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  • 251. Forssgren, Alexandra
    et al.
    Fransson, Ingvor
    Nelzén, Olle
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences. Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Leg ulcer point prevalence can be decreased by broad-scale intervention: a follow-up cross-sectional study of a defined geographical population2008In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 88, no 3, p. 252-6Article in journal (Refereed)
    Abstract [en]

    In 1988 a cross-sectional epidemiological study was performed in Skaraborg County, Sweden, establishing leg ulcer point prevalence. Based on the results of that study a complete change in the care of leg ulcer patients was brought into practice. The objective of this postal cross-sectional follow-up study was to evaluate the success of the new management strategy. Responding healthcare providers were asked to report all patients with an open wound below the knee that did not heal within a 6-week period after onset of ulceration. Validity of results was ensured by examining 203 randomly selected patients. Based on clinical examination, an assessment of the underlying causes of ulceration was made. The study setting was inpatient and outpatient care in hospitals, primary care and community care within Skaraborg, with a population of 254,111. The response rate was 100% from district nurses, hospital wards and outpatient clinics. Reports were collected from healthcare providers, mainly nurses, in all 15 communities. A total of 621 individual patients with active leg ulcers were identified. Age-adjusted sex ratio of ulcer patients was 1:1.1 (M:F). The median age was 79 years. A total of 507 patients (82%) were older than 64 years. District and community nurses provided care for the majority (88.5%) of patients. The study verified a point prevalence of 2.4/1000 population in 2002 compared with 3.1/1000 in 1988, a 23% decrease in leg ulcer prevalence. Venous insufficiency was still the dominating causative factor, although the number of patients with venous leg ulcers was reduced by 46%. Arterial ulcers had decreased by 23%, while patients with ulcers of diabetic and multifactorial causes were increased. In conclusion, it is likely that this reduction in point prevalence reflects the introduction of the change in management strategy undertaken in the area.

  • 252. Fowkes, F. G. R.
    et al.
    Murray, G. D.
    Butcher, I.
    Folsom, A. R.
    Hirsch, A. T.
    Couper, D. J.
    DeBacker, G.
    Kornitzer, M.
    Newman, A. B.
    Sutton-Tyrrell, K. C.
    Cushman, M.
    Lee, A. J.
    Price, J. F.
    D'Agostino, R. B., Sr.
    Murabito, J. M.
    Norman, P. E.
    Masaki, K. H.
    Bouter, L. M.
    Heine, R. J.
    Stehouwer, C. D. A.
    McDermott, M. M.
    Stoffers, H. E. J. H.
    Knottnerus, J. A.
    Ögren, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Hedblad, B.
    Koenig, W.
    Meisinger, C.
    Cauley, J. A.
    Franco, O. H.
    Hunink, M. G. M.
    Hofman, A.
    Witteman, J. C.
    Criqui, M. H.
    Langer, R. D.
    Hiatt, W. R.
    Hamman, R. F.
    Development and validation of an ankle brachial index risk model for the prediction of cardiovascular events2014In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 21, no 3, p. 310-320Article in journal (Refereed)
  • 253. Francis, C. W.
    et al.
    Kessler, C. M.
    Goldhaber, S. Z.
    Kovacs, M. J.
    Monreal, M.
    Huisman, M. V.
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Turpie, A. G.
    Ortel, T. L.
    Spyropoulos, A. C.
    Pabinger, I.
    Kakkar, A. K.
    Treatment of venous thromboembolism in cancer patients with dalteparin for up to 12months: the DALTECAN Study2015In: Journal of Thrombosis and Haemostasis, ISSN 1538-7933, E-ISSN 1538-7836, Vol. 13, no 6, p. 1028-1035Article in journal (Refereed)
    Abstract [en]

    BackgroundTreatment of venous thromboembolism (VTE) in patients with cancer has a high rate of recurrence and bleeding complications. Guidelines recommend low-molecular-weight heparin (LMWH) for at least 3-6months and possibly indefinitely for patients with active malignancy. There are, however, few data supporting treatment with LMWH beyond 6months. The primary aim of the DALTECAN study (NCT00942968) was to determine the safety of dalteparin between 6 and 12months in cancer-associated VTE. MethodsPatients with active cancer and newly diagnosed VTE were enrolled in a prospective, multicenter study and received subcutaneous dalteparin for 12months. The rates of bleeding and recurrent VTE were evaluated at months 1, 2-6 and 7-12. FindingsOf 334 patients enrolled, 185 and 109 completed 6 and 12months of therapy; 49.1% had deep vein thrombosis (DVT); 38.9% had pulmonary embolism (PE); and 12.0% had both on presentation. The overall frequency of major bleeding was 10.2% (34/334). Major bleeding occurred in 3.6% (12/334) in the first month, and 1.1% (14/1237) and 0.7% (8/1086) per patient-month during months 2-6 and 7-12, respectively. Recurrent VTE occurred in 11.1% (37/334); the incidence rate was 5.7% (19/334) for month 1, 3.4% (10/296) during months 2-6, and 4.1% (8/194) during months 7-12. One hundred and sixteen patients died, four due to recurrent VTE and two due to bleeding. ConclusionMajor bleeding was less frequent during dalteparin therapy beyond 6months. The risk of developing major bleeding complications or VTE recurrence was greatest in the first month of therapy and lower over the subsequent 11 months.

  • 254. Fransson, Maria
    et al.
    Rydningen, Hans
    Henriksson, Anders E.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Early Coagulopathy in Patients With Ruptured Abdominal Aortic Aneurysm2012In: Clinical and applied thrombosis/hemostasis, ISSN 1076-0296, E-ISSN 1938-2723, Vol. 18, no 1, p. 96-99Article in journal (Refereed)
    Abstract [en]

    Ruptured abdominal aortic aneurysm (AAA) is associated with a high mortality despite surgical management. Earlier reports indicate that a major cause of immediate intraoperative death in patients with ruptured AAA is related to hemorrhage due to coagulopathy. Acidosis is, besides hypothermia and hemodilution, a possible cause of coagulopathy. The aim of the present study was to investigate the incidence of coagulopathy and acidosis preoperatively in patients with ruptured AAA in relation to the clinical outcome with special regard to the influence of shock. For this purpose, 95 consecutive patients who underwent surgery for AAA (43 ruptured with shock, 12 ruptured without shock, and 40 nonruptured) were included. Coagulopathy was defined as prothrombin time (international normalized ratio [INR]) >= 1.5 and acidosis was defined as base deficit >= 6 mmol/L. Mortality and postoperative complications were recorded. The present study shows a state of acidosis at the start of surgery in 30 of 55 patients with ruptured AAA. However, only in 7 of 55 patients with ruptured AAA a state of preoperative coagulopathy was demonstrated. Furthermore, in our patients with shock due to ruptured AAA only 2 of 12 deaths were due to coagulopathy and bleeding. Indeed, our results show a relatively high incidence of thrombosis-related causes of death in patients with ruptured AAA, indicating a relation to an activated coagulation in these patients. These findings indicate that modern emergency management of ruptured AAA has improved in the attempt to prevent fatal coagulopathy.

  • 255.
    Fridh, E. Baubeta
    et al.
    Ryhov Cty Hosp, Dept Radiol, Jonkoping, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Radiol, Gothenburg, Sweden..
    Andersson, M.
    Ryhov Cty Hosp, Dept Vasc Surg, Jonkoping, Sweden.;Linkoping Univ, Dept Clin & Expt Med, Fac Hlth Sci, Linkoping, Sweden..
    Thuresson, M.
    Statisticon AB, Uppsala, Sweden..
    Sigvant, B.
    Karlstad Cent Hosp, Dept Vasc Surg, Karlstad, Sweden.;Karolinska Inst, Dept Clin Sci & Educ, Sodersjukhuset, Stockholm, Sweden..
    Kragsterman, Björn
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Johansson, S.
    AstraZeneca Gothenburg, Molndal, Sweden..
    Hasvold, P.
    AstraZeneca Nord Balt, Sodertalje, Sweden..
    Falkenberg, M.
    Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Radiol, Gothenburg, Sweden..
    Nordanstig, J.
    Gothenburg Univ, Dept Vasc Surg, Sahlgrenska Univ Hosp & Acad, Gothenburg, Sweden.;Gothenburg Univ, Inst Med, Sahlgrenska Univ Hosp & Acad, Dept Mol & Clin Med, Gothenburg, Sweden..
    Amputation Rates, Mortality, and Pre-operative Comorbidities in Patients Revascularised for Intermittent Claudication or Critical Limb Ischaemia: A Population Based Study2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 4, p. 480-486Article in journal (Refereed)
    Abstract [en]

    Objectives: The aims of this population based study were to describe mid-to long-term amputation risk, cumulative incidence of death or amputation, and differences in pre-operative comorbidities in patients revascularised for lower limb peripheral artery disease (PAD).

    Methods: This was an observational cohort study. Data from the Swedish National Quality Registry for Vascular Surgery (Swedvasc) were combined with mandatory national health care registries and patient medical records. All patients who underwent revascularisation in Sweden between May 2008 and May 2013 for intermittent claudication (IC) or critical limb ischaemia (CLI), aged 50 years and older, were identified through the Swedvasc database. The mandatory national health care registries and medical records provided data on comorbidities, mortality, and major amputations.

    Results: A total of 16,889 patients with PAD (IC, n = 6272; CLI, n = 10,617) were studied. The incidence of amputations in IC patients was 0.4% (range 0.3%-0.5%) per year. Among CLI patients, the amputation rate during the first 6 months following revascularisation was 12.0% (95% CI 11.3-12.6). Thereafter, the incidence declined to approximately 2% per year. The cumulative combined incidence of death or amputation 3 years after revascularisation was 12.9% (95% CI 12.0-13.9) in IC patients and 48.8% (95% CI 47.7-49.8) in CLI patients. Among CLI patients, compared with IC patients, the prevalence of diabetes, ischaemic stroke, heart failure, and atrial fibrillation was approximately doubled and renal failure was nearly tripled, even after age standardisation.

    Conclusion: The risk of amputation is particularly high during the first 6 months following revascularisation for CLI. IC patients have a benign course in terms of limb loss. Mortality in both IC and CLI patients is substantial. Revascularised CLI patients have different comorbidities from IC patients.

  • 256.
    Fridh, Erik Baubeta
    et al.
    Ryhov Cty Hosp, Dept Radiol, Jonkoping, Sweden;Gothenburg Univ, Sahlgrenska Acad, Inst Clin Sci, Dept Radiol, Gothenburg, Sweden.
    Andersson, Manne
    Ryhov Cty Hosp, Dept Vasc Surg, Jonkoping, Sweden;Linkoping Univ, Fac Hlth Sci, Dept Clin & Expt Med, Linkoping, Sweden.
    Thuresson, Marcus
    Statisticon AB, Uppsala, Sweden.
    Sigvant, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Karlstad Cent Hosp, Dept Vasc Surg, Karlstad, Sweden.
    Kragsterman, Björn
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Johansson, Saga
    AstraZeneca Nord Balt, Sodertalje, Sweden.
    Hasvold, Pal
    AstraZeneca Gothenburg, Molndal, Sweden.
    Nordanstig, Joakim
    Gothenburg Univ, Sahlgrenska Univ Hosp & Acad, Dept Vasc Surg, Gothenburg, Sweden;Gothenburg Univ, Sahlgrenska Univ Hosp & Acad, Inst Med, Gothenburg, Sweden;Gothenburg Univ, Sahlgrenska Univ Hosp & Acad, Dept Mol & Clin Med, Gothenburg, Sweden.
    Falkenberg, Marten
    Gothenburg Univ, Sahlgrenska Acad, Inst Clin Sci, Dept Radiol, Gothenburg, Sweden.
    Editor's Choice - Impact of Comorbidity, Medication, and Gender on Amputation Rate Following Revascularisation for Chronic Limb Threatening Ischaemia2018In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 56, no 5, p. 681-688Article in journal (Refereed)
    Abstract [en]

    Objective/background: Chronic limb threatening ischaemia (CLTI) has a high risk of amputation and mortality. Increased knowledge on how sex, comorbidities, and medication influence these outcomes after revascularisation may help optimise results and patient selection. Methods: This population based observational cohort study included all individuals revascularised for CLTI in Sweden during a five year period (10,617 patients in total). Data were retrieved and merged from mandatory national healthcare registries, and specifics on amputations were validated with individual medical records. Results: Mean age at revascularisation was 76.8 years. Median follow up was 2.7 years (range 0-6.6 years). Male sex (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.09-1.33), renal insufficiency (HR 1.57, 95% CI 1.32-1.87), diabetes (HR 1.45, 95% CI 1.32-1.60), and heart failure (HR 1.17, 95% CI 1.05-1.31) were independently associated with an increased amputation rate, whereas the use of statins (HR 0.71, 95% CI 0.64-0.78) and low dose acetylsalicylic acid (HR 0.77, 95% CI 0.70-0.86) were associated with a reduced amputation rate. For the combined end point of amputation or death, an association with increased rates was found for male sex (HR 1.25, 95% CI 1.18-1.32), renal insufficiency (HR 1.94, 95% CI 1.75-2.14), heart failure (HR 1.50, 95% CI 1.40-1.60), and diabetes (HR 1.31, 95% CI 1.23-1.38). The use of statins (HR 0.74, 95% CI 0.67-0.82) and low dose acetylsalicylic acid (HR 0.82, 95% CI 0.77-0.881) were related to a reduced risk of amputation or death. Conclusions: Renal insufficiency is the strongest independent risk factor for both amputation and amputation/ death in revascularised CLTI patients, followed by diabetes and heart failure. Men with CLTI have worse outcomes than women. These results may help govern patient selection for revascularisation procedures. Statin and low dose acetylsalicylic acid are associated with an improved limb outcome. This underlines the importance of preventive medication to reduce general cardiovascular risk and increase limb salvage.

  • 257.
    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.

  • 258. Geerts, William H.
    et al.
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Pineo, Graham F.
    Heit, John A.
    Samama, Charles M.
    Lassen, Michael R.
    Colwell, Clifford W.
    Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)2008In: Chest, ISSN 0012-3692, E-ISSN 1931-3543, Vol. 133, no 6 Suppl, p. 381S-453SArticle, review/survey (Refereed)
    Abstract [en]

    This article discusses the prevention of venous thromboembolism (VTE) and is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggestions imply that individual patient values may lead to different choices (for a full discussion of the grading, see the "Grades of Recommendation" chapter by Guyatt et al). Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A). For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC). For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and that most receive thromboprophylaxis (Grade 1A).

  • 259. Gibbons, C
    et al.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Jensen, LP
    Laustsen, J
    Lees, T
    Moreno-Carriles, R
    Troeng, Thomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    The first Vascunet report on abdominal aortic aneurysm surgery: The European Society of Vascular Surgery2007Report (Other (popular science, discussion, etc.))
  • 260. Gillespie, David L.
    et al.
    Kistner, Bob
    Glass, Carolyn
    Bailey, Brad
    Chopra, Arun
    Ennis, Bill
    Marston, Bill
    Masuda, Elna
    Moneta, Greg
    Nelzen, Olle
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Raffetto, Joe
    Raju, Seshadri
    Vedantham, Suresh
    Wright, David
    Falanga, Vincent
    Venous ulcer diagnosis, treatment, and prevention of recurrences2010In: Journal of vascular surgery, ISSN 0741-5214, Vol. 52, no 5 Suppl, p. 8S-14SArticle in journal (Refereed)
  • 261. 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.

  • 262. Gottsäter, A
    et al.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Aterosklerotisk kärlsjukdom2016In: Kirurgi / [ed] Jeppsson, Ljungqvist, Naredi och Sund, Studentlitteratur AB, 2016, 4, p. 565-574Chapter in book (Refereed)
  • 263. Gredmark-Russ, Sara
    et al.
    Dzabic, Mensur
    Rahbar, Afsar
    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.
    Larsson, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology.
    Michel, Jean-Baptiste
    Söderberg-Nauclér, Cecilia
    Active cytomegalovirus infection in aortic smooth muscle cells from patients with abdominal aortic aneurysm2009In: Journal of Molecular Medicine, ISSN 0946-2716, E-ISSN 1432-1440, Vol. 87, no 4, p. 347-356Article in journal (Refereed)
    Abstract [en]

    Cytomegalovirus (CMV) is associated with atherosclerosis and transplant vascular sclerosis. The aim of this study was to explore the hypothesis that active CMV infection in the vessel wall could be associated with abdominal aortic aneurysm (AAA). We examined the prevalence of CMV in AAA specimens from 22 patients undergoing surgery and, in five cases, characterized the function of smooth muscle cells (SMCs) from the aneurysm in vitro. Twenty-one (95%) of the 22 AAA specimens were CMV positive by a polymerase chain reaction assay, in situ hybridization, or a highly sensitive immunohistochemical staining technique. No positive cells were found in aortas from three CMV-seronegative organ donor cadavers. CMV immediate-early and late antigens were expressed in SMCs in the lesions and were associated with 5-lipoxygenase (5-LO) expression. CMV-positive intimal SMCs migrated 6.6 +/- 1.5 times more efficiently than CMV-negative medial SMCs (p < 0.05). In vitro CMV infection of medial SMCs resulted in a 3.2 +/- 1.2 times increase in migration (p < 0.05). The intimal migration was significantly inhibited by antibodies against basic fibroblast growth factor (bFGF; p < 0.05) in a dose-dependent fashion. Antibodies against platelet-derived growth factor (PDGF)-AB, insulin-like growth factor 1, vascular endothelial growth factor (VEGF), RANTES, monocyte chemoattractant protein 1 (MCP-1), macrophage inflammatory protein (MIP)-1alpha, or interleukin-1beta did not significantly affect intimal SMC migration. However, intimal and medial SMCs secreted similar amounts of bFGF, MCP-1, MIP-1alpha, RANTES, PDGF-AB, PDGF-BB, epidermal growth factor, and VEGF. CMV infection in vitro of intimal and medial cells did not result in significant changes of bFGF or MCP-1 secretion. Since CMV infection can affect several functional parameters in SMCs, including several key factors in infected SMCs, our findings provide support for the hypothesis that CMV contributes to the pathogenesis of abdominal aortic aneurysm.

  • 264. Grima, M.J.
    et al.
    Karthikesalingam, A
    Holt, P.J
    Vidal-Diez, A
    Thompson, M.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.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Comparative Analysis of the Outcomes of Elective Abdominal Aortic Aneurysm Repair in England and Sweden: Context for Contemporary Practice2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 5, p. 667-667Article in journal (Refereed)
  • 265.
    Grip, Olivia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Välj ....
    Acute limb ischaemia: Treatment, outcome and time trends2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

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

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

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

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

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

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

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

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

    List of papers
    1. Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion
    Open this publication in new window or tab >>Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion
    Show others...
    2014 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 9Article in journal (Refereed) Published
    Abstract [en]

    Background

    Thrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications

    This was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA).

    Results

    Some 749 procedures in 644 patients of median age 73 years were studied; 353 (47·1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38·8 per cent, acute arterial thrombosis in 32·2 per cent, embolus in 22·3 per cent and popliteal aneurysm in 6·7 per cent. Concomitant heparin infusion was used in 63·2 per cent. The mean dose of rtPA administered was 21·0 mg, with a mean duration of 25·2 h. Technical success was achieved in 80·2 per cent. Major amputation and death within 30 days occurred in 13·1 and 4·4 per cent respectively. Bleeding complications occurred in 227 treatments (30·3 per cent). Blood transfusion was needed in 104 (13·9 per cent). Three patients (0·4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation‐free survival was 83·6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2·98; P <0·001). Independent risk factors for fasciotomy were severe ischaemia (OR 2·94) and centre (OR 6·50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0·30; P = 0·003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3·82) and renal insufficiency (OR 3·86).

    Conclusion

    Both treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra‐arterial thrombolysis appeared to offer no advantage.

    Place, publisher, year, edition, pages
    Uppsala: , 2014
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-360872 (URN)10.1002/bjs.9579 (DOI)
    Available from: 2018-09-19 Created: 2018-09-19 Last updated: 2018-12-12Bibliographically approved
    2. Long-term Outcome after Thrombolysis for Acute Lower Limb Ischaemia
    Open this publication in new window or tab >>Long-term Outcome after Thrombolysis for Acute Lower Limb Ischaemia
    2017 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 53, no 6, p. 853-861Article in journal (Refereed) Published
    Abstract [en]

    Objectives: The purpose was to study long-term outcome after thrombolysis for acute arterial lower limb ischaemia, and to evaluate the results depending on the underlying aetiology of arterial occlusion.

    Methods: This was a retrospective study of patients entered into a prospective database. Patients were identified in prospective databases from two vascular centres, including a large number of variables. Case records were analysed retrospectively. Through cross linkage with the Population Registry 100% accurate survival data were obtained. Between January 2001 and December 2013, 689 procedures were included. The aetiology of ischaemia was graft/stent/stent graft occlusion in 39.8%, arterial thrombosis in 27.7%, embolus in 25.1% and popliteal aneurysm in 7.4%.

    Results: The mean follow-up was 59.4 months (95% CI, 56.1-62.7), during which 32.9% needed further re interventions, 16.4% underwent amputation without re-intervention, and 50.7% had no re-intervention. The need for re-intervention during follow-up was 48.0% in the graft/stent occlusions group, 34.0% of the popliteal aneurysm group, 25.4% in the thrombosis group, and 16.3% in the embolus group (p < .001). The overall primary patency rates were 69.1% and 55.9% at 1 and 5 years, respectively. Primary patency at 5 years was higher for the embolus group (83.3%, p = .002) and lower for the occluded graft/stent group (43.3%, p < .001). Secondary patency rates were 80.1% and 75.2% at 1 and 5 years, respectively, without difference between the subgroups. The amputation rate was lower in the embolic group at 1 and 5 years (8.1% and 11.1%, respectively, p = .001). Survival was higher in the group with occluded.popliteal aneurysms at 5 years (83.3%, p = 0.004). Amputation free survival was 72.1% and 45.2% at 1 and 5 years; lower in the occluded graft/stent group at five years (37.9%, p = .007).

    Conclusion: Intra-arterial thrombolytic therapy achieves good medium and long-term clinical outcome, reducing the need of open surgical treatment in most patients.

    Keywords
    Thrombolysis, Acute limb ischaemia, Long-term outcome, Long-term follow-up, Amputation free survival, Aetiological subgroups
    National Category
    Cardiac and Cardiovascular Systems Surgery
    Identifiers
    urn:nbn:se:uu:diva-329713 (URN)10.1016/j.ejvs.2017.02.003 (DOI)000403518800018 ()28291676 (PubMedID)
    Available from: 2017-10-03 Created: 2017-10-03 Last updated: 2018-10-24Bibliographically approved
    3. Open versus endovascular revascularization in the treatment of acute lower limb ischaemia
    Open this publication in new window or tab >>Open versus endovascular revascularization in the treatment of acute lower limb ischaemia
    Show others...
    2018 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 12, p. 1598-1606Article in journal (Refereed) Published
    Abstract [en]

    Background: Consensus is lacking regarding intervention for patients with acute lower limb ischaemia (ALI). The aim was to study amputation-free survival in patients treated for ALI by either primary open or endovascular revascularization.

    Methods: The Swedish Vascular Registry (Swedvasc) was combined with the Population Registry and National Patient Registry to determine follow-up on mortality and amputation rates. Revascularization techniques were compared by propensity score matching 1:1.

    Results: Of 9736 patients who underwent open surgery and 6493 who had endovascular treatment between 1994 and 2014, 3365 remained in each group after propensity score matching. Results are from the matched cohort only. Mean age of the patients was 74⋅7 years; 47⋅5 per cent were women and mean follow-up was 4⋅3 years. At 30-day follow-up, the endovascular group had better patency (83⋅0 versus 78⋅6 per cent; P < 0⋅001). Amputation rates were similar at 30 days (7⋅0 per cent in the endovascular group versus 8⋅2 per cent in the open group; P = 0⋅113) and at 1 year (13⋅8 versus 14⋅8 per cent; P = 0⋅320). The mortality rate was lower after endovascular treatment, at 30 days (6⋅7 versus 11⋅1 per cent; P < 0⋅001) and after 1 year (20⋅2 versus 28⋅6 per cent; P < 0⋅001). Accordingly, endovascular treatment had better amputation-free survival at 30 days (87⋅5 versus 82⋅1 per cent; P < 0⋅001) and 1 year (69⋅9 versus 61⋅1 per cent; P < 0⋅001). The number needed to treat to prevent one death within the rst year was 12 with an endovascular compared with an open approach. Five years after surgery, endovascular treatment still had improved survival (HR 0⋅78, 99 per cent c.i. 0⋅70 to 0⋅86) but the difference between the treatment groups occurred mainly in the rst year.

    Conclusion: Primary endovascular treatment for ALI appeared to reduce mortality compared with open surgery, without any difference in the risk of amputation.

    National Category
    Medical and Health Sciences Surgery
    Research subject
    Medical Science; Surgery
    Identifiers
    urn:nbn:se:uu:diva-363353 (URN)10.1002/bjs.10954 (DOI)000447124200007 ()
    Available from: 2018-10-17 Created: 2018-10-17 Last updated: 2018-12-12Bibliographically approved
    4. Time-trends and management of acute aortic occlusion: a 21-years´ experience
    Open this publication in new window or tab >>Time-trends and management of acute aortic occlusion: a 21-years´ experience
    (English)In: Article in journal (Other academic) Submitted
    Abstract [en]

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

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

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

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

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

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

    National Category
    Medical and Health Sciences
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-363356 (URN)
    Available from: 2018-10-17 Created: 2018-10-17 Last updated: 2018-10-24Bibliographically approved
  • 266.
    Grip, Olivia
    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.
    There is no advantage using heparin with intra-arterial thrombolysis2015In: Vascular and Endovascular Controversies Update / [ed] Greenhalgh R, London: BIBA Publishing , 2015, p. 315-320Chapter in book (Other academic)
  • 267.
    Grip, Olivia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Kuoppala, M.
    Acosta, S.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Akeson, J.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 9, p. 1105-1112Article in journal (Refereed)
    Abstract [en]

    Background: Thrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications. Methods: This was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA). Results: Some 749 procedures in 644 patients of median age 73 years were studied; 353 (47.1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38.8 per cent, acute arterial thrombosis in 32.2 per cent, embolus in 22.3 per cent and popliteal aneurysm in 6.7 per cent. Concomitant heparin infusion was used in 63.2 per cent. The mean dose of rtPA administered was 21.0mg, with a mean duration of 25.2 h. Technical success was achieved in 80.2 per cent. Major amputation and death within 30 days occurred in 13.1 and 4.4 per cent respectively. Bleeding complications occurred in 227 treatments (30.3 per cent). Blood transfusion was needed in 104 (13.9 per cent). Three patients (0.4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation-free survival was 83.6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2.98; P < 0 001). Independent risk factors for fasciotomy were severe ischaemia (OR 2.94) and centre (OR 6 50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0.30; P = 0.003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3.82) and renal insufficiency (OR 3.86). Conclusion: Both treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra-arterial thrombolysis appeared to offer no advantage.

  • 268.
    Grip, Olivia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Välj ....
    Kuoppala, Monica
    Acosta, Stefan
    Wanhainen, Anders
    Åkesson, Jonas
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Department of Surgical Sciences, Section of Vascular Surgery, Uppsala, and Lund University, Department of Clinical Sciences Malmö, Malmö, Sweden.
    Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 9Article in journal (Refereed)
    Abstract [en]

    Background

    Thrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications

    This was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA).

    Results

    Some 749 procedures in 644 patients of median age 73 years were studied; 353 (47·1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38·8 per cent, acute arterial thrombosis in 32·2 per cent, embolus in 22·3 per cent and popliteal aneurysm in 6·7 per cent. Concomitant heparin infusion was used in 63·2 per cent. The mean dose of rtPA administered was 21·0 mg, with a mean duration of 25·2 h. Technical success was achieved in 80·2 per cent. Major amputation and death within 30 days occurred in 13·1 and 4·4 per cent respectively. Bleeding complications occurred in 227 treatments (30·3 per cent). Blood transfusion was needed in 104 (13·9 per cent). Three patients (0·4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation‐free survival was 83·6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2·98; P <0·001). Independent risk factors for fasciotomy were severe ischaemia (OR 2·94) and centre (OR 6·50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0·30; P = 0·003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3·82) and renal insufficiency (OR 3·86).

    Conclusion

    Both treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra‐arterial thrombolysis appeared to offer no advantage.

  • 269.
    Grip, Olivia
    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.
    Lund Univ, Dept Clin Sci, Malmo, Sweden..
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Long-term Outcome after Thrombolysis for Acute Lower Limb Ischaemia2017In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 53, no 6, p. 853-861Article in journal (Refereed)
    Abstract [en]

    Objectives: The purpose was to study long-term outcome after thrombolysis for acute arterial lower limb ischaemia, and to evaluate the results depending on the underlying aetiology of arterial occlusion.

    Methods: This was a retrospective study of patients entered into a prospective database. Patients were identified in prospective databases from two vascular centres, including a large number of variables. Case records were analysed retrospectively. Through cross linkage with the Population Registry 100% accurate survival data were obtained. Between January 2001 and December 2013, 689 procedures were included. The aetiology of ischaemia was graft/stent/stent graft occlusion in 39.8%, arterial thrombosis in 27.7%, embolus in 25.1% and popliteal aneurysm in 7.4%.

    Results: The mean follow-up was 59.4 months (95% CI, 56.1-62.7), during which 32.9% needed further re interventions, 16.4% underwent amputation without re-intervention, and 50.7% had no re-intervention. The need for re-intervention during follow-up was 48.0% in the graft/stent occlusions group, 34.0% of the popliteal aneurysm group, 25.4% in the thrombosis group, and 16.3% in the embolus group (p < .001). The overall primary patency rates were 69.1% and 55.9% at 1 and 5 years, respectively. Primary patency at 5 years was higher for the embolus group (83.3%, p = .002) and lower for the occluded graft/stent group (43.3%, p < .001). Secondary patency rates were 80.1% and 75.2% at 1 and 5 years, respectively, without difference between the subgroups. The amputation rate was lower in the embolic group at 1 and 5 years (8.1% and 11.1%, respectively, p = .001). Survival was higher in the group with occluded.popliteal aneurysms at 5 years (83.3%, p = 0.004). Amputation free survival was 72.1% and 45.2% at 1 and 5 years; lower in the occluded graft/stent group at five years (37.9%, p = .007).

    Conclusion: Intra-arterial thrombolytic therapy achieves good medium and long-term clinical outcome, reducing the need of open surgical treatment in most patients.

  • 270.
    Grip, Olivia
    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.
    Acute Aortic Occlusion: Nationwide Cohort Study2019In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 139, no 2, p. 292-294Article in journal (Refereed)
  • 271.
    Grip, Olivia
    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.
    Temporal Trends and Management of Acute Aortic Occlusion: A 21 Year Experience2019In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 58, no 5, p. 690-696Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim was to study patients with acute aortic occlusion (AAO), a rare and life threatening event, in a population based cohort and the outcome of surgical treatment.

    Methods: The Swedish nationwide vascular database (Swedvasc) was used to identify cases, and the population registry to study long term survival. Variables associated with outcome were tested with the chi-square test and analysis of variance.

    Results: During the 21 year study period (1994-2014), 693 cases of surgical treatment for AAO were included, with a yearly incidence of 3.6 per million inhabitants. Mean +/- SD age was 69.9 +/- 11.2 years, 352 patients (50.8%) were women, and mean +/- SD length of follow up was 5.2 +/- 5.5 years. Most patients presented with bilateral acute limb ischaemia (596 patients, 86.0%). The aetiology of AAO was native artery thrombosis in 458 patients (66.1%), saddle embolus in 152 (21.9%), and occluded graft/stent/stent grafts in 83 (12.0%). The proportion of occluded grafts/stent/stent grafts increased during the study period (n = 14 [6.7%] in 1994-2000 vs. n = 45 [17.4%] in 2008-2014; p < .001) with a simultaneous reduction of arterial thrombosis (n = 149 [71.6%] in 1994-2000 vs. n = 158 [61.2%] in 2008-2014; p <. 001). Major amputation above the ankle was performed in 39 patients (8.5%), and 140 patients died within 30 days of surgery (20.2%). Thirty day mortality rate was lower after occluded grafts/stents/stent grafts (eight patients [9.6%]) and higher after saddle embolus (47 patients [30.9%]); p < .001). There was a reduction in overall 30 day mortality over time (n = 53 [25.5%] in 1994-2000 vs. n = 40 [15.5%] in 2008-2014; p = .007). Long term survival revealed significant differences between the subgroups, although the difference occurred early after the event (p < .001).

    Conclusions: Mortality after surgical treatment of AAO is improving over time, yet a significant mortality rate was observed throughout the study period. The proportion of AAO secondary to occluded grafts/stents/stent grafts increased over time.

  • 272.
    Grip, Olivia
    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.
    Time-trends and management of acute aortic occlusion: a 21-year experienceIn: Article in journal (Other academic)
    Abstract [en]

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

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

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

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

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

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

  • 273.
    Grip, Olivia
    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.
    Time-trends and management of acute aortic occlusion: a 21-years´ experienceIn: Article in journal (Other academic)
    Abstract [en]

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

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

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

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

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

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

  • 274.
    Grip, Olivia
    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.
    Michaëlsson, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Lindhagen, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Open versus endovascular revascularization in the treatment of acute lower limb ischaemia2018In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 12, p. 1598-1606Article in journal (Refereed)
    Abstract [en]

    Background: Consensus is lacking regarding intervention for patients with acute lower limb ischaemia (ALI). The aim was to study amputation-free survival in patients treated for ALI by either primary open or endovascular revascularization.

    Methods: The Swedish Vascular Registry (Swedvasc) was combined with the Population Registry and National Patient Registry to determine follow-up on mortality and amputation rates. Revascularization techniques were compared by propensity score matching 1:1.

    Results: Of 9736 patients who underwent open surgery and 6493 who had endovascular treatment between 1994 and 2014, 3365 remained in each group after propensity score matching. Results are from the matched cohort only. Mean age of the patients was 74⋅7 years; 47⋅5 per cent were women and mean follow-up was 4⋅3 years. At 30-day follow-up, the endovascular group had better patency (83⋅0 versus 78⋅6 per cent; P < 0⋅001). Amputation rates were similar at 30 days (7⋅0 per cent in the endovascular group versus 8⋅2 per cent in the open group; P = 0⋅113) and at 1 year (13⋅8 versus 14⋅8 per cent; P = 0⋅320). The mortality rate was lower after endovascular treatment, at 30 days (6⋅7 versus 11⋅1 per cent; P < 0⋅001) and after 1 year (20⋅2 versus 28⋅6 per cent; P < 0⋅001). Accordingly, endovascular treatment had better amputation-free survival at 30 days (87⋅5 versus 82⋅1 per cent; P < 0⋅001) and 1 year (69⋅9 versus 61⋅1 per cent; P < 0⋅001). The number needed to treat to prevent one death within the rst year was 12 with an endovascular compared with an open approach. Five years after surgery, endovascular treatment still had improved survival (HR 0⋅78, 99 per cent c.i. 0⋅70 to 0⋅86) but the difference between the treatment groups occurred mainly in the rst year.

    Conclusion: Primary endovascular treatment for ALI appeared to reduce mortality compared with open surgery, without any difference in the risk of amputation.

  • 275.
    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.

  • 276.
    Gürtelschmid, Mikael
    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.
    Comparison of three ultrasound methods of measuring the diameter of the abdominal aorta2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 6, p. 633-636Article in journal (Refereed)
    Abstract [en]

    Background: Three ultrasound methods of measuring the diameter of the abdominal aorta exist: the outer-to-outer (OTO) method, where callipers are placed on the outer layer of the aortic wall; the inner-to-inner (ITI) method, where callipers are placed on the inner layer of the aortic wall; and the leading edge-to-leading edge (LELE) method, where callipers are placed on the outer layer of the anterior wall and the inner layer of the posterior wall. The aim was to determine the variability of the three methods, differences between them, and the consequences on prevalence estimates. Methods: Some 127 consecutive patients with a small abdominal aortic aneurysm (AAA) were included. The maximal anteroposterior diameter was measured using the OTO, ITI and LELE methods by two vascular sonographers who were blinded to each other's measurements. The variability was described as the standard deviation. Results: The variability was 2.7 (95 per cent limits of agreements +/- 5.4) mmfor the OTO, 2.3 (+/- 4.6) mm for the ITI and 2.0 (+/- 4.0) mm for the LELE method. The corresponding coefficients of variability were 6.4, 6.1 and 5.0 per cent. The difference was 4.1mm between ITI and OTO (P < 0.001), 2.0 mm between ITI and LELE (P < 0.001), and 2.1mm between LELE and OTO (P < 0.001). Conclusion: LELE measurement was the most reproducible method of measuring the abdominal aorta. All methods showed a high degree of variability.

  • 277. Hammarskjöld, Fredrik
    et al.
    Nielsen, Niklas
    Rödjer, Stig
    Pärsson, Håkan
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences. Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Falkmer, Ursula
    Malmvall, Bo-Eric
    Perifert inlagd central venkateter ännu inte utvärderad för kliniskt bruk:  Mer vetenskapligt stöd krävs, visar litteraturstudie2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 21, p. 1576-80Article in journal (Refereed)
  • 278.
    Hammo, Sari
    et al.
    Karolinska Inst, Dept Vasc Surg, Stockholm, Sweden;Karolinska Univ Hosp, Stockholm, Sweden.
    Larzon, Thomas
    Orebro Univ Hosp, Fac Med & Vasc Surg, Dept Cardiothorac & Vasc Surg, Orebro, Sweden.
    Hultgren, Rebecka
    Karolinska Inst, Dept Vasc Surg, Stockholm, Sweden;Karolinska Univ Hosp, Stockholm, Sweden.
    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.
    Resch, Timothy
    Skane Univ Hosp, Vasc Ctr, Malmo, Sweden.
    Falkenberg, Marten
    Sahlgrens Univ Hosp, Dept Hybrid & Intervent Surg, Unit Vasc Surg, Gothenburg, Sweden.
    Forssell, Claes
    Linkoping Univ, Dept Thorac & Vasc Surg, Linkoping, Sweden;Linkoping Univ, Dept Med & Hlth Sci, Linkoping, Sweden.
    Sonesson, Bjorn
    Skane Univ Hosp, Vasc Ctr, Malmo, Sweden.
    Pirouzram, Artai
    Orebro Univ Hosp, Fac Med & Vasc Surg, Dept Cardiothorac & Vasc Surg, Orebro, Sweden.
    Roos, Hakan
    Sahlgrens Univ Hosp, Dept Hybrid & Intervent Surg, Unit Vasc Surg, Gothenburg, Sweden.
    Hellgren, Tina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Khan, Shazhad
    Skane Univ Hosp, Vasc Ctr, Malmo, Sweden.
    Hoijer, Jonas
    Karolinska Inst, Inst Environm Med, Unit Biostat, Stockholm, Sweden.
    Wahlgren, Carl-Magnus
    Karolinska Inst, Dept Vasc Surg, Stockholm, Sweden;Karolinska Univ Hosp, Stockholm, Sweden.
    Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study2019In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 57, no 6, p. 788-794Article in journal (Refereed)
    Abstract [en]

    Objective: The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). Methods: This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression. Results: There were 140 patients (age [mean +/- SD] 74.1 +/- 8.8 years; 56% men; aneurysm size 64.8 +/- 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.194.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p = .001), stroke (HR 2.63; 95% CI 1.37-5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p = .001) were all associated with mortality. Conclusions: This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

  • 279.
    Hansen, Tomas
    et al.
    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.
    Sörensen, Jens
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Johansson, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Lymph nodes as a potential pitfall in carotid plaque imaging with FDG-PET/CT2011In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 215, no 1, p. 247-248Article in journal (Refereed)
  • 280. Harenberg, Job
    et al.
    Kakkar, A.
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Barrowcliffe, T.
    Casu, B.
    Fareed, J.
    Mismetti, P.
    Ofosu, F. A.
    Raake, W.
    Samama, M.
    Schulman, S.
    Recommendations on biosimilar low-molecular-weight heparins2009In: Journal of Thrombosis and Haemostasis, ISSN 1538-7933, E-ISSN 1538-7836, Vol. 7, no 7, p. 1222-1225Article in journal (Refereed)
    Abstract [en]

    Based on the results of large clinical trials, several low-molecular-weight heparins (LMWHs) have been approved for prophylaxis and the treatment of venous and arterial thromboembolism. As a result of expiration or pending expiration of patent protection of the originator LMWHs, many generic or biosimilar LMWHs have been approved in some countries and more are likely to be approved elsewhere. Their greater availability may reduce the treatment costs. The Working Party on Requirements for Development of Biosimilar LMWHs of the Subcommittee on Control of Anticoagulation, Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis has reached a consensus on recommendations to ensure the quality of biosimilar LMWHs as compared with the originator LMWHs.

  • 281.
    Hassan, Baderkhan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Endovascular aortic aneurysm repair: Aspects of follow-up and complications2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Endovascular aortic aneurysm repair (EVAR) is the procedure of choice in most patients with abdominal aortic aneurysm. The drawbacks of EVAR are a higher rate of complications and frequent need for reinterventions, requiring regular postoperative follow-up. Non-stratified follow-up may have a deleterious effect on patients and the health care system. The aim of this thesis is to develop strategies that can stratify the EVAR follow-up programme according to an individual patient´s risk profile.

    Study I, an international multicentre study of all abdominal aortic aneurysm (AAA) patients with EVAR in three centres (2000 to 2011) demonstrated a lower rate of late complications and reinterventions in patients with sac shrinkage during the first postoperative year, compared to the non-shrinkage group.

    Study II, an international multicentre study of patients treated for a ruptured aortic aneurysm with EVAR in three centres (2000 to 2012) demonstrated that ruptured EVAR (rEVAR) in patients with hostile anatomy is associated with a high rate of graft-related complications, reinterventions and increased overall mortality.

    Study III, a two-centre cohort study of 326 patients with EVAR (2001 to 2012), with first postoperative computerised tomographic angiography (CTA) within one year of the operation. Patients with adequate proximal and distal sealing zones and no endoleak in the first postoperative CTA had significantly lower risk for AAA-related complications and reinterventions up to five years postoperatively.

    Study IV, studied all complications and reinterventions in a two-centre cohort study of all EVAR patients (1998 to 2012), One-fourth of the patients in the study developed complications during a mean follow-up of five years. Most complications were asymptomatic imaging-detected. Ultrasound could detect most of the clinically significant complications.

    List of papers
    1. Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair
    Open this publication in new window or tab >>Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair
    Show others...
    2014 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 7, p. 802-810Article in journal (Refereed) Published
    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.

    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-228003 (URN)10.1002/bjs.9516 (DOI)000335648000010 ()
    Available from: 2014-07-03 Created: 2014-07-02 Last updated: 2017-12-05Bibliographically approved
    2. Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm
    Open this publication in new window or tab >>Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm
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    2016 (English)In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 23, no 6, p. 919-927Article in journal (Refereed) Published
    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.

    Keywords
    abdominal aortic aneurysm, complications, endovascular aneurysm repair, instructions for use, mortality, neck angulation, neck diameter, neck length, secondary interventions, stent-graft
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-308343 (URN)10.1177/1526602816658494 (DOI)000387483900012 ()27385153 (PubMedID)
    Available from: 2016-11-24 Created: 2016-11-24 Last updated: 2017-12-04Bibliographically approved
    3. Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging
    Open this publication in new window or tab >>Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging
    Show others...
    2018 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 05, no 6, p. 709-718Article in journal (Refereed) Published
    Abstract [en]

    Background

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

    Methods

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

    Results

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

    Conclusion

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

    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-334332 (URN)10.1002/bjs.10766 (DOI)000430058000014 ()
    Available from: 2017-11-22 Created: 2017-11-22 Last updated: 2018-08-08Bibliographically approved
    4. Detection of late complications after endovascular abdominal aortic aneurysm repair and implications for follow-up
    Open this publication in new window or tab >>Detection of late complications after endovascular abdominal aortic aneurysm repair and implications for follow-up
    (English)Manuscript (preprint) (Other academic)
    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-334329 (URN)
    Available from: 2017-11-22 Created: 2017-11-22 Last updated: 2017-12-04
  • 282.
    Hasvold, Pal
    et al.
    AstraZeneca Nord Balt, Dept Med, S-15185 Sodertalje, Sweden.;Univ Oslo, Fac Med, POB 1078, N-0316 Oslo, Norway..
    Nordanstig, Joakim
    Sahlgrens Univ Hosp, Dept Vasc Surg, Bla Straket 5, S-41345 Gothenburg, Sweden.;Gothenburg Univ, Sahlgrenska Acad, Dept Mol & Clin Med, Inst Med, Bla Straket 5B Wallenberglab SU, S-40530 Gothenburg, Sweden..
    Kragsterman, Björn
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Kristensen, Thomas
    AstraZeneca Nord Balt, Dept Med, S-15185 Sodertalje, Sweden..
    Falkenberg, Marten
    Sahlgrens Acad, Inst Clin Sci, Dept Radiol, S-41345 Gothenburg, Sweden..
    Johansson, Saga
    AstraZeneca Gothenburg, AstraZeneca R&D, Pepparedsleden 1, S-43153 Molndal, Sweden..
    Thuresson, Marcus
    Statisticon AB, Ostra Agatan 31, S-75322 Uppsala, Sweden..
    Sigvant, Birgitta
    Karlstad Cent Hosp, Dept Vasc Surg, Rosenborgsgatan 2, S-65230 Karlstad, Sweden.;Karolinska Inst, Sodersjukhuset, Dept Clin Sci & Educ, Solnavagen 1, S-17177 Stockholm, Sweden..
    Long-term cardiovascular outcome, use of resources, and healthcare costs in patients with peripheral artery disease: results from a nationwide Swedish study2018In: European Heart Journal - Quality of Care and Clinical Outcomes, ISSN 2058-5225, E-ISSN 2058-1742, Vol. 4, no 1, p. 10-17Article in journal (Refereed)
    Abstract [en]

    Aims: Data on long-term healthcare costs of patients with peripheral artery disease (PAD) is limited, and the aim of this study was to investigate healthcare costs for PAD patients at a nationwide level.

    Methods and results: A cohort study including all incident patients diagnosed with PAD in the Swedish National Patient Register between 2006-2014, and linked to cause of death-and prescribed drug registers. Mean per-patient annual healthcare costs (2015 Euros (sic)) (hospitalisations and out-patient visits) were divided into cardiovascular (CV), lower limb and non-CV related cost. Results were stratified by high and low CV risk. The study included 66,189 patients, with 221,953 observation-years. Mean total healthcare costs were (sic)6,577, of which 26% was CV-related ((sic)1,710), during the year prior to the PAD diagnosis. First year after PAD diagnosis, healthcare costs were (sic)12,549, of which (sic)3,824 (30%) was CV-related and (sic)3,201 (26%) lower limb related. Highrisk CV patients had a higher annual total healthcare and CV related costs compared to low risk CV patients during follow-up ((sic)7,439 and (sic)1,442 versus (sic)4,063 and (sic)838). Annual lower limb procedure costs were (sic)728 in the PAD population, with lower limb revascularisations as key cost driver ((sic)474).

    Conclusion: Non-CV related hospitalizations and outpatient visits were the largest cost contributors for PAD patients. There is a substantial increase in healthcare costs in the first year after being diagnosed with PAD, driven by PAD follow-up and lower limb related procedures. Among the CV-related costs, hospitalisations and outpatient visits related to PAD represented the largest costs.