Overall outcome after endovascular aneurysm repair with a first-generation stent graft (Vanguard): A 20-year single-center experience.

OBJECTIVE: The problems with first-generation stent grafts for endovascular aneurysm repair are well known, but their long-term outcome remains to be established. The purpose of the study was to characterize the outcome of patients treated for abdominal aortic aneurysm (AAA) with a first-generation stent graft, Vanguard (Boston Scientific, Natick, Mass), in a single academic center with a follow-up of up to 20 years. METHODS: There were 48 AAA patients electively treated with a Vanguard stent graft between February 1997 and November 1999. The patients were monitored annually until the end of 2018. The outcomes were overall survival and the number of graft-related complications and reinterventions. RESULTS: The mean age was 70 years (range, 54-85 years), and the mean follow-up was 107 months (range, 6-262 months). All stent grafts were successfully implanted, but 90% of the patients encountered graft-related complications during follow-up. The most common complications were endoleaks (type I, 27%; type II, 29%; type III, 31%), stent fracture (46%), graft thrombosis (31%), and migration (40%). A total of 40 (83%) patients required a secondary procedure during long-term follow-up. The endovascular method for treating the complication was successful in 73 (87%) of 84 cases. There were no primary conversions, but 10 patients (21%) required a late conversion. In five cases, the complications required relining with a newer device. There were four AAA ruptures (8.3%), two of them fatal. The cumulative overall survival rates were 94%, 69%, 33%, 15%, and 13% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. CONCLUSIONS: The use of the Vanguard, a first-generation stent graft, was associated with multiple graft-related complications. However, these complications could mainly be treated by endovascular means. The Vanguard stent graft is a good example of how new technology can cause unpredictable problems that can magnify the workload and endanger the patient's well-being even decades after the initial procedure.

Systematic Long-term Follow Up After Endovascular Abdominal Aortic Aneurysm Repair With the Zenith Stent Graft.

OBJECTIVE/BACKGROUND: Although endovascular aneurysm repair (EVAR) has been widely adopted, long-term data remain limited. This study analyses the long-term outcome (16 years) after EVAR with the Zenith stent graft in a single academic centre. METHODS: From 2000 to 2010, 282 patients with an abdominal aortic aneurysm (AAA) were treated electively and monitored annually. Primary outcomes were overall and AAA rupture free survival; the secondary outcomes were complication and re-intervention free survival. Kaplan-Meier analysis was used to examine survival. RESULTS: The median patient age was 76 years (range 49-92 years) and mean aneurysm diameter 61 mm (range 40-110 mm). Patients were followed for a median of 76 months (range 0-201 months). Overall survival was 93% (SE 0.02), 61% (SE 0.08), 25% (SE 0.16), and 9% (0.19) at 1, 2, 5, 10, and 16 years, respectively. Ten (3.5%) AAA ruptures occurred, and the cumulative AAA rupture free survival was 100%, 98% (SE 0.01), 96% (SE0.02), and 79% (SE 0.12) at 1, 5, 10, and 16 years, respectively. The mean annual AAA rupture rate was 0.5%. Freedom from any stent graft related complications was 68% (SE 0.03), 58% (SE 0.09), 54% (SE 0.17), and 52% (SE 0.21), respectively; freedom from graft related re-interventions was 95% (SE 0.01), 80% (SE 0.08), 73% (SE 0.11), 70% (SE 0.16), at 1, 5, 10, and 16 years, respectively. Five (1.8%) late conversions were required during follow up. The variables that significantly and independently correlated with ruptured AAA were pre-operative aneurysm size and primary type II endoleak. The latter was the only independent significant factor to increase the risk of re-intervention. CONCLUSION: The number of graft related complications is high after EVAR, and new complications keep appearing years after the initial procedure. Even though fatal AAA rupture after EVAR is rare, it cannot be totally avoided despite systematic follow up.

Survival of Patients and Treatment-Related Outcome After Intra-Arterial Thrombolysis for Acute Lower Limb Ischemia.

BACKGROUND: The aim of this study is to evaluate the long-term survival and treatment-related outcome in patients treated with intra-arterial thrombolysis for acute lower limb ischemia. METHODS: The study was based on a prospective vascular database with retrospectively obtained supplementary information from the patients' files. Additionally, data on the patients' date and cause of death were obtained from Statistics Finland. A total of 155 patients with symptoms or signs of category I-IIa acute lower limb ischemia and angiographic evidence of native artery or bypass graft thromboembolic events were treated with intra-arterial catheter-directed thrombolysis (CDT). Patients with severe ischemic stages at admission or those with contraindications for thrombolysis (n = 185) were treated with conventional surgical modalities and excluded from further analysis. RESULTS: The mean age of the patients at admission was 73 years (95% confidence interval 70.1-74.6). For descriptive purposes, age quartiles were used (≤64, 65-74, 75-82.5, ≥83). The mean follow-up time was 126.3 months. The primary patency rates of native arteries/bypass grafts were 59.8%/31.7%, 35.4%/17.1%, and 18.7%/15.2% at 1, 5, and 10 years, respectively (P = 0.01). Correspondingly, the respective secondary patency rates were 65.2%/55.6%, 46.7%/39.8%, and 22.8%/30.5% (P = 0.88). A total of 190 additional procedures on 122 patients were required to preserve the patency after hospital discharge. At 1 year the cumulative survival was 78%, at 5 years 56%, and at 10 years 29%. The most common cause of death was cardiovascular (68.5%), predominantly presented by an acute coronary syndrome, while 9.6% died of cancer, 6.8% of pulmonary diseases, 8.2% of cerebrovascular causes, and 19.2% owing to trauma and other reasons. Atrial fibrillation (hazards ratio [HR] 2.31) and age over 83 years (HR 5.23 per age category) were significantly and independently associated with poorer cumulative post-procedural survival. Bypass graft thrombosis was associated with an increase in major amputations after CDT (HR 14.77). However, the presence of synthetic bypass grafts had a protective influence on limb salvage (HR 0.086). A total of 39 (25.2%) major amputations were performed during the follow-up period. Age over 75 years was the only significant and independent factor to negatively impact on amputation-free survival (HR 2.01), which was 24% at 10 years. CONCLUSIONS: The long-term patency after CDT is unfavorable, and additional procedures are needed to preserve adequate distal perfusion. Approximately 30% of the patients are alive at 10 years after the initial CDT. Increasing age and atrial fibrillation have a negative effect on the patients' survival.

Bacterial signatures in thrombus aspirates of patients with lower limb arterial and venous thrombosis.

OBJECTIVE: Increasing data supports the role of bacterial inflammation in adverse events of cardiovascular and cerebrovascular diseases. In our previous research, DNA of bacterial species found in coronary artery thrombus aspirates and ruptured cerebral aneurysms were mostly of endodontic and periodontal origin, where Streptococcus mitis group DNA was the most common. We hypothesized that the genomes of S mitis group could be identified in thrombus aspirates of patients with lower limb arterial and deep venous thrombosis. METHODS: Thrombus aspirates and control blood samples taken from 42 patients with acute or acute-on-chronic lower limb ischemia (Rutherford I-IIb) owing to arterial or graft thrombosis (n = 31) or lower limb deep venous thrombosis (n = 11) were examined using a quantitative real-time polymerase chain reaction to detect all possible bacterial DNA and DNA of S mitis group in particular. The samples were considered positive, if the amount of bacterial DNA in the thrombus aspirates was 2-fold or greater in comparison with control blood samples. RESULTS: In the positive samples the mean difference for the total bacterial DNA was 12.1-fold (median, 7.1), whereas the differences for S mitis group DNA were a mean of 29.1 and a median of 5.2-fold. Of the arterial thrombus aspirates, 57.9% were positive for bacterial DNA, whereas bacterial genomes were found in 75% of bypass graft thrombosis with 77.8% of the prosthetic grafts being positive. Of the deep vein thrombus aspirates, 45.5% contained bacterial genomes. Most (80%) of bacterial DNA-positive cases contained DNA from the S mitis group. Previous arterial interventions were significantly associated with the occurrence of S mitis group DNA (P = .049, Fisher's exact test). CONCLUSIONS: This is the first study to report the presence of bacterial DNA, predominantly of S mitis group origin, in the thrombus aspirates of surgical patients with lower limb arterial and deep venous thrombosis, suggesting their possible role in the pathogenesis of thrombotic events. Additional studies will, however, be needed to reach a final conclusion.

Differential isoform expression and selective muscle involvement in muscular dystrophies.

Despite the expression of the mutated gene in all muscles, selective muscles are involved in genetic muscular dystrophies. Different muscular dystrophies show characteristic patterns of fatty degenerative changes by muscle imaging, even to the extent that the patterns have been used for diagnostic purposes. However, the underlying molecular mechanisms explaining the selective involvement of muscles are not known. To test the hypothesis that different muscles may express variable amounts of different isoforms of muscle genes, we applied a custom-designed exon microarray containing probes for 57 muscle-specific genes to assay the transcriptional profiles in sets of human adult lower limb skeletal muscles. Quantitative real-time PCR and whole transcriptome sequencing were used to further analyze the results. Our results demonstrate significant variations in isoform and gene expression levels in anatomically different muscles. Comparison of the known patterns of selective involvement of certain muscles in two autosomal dominant titinopathies and one autosomal dominant myosinopathy, with the isoform and gene expression results, shows a correlation between the specific muscles involved and significant differences in the level of expression of the affected gene and exons in these same muscles compared with some other selected muscles. Our results suggest that differential expression levels of muscle genes and isoforms are one determinant in the selectivity of muscle involvement in muscular dystrophies.

Muraglitazar-eluting bioabsorbable vascular stent inhibits neointimal hyperplasia in porcine iliac arteries.

PURPOSE: To evaluate the biocompatibility of a new muraglitazar-eluting polylactide copolymer stent and investigate its ability to prevent the formation of intimal hyperplasia. MATERIALS AND METHODS: Ten self-expandable muraglitazar-eluting poly-96 L/4D-lactic acid (PLA96) stents and 10 self-expandable control PLA96 stents were implanted into porcine common iliac arteries. After 28 days follow-up, all stent-implanted iliac arteries were harvested and prepared for quantitative histomorphometric analysis. RESULTS: Angiographic analysis revealed that one control PLA96 stent had occluded and one had migrated. Histomorphometric analysis demonstrated that, with the control PLA96 stent, the luminal diameter and area were decreased versus the muraglitazar-eluting PLA96 stents (means ± standard error of the mean, 3.58 mm ± 0.34 vs 4.16 mm ± 0.14 and 9.83 mm(2) ± 2.41 vs 13.75 mm(2) ± 0.93, respectively). The control PLA96 stent induced more intimal hyperplasia than the bioactive muraglitazar-eluting PLA96 stent (557 µm ± 122 vs 361 µm ± 32). Vascular injury scores demonstrated only mild vascular trauma for both stents (muraglitazar-eluting, 0.68 ± 0.07; control, 0.75 ± 0.08). Inflammation scores also showed mild inflammation for both stents (muraglitazar-eluting, 1.05 ± 0.17; control, 1.23 ± 0.19). CONCLUSIONS: This new muraglitazar-eluting PLA96 stent was shown to be biocompatible with a tendency for better patency and less intimal hyperplasia compared with the control PLA96 stents.

Independent factors predicting early lower limb intra-arterial thrombolysis failure.

BACKGROUND: Risk factors for early catheter-directed intra-arterial thrombolysis failure in acute lower limb ischemia remain unclear. METHODS: One hundred forty-nine limbs with acute artery or bypass graft thrombosis underwent catheter-directed thrombolysis (maximum of 48 hours). A retrospective data analysis was carried out to assess possible risk factors for early, 30-day treatment failure. RESULTS: Seventy-nine men (53%) and 70 women (47%) with a median age of 70 (range 32-93) years were treated. Treatment outcomes were determined as success (N = 115, 77%) or failure (N = 34, 23%). The failure criteria comprised rapid progression of ischemia (N = 4, 2.7%) and major bleeding complications (N = 2, 1.3%), both requiring thrombolysis termination and surgery. Inability to reopen native arteries/grafts (N = 10, 6.7%), run-off vessels (N = 10, 6.7%), in-hospital death (N = 4, 2.7%), the need for major amputation (N = 13, 8.7%), and reocclusions (N = 5, 3.4%) within the 30-day follow-up period were also considered as failures. Multivariate analysis of the risk factors' impact on the success of thrombolysis revealed such independent parameters as hypercholesterolemia (OR 0.16, 95% CI 0.06-0.42, P < 0.0001), previous bypass grafting of the ipsilateral limb (OR 0.18, 95% CI 0.06-0.53, P = 0.002), and duration of ischemia prior to the initiation of thrombolysis (OR 0.95, 95% CI 0.91-0.99, P = 0.009, per day). CONCLUSION: According to our results, factors independently predicting early failure include hypercholesterolemia, previous bypass grafting, and a delay in treatment initiation. Moreover, catheter-directed intra-arterial thrombolysis can be considered safe and effective in the treatment of acute lower limb ischemia.

[Should we start AAA screening in Finland?]. / Onko vatsa-aortan aneurysman seulontaan aihetta suomessa?

Abdominal aortic aneurysms (AAA) are usually asymptomatic before rupture. Through ultrasound screening AAA can be found before rupture. In Europe England and Sweden have started one-time ultrasound screening for men at age 65. Many studies around Europe have shown that screening is cost-effective. In a recent Finnish study one-time screening for men at age 65 would be a more effective option than the current practice where no screening is offered. Screening for abdominal aortic aneurysm among 65-year-old women would entail less additional costs but fewer life years gained than screening for men. Starting the screening would require additional resources in the Finnish health care system as compared to the current policy.

Long-term experience of endovascular aneurysm repair with Zenith prosthesis: diminishing graft-related complications over time.

BACKGROUND: Only limited data on the long-term results after endovascular aneurysm repair exist to date. MATERIALS: Data on 282 patients with an abdominal aortic aneurysm treated with a Zenith endoprosthesis between March 2000 and March 2010 were retrospectively analyzed from a prospective database. Operative, total, and aneurysm-related mortality was assessed, as were graft-related complications and reinterventions. RESULTS: All procedures were performed successfully without primary conversions. Median follow-up was 40 months (range: 1-119 months). Thirty-day mortality was 1.4%, and aneurysm-related mortality was 0.7%. Cumulative survival was 62% at 5 years and 52% at 8 years. Graft-related complications occurred in 107 (38%) patients. The most common finding was a type II endoleak (n = 73) that sealed mainly spontaneously (n = 46, 63%). Most endoleaks, and complications in general (87%), appeared during the first 3 years of follow-up, and no events occurred after 6 years. Altogether, 59 additional procedures, mainly embolizations (n = 35), in 38 patients (24%) were required owing to graft-related complications. Of all the reinterventions, 82% were performed during the first 4 years, and no new complications were treated after 6 years. CONCLUSION: Complications and reinterventions related to endovascular aneurysm repair become practically nonexistent after 5 to 6 years. This finding suggests that a lifelong follow-up may not always be needed after treatment with a Zenith endoprosthesis.

Challenging treatment of multiple late complications after endovascular aneurysm repair.

BACKGROUND: To report a case of multiple additional procedures after successful endovascular treatment of abdominal aortic aneurysm. METHODS: An endovascular abdominal aortic aneurysm repair with a bifurcated aortic Vanguard endograft successfully performed in 1999 resulted in multiple complications, including endoleaks and a row separation, treated endovascularly. Subsequently, tuberculosis sepsis and prosthesis infection resulted in long-term antibiotic treatment. Additional graft leaks, aneurysm sack growth, and sack ruptures were also treated endovascularly because the patient consistently denied open repair. Endovascular procedures, however, did not solve the problem, turning to be increasingly challenging. The patient finally approved open graft removal and aortobifemoral reconstruction that were successfully performed 11 years after the initial endograft implantation. RESULTS: The patient has recovered from surgery well and is asymptomatic. No evidence of bacterial colonization was found according to the specimen taken during the laparotomy. CONCLUSION: Vanguard and other first-generation aortic endografts are associated with high incidence of complications and reinterventions. Open surgery is a method of choice in similar cases.

EVAR may reduce the risk of aneurysm rupture despite persisting type Ia endoleaks.

PURPOSE: To determine the risk of aneurysm rupture in patients with persisting proximal type Ia endoleaks following endovascular aneurysm repair (EVAR) in comparison to the risk of rupture of untreated abdominal aortic aneurysms (AAA) of similar size. METHODS: Among 400 patients who where treated with EVAR from 1996 to 2003 at a single center, 21 (5.3%) patients (13 men; mean age 78.0±5.0 years, range 67-86) with large (≥5.5 cm) aneurysms had imaging evidence of type Ia endoleaks that persisted >10 months (type Ia group) despite secondary endovascular treatment. These patients were compared to 24 untreated AAA patients (17 men; mean age 73.8±5.2 years, range 64-88) with large aneurysms from a separate geographic region with a well-established aneurysm treatment program before EVAR became available (1990-1998). RESULTS: There were no significant differences between the type Ia and the untreated AAA patients with regard to age (79±8 vs. 74±5 years), gender (38% vs. 29% women), baseline aneurysm diameter (6.1±0.7 vs. 6.4±0.9 cm), or length of follow-up (32±23 vs. 29±40 months). During the follow-up period, the rate of aneurysm enlargement was significantly lower in type Ia patients (0.19 cm/y) than in untreated AAA patients (0.54 cm/y, p = 0.03). One (4.8%) patient with a persisting type Ia endoleak and 2-cm aneurysm enlargement (0.8 cm/y) had aneurysm rupture after 2.5 years, while 12 (50%) of the 24 untreated aneurysms ruptured (p = 0.001), which was the primary cause of death in this group. The rupture rate was 1.8 per 100 patient-years in the type Ia group and 20.7 per 100 patient-years in the untreated AAA group. Aneurysm-related mortality was significantly reduced in the type Ia group compared to the untreated AAA group at 36 months (11% vs. 52%, p = 0.004). In the multivariate analysis, factors associated with death were an untreated AAA (odds ratio 97, p = 0.004), female gender (odds ratio 9.7, p = 0.02), and baseline aneurysm size (odds ratio 4.7/cm, p = 0.03). CONCLUSION: This study suggests that EVAR may reduce the risk of rupture and aneurysm-related death despite the presence of a persisting type Ia endoleak. This finding is limited to patients with aortic endografts that are in good position. The mechanism of protection from rupture is unclear but may be related to reducing the rate of aneurysm enlargement.

Peripheral arterial disease in octogenarians and nonagenarians: factors predicting survival.

BACKGROUND: To describe the prevalence and character of complications associated with revascularization procedures as a result of peripheral arterial disease in octogenarians and nonagenarians and to assess their overall survival depending on baseline characteristics, type of treatment modality, and possible procedure-related complications. A retrospective clinical study was carried out. METHODS: A total of 383 patients aged >80 years, referred with suspected peripheral arterial disease, were categorized into octogenarians and nonagenarians. Data regarding cardiovascular risk factors, comorbidities, type of treatment, and possible procedure-related complications were collected from patients' files. The cohort was followed up for total mortality until December 31, 2007, by means of record linkage with the National Causes of Death Register. RESULTS: A total of 57 (14.9%) patients were treated surgically, whereas 71 (18.5%) underwent an endovascular procedure. Conservative treatment was chosen significantly more often for nonagenarians (p = 0.032). Postoperative complications (nonfatal, 13.2%; fatal, 3.1%) were equally distributed between the age groups and genders (p = 0.840 and p = 0.820, respectively) but were significantly more common after surgical procedures (p < 0.001 for both fatal and nonfatal complications). As expected, the overall survival was significantly poorer among nonagenarians as compared with octogenarians (33 vs. 45 months, respectively; p < 0.001). Older age, critical limb ischemia (CLI), and males were independently associated with mortality (odds ratio [OR]: 1.89, 95% confidence levels [CI]: 1.18-3.04; OR: 3.72, 95% CI: 2.34-5.91; and OR: 1.77, 95% CI: 1.10-2.80, respectively). The survival for nonagenarian men with CLI was 24 months and for women 28, regardless of the treatment modality. CONCLUSIONS: Octo- and nonagenarians seem to tolerate arterial reconstruction relatively well. Endovascular interventions should be favored over surgical procedures as they are associated with fewer complications. At the same time, the life expectancy of nonagenarians with CLI is limited to approximately 2 years, irrespective of the method of treatment. Further studies should be conducted to clarify the actual effect of vascular reconstructions among the elderly population with regard to benefits of both costs and quality of life.

[Subclavian steal syndrome]. / Subclavian steal -oireyhtymä.

Subclavian steal syndrome is a circulatory disorder usually caused by atherosclerosis and accompanied by ischemic symptoms of the vertebrobasilar region and the hand. In many cases, significant vascular lesions are found also in other arteries. In more than 80% of cases the blood vessel lesion is on the left, and a significant stenosis or occlusion causes an inter-arm pressure gradient of > 20 mmHg, resulting in retrograde blood flow of the ipsilateral vertebral artery. In local stenosis, conservative treatment can be combined with an intravascular procedure, and in occlusions or other arterial lesions requiring operative treatment, with bypass surgery.

[Vascular malformations associated with Marfan syndrome, Ehlers-Danlos syndrome and neurofibromatosis 1 and their surgical treatment]. / Marfanin oireyhtymään, Ehlers-Danlosin oireyhtymään ja neurofibromatoosi 1: een liittyvät verisuonimuutokset ja niiden kirurginen hoito.

The Marfan syndrome, vascular type Ehlers-Danlos syndrome and neurofibromatosis 1 are associated with vascural complications that may be fatal. Therefore, referral to treatment should be properly timed, followed by therapy taking special features of the disease into consideration. When treating a vascular malformation related to an inherited disorder, it is important to collaborate with clinical geneticists in order to obtain genetic counseling and DNA diagnostics as well as to elucidate the status of close relatives.

Urethral in situ biocompatibility of new drug-eluting biodegradable stents: an experimental study in the rabbit.

OBJECTIVE: To assess the effect of drug-eluting properties on the degradation process and the biocompatibility of biodegradable drug-eluting urethral stents. MATERIALS AND METHODS: Braided biodegradable 80 L/20D-PLGA (copolymer of polylactide and polyglycolide) stents with drug-eluting properties were used as the test material. The drugs analysed were indomethacin, dexamethasone and ciprofloxacine. 80 L/20D-PLGA stents without a drug coating served as controls. In all, 16 male rabbits were used and divided into four groups. The stents were inserted under general anaesthesia into the posterior urethra. After 1 month, the rabbits were killed and the urethra removed for histological and optic microscopy analyses. RESULTS: Control stents and the dexamethasone-eluting stents degraded totally during the follow-up period. Conversely, in both indomethacin- and ciprofloxacine-eluting stent groups, the degradation process was significantly delayed and they induced an increase in epithelial hyperplasia. Histological analysis showed that all the stents induced eosinophilia, but there were no significant differences in the intensity of acute or chronic inflammatory reactions and fibrosis. CONCLUSIONS: A drug-eluting capacity can be added to biodegradable stents. The addition of a drug influences the biodegradation time of PLGA urethral stents. Further studies are needed, to find the proper concentrations and releasing profiles of the drugs to achieve the desired bioactivity and biocompatibility properties.

[Challenging treatment of aortic aneurysm is under change]. / Aortta-aneurysman vaativa hoito muuttumassa.

Abdominal aortic aneurysm is a common and increasing health risk. Indication for therapy in men is an aneurysm over 55 mm and in women, over 50 mm in diameter. Novel endovascular treatment procedures are nowadays suitable for a large proportion of patients and will improve patient safety, shorten the duration of therapy and speed up rehabilitation. Therapeutically very challenging problems are aneurysms affecting the renal and visceral arteries, infections of aortic prostheses as well as aneurysmal ruptures during emergency services. Managing of these problems requires experience, whereby centralizing their treatment will improve treatment outcome.

[Emergency problems in vascular surgery]. / Päivystysongelmat verisuonikirurgiassa.

The most typical emergency patient of vascular surgery is suffering from urgent lower limb ischemia, potentially threatening the viability of the limb. Life-threatening conditions requiring immediate treatment include rupture of the abdominal aorta as well as septicemia associated with necrosis of a neuropathic-ischemic leg of the diabetic patient. Stenosis of the carotid artery requires an emergency operation, if in spite of antithrombotic medication the patient exhibits persistent transient symptoms of paresis or attacks of blindness. Vascular injury should be suspected and a vascular surgeon consulted in limb injuries, if the pulse cannot be conclusively felt distally.

[What is known about the effectiveness of vascular surgery?]. / Mitä tiedetään verisuonikirurgian vaikuttavuudesta.

According to nationally consistent guidelines for nonurgent care, the aim is to make decisions of treatment and prioritizing on systematically clear grounds both within the public and the private sector. In vascular surgery, vertical prioritizing has been carried out and attempts have been made to extensively assess the effectiveness of therapy. We aim to provide a review of the current state of vascular surgery and the resulting health benefit by using the available rough effectiveness indicators, as a register for national quality assurance is lacking.

VASIM: an automated tool for the quantification of carotid atherosclerosis by computed tomography angiography.

The diagnostic imaging techniques currently used to evaluate the arterial atherosclerosis hinge on the manual marking and calculation of the stenosis degree. However, the manual assessment is highly dependent on the operator and characterized by low replicability. The study aimed to develop a fully-automated tool for the segmentation and analysis of atherosclerosis in the extracranial carotid arteries. The dataset consisted of 59 randomly-chosen individuals who had undergone head-and-neck computed tomography angiography (CTA), at the Tampere University Hospital, Tampere, Finland. The analysis algorithm was mainly based on the detection of carotid arteries, delineation of the vascular wall, and extraction of the atherosclerotic plaque. To improve the vascular detection rate, the model-based and volume-wide analytical approaches were deployed. A new fully-automated vascular imaging (VASIM) software tool was developed. For stenosis over 50%, the success rate was 83% for the detection and segmentation. Specificity and sensitivity of the algorithm were 25% and 83%, respectively. The overall accuracy was 71%. The VASIM tool is the first published approach for the fully-automated analysis of atherosclerosis in extracranial carotid arteries. The tool provides new outputs, which may help with the quantitative and qualitative, clinical evaluation of the atherosclerosis burden and evolution. The findings from this study provide a basis for the further development of automated atherosclerosis diagnosis and plaque analysis with CTA.

Expression of sterol regulatory element-binding transcription factor (SREBF) 2 and SREBF cleavage-activating protein (SCAP) in human atheroma and the association of their allelic variants with sudden cardiac death.

BACKGROUND: Disturbed cellular cholesterol homeostasis may lead to accumulation of cholesterol in human atheroma plaques. Cellular cholesterol homeostasis is controlled by the sterol regulatory element-binding transcription factor 2 (SREBF-2) and the SREBF cleavage-activating protein (SCAP). We investigated whole genome expression in a series of human atherosclerotic samples from different vascular territories and studied whether the non-synonymous coding variants in the interacting domains of two genes, SREBF-2 1784G>C (rs2228314) and SCAP 2386A>G, are related to the progression of coronary atherosclerosis and the risk of pre-hospital sudden cardiac death (SCD). METHODS: Whole genome expression profiling was completed in twenty vascular samples from carotid, aortic and femoral atherosclerotic plaques and six control samples from internal mammary arteries. Three hundred sudden pre-hospital deaths of middle-aged (33-69 years) Caucasian Finnish men were subjected to detailed autopsy in the Helsinki Sudden Death Study. Coronary narrowing and areas of coronary wall covered with fatty streaks or fibrotic, calcified or complicated lesions were measured and related to the SREBF-2 and SCAP genotypes. RESULTS: Whole genome expression profiling showed a significant (p = 0.02) down-regulation of SREBF-2 in atherosclerotic carotid plaques (types IV-V), but not in the aorta or femoral arteries (p = NS for both), as compared with the histologically confirmed non-atherosclerotic tissues. In logistic regression analysis, a significant interaction between the SREBF-2 1784G>C and the SCAP 2386A>G genotype was observed on the risk of SCD (p = 0.046). Men with the SREBF-2 C allele and the SCAP G allele had a significantly increased risk of SCD (OR 2.68, 95% CI 1.07-6.71), compared to SCAP AA homologous subjects carrying the SREBF-2 C allele. Furthermore, similar trends for having complicated lesions and for the occurrence of thrombosis were found, although the results were not statistically significant. CONCLUSION: The results suggest that the allelic variants (SREBF-2 1784G>C and SCAP 2386A>G) in the cholesterol homeostasis regulating SREBF-SCAP pathway may contribute to SCD in early middle-aged men.