The association between bacterial infections and the risk of coronary heart disease in type 1 diabetes.

BACKGROUND: Diabetes increases the risk of infections and coronary heart disease (CHD). Whether infections increase the risk of CHD and how this applies to individuals with diabetes is unclear. OBJECTIVES: To investigate the association between bacterial infections and the risk of CHD in type 1 diabetes. METHODS: Individuals with type 1 diabetes (n = 3781) were recruited from the Finnish Diabetic Nephropathy Study (FinnDiane), a prospective follow-up study. CHD was defined as incident events: fatal or nonfatal myocardial infarction, coronary artery bypass surgery or percutaneous coronary intervention, identified through national hospital discharge register data. Infections were identified through national register data on all antibiotic purchases from outpatient care. Register data were available from 1 January 1995 to 31 December 2015. Bacterial lipopolysaccharide (LPS) activity was measured from serum samples at baseline. Data on traditional risk factors for CHD were collected during baseline and consecutive visits. RESULTS: Individuals with an incident CHD event (n = 370) had a higher mean number of antibiotic purchases per follow-up year compared to those without incident CHD (1.34 [95% CI: 1.16-1.52], versus 0.79 [0.76-0.82], P < 0.001), as well as higher levels of LPS activity (0.64 [0.60-0.67], versus 0.58 EU mL-1 [0.57-0.59], P < 0.001). In multivariable-adjusted Cox proportional hazards models, the mean number of antibiotic purchases per follow-up year was an independent risk factor for incident CHD (HR 1.21, 95% CI: 1.14-1.29, P < 0.0001). High LPS activity was a risk factor for incident CHD (HR 1.93 [1.34-2.78], P < 0.001) after adjusting for static confounders. CONCLUSION: Bacterial infections are associated with an increased risk of incident CHD in individuals with type 1 diabetes.

Bloodstream infections following different types of surgery in a Finnish tertiary care hospital, 2009-2014.

The risk and outcome of bloodstream infections (BSIs) were evaluated following surgery. BSIs were identified in Helsinki University Hospital during 2009-2014 as part of the national surveillance. Of 711 BSIs identified, 51% were secondary and 49% primary. The rate was highest after cardiovascular surgery (8.7 per 1000 procedures) and lowest after gynaecologic (1.0 per 1000). Surgical site infection was the most frequent source of secondary BSIs (34%) and 45% of primary BSIs were central-line-associated. The 28-day case fatality ranged from zero in gynaecology/obstetrics to 21% in cardiovascular surgery. Besides BSIs related to surgical site infections, half of BSIs were primary, providing additional foci for prevention.

Thrombocytopaenia during methicillin-sensitive Staphylococcus aureus bacteraemia.

The prognostic impact of thrombocytopaenia in Staphylococcus aureus bacteraemia (SAB) has previously been determined at bacteraemia onset only and relevant pre-bacteraemic thrombocytopaenia predisposing parameters have not been accounted for. We evaluated the prognostic impact of low thrombocyte count in SAB excluding pre-bacteraemic factors potentially causing thrombocytopaenia. This was a multicentre retrospective analysis of methicillin-sensitive SAB (MS-SAB) patients. Thrombocyte count was determined at blood culture collection and at days 3 and 7. Thrombocytopaenia was defined as a thrombocyte count less than 150 ×109/L. Patients with chronic alcoholism, liver diseases and haematologic malignancies were excluded. Altogether, 495 patients were identified. Thrombocytopaenia at blood culture and at day 3 associated to endocarditis (p < 0.05 and p < 0.01) and defervescence (p < 0.001 and p < 0.01). Mortality at 90 days was higher for patients with thrombocytopaenia at blood culture collection (26 vs. 16%, p < 0.05), at day 3 (32 vs. 13%, p < 0.01) and at day 7 (50 vs. 14%, p < 0.001). In receiver operating characteristic analyses, thrombocytopaenia predicted a poor outcome at blood culture collection (p < 0.05), at day 3 (p < 0.001) and at day 7 (p < 0.001). When accounting for all prognostic parameters, thrombocytopaenia at day 3 [hazard ratio (HR), 1.83; p = 0.05] demonstrated a trend towards poor outcome, whereas thrombocytopaenia at day 7 (HR, 3.64; p < 0.001) associated to poor outcome. Thrombocytopaenia at blood culture collection was not a prognostic parameter when all prognostic factors were taken into account. However, thrombocytopaenia at day 3 indicated a poor outcome and thrombocytopaenia at day 7 was a significant independent negative prognostic marker that has not been previously reported in SAB.

Elevated soluble urokinase plasminogen activator receptor (suPAR) predicts mortality in Staphylococcus aureus bacteremia.

The soluble form of urokinase-type plasminogen activator receptor (suPAR) is a new inflammatory marker. High suPAR levels have been shown to associate with mortality in cancer and in chronic infections like HIV and tuberculosis, but reports on the role of suPAR in acute bacteremic infections are scarce. To elucidate the role of suPAR in a common bacteremic infection, the serum suPAR levels in 59 patients with Staphylococcus aureus bacteremia (SAB) were measured using the suPARnostic ELISA assay and associations to 1-month mortality and with deep infection focus were analyzed. On day three, after the first positive blood culture for S. aureus, suPAR levels were higher in 19 fatalities (median 12.3; range 5.7-64.6 ng/mL) than in 40 survivors (median 8.4; range 3.7-17.6 ng/mL, p = 0.002). This difference persisted for 10 days. The presence of deep infection focus was not associated with elevated suPAR levels as compared to patients with no deep infection focus. suPAR was found to be prognostic for mortality in receiver operator characteristic (ROC) curve analysis, which was not observed for serum C-reactive protein (CRP); the area under the curve (AUC) for suPAR was 0.754 (95% confidence interval [CI], 0.615-0.894, p = 0.003) and for CRP, it was 0.596 (95% CI, 0.442-0.750, p = 0.253). The optimal suPAR cut-off value in predicting 1-month mortality was 9.25 ng/mL. In conclusion, our study demonstrates that the new promising biomarker, serum suPAR concentration, was able to predict mortality in SAB.

Pulmonary histopathology in dalmatians with familial acute respiratory distress syndrome (ARDS).

The histopathological changes in the lungs of 12 related Dalmatians with idiopathic acute respiratory distress syndrome (ARDS) are described. Affected dogs had multiple foci of marked atypical hyperplasia and squamous metaplasia of the bronchiolar epithelium, patchy ongoing fibrosis with myofibroblastic metaplasia, smooth muscle hyperplasia and occasional honeycombing of alveolar walls, and hyperplasia of atypical type II pneumocytes. There was an abrupt transition between these proliferative lesions and areas of acute alveolar oedema with hyaline membranes in partially normal lung. Diseased areas were associated with moderate lymphohistiocytic interstitial inflammation. Immunohistochemical labelling for cytokeratin expression indicated that the metaplastic epithelium was of bronchiolar origin and that it extended into peribronchiolar alveolar spaces. Some of the bronchiolar lesions were pre-neoplastic and one adult dog suffered from bronchoalveolar carcinoma. These lesions are compared with the two forms of idiopathic interstitial pneumonia reported as causes of ARDS in man: acute interstitial pneumonia (AIP) and acute exacerbation of idiopathic pulmonary fibrosis (IPF). The observed lesions in the Dalmatians are distinct from the diffuse alveolar damage that characterizes AIP, but show some histological similarities to the usual interstitial pneumonia (UIP) that occurs in IPF with acute exacerbation in man. UIP has not previously been described in the dog.

Immunoglobulins and complement factor C4 in adult rhinosinusitis.

We assessed whether complement and its factor C4 or abnormal immunoglobulin levels are associated with chronic or recurrent rhinosinusitis. We used multiple patient and control groups to obtain clinically meaningful data. Adult chronic or recurrent rhinosinusitis and acute purulent rhinosinusitis patients were compared with unselected adults and controls without previous rhinosinusitis. Associated clinical factors were reviewed. Levels of immunoglobulins, plasma C3, C4 and classical pathway haemolytic activity were analysed. C4 immunophenotyping was used to detect C4A and C4B deficiencies as null alleles. Complement was up-regulated in rhinosinusitis. C4A nulls and low IgA, IgG, IgG1, IgG2, IgG3 and IgG4 levels were all more common in chronic or recurrent rhinosinusitis patients than in unselected and healthy controls. We searched for relevant differences between the patient groups. According to stepwise logistic regression analysis, nasal polyposis [odds ratio (OR) 10.64, 95% confidence interval (CI) 2.5-45.7, P = 0.001], bronchial asthma (OR 8.87, 95% CI 2.3-34.9, P = 0.002), C4A null alleles (OR 5.84, 95% CI 1.4-24.9, P = 0.017) and low levels of IgG4 together with either IgG1 or IgG2 (OR 15.25, 95% CI 1.4-166.8, P = 0.026) were more common in chronic or recurrent rhinosinusitis than in acute rhinosinusitis patients. Isolated low IgG subclasses had limited value in patient assessment. C4A null alleles are associated with chronic or recurrent rhinosinusitis, potentially through their effect on immune defence and inflammation control. Multiple clinical and immunological parameters may need to be evaluated when searching for prognostic variables.

Identification of target genes in laryngeal squamous cell carcinoma by high-resolution copy number and gene expression microarray analyses.

Molecular mechanisms contributing to initiation and progression of head and neck squamous cell carcinoma are still poorly known. Numerous genetic alterations have been described, but molecular consequences of such alterations in most cases remain unclear. Here, we performed an integrated high-resolution microarray analysis of gene copy number and expression in 20 laryngeal cancer cell lines and primary tumors. Our aim was to identify genetic alterations that play a key role in disease pathogenesis and pinpoint genes whose expression is directly impacted by these events. Integration of DNA level data from array-based comparative genomic hybridization with RNA level information from oligonucleotide microarrays was achieved with custom-developed bioinformatic methods. High-level amplifications had a clear impact on gene expression. Across the genome, overexpression of 739 genes could be attributed to gene amplification events in cell lines, with 325 genes showing the same phenomenon in primary tumors including FADD and PPFIA1 at 11q13. The analysis of gene ontology and pathway distributions further pinpointed genes that may identify potential targets of therapeutic intervention. Our data highlight genes that may be critically important to laryngeal cancer progression and offer potential therapeutic targets.

Infections of the central nervous system of suspected viral origin: a collaborative study from Finland.

We studied 3231 patients with acute central nervous system (CNS) symptoms of suspected viral origin to elucidate the current etiologic spectrum. In 46% of the cases, a viral finding was observed. Varicella-zoster virus (VZV) was the main agent associated with encephalitis, as well as meningitis and myelitis. VZV comprised 29% of all confirmed or probable etiologic agents. Herpes simplex virus (HSV) and enteroviruses accounted 11% each, and influenza A virus 7%. VZV seems to have achieved a major role in viral infections of CNS. In encephalitis in our population, VZV is clearly more commonly associated with these neurological diseases than HSV. The increase in VZV findings may in part be a pseudophenomenon due to improved diagnostic methods, however, a true increase may have occurred and the pathogenetic mechanisms behind this should be elucidated.

Efficacy of once-daily tobramycin monotherapy for acute pulmonary exacerbations of cystic fibrosis: a preliminary study.

Our objective was to compare the efficacy, safety, and microbiology of once-daily intravenous (IV) tobramycin with conventional 8-hourly tobramycin/ceftazidime IV therapy for acute Pseudomonas aeruginosa (PA) pulmonary exacerbations in cystic fibrosis (CF). CF patients with PA-induced pulmonary exacerbations were allocated to receive either once-daily tobramycin (Mono) or conventional therapy with tobramycin/ceftazidime given 8-hourly (Conv). The two longitudinal groups received therapy in a double-blind, randomized manner over a period of 2 years. Tobramycin doses were adjusted to achieve a daily area under the time-concentration curve of 100 mg x hr/L in both groups. Results were assessed for both short-term changes (efficacy and safety after 10 days of IV antibiotics during acute exacerbations) and long-term changes (efficacy, safety, and sputum microbiology between study entry and exit). Pulmonary function tests (PFTs) on admission were similar in both groups. After 10 days of IV antibiotics, absolute mean improvements in percent of predicted PFTs were 12.8, 12.1, and 13.7 for forced expiratory volume in 1 sec (FEV(1)), forced vital capacity (FVC), and forced expired flow between 25--75% of FVC (FEF(25--75%)) in the Conv group (n = 51 admissions) compared to 10.6, 9.9, and 10.6 in the Mono group (n = 47)(P<0.05 for all). Sixteen percent in the Conv group and 15% of patients in the Mono group did not respond to therapy by day 10. Long-term PFT patterns were similar for the Conv and Mono groups. The time between admissions did not differ. The Mono group showed a significant increase in tobramycin minimum inhibitory concentrations (MICs) against PA from study entry to study exit (P = 0.02, n = 27 strains); this failed to reach significance in the Conv group (P = 0.08, n = 25). There was no significant increase in the number of isolates, with MIC> or =8 mg/L in both groups. No short- or long-term changes in audiology or serum creatinine were found in either group. After 10 days of IV therapy, the urinary enzyme N-acetyl-beta-d-glucosaminidase/creatinine ratios increased in both groups (P0.05). This increase was greater in the Conv compared to the Mono group (P < 0.05). We conclude that this pilot study indicates once-daily tobramycin therapy to be as effective and safe as conventional 8-hourly tobramycin/ceftazidime therapy. Combination antibacterial therapy appears to offer no clinical advantage over once-daily tobramycin monotherapy. Tobramycin once-daily monotherapy is a potential alternative to conventional IV antibacterial therapy which deserves further investigation, including the impact on susceptibility of PA to tobramycin.

Comparative absorption and variability in absorption of estradiol from a transdermal gel and a novel matrix-type transdermal patch.

OBJECTIVES: To compare the absorption of estradiol from a transdermal gel and a novel matrix-type patch and to study the variability in absorption. METHODS: Twenty-four healthy postmenopausal women were treated in an open, randomized, cross-over study for 18 days with 1.0 mg estradiol daily as a transdermal gel and a transdermal patch releasing estradiol 50 microg/24 h without a wash-out between the periods. Venous blood samples for estradiol pharmacokinetics were taken on the 15th and 18th study days of the gel period and during the 15th-18th study days during the patch period. RESULTS: There was no significant difference in peak estradiol level or area under the estradiol time-concentration curve between the gel and the patch. However, trough estradiol concentration was significantly lower and fluctuation higher with the patch. Estradiol time-concentration curves on the 15th and 18th study days with the gel were almost superimposable. A significant difference was observed in peak estradiol levels, whereas area under the curve or trough estradiol level did not differ between the 15th and 18th study days with the gel. Inter- and intra-individual coefficients of variability were around 30% for peak estradiol level and area under the curve, except for the intra-individual coefficient of variability for area under the curve (21%) for the gel. The total coefficient of variability for area under the curve was 35% for the gel and 39% for the patch. CONCLUSIONS: A daily 1.0 mg estradiol dose as a transdermal gel seems to correspond with a matrix-type patch releasing 50 microg estradiol daily in the extent of estradiol absorption. High variability was associated with both treatments, and both the variabilities within and between the subjects were high with the gel. Wider than generally applied confidence limits should be applied for bioequivalence testing of transdermal estradiol formulations.

Cerebral cast angiography as an aid to medicolegal autopsies in cases of death after adult cardiac surgery.

Due to an increase in age of the patient population in cardiac surgery, cerebral complications are increasing in frequency, also as a cause of death. In order to reveal cerebral pathology associated with a fatal outcome after cardiac surgery, we re-evaluated the cast angiographs and medico-legal autopsy documents of 144 adult cardiac surgery subjects over a 7-year period. Special attention was paid to the ability of post-mortem cast angiography to aid in diagnosing cerebral pathology. The autopsy detected new ischemic cerebral lesions in 29 (20%) cases, of which 22 (15.3%) were recent infarcts, and 7 were cases of anoxic brain damage. Of the recent cerebral infarcts, 12 were associated with cerebral artery thrombosis, 4 showed multiple lesions, and the remaining 6 were small single infarcts. In addition, one subject had an intracerebral hemorrhage and 72 (50%) cerebral edema. By cast angiography, the leakage of contrast medium in the case of intracerebral hemorrhage and stenoses of intracranial and cervical arteries could be well demonstrated and also revealed 17 (77%) of the 22 recent cerebral infarcts. It was found to be suitable for detecting recent brain infarcts associated with main cerebral artery thrombosis, with a sensitivity of 92% (11 out of 12 cases), but was less sensitive in showing small recent infarcts with a sensitivity of 60% (6 out of 10 cases) and inferior for the older ones where none of the 6 cases were detected. Filling defects caused by cerebral edema were difficult to differentiate from technical errors and were encountered in 7 (4.8%) cases. A significant predictor for the 29 recent ischemic brain lesions was perioperative hypotension. The immediate cause of death was most often of cardiac (83%) and cerebral (14%) origin. In 14 cases, cerebral damage was considered to be an additional cause of death. The use of cerebral post-mortem cast angiography should be recommended, especially for its excellent ability to visualize intravascular pathology such as arterial stenoses and thromboses, with a 92% sensitivity in showing new main cerebral artery thromboses, before likely distortion of the vascular anatomy by dissection.

Reperfusion injury associated with one-fourth of deaths after coronary artery bypass grafting.

BACKGROUND: This study of reperfusion injury after coronary artery bypass grafting focuses on its contribution to fatal outcome, on its connection with myocardial infarction (MI) and on risk factors. METHODS: A consecutive series of 190 patients (mean age 61.7+/-8.9 years) dying within 30 days following coronary artery bypass grafting was autopsied with concomitant postmortem angiography during 1980 to 1993. RESULTS: Reperfusion injury was revealed in 49 (25.8%) patients, with concomitant MI in almost all (46 of 49) (p < 0.01). Reperfusion injury occurred in association with preoperative New York Heart Association (NYHA) III classification (p < 0.05), coronary endarterectomy (p < 0.01), long aortic clamping time (p < 0.01), and short postoperative survival (p < 0.05). CONCLUSIONS: Reperfusion injury was observed in one fourth of the deaths in association with MI. It occurred more often in patients with preoperative NYHA III symptoms and in those in whom endarterectomy was carried out and the anoxic time of the myocardium was longer. The shorter postoperative survival time indicates the lethal nature of this complication.

Effect of dose on the absorption of estradiol from a transdermal gel.

OBJECTIVES: To study whether dose adjustments in transdermal estradiol gel treatment would result in proportional changes in estradiol bioavailability and concentrations. METHODS: In an open study, 23 healthy postmenopausal women were treated consecutively with 0.5, 1.0 and 1.5 mg estradiol daily as a transdermal gel. Each dose was given for 16 days. Venous blood samples for serum estradiol and estrone measurements with RIA were taken at steady state on the 16th study day. From these concentrations, pharmacokinetic parameters for estradiol were calculated and corrected to correspond to equal dose by dividing the values by the dose. RESULTS: Area under the estradiol time-concentration curve and peak estradiol level increased linearily and dose-proportionally with daily estradiol doses of 0.5-1.5 mg. This was shown by lack of significant differences in the dose-corrected parameters. However, the 90% confidence intervals between the doses were outside the commonly accepted levels for bioequivalence. Peak estradiol level was clearer and occurred earlier with the highest 1.5 mg estradiol dose, while more stable estradiol levels were seen with the lowest 0.5 mg estradiol dose. CONCLUSIONS: The amount of estradiol on a certain skin area seems to be the determining factor in absorption. With higher estradiol doses, the absorption will be accelerated with a clearer peak estradiol level. The linear and dose proportional absorption indicates that flexible dose adjustments within the dose range of 0.5-1.5 mg estradiol daily can be made with an anticipated effect in estradiol bioavailability and concentrations.

A comparison of remifentanil and alfentanil for use with propofol in patients undergoing minimally invasive coronary artery bypass surgery.

UNLABELLED: Most patients undergoing minimally invasive direct coronary artery bypass surgery can be awakened and tracheally extubated in the operating room. We have compared two techniques of total IV anesthesia in this patient population: 30 patients (aged 44 to 74 yr; 24 male) premedicated with temazepam were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 2 microg/kg or with alfentanil 40 microg/kg, with propofol, and maintained with remifentanil at 0.25 or 0.5 microg x kg(-1) x min(-1) or alfentanil at 0.5 or 1 microg x kg(-1) x min(-1). The stable maintenance infusion rate of propofol was adjusted for age. Times to awakening and tracheal extubation were recorded. Postoperatively, IV morphine provided by patient-controlled analgesia was used for 48 h. Times to awakening and tracheal extubation (mean +/- SD) were shorter (P < 0. 01) in patients receiving remifentanil, and interpatient variations in times to awakening and tracheal extubation smaller (awakening 25 +/- 7 vs 74 +/- 32 min, and extubation 27 +/- 7 vs 77 +/- 32 min). Analysis of variance revealed that postoperative consumption of morphine was dependent on both the intraoperative opioid and the time elapsed after surgery (P < 0.05): patient-controlled analgesia morphine use during the first 3 h after awakening was more in patients receiving remifentanil (P < 0.01). IMPLICATIONS: Recovery of patients undergoing Minimally Invasive Direct Coronary Artery Bypass Surgery is significantly shorter and more predictable after total IV anesthesia with remifentanil-propofol than with alfentanil-propofol, which may be important if the goal is that patients will be awakened and tracheally extubated in the operating room.

Ventricular Arrhythmia Suppression by Magnesium Treatment after Coronary Artery Bypass Surgery.

Ventricular arrhythmias occur frequently shortly after coronary artery bypass grafting (CABG), and their occurrence coincides with the postoperative decline in serum magnesium (Mg) levels. To examine if this decline causes ventricular arrhythmias and if their appearance could be reduced by intravenous Mg administration, 140 consecutive CABG patients were randomized to receive 70 mmol of Mg sulphate (N = 69) or placebo (N = 71) over two days. Serum Mg concentration fell to 0.77 mmol/l in the control group but rose to 1.09 mmol/l in the Mg group (p < 0.001). On 48 h Holter, the number of ventricular premature complexes (VPC) on the third postoperative day was reduced in the Mg group (4 +/- 5 vs 12 +/- 21 VPCs/h; p < 0.05) and the incidence of complex ventricular arrhythmias (Lown grade 2-5) was significantly diminished (19% vs 41% of the patients; p < 0.05). In multivariate analysis, high risk ventricular arrhythmias (repetitive polymorphic ventricular complexes, couplets, R-on-T complexes or operative tachycardia) were independently predicted by high number of bypassed vessels (p = 0.01), poor NYHA functional class (p = 0.06), preoperative diuretic use (p = 0.07), and low postoperative Mg levels (p = 0.08). In conclusion, correction of the postoperative decline in serum Mg concentration decreases the occurrence of early VPCs and complex ventricular arrhythmias. Patients with extensive underlying coronary artery disease and prior diuretic therapy appear to benefit greatest from Mg treatment.http://link.springer-ny.com/link/service/journals/00547/bibs/8n3p165.html

Absorption and bioavailability of oestradiol from a gel, a patch and a tablet.

OBJECTIVES: To compare oestradiol and oestrone concentrations and bioavailability after a single dose and at a steady state during oral oestradiol valerate, transdermal oestradiol gel and transdermal oestradiol patch treatments. METHODS: Two open, randomised, cross-over studies were conducted. In the first study, 12 healthy postmenopausal women received 1.5 mg oestradiol as a transdermal gel or a 2 mg oestradiol valerate tablet daily for 14 days. In the second study, 15 postmenopausal women were treated for 18 days with 1.5 mg oestradiol gel or a transdermal patch releasing oestradiol 50 microg/24 h (replaced every 72 h). Venous blood samples for serum oestradiol and oestrone measurements with RIA were taken until 24 or 72 h after the first and last doses. RESULTS: The tablet and the transdermal gel yielded similar serum oestradiol profiles with a peak concentration 4-5 h after administration. The patch resulted in relatively stable oestradiol levels during the mid third of the wearing time whereas much lower levels were observed in the beginning and towards the end. There was no difference in the fluctuation between the peak and trough oestradiol levels between the gel (56 or 67%) and the tablet (54%) while the fluctuation was greater with the patch (89%). The bioavailability of oestradiol from the gel was 61% as compared with the tablet and 109% as compared with the patch. The gel was not bioequivalent with the tablet or the patch. CONCLUSIONS: The doses used of the transdermal gel and the patch roughly corresponded to each other with regard to the amount of oestradiol absorbed whereas the bioavailability from the tablet was significantly higher than from the gel. The lack of bioequivalence, the different serum oestradiol profiles and the large intersubject variability suggest that individual dose adjustments may be needed when changing administration form.

Infrarenal endoluminal bifurcated stent graft infected with Listeria monocytogenes.

Prosthetic graft infection as a result of Listeria monocytogenes is an extremely rare event that recently occurred in a 77-year-old man who underwent endoluminal stent grafting for infrarenal abdominal aortic aneurysm. The infected aortic endoluminal prosthesis was removed by means of en bloc resection of the aneurysm and contained endograft with in situ aortoiliac reconstruction. At the 10-month follow-up examination, the patient was well and had no signs of infection.

Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts.

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.