3%). Outflow angioplasty was performed in three cases (two distal anastomotic, one run-off vessel, 5.6%). The 1-year patency rate was 76.2% (standard error (SE) 6.7%), limb salvage rate 79.3% (SE 6.7%). Amputation-free survival was 93.5% at 30 days (SE 3.6%) and 67.5% at 1 year (SE 7.5%). CONCLUSION: This thermosensitive polymer is a potentially safe and useful atraumatic device to achieve a blood-less distal anastomotic field in infra-popliteal bypasses. The technique avoids other potentially traumatic methods of vessel control, which may be particularly important in patients with calcified distal vessels.

  • 34.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Clough, R. E.
    Lyons, O. T. A.
    Bell, R. E.
    Carrell, T. W.
    Zayed, H. A.
    Waltham, M.
    Taylor, P. R.
    Predictors of Outcome after Endovascular Repair for Chronic Type B Dissection2012In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 43, no 4, p. 386-391Article in journal (Refereed)
    Abstract [en]

    Objectives: To assess the durability of endovascular repair (TEVAR) in chronic type B dissection (CD) and identify factors predictive of outcome. Design: Retrospective analysis of a prospective database.

    Materials: Patients undergoing TEVAR for CD at a tertiary referral centre 2000-2010.

    Methods: Analysis of pre-operative characteristics, operative outcome, false lumen thrombosis, aortic diameter and survival.

    Results: 58 consecutive patients were included (49 elective, 9 urgent, mean age 66 years). Mean aortic diameter was 6.4 cm (Standard deviation SD 1.3 cm). Three patients died perioperatively (5%, 1 urgent, 2 elective). Complications included retrograde type A dissection (n = 3), paraplegia (1), and transient ischaemic attack (1). Estimated survival (Kaplan-Meier) was 89% (1-year) and 64% (3-years). Forty-seven patients had mid-term imaging follow-up at mean 38 months. Reintervention rate was 15% at 1-year and 29% at 3-years. Aortic diameter decreased in 24, was stable in 15 and increased in 8. Mid-term survival was higher in patients with aortic remodelling (reduction of aortic diameter >0.5 cm; 3-year 89%) than without (54%; Log Rank p = 0.005). Remodelling occurred with extensive false lumen thrombosis.

    Conclusion: Satisfactory mid-term outcome after TEVAR for CD remains a challenge. Survival is associated with aortic remodelling, which is related to persistence of flow in the false lumen.

  • 35.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Clough, R
    Taylor, P
    Coeliac axis compression and nutcracker syndrome2012In: 34th Symposium Book: Vascular and Endovascular Controversies Update / [ed] Roger M Greenhalgh, London: BIBA Publishing , 2012Chapter in book (Other academic)
  • 36.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Clough, Rachel E.
    Taylor, Peter R.
    Regarding "Patient outcomes and thoracic aortic volume and morphologic changes following thoracic endovascular aortic repair in patients with complicated chronic type B aortic dissection"2013In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 57, no 3, p. 899-899Article in journal (Refereed)
  • 37.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lees, T
    Beiles, B
    Jensen, L P
    Venermo, M
    Simo, G
    Palombo, D
    Halbakken, E
    Troëng, Thomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wigger, P
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Treatment of abdominal aortic aneurysm in nine countries 2005-2009: a vascunet report2011In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 42, no 5, p. 598-607Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To study contemporary treatment and outcome of abdominal aortic aneurysm (AAA) repair in nine countries.

    DESIGN AND METHODS: Data on primary AAA repairs 2005-2009 were amalgamated from national and regional vascular registries in Australia, Denmark, Finland, Hungary, Italy, Norway, Sweden, Switzerland and the UK. Primary outcome was in-hospital or 30-day mortality. Multivariate logistic regression was used to assess case-mix.

    RESULTS: 31,427 intact AAA repairs were identified, mean age 72.6 years (95% CI 72.5-72.7). The rate of octogenarians and use of endovascular repair (EVAR) increased over time (p < 0.001). EVAR varied between countries from 14.7% (Finland) to 56.0% (Australia). Overall perioperative mortality after intact AAA repair was 2.8% (2.6-3.0) and was stable over time. The perioperative mortality rate varied from 1.6% (1.3-1.8) in Italy to 4.1% (2.4-7.0) in Finland. Increasing age, open repair and presence of comorbidities were associated with outcome. 7040 ruptured AAA repairs were identified, mean age 73.8 (73.6-74.0). The overall perioperative mortality was 31.6% (30.6-32.8), and decreased over time (p = 0.004).

    CONCLUSIONS: The rate of AAA repair in octogenarians as well as EVAR increased over time. Perioperative outcome after intact AAA repair was stable over time, but improved after ruptured repair. Geographical differences in treatment of AAA remain.

  • 38.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lundkvist, Jonas
    Medical Management Centre, Karolinska Institutet.
    Holmberg, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Challenges in analysis and interpretation of cost data in vascular surgery2010In: Journal of vascular surgery, ISSN 0741-5214, Vol. 51, no 1, p. 148-154Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Health economic arguments have become increasingly important in clinical decision making, especially when new treatment modalities are introduced. This study reviews the methods used in health economic reports of abdominal aortic aneurysm (AAA) repair and uses original cost data to study how different methods affect interpretation of results in terms of cost differences and economic efficiency. DESIGN: Publications referenced in PubMed from 2003 to 2008 studying cost of AAA repair were reviewed. Original population-based cost data of AAA repair were analyzed, comparing open (OR) and endovascular repair (EVAR). Means, medians, and cost distributions were calculated, and differences were analyzed with four different statistical methods. RESULTS: The review showed a mixture of statistical methods used in AAA treatment cost-comparison studies. Presentation of cost data and inclusion criteria varied between studies. The analysis of original data showed skewed distribution of cost data, with large differences between mean and median cost. Although mean values indicated a lower total, perioperative, and postoperative cost for EVAR, the median values indicated OR was the least costly method. Exclusion of extreme values lowered mean perioperative cost of OR by 10%, while cost of EVAR was unaffected. Inferential testing of cost differences by means of four statistical methods showed that P values were highly dependent on test methodology. CONCLUSIONS: Conclusions of health economic reports can be highly dependent on how the data are presented and the statistical methods that are used. We recommend that cost data be presented as mean values with distributions. Exclusion of outliers and focus on P values should be avoided.

  • 39.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Rantatalo, Matti
    Bjurholm, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Thelin, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Eriksson, Lars-Gunnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Aortic rupture after spinal correction for scoliosis in the presence of a thoracic stent graft2010In: Journal of Vascular Surgery, ISSN 0741-5214, Vol. 52, no 6, p. 1663-1657Article in journal (Refereed)
    Abstract [en]

    Corrective surgery for scoliosis often results in a lengthening of the spinal column and relative change of the position of the adjacent anatomical structures such as the aorta. The extent of these anatomical changes could be affected by the presence of a rigid aortic stent graft in the descending thoracic aorta. We present a case of aortic rupture after spinal correction for scoliosis in a 56-year-old female with a thoracic aortic stent graft. Extensive elongation of the aorta with concentration of the stress forces at the lower margin of the stent graft resulted in a weakening of the aortic wall and subsequent rupture.

  • 40.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Venermo, M.
    Beiles, B.
    Menyhei, G.
    Altreuther, M.
    Loftus, I.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Regional Differences in Case Mix and Peri-operative Outcome After Elective Abdominal Aortic Aneurysm Repair in the Vascunet Database2015In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 49, no 6, p. 646-652Article in journal (Refereed)
    Abstract [en]

    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 pen-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 pen-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 pen-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 pen-operative mortality. Further audit is warranted to assess the underlying reasons for the regional variation in case-mix.

  • 41.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Accurate and Reproducible Diameter Measurement is Essential in Surveillance and Treatment of Thoracic Aortic Aneurysms2014In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 47, no 1, p. 27-27Article in journal (Refereed)
  • 42.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Elective AAA repair in octo- and nonagenarians2015In: Vascular and Endovascular Controversies Update / [ed] Greenhalgh R, London: BIBA Publishing , 2015, p. 261-268Chapter in book (Other academic)
  • 43.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lundkvist, Jonas
    Lindstrom, David
    Cost-effectiveness of intensive smoking cessation therapy among patients with small abdominal aortic aneurysms2011In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 54, no 3, p. 628-636Article in journal (Refereed)
    Abstract [en]

    Introduction: Smoking cessation is one of the few available strategies to decrease the risk for expansion and rupture of small abdominal aortic aneurysms (AAAs). The cost-effectiveness of an intensive smoking cessation therapy in patients with small AAAs identified at screening was evaluated. Methods: A Markov cohort simulation model was used to compare an 8-week smoking cessation intervention with adjuvant pharmacotherapy and annual revisits vs nonintervention among 65-year-old male smokers with a small AAA identified at screening. The smoking cessation rate was tested in one-way sensitivity analyses in the intervention group (range, 22%-57%) and in the nonintervention group (range, 3%-30%). Literature data on the effect of smoking on AAA expansion and rupture was factored into the model. Results: The intervention was cost-effective in all tested scenarios and sensitivity analyses. The smoking cessation intervention was cost-effective due to a decreased need for AAA repair and decreased rupture rate even when disregarding the positive effects of smoking cessation on long-term survival. The incremental cost/effectiveness ratio reached the willingness-to-pay threshold value of 25,000 per life-year gained when assuming an intervention cost of >(sic)3250 or an effect of <= 1% difference in long-term smoking cessation between the intervention and nonintervention groups. Smoking cessation resulted in a relative risk reduction for elective AAA repair by 9% and for rupture by 38% over 10 years of follow-up. Conclusions: An adequate smoking cessation intervention in patients with small AAAs identified at screening can cost-effectively increase long-term survival and decrease the need for AAA repair.

  • 44.
    Mani, Kevin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Ålund, Martina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lundkvist, Jonas
    Medical management centre, Karolinska Institutet.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Screening for Abdominal Aortic Aneurysm among Patients Referred to the Vascular Laboratory is Cost-effective2010In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 39, no 2, p. 208-216Article in journal (Refereed)
    Abstract [en]

    Screening for abdominal aortic aneurysm (AAA) in high-risk groups has been recommended based on a high prevalence of disease, while being questioned due to a high frequency of co-morbidities and inferior life-expectancy. We evaluated the long-term outcome and the cost-effectiveness of selective AAA screening among patients referred to the vascular laboratory for arterial examination. METHODS: A total of 5924 patients, referred to the vascular laboratory of a university hospital, were screened for AAA with ultrasound (definition: slashed circle>/=30mm), 1993-2005. Outcome data were gathered through hospital records and the national population registry. A Markov model was used for health-economic evaluation. RESULTS: An AAA was detected in 181 patients (mean age 72.8 years), of whom 21.5% underwent elective repair (perioperative mortality 5.1%) after 7.5 years of follow-up. Four of six patients diagnosed with AAA rupture were operated upon. Relative 5-year survival compared with the general Swedish population, controlled for age and sex, was 80.4% (95% confidence interval (CI): 70.8-88.8). The cost-effectiveness was robust in base-case (11 084 Euro/life year gained) and in sensitivity analyses of prevalence, cost and survival. CONCLUSIONS: Patients in whom AAA was detected at selective screening had inferior long-term survival and were operated on less frequently, compared with AAA patients described in previous studies. Yet, selective screening at the vascular laboratory was cost-effective.

  • 45. Mitchell, D
    et al.
    Venermo, M
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Troëng, Thomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Debus, S
    Szeberin, Z
    Hansen, A K
    Beiles, B
    Setacci, C
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Menyhei, G
    Heller, G
    Danielsson, G
    Loftus, I
    Thomson, I
    Vogt, K
    Jensen, L
    Altreuther, M
    Eldrup, N
    Wigger, P
    Moreno-Carriles, R
    Lees, T
    Quality Improvement in Vascular Surgery: The Role of Comparative Audit and Vascunet.2015In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 49, no 1Article in journal (Refereed)
  • 46. Monsen, C.
    et al.
    Acosta, S.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wann-Hansson, C.
    A randomised study of NPWT closure versus alginate dressings in peri-vascular groin infections: quality of life, pain and cost2015In: Journal of Wound Care, ISSN 0969-0700, E-ISSN 2052-2916, Vol. 24, no 6, p. 252-260Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to compare the vacuum assisted wound closure (VAC) system (negative pressure wound therapy; NPWT) and alginate wound dressings in terms of quality of life (QoL), pain resource use and cost in patients with deep peri-vascular groin infection after vascular surgery. Method: Patients with deep peri-vascular groin infection (Szilagyi grade III) were included and randomised to NPWT or alginate therapy. EuroQol 5D (EQ-5D) and brief pain inventory (BPI) were used to evaluate QoL and pain, respectively. l Results: Wound healing time until complete skin epithelialisation was shorter in the NPWT (n=9) compared to the alginate group (n=7), median 57 and 104 days, respectively (p=0.026). No difference was recorded in QoL and pain between the groups at study start and the second assessment. QoL analysis within groups between time points, showed that patients in NPWT groups improved in EQ-5D domains, 'self-care' (p= 0.034), 'usual activities' (p=0.046); EQ-5D index value (p=0.046) and EQ-VAS (p=0.028). Patients in the NPWT group reported significantly less pain 'affecting their relations with other people' and 'sleep' between time points. The NPWT group had significantly fewer dressing changes compared to the alginate group (p<0.001). The median frequency of wound dressing changes outside hospital was 20 (IQR 6-29) in the NPWT group (n=9), compared to 48 (IQR 42-77) in the alginate group (n=8; p=0.004). The saved personnel time for wound care in the first week for the NPWT group, compared with the alginate group, was 4.5 hours per week per nurse. The total hospitalised care cost was 83-87% of the total cost in both groups. Conclusion: NPWT therapy in patients with deep peri-vascular groin infection can be regarded as the dominant strategy due to improved clinical outcome with equal cost and quality of life measures.

  • 47. Petersén, Åsa
    et al.
    Mani, Kevin
    Brundin, Patrik
    Recent advances on the pathogenesis of Huntington's disease1999In: Experimental Neurology, ISSN 0014-4886, E-ISSN 1090-2430, Vol. 157, no 1, p. 1-18Article in journal (Refereed)
    Abstract [en]

    We review recent advances regarding the pathogenesis of Huntington's disease (HD). This genetic neurodegenerative disorder is caused by an expanded CAG repeat in a gene coding for a protein, with unknown function, called huntingtin. There is selective death of striatal and cortical neurons. Both in patients and a transgenic mouse model of the disease, neuronal intranuclear inclusions, immunoreactive for huntingtin and ubiquitin, develop. Huntingtin interacts with the proteins GAPDH, HAP-1, HIP1, HIP2, and calmodulin, and a mutant huntingtin is specifically cleaved by the proapoptotic enzyme caspase 3. The pathogenetic mechanism is not known, but it is presumed that there is a toxic gain of function of the mutant huntingtin. Circumstantial evidence suggests that excitotoxicity, oxidative stress, impaired energy metabolism, and apoptosis play a role.

  • 48. Spiliopoulos, Stavros
    et al.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Sabharwal, Tarun
    Krokidis, Miltiadis
    Gkoutzios, Panagiotis
    First application of the 'lasso technique' on an endograft with suprarenal fixation stent2013In: VASCULAR, ISSN 1708-5381, Vol. 21, no 3, p. 177-181Article in journal (Refereed)
    Abstract [en]

    The authors report the use of the 'lasso technique' for the preservation of bilateral renal artery patency, following the intraoperative proximal migration of an aortic endograft with suprarenal bare metal fixation and anchoring barbs, due to device delivery failure. During an emergency endovascular repair of a ruptured mycotic abdominal aortic aneurysm using the Zenith Flex device, the main body of the graft migrated proximally to cover both renal arteries. Attempts to pull down the graft using balloons were not effective. Finally, the 'lasso technique' using a guidewire over the aortic bifurcation was employed and successfully adjusted the graft below the level of the renal arteries. No procedure-related complications were noted. The endovascular repair was used as a bridging procedure and two months following the primary endovascular procedure, open surgical repair of the infected aneurysm with excision of the stent graft was performed. The patient is alive after eight months follow-up.

  • 49.
    Sveinsson, Magnus
    et al.
    Reg Hosp Helsingborg, Helsingborg, Sweden..
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Kristmundsson, Thorarinn
    Skane Univ Hosp, Lund, Sweden..
    Dias, Nuno
    Skåne Univ Hosp, Lund, Sweden..
    Sonesson, Bjorn
    Skåne Univ Hosp, Lund, Sweden..
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Pesch, Timothy
    Skåne Univ Hosp, Lund, Sweden..
    Juxtarenal Endovascular Therapy With Fenestrated and Branched Stent Grafts After Previous Infrarenal Repair2017In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 65, no 6, p. 149S-149SArticle in journal (Other academic)
  • 50.
    Svensjö, Sverker
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Lundkvist, Jonas
    Medical Management Centre, Karolinska Institutet, Stockholm.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Screening for Abdominal Aortic Aneurysm in 65-Year-old Men Remains Cost-effective with Contemporary Epidemiology and Management2014In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 47, no 4, p. 357-365Article in journal (Refereed)
    Abstract [en]

    Objectives

    The epidemiology and management of abdominal aortic aneurysms (AAA) has changed significantly, with lower prevalence, increased longevity of patients, increased use of endovascular aneurysm repair (EVAR), and improved outcome. The clinical and health economic effectiveness of one-time screening of 65-year-old men was assessed within this context.

    Methods

    One-time ultrasound screening of 65-year-old men (invited) versus no screening (control) was analysed in a Markov model. Data on the natural course of AAA (risk of repair and rupture) was based on randomised controlled trials. Screening detected AAA prevalence (1.7%), surgical management (50% EVAR), repair outcome, costs, and long-term survival were based on contemporary population-based data. Incremental cost-efficiency ratios (ICER), absolute and relative risk reduction for death from AAA (ARR, RRR), numbers needed to screen (NNS), and life-years gained were calculated. Annual discounting was 3.5%.

    Results

    In base case at 13-years follow-up the ICER was €14,706 per incremental quality-adjusted life-year (QALY); ARR was 15.1 per 10,000 invited, NNS was 530, and QALYs gained were 56.5 per 10,000 invited. RRR was 42% (from 0.36% in control to 0.21% in invited). In a lifetime analysis the ICER of screening decreased to €7,570/QALY. The parameters with highest impact on the cost-efficiency of screening in the sensitivity analysis were the prevalence of AAA (threshold value <0.5%) and degree of incidental detection in the control cohort.

    Conclusions

    In the face of recent changes in the management and epidemiology of AAA, screening men for AAA remains cost-effective and delivers significant clinical impact.

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