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  • 1. Acosta, Stefan
    et al.
    Seternes, Arne
    Venermo, Maarit
    Vikatmaa, Leena
    Sörelius, Karl
    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.
    Svensson, Mats
    Djavani, Khatereh
    Department of Surgery, Gävle Hospital, Gävle, Sweden.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: an International Multicentre Study2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 6, p. 697-705Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:

    Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation.

    METHODS:

    This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate.

    RESULTS:

    Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation.

    CONCLUSIONS:

    VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.

  • 2.
    Sörelius, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Aortic infections: The Nadir of Vascular Surgery2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Aortic infections are rare, life-threatening and constitute a major challenge in surgical management. This thesis aims to evaluate short – and long-term outcome of endovascular aortic repair (EVAR) for mycotic aortic aneurysms (MAA) and the subsequent risk of recurrent infections, changes in surgical practice over time for abdominal MAAs in Sweden and outcome for different treatment modalities, as well as the risk of secondary vascular infection after treatment with Open abdomen after aortic surgery.

    Paper I, a retrospective single centre study of patients with MAA treated with EVAR, demonstrated a good short-term outcome, 91% survival at 30-days, and acceptable mid-term survival, 73% at 1-year.

    Paper II, a retrospective international multicentre study of patients treated with EVAR for MAA, confirmed the results in paper I, and showed that EVAR is feasible and for most MAA patients a durable treatment option, 5-year survival was 55% and 10-year 41%. A total of 19% died from an infection-related complication, mostly during the first postoperative year. Non-Salmonella-positive culture was a predictor for late infection–related death.

    Paper III, a population-based cohort study on all abdominal MAAs operated on between 1994-2014 in Sweden. Overall survival was 86% at 3-months, 79% at 1-year and 59% at 5-years. The survival was significantly better after endovascular compared to open repair up to 1-year without increasing recurrence of infection or reoperation, thereafter there was no difference. After 2001 EVAR constituted 60 % of all repairs, thus indicating a paradigm shift in treatment for abdominal MAAs in Sweden.

    Paper IV, a prospective multicentre study of patients treated with open abdomen after aortic surgery. Infectious complications, such as graft infections, occurred after intestinal ischaemia and prolonged OA-treatment, and were often fatal.

    List of papers
    1. Endovascular repair of mycotic aortic aneurysms
    Open this publication in new window or tab >>Endovascular repair of mycotic aortic aneurysms
    Show others...
    2009 (English)In: Journal of vascular surgery, ISSN 0741-5214, Vol. 50, no 2, p. 269-274Article in journal (Refereed) Published
    Abstract [en]

    PURPOSE: We report our single-center experience of early and midterm outcome after endovascular repair of mycotic aortic aneurysms (MAA). METHODS: Case records were retrospectively reviewed of 11 patients who underwent endovascular repair of 13 MAAs between 2000 and 2007. The aneurysms were localized in the aortic arch in 1 patient, descending thoracic aorta in 4, suprarenal abdominal aorta in 3, and infrarenal abdominal aorta in 5. RESULTS: Mean follow-up was 27 months. A bleeding aortoesophageal fistula resulted in one in-hospital death <or=30 days. Three patients died later: one each of sepsis, stent migration that caused intestinal ischemia, and an unknown cause. Two patients had recurrent sepsis postoperatively but no vascular complications, two had elevated inflammatory markers during follow-up but were asymptomatic, and three patients had an uneventful follow-up. CONCLUSIONS: Endovascular treatment for MAA was feasible, with acceptable perioperative mortality and midterm outcome in this single-center case series. Recurrent sepsis and late relapse with a second MAA occurred, indicating the need of long-term antibiotic therapy and follow-up, as well as the possible need for secondary open repair in selected cases. Further research is warranted to evaluate long-term outcome.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-110122 (URN)10.1016/j.jvs.2009.01.001 (DOI)000268610000005 ()19446985 (PubMedID)
    Available from: 2009-11-04 Created: 2009-11-04 Last updated: 2016-08-31Bibliographically approved
    2. Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study
    Open this publication in new window or tab >>Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study
    Show others...
    2014 (English)In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 130, no 24, p. 2136-2142Article in journal (Refereed) Published
    Abstract [en]

    Background-Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection-related complications and long-term survival. Methods and Results-All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39-86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella-positive culture as predictors for late infection-related death. Conclusions-Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonellapositive blood cultures were more likely to die from late infection.

    Keywords
    aneurysm, aorta, infection, surgery
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:uu:diva-241408 (URN)10.1161/CIRCULATIONAHA.114.009481 (DOI)000346141900011 ()25378548 (PubMedID)
    Available from: 2015-01-19 Created: 2015-01-12 Last updated: 2017-12-05Bibliographically approved
    3. Nationwide study demonstrates paradigm shift in treatment of mycotic abdominal aortic aneurysms
    Open this publication in new window or tab >>Nationwide study demonstrates paradigm shift in treatment of mycotic abdominal aortic aneurysms
    Show others...
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: Radical open surgery (OR) is considered gold standard for management of mycotic abdominal aortic aneurysms (MAAAs). Endovascular repair (EVAR) is a less invasive but controversial treatment option for MAAA because the stentgraft is implanted in an infected field, whilst recent reports indicate promising outcome. No reliable comparative data exists. This nationwide study assesses outcome after OR and EVAR for MAAA in a population-based cohort.

    Methods: All patients treated in Sweden for MAAAs 1994-2014 were identified in the Swedish vascular registry. Twenty-seven vascular units participated in data collection according to a predefined protocol. Survival was cross-matched with the population registry.

    Results: 132 patients with 144 MAAAs were identified, (0.6% of all operated AAA in Sweden). Median age was 70 years (SD 9.2), 51 were immunosuppressed, and 50 presented with rupture. Survival at 3-months was 86% (95% CI 80-92%), 1-year 79% (72-86%), and 5- years 59% (50-68%).

    The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994-2000 0%, 2001-2007 58%, 2008-2014 60%). Open repair was performed in 62 patients (47%); aortic resection and extra-anatomical bypass (n=7), in-situ reconstruction (n=50), patch plasty (n=3), and two died intraoperatively OR attempt. EVAR was performed in 70 patients (53%); standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stentgrafting (n=7).

    Survival at 3-months was inferior for OR compared to EVAR in Kaplan-Meier analysis (74% vs 96%, p<0.001), with a similar trend present at 1-year (73% vs 84%, p=0.054). A propensity score weighted risk-adjusted analysis confirmed the early survival benefit of EVAR. During follow-up (median OR 36, EVAR 41 months) there was no difference in long- term survival (5-years 60 vs 58%, p=0.771), infection-related complications (18 vs 24%, p=0.439), or reoperation (21% vs 24%, p=0.650). In a multivariable analysis OR was a significant risk factor for death at 3-months (odds ratio 6.96, p=0.004).

    Conclusion: This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR achieved improved short-term survival compared to OR, without increasing the risk of serious infection-related complications or reoperations.

    Keywords
    Mycotic, infected, aortic, aneurysm, abdominal
    National Category
    Medical and Health Sciences
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-300952 (URN)
    Available from: 2016-08-16 Created: 2016-08-16 Last updated: 2016-08-31Bibliographically approved
    4. Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction
    Open this publication in new window or tab >>Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction
    Show others...
    2013 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, p. 588-594Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVES:

    Open abdomen (OA) treatment is sometimes necessary after surgery for aortic aneurysm (AA), to prevent or treat abdominal compartment syndrome (ACS). A multicentre study evaluating vacuum-assisted wound closure (100-150 mmHg) and mesh-mediated fascial traction (VAWCM) was performed.

    METHODS:

    All patients treated with OA after AA repair (2006-2009) were prospectively registered at four centres; those treated <5 days were excluded. All surviving patients underwent a 1-year follow-up, including computed tomography (CT) examination.

    RESULTS:

    Among 1041 patients treated with open or endovascular repair of AA, 28 (2.9%) had OA treatment with VAWCM; another two had VAWCM after hybrid operations for thoraco-abdominal AA. Eighteen (60%) were operated on for rupture and 12 (40%) electively. Eight had suprarenal or thoraco-abdominal aneurysms. Eight (27%) died within 30 days, none due to OA-related complications. Four died before abdominal closure; primary delayed fascial closure was achieved in all survivors. One-year mortality was 50%. Ten (33%) had bowel ischaemia requiring bowel resection. Late potential OA-related infectious complications occurred in five (17%), all of whom first developed intestinal ischaemia: entero-atmospheric fistulae (two), graft infections (two), aorto-enteric fistula (one). One year follow-up with clinical evaluation and CT showed no signs of graft infection. Incisional hernias occurred in 9 of 15 patients (60%); only three were symptomatic.

    CONCLUSION:

    VAWCM provided high fascial closure rate after AA repair and long-term OA treatment. Infectious complications occur after intestinal ischaemia and prolonged OA treatment, and are often fatal. The poor prognosis among patients needing OA after AA surgery may be improved by using VAWCM, permitting earlier closure.

    Keywords
    Aortic aneurysm; Open abdomen; Vacuum-assisted wound closure; Mesh; Abdominal compartment syndrome; Mortality; Infections
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-199892 (URN)10.1016/j.ejvs.2013.01.041 (DOI)000320745100010 ()23465456 (PubMedID)
    Funder
    Swedish Research Council, K2010-65X-20406-04-3
    Available from: 2013-05-17 Created: 2013-05-17 Last updated: 2017-12-06Bibliographically approved
  • 3.
    Sörelius, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Re: "Management of Atherosclerotic Carotid and Vertebral Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)"2018In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 55, no 1, p. 142-142Article in journal (Refereed)
  • 4.
    Sörelius, Karl
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    di Summa, Pietro G.
    CHU Vaudois, Dept Plast Reconstruct & Hand Surg, Lausanne, Switzerland..
    On the Diagnosis of Mycotic Aortic Aneurysms2018In: Clinical Medicine Insights: Cardiology, ISSN 1179-5468, E-ISSN 1179-5468, Vol. 12Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: There is striking paucity in consensus on the terminology, definition, and diagnostic criteria of mycotic aortic aneurysms. This literature study aims to elucidate this scientific omission, discuss its consequences, and present a proposition for reporting items on this disease.

    METHODS: A systematic literature review on PubMed and Medline using mycotic and infected aortic aneurysms between 1850 and 2017 was performed. Articles were assessed according to a protocol regarding terminology, definition, and diagnostic criteria. Case series with less than 5 patients were excluded.

    RESULTS: A total of 49 articles were included. The most prevalent term was mycotic aortic aneurysm but there was no widely accepted definition. Most modern publications used a diagnostic workup based on a combination on clinical presentation, laboratory results, imaging findings, and intraoperative findings. How these protean variables should be balanced was unclear. A proposition of reporting items was framed and consisted of definition of disease used, basis of diagnostic workup, exclusion criteria, patient characteristics, laboratory and imaging findings, aneurysm anatomy, details on treatment, pre/postoperative antibiotic treatment, and details on follow-up.

    CONCLUSIONS: This article emphasizes the need to standardize definition, terminology, and diagnostic criteria for mycotic aortic aneurysms and proposes reporting items enhancing comparability between studies.

  • 5.
    Sörelius, Karl
    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.
    Nyman, Rickard
    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.
    Endovascular repair of mycotic aortic aneurysms2009In: Journal of vascular surgery, ISSN 0741-5214, Vol. 50, no 2, p. 269-274Article in journal (Refereed)
    Abstract [en]

    PURPOSE: We report our single-center experience of early and midterm outcome after endovascular repair of mycotic aortic aneurysms (MAA). METHODS: Case records were retrospectively reviewed of 11 patients who underwent endovascular repair of 13 MAAs between 2000 and 2007. The aneurysms were localized in the aortic arch in 1 patient, descending thoracic aorta in 4, suprarenal abdominal aorta in 3, and infrarenal abdominal aorta in 5. RESULTS: Mean follow-up was 27 months. A bleeding aortoesophageal fistula resulted in one in-hospital death <or=30 days. Three patients died later: one each of sepsis, stent migration that caused intestinal ischemia, and an unknown cause. Two patients had recurrent sepsis postoperatively but no vascular complications, two had elevated inflammatory markers during follow-up but were asymptomatic, and three patients had an uneventful follow-up. CONCLUSIONS: Endovascular treatment for MAA was feasible, with acceptable perioperative mortality and midterm outcome in this single-center case series. Recurrent sepsis and late relapse with a second MAA occurred, indicating the need of long-term antibiotic therapy and follow-up, as well as the possible need for secondary open repair in selected cases. Further research is warranted to evaluate long-term outcome.

  • 6.
    Sörelius, Karl
    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.
    Sedivy, Petr
    Wahlgren, Carl-Magnus
    Taylor, Peter
    Clough, Rachel E.
    Lyons, Oliver
    Thompson, Matt
    Brownrigg, Jack
    Ivancev, Krassi
    Davis, Meryl
    Jenkins, Michael P.
    Jaffer, Usman
    Bown, Matt
    Rancic, Zoran
    Mayer, Dieter
    Brunkwall, Jan
    Gawenda, Michael
    Koelbel, Tilo
    Jean-Baptiste, Elixene
    Moll, Frans
    Berger, Paul
    Liapis, Christos D.
    Moulakakis, Konstantinos G.
    Langenskiold, Marcus
    Roos, Hakan
    Larzon, Thomas
    Pirouzram, Artai
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study2014In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 130, no 24, p. 2136-2142Article in journal (Refereed)
    Abstract [en]

    Background-Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection-related complications and long-term survival. Methods and Results-All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39-86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella-positive culture as predictors for late infection-related death. Conclusions-Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonellapositive blood cultures were more likely to die from late infection.

  • 7.
    Sörelius, Karl
    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.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Endovascular treatment of mycotic aortic aneurysms: a paradigm shift2017In: Journal of Cardiovascular Surgery, ISSN 0021-9509, E-ISSN 1827-191X, Vol. 58, no 6, p. 870-874Article, review/survey (Refereed)
    Abstract [en]

    Treatment of mycotic aortic aneurysms (MAAs) composes a particularly difficult challenge. Open repair has been considered the gold standard, despite lack of evidence supporting its superiority compared with the emerging alternative endovascular aortic repair (EVAR). This review discusses the pros and cons of EVAR for MAAs by dissecting the three largest publications on MAAs, and concludes that there has been a paradigm shift in treatment of MAAs for the benefit of EVAR.

  • 8.
    Sörelius, Karl
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal 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.
    Hybrid treatment of a post-EVAR aortoenteric fistula2014In: Vascular, ISSN 1708-5381, E-ISSN 1708-539X, Vol. 22, no 5, p. 385-389Article in journal (Refereed)
    Abstract [en]

    This report presents a case of secondary aortoenteric fistula after endovascular aortic repair in a fragile patient: The fistula developed due to aneurysm shrinkage and remodeling of the stent graft, resulting in a kink eroding through the aneurysm wall into the duodenum. The aortoenteric fistula was successfully treated with a hybrid procedure with endovascular aortic repair, followed by open enteroraphy and omental flap coverage of the stent graft and local antibiotic irrigation. Despite the presence of the stent graft in a previously infected field, the patient has recovered from the acute event with no septic recurrence or hemorrhage during four years of follow-up.

  • 9.
    Sörelius, Karl
    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.
    Acosta, S
    Svensson, M
    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.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction2013In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, p. 588-594Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:

    Open abdomen (OA) treatment is sometimes necessary after surgery for aortic aneurysm (AA), to prevent or treat abdominal compartment syndrome (ACS). A multicentre study evaluating vacuum-assisted wound closure (100-150 mmHg) and mesh-mediated fascial traction (VAWCM) was performed.

    METHODS:

    All patients treated with OA after AA repair (2006-2009) were prospectively registered at four centres; those treated <5 days were excluded. All surviving patients underwent a 1-year follow-up, including computed tomography (CT) examination.

    RESULTS:

    Among 1041 patients treated with open or endovascular repair of AA, 28 (2.9%) had OA treatment with VAWCM; another two had VAWCM after hybrid operations for thoraco-abdominal AA. Eighteen (60%) were operated on for rupture and 12 (40%) electively. Eight had suprarenal or thoraco-abdominal aneurysms. Eight (27%) died within 30 days, none due to OA-related complications. Four died before abdominal closure; primary delayed fascial closure was achieved in all survivors. One-year mortality was 50%. Ten (33%) had bowel ischaemia requiring bowel resection. Late potential OA-related infectious complications occurred in five (17%), all of whom first developed intestinal ischaemia: entero-atmospheric fistulae (two), graft infections (two), aorto-enteric fistula (one). One year follow-up with clinical evaluation and CT showed no signs of graft infection. Incisional hernias occurred in 9 of 15 patients (60%); only three were symptomatic.

    CONCLUSION:

    VAWCM provided high fascial closure rate after AA repair and long-term OA treatment. Infectious complications occur after intestinal ischaemia and prolonged OA treatment, and are often fatal. The poor prognosis among patients needing OA after AA surgery may be improved by using VAWCM, permitting earlier closure.

  • 10.
    Sörelius, Karl
    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.
    Furebring, Mia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infectious Diseases.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Gillgren, Peter
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair2016In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 134, no 23, p. 1822-1832Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: -No reliable comparative data exist between open repair (OR) and endovascular repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes after OR and EVAR for MAAA in a population-based cohort.

    METHODS: -All patients treated for MAAAs in Sweden between1994-2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time-trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank test. A propensity score weighted correction for risk factor differences in the two groups was performed, including the operation year to account for differences in treatment and outcomes over time.

    RESULTS: -132 patients were identified, (0.6% of all operated AAA in Sweden). Mean age was 70 years (SD 9.2), and 50 presented with rupture. Survival at 3-months was 86% (95% CI 80-92%), 1-year 79% (72-86%), and 5-years 59% (50-68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994-2000 0%, 2001-2007 58%, 2008-2014 60%). Open repair was performed in 62 patients (47%); aortic resection and extra-anatomical bypass (n=7), in-situ reconstruction (n=50), patch plasty (n=3), and 2 patients died intraoperatively. EVAR was performed in 70 patients (53%); standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3-months was lower for OR compared with EVAR (74% vs 96%, p<0.001), with a similar trend present at 1-year (73% vs 84%, p=0.054). A propensity score weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5-years 60 vs 58%, p=0.771), infection-related complications (18 vs 24%, p=0.439), or reoperation (21% vs 24%, p=0.650).

    CONCLUSIONS: -This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival compared with OR, without higher associated incidence of serious infection-related complications or reoperations.

  • 11.
    Sörelius, Karl
    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.
    Mia, Furebring
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infectious Diseases.
    Martin, Björck
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Peter, Gillgren
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Nationwide study demonstrates paradigm shift in treatment of mycotic abdominal aortic aneurysmsManuscript (preprint) (Other academic)
    Abstract [en]

    Background: Radical open surgery (OR) is considered gold standard for management of mycotic abdominal aortic aneurysms (MAAAs). Endovascular repair (EVAR) is a less invasive but controversial treatment option for MAAA because the stentgraft is implanted in an infected field, whilst recent reports indicate promising outcome. No reliable comparative data exists. This nationwide study assesses outcome after OR and EVAR for MAAA in a population-based cohort.

    Methods: All patients treated in Sweden for MAAAs 1994-2014 were identified in the Swedish vascular registry. Twenty-seven vascular units participated in data collection according to a predefined protocol. Survival was cross-matched with the population registry.

    Results: 132 patients with 144 MAAAs were identified, (0.6% of all operated AAA in Sweden). Median age was 70 years (SD 9.2), 51 were immunosuppressed, and 50 presented with rupture. Survival at 3-months was 86% (95% CI 80-92%), 1-year 79% (72-86%), and 5- years 59% (50-68%).

    The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994-2000 0%, 2001-2007 58%, 2008-2014 60%). Open repair was performed in 62 patients (47%); aortic resection and extra-anatomical bypass (n=7), in-situ reconstruction (n=50), patch plasty (n=3), and two died intraoperatively OR attempt. EVAR was performed in 70 patients (53%); standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stentgrafting (n=7).

    Survival at 3-months was inferior for OR compared to EVAR in Kaplan-Meier analysis (74% vs 96%, p<0.001), with a similar trend present at 1-year (73% vs 84%, p=0.054). A propensity score weighted risk-adjusted analysis confirmed the early survival benefit of EVAR. During follow-up (median OR 36, EVAR 41 months) there was no difference in long- term survival (5-years 60 vs 58%, p=0.771), infection-related complications (18 vs 24%, p=0.439), or reoperation (21% vs 24%, p=0.650). In a multivariable analysis OR was a significant risk factor for death at 3-months (odds ratio 6.96, p=0.004).

    Conclusion: This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR achieved improved short-term survival compared to OR, without increasing the risk of serious infection-related complications or reoperations.

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