Leukocyte subsets and abdominal aortic aneurysms detected by screening in men.

OBJECTIVE: In the present case-control study, we describe the associations between leukocyte subsets in blood and early, screening-detected AAA in men. An abdominal aortic aneurysm (AAA) may result in a life-threatening rupture of the aortic wall. The trigger for AAA formation remains unknown, but the vascular adventitia of advanced AAAs is infiltrated by various leukocytes, indicating that the pathogenesis may involve inflammation. METHODS: In Sweden, all 65-year-old men are invited to an ultrasound examination for detection of AAA. At the Gothenburg screening site, 16 256 men were examined in 2013-2017, 1.2% of whom had an AAA (diameter of the infrarenal aorta ≥30 mm). All men with AAA at screening as well as a randomized selection of AAA-free screened men were invited to participate in a case-control study. RESULTS: The median diameter of AAAs was 33 mm. Men with an AAA (n = 151) had a higher frequency of smoking, hypertension and statin use than controls (n = 224). Blood levels of neutrophils, lymphocytes, monocytes and basophils were higher in individuals with an AAA, but eosinophil count did not differ from controls. Odds ratios (95% confidence interval) for AAA were 8.6 (4.2-17.4), 3.5 (1.9-6.6) and 3.3 (1.8-6.3) for the highest versus lowest quartile of neutrophils, lymphocytes and monocytes, respectively. For neutrophils and lymphocytes, the association with AAA remained significant after adjustment for smoking and other known risk factors/markers. CONCLUSION: Several, but not all, subsets of circulating leukocytes are associated with screening-detected AAA in men, which is insufficiently explained by associations with smoking and other confounders.

Weak Links in the Early Chain of Care of Acute Lower Limb Ischaemia in Terms of Recognition and Emergency Management.

OBJECTIVES: Acute lower limb ischaemia (ALLI) is a potentially fatal, limb threatening medical emergency. Early treatment is essential for a good outcome. The aim was to describe the early chain of care in ALLI focusing on lead times and emergency management in order to identify weak links for improvement. METHODS: This was a retrospective, descriptive case study. This study analysed the medical records of all patients with a main discharge diagnosis of ALLI between January 2009 and December 2014. Predetermined emergency care data on lead times, diagnosis recognition, presenting symptoms, emergency care treatment and outcome were collected for patients who were transported by the Emergency Medical Service (EMS) and those who were not. RESULTS: In total, 552 medical records were audited of which 195 patients fulfilled the inclusion criteria and were analysed. Among them were 117 (60%) transported by the EMS. The median time from symptom onset to revascularisation was 23 (interquartile range [IQR] 10-55; EMS transported) and 93 (IQR 42-152, not EMS transported) hours (p < .01). The time from symptom onset to arrival in hospital was 5 (IQR 2-26; EMS transported) and 48 (IQR 6-108; not EMS transported) hours. After arrival in hospital, the median time to first doctor evaluation was 51 (IQR 28-90; EMS transported) and 80 (IQR 44-169; not EMS transported) minutes, p = .01. Low molecular weight heparin (LMWH) was given to 72% of patients in the emergency department (ED) and a multivariate analysis showed that the use of LMWH was associated with a more favourable outcome. CONCLUSIONS: Both the time spent in the ED and the time from the onset of symptoms to revascularisation were considerably longer than optimal. Time delays in the early treatment chain can mainly be attributed to "patient delay" and a considerable time spent in hospital before revascularisation. The use of LMWH as an integral part of ED management was associated with a better outcome.

The Impact of Initial Misdiagnosis of Ruptured Abdominal Aortic Aneurysms on Lead Times, Complication Rate, and Survival.

OBJECTIVE/BACKGROUND: To investigate the frequency of initial misdiagnosis and the clinical consequences of an initial misdiagnosis of ruptured abdominal aortic aneurysms (rAAA). METHODS: This was a retrospective cohort study. Data from the Swedish National Registry for Vascular Surgery (Swedvasc) and medical charts were extracted for patients treated for rAAA in the West of Sweden in the period 2008-14. Initially misdiagnosed patients were compared with correctly diagnosed patients. RESULTS: In all, 261 patients were included in the study. Patients with rAAA were initially misdiagnosed in 33% (n = 86) of the cases and this caused a 4.8 hour (median time) additional delay to surgical intervention. There were no differences in 30 day mortality between initially misdiagnosed patients and correctly diagnosed patients (27.9% vs. 28.0%; p = 1.00). The adjusted odds ratio for mortality in initially misdiagnosed patients compared with correctly diagnosed patients was 0.78 (95% confidence interval 0.38-1.60). No difference was observed between the groups regarding 90 day mortality, length of intensive care, need for post-operative ventilator support, need of haemodialysis support, and length of hospital stay. CONCLUSION: Misdiagnosis is common in patients with rAAA, and treatment is significantly delayed in misdiagnosed patients. The study did not show any survival disadvantage or increased frequency of post-operative complications in misdiagnosed patients despite the delayed treatment. However, only patients who reached surgical intervention were included in the analysis.

Low post-operative mortality after surgery on patients with screening-detected abdominal aortic aneurysms: a Swedvasc registry study.

OBJECTIVES: Screening for abdominal aortic aneurysms (AAAs) substantially reduces aneurysm-related mortality in men and is increasing worldwide. This cohort study compares post-operative mortality and complications in men with screening-detected vs. non-screening-detected AAAs. METHODS: Data were extracted from the Swedish National Registry for Vascular Surgery (Swedvasc) for all screening-detected men treated for AAA (n = 350) and age-matched controls treated for non-screening-detected AAA (n = 350). RESULTS: There were no differences in baseline characteristics besides age, which was lower in the screening-detected group than in the non-screening-detected group (median 66 vs. 68, p < .001). Open repair was used more frequently than endovascular aortic repair (EVAR) in patients with screening-detected AAAs than in non-screening-detected controls (56% vs. 45% p = .005). No differences in major post-operative complications at 30 days were observed between the groups. In patients treated with open repair there were no differences in 30-day, 90-day or 1-year mortality in screening-detected patients compared to non-screening-detected controls (1.0% vs. 3.2% p = .25, 2.1% vs. 4.5% p = .23, 4.1% vs. 5.8% p = .61). None of the patients treated with EVAR in either group died within 30 days. The 90-day mortality after EVAR was lower in patients with screening-detected AAA than in those with non-screening-detected AAAs (0.0% vs. 3.1%, p = .04). No difference in the 1-year mortality was detected in the EVAR-patients between the two groups (1.4% vs. 4.7%, p = .12). CONCLUSIONS: The contemporary post-operative mortality after AAA surgery was low in this national audit of patients with screening-detected AAAs and age-matched controls. Patients with screening-detected AAAs have the same frequency of complications at 30 days as patients with non-screening-detected AAA. This study gives further support to national screening programs for the detection of AAA in men.

Nationwide experience of cardio- and cerebrovascular complications during infrainguinal endovascular intervention for peripheral arterial disease and acute limb ischaemia.

OBJECTIVES: Endovascular treatment for peripheral arterial disease (PAD) is increasingly used and also continuously applied to more severe vascular pathology. Only few studies report on systemic complications during these procedures, but it is important to address these risks. We report the results of a recent national audit on cardio- and cerebrovascular complications after endovascular procedures for PAD. METHODS: Data from the Swedish Vascular Registry (Swedvasc) were retrieved on all infrainguinal endovascular procedures performed between May 2008 and December 2011. A total of 9187 cases were analysed regarding the prevalence of myocardial infarction and major stroke within 30 days post-intervention. A literature review in PubMed and Cochrane databases was conducted. RESULTS: The risk of myocardial infarction was 0.3% in intermittent claudication, 1.2% in critical limb ischaemia and 1% in acute limb ischaemia. Corresponding risk of major stroke was 0.4%, 0.3% and 1.4%. Thrombolytic therapy was associated with a threefold risk of major stroke. Only a few studies relevant to the subject were found during the literature review. CONCLUSIONS: In this population-based study we found a low risk of cardiac complications, but catheter-administered thrombolytic therapy entailed a non-negligible risk of major stroke.