Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years.

BACKGROUND: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. METHODS: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. RESULTS: A total of 83,253 patients were included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. CONCLUSIONS: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.

Editor's Choice - Carotid Stenosis Treatment: Variation in International Practice Patterns.

OBJECTIVES: The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR). METHODS: Data from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country. RESULTS: Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0-72%), Hungary (5-55%), and the United States (0-100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4-7.7). CONCLUSIONS: Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world.

Editor's Choice: Contemporary treatment of popliteal artery aneurysm in eight countries: A Report from the Vascunet collaboration of registries.

OBJECTIVES: To study contemporary popliteal artery aneurysm (PA) repair. METHODS: Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland). RESULTS: From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers. Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%. Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture. CONCLUSIONS: Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted.

Proteomic analyses of early response of unicellular eukaryotic microorganism Tetrahymena thermophila exposed to TiO2 particles.

Key biological functions involved in cell survival have been studied to understand the difference between the impact of exposure to TiO2 nanoparticles (TiO2-NPs) and their bulk counterparts (bulk-TiO2). By selecting a unicellular eukaryotic model organism and applying proteomic analysis an overview of the possible impact of exposure could be obtained. In this study, we investigated the early response of unicellular eukaryotic protozoan Tetrahymena thermophila exposed to TiO2-NPs or bulk-TiO2 particles at subtoxic concentrations for this organism. The proteomic analysis based on 2DE + nLC-ESI-MS/MS revealed 930 distinct protein spots, among which 77 were differentially expressed and 18 were unambiguously identified. We identified alterations in metabolic pathways, including lipid and fatty acid metabolism, purine metabolism and energetic metabolism, as well as salt stress and protein degradation. This proteomic study is consistent with our previous findings, where the early response of T. thermophila to subtoxic concentrations of TiO2 particles included alterations in lipid and fatty acid metabolism and ion regulation. The response to the lowest TiO2-NPs concentration differed significantly from the response to higher TiO2-NPs concentration and both bulk-TiO2 concentrations. Alterations on the physiological landscape were significant after exposure to both nano- and bulk-TiO2; however, no toxic effects were evidenced even at very high exposure concentrations. This study confirms the relevance of the alteration of the lipid profile and lipid metabolism in understanding the early impact of TiO2-NPs in eukaryotic cells, for example, phagocytosing cells like macrophages and ciliated cells in the respiratory epithelium.

White blood cell and endothelial cell response to endovascular procedures in the leg.

AIM: The longterm patency of endovascular procedures is partly depending on restenosis by intimal hyperplasia, a process depending on inflammatory mechanisms resembling the mechanisms of normal repair and the process of atherosclerosis. The aim of this study was to characterize the inflammatory response of white blood cells (WBC) and endothelial cells following endovascular procedures in the leg. METHODS: Venous blood samples were drawn from a cubital vein before and 2 hours after intervention in 19 patients suffering from peripheral arterial occlusive disease (PAOD). Flow cytometry was used to identify and determine the concentrations of WBC and platelets and to measure CD11b/CD18 on WBC and CD41 on platelets. Soluble endothelial markers (sICAM-1, sE-selectin, sP-selectin and sVCAM-1) were measured by ELISA technique. RESULTS: WBC were downregulated following endovascular procedures. The endothelial cell response was limited and only downregulation of sP-selectin reached significant levels. The results were more evident in the group of patients with critical limb ischemia (CLI) compared to patients with intermittent claudication (IC). CONCLUSION: Endovascular procedures in the leg evoke only a limited response which is depending on the degree of ischemia and the magnitude of the interventional procedure.

Global venous function correlates better than duplex derived reflux to clinical class in the evaluation of chronic venous disease.

AIM: To compare the symptoms and signs of patients with chronic venous disease with the objective results of duplex ultrasound and plethysmography (foot volumetry). METHODS: One hundred and one patients with symptomatic chronic venous disease were investigated with duplex ultrasound and foot volumetry. Patients were classified according to the CEAP classification and the symptoms of pain, heaviness, tiredness, ankle swelling and night cramps were graded. The severity of the disease was judged objectively by the reflux time (sum of reflux time at 6 levels) and the venous function was measured globally with expelled volume (ml) and refilling rate (Q) (ml/100 mlxmin) after exercise, and expelled volume related to foot volume (EVrel), (ml/100 ml). The ratio Q/EVrel)was calculated. Correlation was calculated between clinical class, symptoms and objective parameters. RESULTS: The correlation analyses showed a clear constant relationship between the CEAP clinical classification and the foot volumetry measures (Q/EVrel), r=0.48; p<0.01) There was no such relationship between clinical class and the sum of duplex calculated reflux time (r=-0.05), or between foot volumetry and reflux time. There was no correlation between the clinical class and the total score of symptoms (r=0.044). CONCLUSION: The clinical class of CEAP classification correlates significantly with foot volumetry parameters. There is no correlation between clinical class and reflux time. The severity of the venous disorder and subsequently the need for treatment is more accurately judged by foot volumetry as a global measure. Clinical classification has a realistic meaning concerning the functional evaluation of venous disease.

Evaluation of side effects after nicotine nasal spray in patients with chronic rhinitis.

Thirty-three subjects with chronic rhinitis used nicotine nasal spray in an open study as an aid in smoking cessation. Thirty-eight percent of them were completely abstinent at 12 weeks, whereas 35% were completely abstinent at 20 weeks. The nasal spray was associated with irritant nasal side effects, which occurred most often in the early stages of treatment. Clinical nasal examinations could not observe any significant impairment in nasal conditions following spray use. In conclusion, this study confirms the short-term safety of the nicotine nasal spray as an aid in smoking cessation.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]. / Varicer och venös insufficiens--behandlingsfilosofi inför 2000-talet.

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

[Endovascular technique in aortic aneurysm. A promising alternative to open surgery]. / Endovaskulär teknik vid aortaaneurysm. Lovande alternativ till öppen kirurgi.

The article consists in a presentation of endovascular surgery for abdominal aortic aneurysm repair in 23 cases. Two cases required conversion to open surgery, but the procedure could be completed in the remaining 21 cases, with a current duration of follow-up of up to 30 months. There was early leakage in one case, and late leakage in five cases. Late conversion has been necessary in three instances, and supplementary endovascular measures have been required in a further two instances. All complications have occurred in those cases operated during the first half of the study period. Modification of the endoprosthesis used and increasing skill have reduced both operation time and the complication rate. Intensive care is no longer required, and the median duration of hospitalisation is three days. Follow-up with magnetic resonance imaging has yielded new and important information.

Association of venous volume and diameter of incompetent perforator veins in the lower limb--implications for perforator vein surgery.

PURPOSE: To define the association between venous volume as measured with air-plethysmography and the duplex ultrasound measured diameter of incompetent perforator of the lower limb. PATIENTS AND METHODS: Thirty-six patients with chronic venous disease were investigated with air-plethysmography and duplex ultrasound. Venous volume and venous filling time was measured. Venous filling index was calculated. The findings were correlated with the diameter of the largest incompetent perforator vein of the lower limb. RESULTS: Twenty-six patients with venous volume in the normal range (80-170 ml) had a median perforator diameter of 3.5 mm (IQR 3.2-4.3). Ten patients with venous volume above 170 ml had median perforator diameter of 5.5 mm (IQR 4.6-7.7). (p=0.001, Mann-Whitney). There was a correlation between the venous volume and diameter of the largest incompetent perforator vein. (Pearson correlation factor 0.69, p=0.01). CONCLUSION: Limb volume correlates to the diameter of the largest incompetent perforator of the calf. Increase in venous limb volume could be partly responsible for an increase in the size of calf perforators thereby promoting incompetence.

A randomised controlled trial of micronised purified flavonoid fraction vs placebo in patients with chronic venous disease.

OBJECTIVE: to evaluate the efficacy of a micronised purified flavonoid fraction (MPFF) in the treatment of chronic venous disease (CVD). DESIGN: prospective double blind, randomised, control study. PATIENTS AND METHODS: one hundred and one patients with symptomatic CVD were randomly allocated to treatment for 60 days with either MPFF (51 patients) or placebo (50 patients) 500 mg twice daily. There were 28 men and 73 women, aged 22-65 years (mean age 48 years). No difference regarding age, gender, clinical class or duration of symptoms was recorded between the treatment and placebo groups. A global score for evaluation of symptoms was used. Patients were investigated with plethysmography (foot-volumetry) and duplex-ultrasonography before and after the treatment period. For statistical comparison Cochran-Mantel-Haenszel test, two-sided Student t-test and covariance analysis were used and p<0.05 was regarded significant. RESULTS: improvement of the global score of symptoms was reported by 21 patients in the MPFF group and by 16 in the placebo group (N.S.). For the whole groups, no significant differences were recorded before and after treatment regarding foot-volumetric or ultrasonographic parameters. On the other hand, in patients with edema (20 in the MPFF group, 23 in the placebo group) ultrasonographic reflux time was significantly reduced for those in the treatment group (p=0.03). This finding did not correlate to clinical symptoms. CONCLUSION: in this study, MPFF did not change the symptoms of CVD, except night cramps. A secondary finding was reduced reflux times in patients with oedema, although no ultrasonographic or foot-volumetric parameters changed significantly for the whole group. The role of MPFF in treatment of patients with CVD needs to be further analysed in a large population.

[Retroperitoneal approach to the abdominal aorta for occlusive disease.].

The abdominal aorta can be approached through the peritoneum or retroperitoneally. The aim of this study was to compare these two routes of exposure. Over a 10 year period, between 1979 and 1989, 48 patients were operated on for an aortobifemoral bypass, because of occlusive diseases of aorta or iliac arteries. The retroperitoneal approach was used in 20 cases and 28 were operated by the standard transperitoneal approach. In a non randomized retrospective study the outcome was compared regarding; operation time, blood transfusion during operation, initiation of alimentation, hospitalisation and mortality. All of the patients were operated on by two experienced vascular surgeons. In the retroperitoneal group there were 11 men and 10 women with a mean age of 63,4 years. In the transperitoneal group there were 16 men and 10 women with a mean age of 60,3 years. With the retroperitoneal approach the operating time was 185 min. v. 248 min. for the transperitoneal group (p<0.05). The fasting period after operation was four days for the retroperitoneal group v. five days for the transperitoneal group (p<0.05). The hospitalization was 11 days when the retroperitoneal approach was used v. 15 days for the transperitoneal group (ns). The results of this study indicate that it is advantageous to approach the abdominal aorta through a retroperitoneal route.

Percutaneous transluminal angioplasty of crural arteries: diabetes and other factors influencing outcome.

OBJECTIVE: to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) of the crural arteries. PATIENTS AND METHODS: a retrospective review of patients treated with PTA of at least one crural artery during an 8-year period (1990--1997). RESULTS: one hundred and fifty-five legs in 140 consecutive patients (mean age 74 years, range 38--91 years) were treated. In 76% a more proximal lesion was also treated. After 1 year, results were significantly better in non-diabetics (improvement rate of 66% vs 32%p <0.05). The outcome for patients with a combination of diabetes, heart disease and renal disease was significantly worse compared to all other patients with an improvement rate of only 9% after 1 year. Patients alive and not amputated at 1 year were significantly more common (p <0.05) among non-diabetics (90%), compared to diabetics (66%). The 1-year mortality for the whole group was 15%, significantly higher for diabetic patients (p =0.04). CONCLUSION: PTA of crural arteries produces reasonably good results in non-diabetic patients. Diabetic patients were doing worse than non-diabetics after a year, though 1-month results were not significantly different. Patients with diabetes, heart disease and renal disease make a high-risk group that has a significantly worse outcome.

Outcome of treatment of ruptured abdominal aortic aneurysms depending on the type of hospital.

OBJECTIVE: To compare the outcome of patients operated on acutely for ruptured abdominal aortic aneurysms (AAA) or otherwise symptomatic aortic aneurysms in a university hospital and in two county hospitals by the same group of vascular surgeons. DESIGN: Retrospective study. SETTING: 1 university and 2 county hospitals, Sweden. SUBJECTS: 108 patients operated on urgently for AAA, 81 at the university hospital, and 27 at the county hospitals between January 1992 and December 1998. INTERVENTION: Repair of the AAA. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: 21 of the 81 patients having urgent repair of an AAA at the university hospital (26%) had been transferred from the county hospitals. Thirteen patients were not operated on, 7 because of their poor general condition and great age (median 84 years), 3 who refused operation, and 3 in whom the diagnosis was incorrect. During the same time period a further 27 haemodynamically unstable patients were operated on by the same vascular surgeons at the county hospitals. The on-table mortality for patients with ruptured AAA and shock was 5/43 (12%) at the university hospital and 4/27 (15%) at the county hospitals. The corresponding in-hospital rates were 11/43 (26%) and 11/27 (41%). Mortality was significantly higher if the operation was delayed by more than 45 minutes. The incidence of postoperative complications was the same in both hospitals. CONCLUSION: If a patient with a ruptured AAA and shock is admitted to the county hospital and operated on by a specialist vascular surgeon the outcome is fully acceptable. The difference seems to be related to the postoperative period. To what extent the delay caused by the surgeon's journey to the county hospital has any influence on the outcome is not possible to evaluate.

Infectious mononucleosis treated by an antihistamine: a comparison of the efficacy of ranitidine (Zantac) vs placebo in the treatment of infectious mononucleosis.

This study investigated whether the course of infectious mononucleosis was influenced by medication with ranitidine (Zantac). A double-blind, placebo-controlled study enrolled 117 patients and either ranitidine 300 mg or placebo were given twice daily for 2 wk. Patients were examined on day 5, 10, 15 and 30. Efficacy variables included severity and duration of fever, scores of cervical lymph node size and tonsil size, eating problems, fatigue, influence on general condition, the use of analgesics and blood analyses. Results were analysed in 91/117 patients. Small differences were found between treatment groups in favour of the active drug. However, they were not statistically significant. After 2 wks of treatment abnormal 'liver enzymes' (ALAT/ASAT) were found in 13/48 (0.27) of the ranitidine group in contrast with 18/36 (0.50) of the placebo group (P = 0.03). The conclusion is that the course of infectious mononucleosis is little influenced by ranitidine treatment for 2 wks. The faster normalization of the 'liver enzymes' may reflect modulation of the immune system by ranitidine.

Intraoperative contamination of synthetic vascular grafts. Effect of glove change before graft implantation. A prospective randomised study.

OBJECTIVES: to investigate the incidence of intraoperative graft contamination, bacterial species and the influence of change of surgeon's gloves on contamination. DESIGN: a prospective randomised study. MATERIALS AND METHODS: forty patients had implantation of synthetic vascular grafts. All patients received intraoperative cloxacillin (2.0 g) or clindamycin (0.6 g) intravenously. The procedures were randomised to two groups: Group 1 - surgeons changed the gloves before the first contact with the vascular prosthesis and Group 2 - operation without glove change. The growth of all bacterial species from graft segments and from the gloves was recorded. The susceptibility to antibiotics was tested. RESULTS: the number of contaminated grafts was similar in the two groups. Growth of bacteria was recorded from 92.5% (37/40) of the graft segments and 33% (51/156) of glove imprints. Of the cultured species, 75% and 47%, respectively, were identified as coagulase-negative staphylococci (CNS). Twenty-eight per cent of CNS were resistant to cloxacillin, 15% to clindamycin, and 10% to cloxacillin and clindamycin. In all, 25% of the CNS strains were resistant to the prophylactic antibiotic used. In 50% of cases, the antibiogram of the CNS strain recovered from gloves agreed with that of the strain harvested from the graft. CONCLUSIONS: a high incidence of graft contamination was found which was not reduced by changing gloves. However, changing gloves did seem to reduce the number of bacterial species.

Response of inflammatory markers to balloon angioplasty in peripheral arterial occlusive disease.

OBJECTIVES: To study the inflammatory response to balloon angioplasty (PTA). DESIGN: Prospective study. MATERIALS: Blood samples were drawn for cytokine analysis from 10 patients undergoing PTA before, after 60 min and 6 h after the balloon inflation. Adhesion molecules were analysed in 14 patients undergoing PTA and in seven patients undergoing angiography only. Arterial samples were taken in eight patients, before PTA, immediately after and 15 min later. Venous samples were taken in six patients and in the group undergoing angiography only. The sampling was before, 60, 90 and 120 min after the procedure. As controls served 15 patients with no signs of peripheral arterial disease. METHODS: Cytokines (IL-6, TNF-alpha) were analysed using ELISA. Adhesion molecule expression on WBC was measured by flow cytometry. RESULTS: A significant increase of IL-6 in the sample taken 6 h after the last balloon inflation was seen in five patients. TNF-alpha was raised only in one patient. The group of patients with peripheral arterial occlusive disease (PAOD) expressed pre-interventionally a higher level of adhesion molecules on WBC compared to the controls. The expression of adhesion molecules (CD11b/CD18) was significantly decreased after PTA. CONCLUSION: Only a very limited cytokine response is caused by PTA reflecting the small surgical trauma. PTA results in a downregulation of detectable CD11b/CD18 expression on WBC in the circulation, which may reflect removal of activated cells through adhesion and extravasation.

Endovenous management of saphenous vein reflux. Endovenous Reflux Management Study Group.

PURPOSE: This study assessed clinical outcomes of two catheter-based endovenous procedures to eliminate or greatly mitigate saphenous vein reflux. MATERIALS AND METHODS: A computer-controlled, dedicated generator and two catheter designs were used to treat 210 patients at 16 private clinic and university centers in Europe. The Closure catheter applied resistive heating over long vein lengths to cause maximum wall contraction for permanent obliteration; the Restore catheter induced a short subvalvular constriction to improve the competence of mobile but nonmeeting leaflets. RESULTS: Closure treatment caused acute obliteration in 141 (93%) of 151 limbs; Restore treatment, shrinking one or more valves, acutely reduced reflux to less than 1 second in 41 (60%) of 68 limbs. Closure treatments were associated with early recanalization (6%), paresthesias (thigh, 9%; leg, 51%; P <.001), 3 skin burns, and 3 deep-vein thrombus extensions, with 1 embolism. Restore treatments were thrombogenic (16%) despite prophylactic anticoagulation, and treated valves enlarged over 6 weeks, becoming less competent. Clinical Efficacy Assessment Project clinical class was significantly improved after both treatments, up to 1 year. At 6 months, 87% of 53 Closure patients were class 0 or 1, 75% were symptom-free, and 96% of 55 treated limbs were completely free of reflux. Fourteen of 31 Restore patients (45%) had no symptoms, but 55% were class 2 or lower and only 19% had less than 1-second reflux. CONCLUSION: Closure treatment is clinically effective, albeit with offsetting complications and early failures; these are being addressed through four procedural modifications. Restore valve shrinking, although conceptually attractive, is too problematic to be competitive with Closure treatment or saphenectomy.