Peripheral arterial disease (PAD) - A challenging manifestation of atherosclerosis.

The diagnosis of peripheral arterial disease (PAD) is not always evident as symptoms and signs may show great variation. As all grades of PAD are linked to both an increased risk for cardiovascular complications and adverse limb events, awareness of the condition and knowledge about diagnostic measures, prevention and treatment is crucial. This article presents in a condensed form information on PAD and its management.

Improved Prognosis and Low Failure Rate with Anticoagulation as First-Line Therapy in Mesenteric Venous Thrombosis.

BACKGROUND: Monotherapy with anticoagulation has been considered as first-line therapy in patients with mesenteric venous thrombosis (MVT). The aim of this study was to evaluate outcome, prognostic factors, and failure rate of anticoagulation as monotherapy, and to identify when bowel resection was needed. METHODS: Retrospective study of consecutive patients with MVT diagnosed between 2000 and 2015. RESULTS: The overall incidence rate of MVT was 1.3/100,000 person-years. Among 120 patients, seven died due to autopsy-verified MVT without bowel resection and 15 underwent immediate bowel resection without prior anticoagulation therapy. The remaining 98 patients received anticoagulation monotherapy, whereof 83 (85%) were treated successfully. Fifteen patients failed on anticoagulation monotherapy, of whom seven underwent bowel resection and eight endovascular therapy. Endovascular therapy was followed by bowel resection in three patients. Two late bowel resections were performed due to intestinal stricture. The 30-day mortality rate was 19.0% in the former (2000-2007) and 3.2% in the latter (2008-2015) part of the study period (p = 0.006). Age ≥75 years (OR 12.4, 95% CI [2.5-60.3]), management during the former as opposed to the latter time period (OR 8.4, 95% CI [1.3-54.7]), and renal insufficiency at admission (OR 8.0, 95% CI [1.2-51.6]) were independently associated with increased mortality in multivariable analysis. CONCLUSIONS: Short-term prognosis in patients with MVT has improved. Contemporary data show that monotherapy with anticoagulation is an effective first choice in MVT patients.

Clinical implications of CT findings in mesenteric venous thrombosis at admission.

PURPOSE: The main aim of this study was to evaluate the association of computed tomography (CT) findings at admission and bowel resection rate in patients with mesenteric venous thrombosis (MVT). It was hypothesized that abnormal intestinal findings on CT were associated with a higher bowel resection rate. METHODS: Retrospective study of MVT patients treated between 2004 and 2017. CT images at admission and at follow-up were scrutinized according to a predefined protocol. Successful recanalization was defined as partial or complete recanalization of the portomesenteric venous thrombosis at the latest CT follow-up (n = 70). RESULTS: We studied 102 patients (median age 58 years, 61 men). Lifelong anticoagulation was initiated in 64 patients, and bowel resection rate was 17%. No referral letter indicated suspicion of MVT, whereas three indicated suspected intestinal ischemia. Previous venous thromboembolism was associated with increased bowel resection rate (p = 0.049). No patient with acute pancreatitis (n = 17) underwent bowel resection (p = 0.068). The presence of mesenteric oedema (p = 0.014), small bowel wall oedema (p < 0.001), small bowel dilatation (p = 0.005), and ascites (p = 0.021) were associated with increased bowel resection rate. Small bowel wall oedema remained as an independent risk factor associated with bowel resection (OR 15.8 [95% CI 3.2-77.2]). Successful thrombus recanalization was achieved in 66% of patients. CONCLUSION: The presence of abnormal intestinal findings secondary to MVT confers an excess risk of need of bowel resection due to infarction. Responsible physicians should therefore scrutinize the CT images at diagnosis together with the radiologist to better tailor clinical surveillance.

Efficacy and safety of outpatient treatment with direct oral anticoagulation in pulmonary embolism.

Anticoagulant treatment of acute pulmonary embolism (PE) has traditionally been hospital-based. The lesser need for monitoring with the increasingly used direct acting oral anticoagulants (DOAC) in comparison to warfarin potentially facilitates outpatient treatment of PE with these drugs. This study aimed to evaluate efficacy and safety of outpatient treatment of PE with DOAC. We extracted data from the Swedish quality registry for patients on oral anticoagulation (AuriculA) for all 245 patients in the southernmost hospital region in Sweden (1.3 million inhabitants) selected for outpatient treatment with of PE with DOAC during 2013-2015. Comorbidites, risk factors, and simplified pulmonary embolism severity index were evaluated at baseline, and death, recurrent venous thromboembolism (VTE), and bleeding was recorded during 6 months of follow-up. Outpatient treatment was defined as discharge from the emergency department within 24 h. During 6 months of follow-up, one patient died during DOAC therapy, the cause of death was unrelated to VTE. No VTE recurrences occured, whereas, one patient experienced major bleeding, and five patients experienced minor bleedings. Outpatient treatment of PE with DOAC is efficient and safe in selected patients.

Testing for thrombophilia in mesenteric venous thrombosis - Retrospective original study and systematic review.

The aim was to perform a local study of risk factors and thrombophilia in mesenteric venous thrombosis (MVT), and to review the literature concerning thrombophilia testing in MVT. Patients hospitalized for surgical or medical treatment of MVT at our center 2000-2015. A systematic review of observational studies was performed. In the local study, the most frequently identified risk factor was Factor V Leiden mutation. The systematic review included 14 original studies. The highest pooled percentage of any inherited thrombophilic factor were: Factor V Leiden mutation 9% (CI 2.9-16.1), prothrombin gene mutation 7% (CI 2.7-11.8). The highest pooled percentage of acquired thrombophilic factors were JAK2 V617F mutation 14% (CI -1.9-28.1). The wide range of frequency of inherited and acquired thrombophilic factors in different populations indicates the necessity to relate these factors to background population based data in order to estimate their overrepresentation in MVT. There is a need to develop guidelines for when and how thrombophilia testing should be performed in MVT.

Primary Stenting of the Superficial Femoral Artery in Intermittent Claudication Improves Health Related Quality of Life, ABI and Walking Distance: 12 Month Results of a Controlled Randomised Multicentre Trial.

BACKGROUND: Invasive treatment of intermittent claudication (IC) because of severe atherosclerotic stenosis or occlusion in the superficial femoral artery (SFA) is controversial. This prospective randomised trial was performed to assess the impact on health related quality of life (HRQoL) of primary stenting with nitinol self expanding stents compared with best medical treatment alone in patients suffering from stable IC due to SFA disease. METHODS: One hundred patients with stable IC caused by SFA disease from seven Swedish hospitals treated with best medical treatment (BMT) were randomised to either the stent (n = 48) or the control (n = 52) group. Change in HRQoL assessed by the Short Form 36 Health Survey (SF-36) and EuroQoL 5 dimensions (EQ5D) 12 months after treatment was the primary outcome measure. Improvement in the Walking Impairment Questionnaire (WIQ), ankle brachial index (ABI), and walking distance were secondary outcomes. RESULTS: HRQoL improved significantly. In the stent group the following SF-36 domains improved: Physical Function, 19 points (p < .001); Bodily Pain, 14 points (p = .001); General Health, 6 points (p = .019); Vitality, 10 points (p = .004); Physical Component Summary, 6.5 points (p < .001); EQ5D, 0.14 points (p = .008); and WIQ 22 points (p < .001). They were unchanged in the control group. Both ABI (from 0.58 ± 0.11 to 0.86 ± 0.19, p < .001, in the stent group and from 0.63 ± 0.17 to 0.70 ± 0.20, p = .005, in the control group) and walking distance (WD) (from 171 ± 90 meters to 613 ± 381 meters, p < .001, in the stent group and from 209 ± 106 m to 335 ± 321 meters, p = .012, in the control group) improved, and at 12 months both the ABI (p < .001) and the WD (p = .001) were higher in the stent group. CONCLUSIONS: In patients with IC caused by lesions in the SFA, the addition of primary stenting to BMT was associated with significant improvement in HRQoL, ABI, and walking distance after 12 months follow-up compared with BMT alone.

Is it safe to withhold long-term anticoagulation therapy in patients with small pulmonary emboli diagnosed by SPECT scintigraphy?

BACKGROUND: The need for anticoagulation therapy (AC) in patients with subsegmental pulmonary embolism (SSPE) diagnosed by computed tomography of the pulmonary arteries (CTPA) has been questioned, as these patients run low risk for recurrent venous thromboembolism (VTE) during 3 months of follow-up. Whether this applies also to patients with small PE diagnosed with pulmonary scintigraphy has not yet been evaluated, however. METHODS: We therefore retrospectively evaluated 54 patients (mean age 62 ± 19 years, 36 [67 %] women) with small PE diagnosed by ventilation/perfusion singe photon emission computed tomography (V/P SPECT) who did not receive conventional long-term AC. RESULTS: More than half of our patients (36[67 %]) received less than 48 h of AC, 11 (20 %) patients were treated for 2-14 days, and 7 (13 %) for 15-30 days. The majority (28 [52 %]) of our patients had a non-low simplified pulmonary emboli severity index (S-PESI), and 7 (13 %) had malignancy. D-dimer was negative in 18 (33 %), positive in 10 (19 %), and not analyzed in 28 (52 %) patients. Phlebography of the lower extremities had been performed with negative result in one patient. During 90 days of follow up no deaths or PE occurred. Seven patients were readmitted to hospital, whereof two (2/54 [4 %]) were diagnosed with deep venous thrombosis (DVT) necessitating AC therapy. CONCLUSION: In conclusion, withholding longterm AC therapy in patients with SSPE diagnosed by V/P SPECT resulted in 4 % risk for recurrence of VTE during 90 days of follow up, and can therefore currently not be recommended.

All Cause Chronic Widespread Pain is Common in Patients with Symptomatic Peripheral Arterial Disease and is Associated with Reduced Health Related Quality of Life.

OBJECTIVE: Invasive treatment of peripheral arterial disease (PAD) does not always lead to improvement, as concomitant diseases might affect walking ability and health related quality of life (HRQoL). Patients with chronic widespread pain (CWP) report worse outcome when treated for cancer and rheumatic diseases. The aim of the present study was to evaluate the prevalence of CWP and its potential association with reduced HRQoL in patients treated for PAD. METHOD: This was a longitudinal cohort study conducted between May 2011 and April 2014, including patients with planned invasive treatment of symptomatic PAD at two vascular clinics in Sweden. In 240 patients with planned treatment of PAD, HRQoL and pain distribution were assessed using the Short Form 36 Health Survey (SF-36), EuroQoL 5 dimensions (EQ5D), Walking Impairment Questionnaire (WIQ), and a questionnaire concerning musculoskeletal pain (Epipain manikin) before and 12 months after treatment. HRQoL was compared in patients with no chronic pain (NCP), with chronic regional pain (CRP), and with CWP. The SF-36 subscales PF, VT, and MH, representing important aspects of HRQoL (physical function, vitality, and mental health), were the main outcome measures. RESULTS: Before treatment 22 (10%) patients reported NCP, 133 (61%) CRP, and 64 (29%) CWP. These proportions did not differ between patients with intermittent claudication (IC) and critical limb ischemia (CLI, p = .150). CWP was more common in women than in men (36% vs. 24%, p = .035.) HRQoL improved significantly after treatment in all groups, but was still significantly reduced in CWP patients. CWP predicted worse outcome in HRQoL after treatment. CONCLUSION: CWP is common and is strongly associated with reduced HRQoL in patients with PAD. Treatment led to significant improvement, but patients with CWP still had significantly reduced HRQoL after treatment. CWP measured by a pain manikin should therefore be taken into account when evaluating disease severity, treatment options, and effect of treatment in PAD.

Cost-effectiveness of Screening for Abdominal Aortic Aneurysm in Combination with Medical Intervention in Patients with Small Aneurysms.

OBJECTIVES: Screening for abdominal aortic aneurysm (AAA) among 65 year old men has been proven cost-effective, but nowadays is conducted partly under new conditions. The prevalence of AAA has decreased, and endovascular aneurysm repair (EVAR) has become the predominant surgical method for AAA repair in many centers. At the Malmö Vascular Center pharmacological secondary prevention with statins, antiplatelet therapy, and blood pressure reduction is initiated and given to all patients with AAA. This study evaluates the cost-effectiveness of AAA screening under the above mentioned conditions. METHODS: This was a Markov cohort simulation. A total of 4,300 65 year old men were invited to annual AAA screening; the attendance rate was 78.3% and AAA prevalence was 1.8%. A Markov model with 11 health states was used to evaluate cost-effectiveness of AAA screening. Background data on rupture risks, costs, and effectiveness of surgical interventions were obtained from the participating unit, the national Swedvasc Registry, and from the scientific literature. RESULTS: The additional costs of the screening strategy compared with no screening were €169 per person and year. The incremental health gain per subject in the screened cohort was 0.011 additional quality adjusted life years (QALYs), corresponding to an incremental cost-effectiveness ratio (ICER) of €15710 per QALY. Assuming a 10% reduction of all cause mortality, the incremental cost of screening was €175 per person and year. The gain per subject in the screened cohort was 0.013 additional QALYs, corresponding to an ICER of €13922 per QALY CONCLUSIONS: AAA screening remains cost-effective according to both the Swedish recommendations and the UK National Institute for Health and Care Excellence recommendations in the new era of lower AAA prevalence, EVAR as the predominant surgical method, and secondary prevention for all AAA patients.

Invasive treatment for infrainguinal claudication has satisfactory 1 year outcome in three out of four patients: a population-based analysis from Swedvasc.

OBJECTIVES: In spite of recommendations advocating conservative best medical treatment, many patients with infrainguinal intermittent claudication (IC) are treated by invasive open and endovascular methods. This study aims to evaluate the incidence and 1-year results of all such treatments during 2009 in Sweden. METHODS: The design was a one-year follow-up through the Swedish Vascular Registry (Swedvasc) of all 775 patients from the Swedish population of 10 million inhabitants in whom 843 invasive infrainguinal procedures (796 index procedures and 47 secondary procedures) were performed for IC in 2009. Index procedures were open surgery in 290 (37%) patients, bilateral in nine cases, giving a total of 299 limbs, endovascular treatment in 447 (58%) patients, bilateral in 10, giving a total of 457 limbs, and hybrid treatment in 38 (5%) patients, bilateral in two cases, giving a total of 40 limbs. Data were analysed both with regard to the number of patients (775) and the number of procedures (843). Clinical outcome was calculated from patient-reported leg function (unchanged, improved, deteriorated) and whether amputation had been necessary or death had occurred. Patent reconstruction at 1 year was also counted as improvement. RESULTS: Improvement at 1 year was seen in 567 (73.2%) patients, (225 [77.6%] in the open surgery group, 320 [71.6%] in the endovascular treatment group, and 22 [57.9%] in the hybrid treatment group). No significant difference was found between the open surgery and endovascular treatment groups comprising 737/775 patients (p = .350). Hybrid treatment gave significantly worse results (p = .046). Fifty-seven (7.3%) patients reported unchanged limb function and 32 (4.1%) patients reported deterioration. Within 30 days two patients died and one patient underwent amputation. Within 1 year 10 patients underwent 11 amputations: five (1.7%) in the open surgery group, three (0.6%) in the endovascular treatment group, and two (7.5%) in the hybrid treatment group; one underwent bilateral amputation (p = .07). Twenty-two patients died: 10 (3.4%) in the open surgery group, 12 (2.7%) in the endovascular treatment group and none in the hybrid treatment group (p = .465). CONCLUSIONS: Reported improvement at 1 year was 73.2% in patients invasively treated for infrainguinal IC. Patients reporting an unchanged or deteriorated clinical state are a considerable clinical challenge. Further studies to determine whether or not invasive treatment of infrainguinal IC is appropriate are justified.

Medical risk factor treatment in peripheral arterial disease. Need for further improvement.

AIM: Risk factors for development of peripheral arterial disease (PAD) are the same as for atherosclerotic coronary or precerebral disease, and patients with PAD have a high prevalence of concomitant atherosclerotic disease in coronary and precerebral arteries. However, these patients are still less likely to receive appropriate pharmacological secondary prevention than patients with coronary artery disease. The aim of this study was to evaluate the treatment of risk factors for patients undergoing open or endovascular surgery for PAD in our vascular department. METHODS: We evaluated pharmacological treatment, lipid levels, blood pressures (BP), and smoking habits one month postoperatively in 953 patients (age [mean ± SD] 71±11 years, 524 [55%] men) undergoing open or endovascular surgical interventions for PAD. RESULTS: We found that 89% of patients received statins and 98% received either platelet aggregation inhibitors or anticoagulants at the one month follow-up. Four hundred nineteen (70%) patients had achieved target level <4.5 mmol/L for s-total cholesterol, and 394 (67%) target level <2.5 mmol/L for s-LDL cholesterol. BP (mean ± SD) was 144±22/76±12 mmHg, systolic and diastolic target BPs (<140 mmHg and <90 mmHg, respectively) were achieved in 482 (51%) and 887 (95%) patients, respectively. The proportion of active smokers had been reduced from 41% preoperatively to 24% at the one month follow-up (P<0.0001). CONCLUSION: Even though our practice has improved, there is still room for better follow-up of pharmacological risk factor treatment in PAD patients.

Impaired vibrotactile sense at low frequencies in fingers in autoantibody positive and negative diabetes.

Vibration thresholds in index and little finger pulps in subjects with autoantibody [GADA, IA-2A and/or ICA] positive and negative diabetes 20 years after diagnosis were higher than in age-matched controls at low frequencies (8 and 16 Hz), irrespective of HbA1c values, indicating selective impairment of Meissner's corpuscles and/or their innervating axons.

Gender differences in outcome after stent treatment of lesions in the femoropopliteal segment.

BACKGROUND AND AIMS: Although endovascular stent treatment is increasingly used in infrainguinal atherosclerotic occlusive disease, outcome with focus on gender differences has not been reported in detail. MATERIAL AND METHODS: One hundred and twelve consecutive patients (67 [60%]) women, undergoing endovascular nitinol stent treatment of atherosclerotic lesions in the femoropopliteal segment were analysed concerning improvement in ankle brachial index (ABI), reinterventions, complications, amputation and survival rates up to 12 months after intervention. Risk factors for amputation and death were analyzed with logistic regression. RESULTS: At presentation, women showed critical limb ischemia (CLI) more often than men (87% vs. 58 %; P = 0.001). After 12 months ABI had improved (from 0.40 ± 0.26 at baseline to 0.86 ± 0.22 after 12 months, P < 0.001), but 16 patients (15%) had been amputated and 27 patients (24 %) had died. After adjustment for age, diabetes mellitus and smoking, female gender was an independent risk factor for amputation (OR 9.0; 95% CI 1.1-76.5; P = 0.045). CONCLUSIONS: Stent treatment of lesions in the femoropopliteal segment had favourable effects on ABI and limb salvage. Treated women more often had CLI and ran a higher risk for amputation within 12 months than men. This might reflect failure of clinicians to adequately appreciate symptoms of atherosclerotic leg artery disease in women.

Influence of preoperative medical assessment prior to elective endovascular aneurysm repair for abdominal aortic aneurysm.

AIM: The aim of this study was to compare preoperative patient evaluation by a vascular physician with a standardized workup protocol prior to elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), in terms of differences in patient medication and mortality. METHODS: Consecutive patients with infrarenal AAA treated with standard EVAR from 1998 to 2006 (group 2) and 2007 to 2011 (group 1) were compared. Patients in group 1 (N.=201) were investigated preoperatively by a vascular physician, evaluating comorbidities and medication. Patients in group 2 (N.=304) underwent a standardized preoperative work-up including spirometry and echocardiography. Median time of follow-up was 23 months in group 1 and 71 months in group 2. RESULTS: The proportion of patients who had on-going medication with anti-platelet and lipid lowering medication at admission was higher in group 1 compared to group 2 (62% versus 51%; P=0.013 and 68% versus 35%; P<0.001). In group 1, the proportion of newly instituted or increased dosage of anti-hypertensive, anti-platelet or lipid lowering medication at preoperative evaluation was 40%, 24% and 31%, respectively. The total cost for preoperative assessment per patient was 272 € in group 1 and 293 € in group 2 (P<0.001). There was no difference in 30-day (P=0.29) or long-term (P=0.24) mortality between the two groups. CONCLUSION: Preoperative assessment by a vascular physician resulted in lower costs and improvement of medication against atherosclerosis, uncontrolled hypertension and perioperative ischemic cardiac events, but mortality was unaffected.

Patterns of markers of inflammation, coagulation and vasoconstriction during follow-up of abdominal aortic aneurysms.

AIM: The etiology of abdominal aortic aneurysm (AAA) includes inflammation, coagulation, and endothelial dysfunction. We have prospectively evaluated relations between these mechanisms and AAA growth. Tumour necrosis factor (TNF)-α, interleukin (IL)-6, endothelin (ET)-1, CD40 ligand and the complex formed between activated protein C (APC) and protein C inhibitor (PCI) were measured annually and related to AAA growth during up to 5 years in 206 patients with conservatively followed AAA. METHODS: We evaluated 163 patients up to 1 year, 126 patients up to 2 years, 83 patients up to 3 years, 53 patients up to 4 years, and 33 patients up to 5 years. The total number of patient follow-up years was 458. RESULTS: ET-1 remained unchanged except for a tendency to increase in the third and fourth years of follow-up. TNF-α decreased significantly during the first year and thereafter increased back to baseline values. There were no changes in IL-6, CD40 ligand, and APC-PCI complex. When patients in the highest and lowest quartiles of AAA growth up to 5 years follow-up were compared, APC-PCI complex levels tended to be higher (P=0.06) in the highest quartile of growth at three years (0.45 µg/l [i.q.r. 0.40-0.77] versus 0.28 µg/L [i.q.r. 0.14-0.36]). Δ-values of ET-1 and TNF-α did not show any correlation to growth. The 14 AAA patients that ruptured during follow-up did not differ from patients with non-ruptured AAA regarding biomarkers. CONCLUSION: In conclusion, none of the investigated mediators could be used to predict growth or rupture, or help to prolong intervals between ultrasound examinations in follow-up of AAA patients.

No signs of progressive beta cell damage during 20 years of prospective follow-up of autoantibody-negative diabetes.

Both type 1 and type 2 diabetes are considered to be associated with different degrees of progressive beta cell damage. However, few long-term studies have been made. Our aim was to study the clinical course of 20 years of diabetes disease, including diabetes progression, comorbidity, and mortality in a prospectively studied cohort of consecutively diagnosed diabetic patients. Among all 233 patients diagnosed with diabetes during 1985-1987 in Malmö, Sweden, 50 of 118 surviving patients were followed-up after 20 years. The age at diagnose was 42.3 ± 23.1 and 57.5 ± 13.6 years for antibody-positive and antibody-negative patients, respectively. HbA1c and plasma lipids were analyzed with regard to metabolic control. Islet antibody-negative patients at diagnosis had highly preserved C-peptide levels after 20 years in contrast to antibody-positive patients (antibody negative: C-peptide 0 years 0.78 ± 0.47 and 20 years 0.70 ± 0.46 (nmol/l), P = 0.51 and antibody positive: C-peptide 0 years 0.33 ± 0.35 and 20 years 0.10 ± 0.18; P < 0.001. Islet antibodies but not age, BMI, or C-peptide at diagnosis were predictors of C-peptide levels at 20 years when analyzed by logistic regression (P < 0.05). HbA1c did not differ between the groups after 20 years. The 20-year mortality was higher among antibody-negative patients, dependent on the higher age at diagnosis in this group (number of deaths: antibody positive: 18 of 56 vs. antibody negative: 109 of 188, P < 0.001). Of the deceased, 79% had died from diseases or complications that may be associated with diabetes. We found no progressive beta cell damage in autoantibody-negative diabetes at a 20-year follow-up of the clinical course of diabetes.

Oxidative stress and endothelin-1 in atherosclerotic renal artery stenosis and effects of renal angioplasty.

AIMS: To examine biomarkers of oxidative stress (oxs), and endothelin (ET)-1, in hypertensive patients with atherosclerotic renal artery stenosis (ARAS) and to evaluate the effect of percutaneous transluminal renal angioplasty (PTRA). METHODS: Baseline measurements were made immediately before renal angiography in patients with suspected ARAS (significant ARAS, n = 83, and non-RAS, n = 59) and in 20 healthy, matched controls. In patients with ARAS, analyses were repeated 4 weeks after PTRA. All patients were treated with statins and acetylsalicylic acid throughout. RESULTS: At baseline there were no significant differences between groups in biomarkers of oxs, whereas high-sensitivity C-reactive protein and blood leukocytes were significantly elevated in group ARAS versus both healthy controls and group non-RAS. Plasma levels of ET-1 and uric acid were significantly increased in group ARAS versus healthy controls prior to angiography and were significantly reduced compared to baseline 4 weeks after PTRA. PTRA had no significant effects on biomarkers of oxs, inflammation or serum creatinine concentrations. CONCLUSIONS: ARAS patients on treatment with antihypertensive agents, acetylsalicylic acid and statins showed elevated inflammatory indices but no increase in oxs. PTRA had no significant effects on inflammatory indices 4 weeks after intervention but reduced plasma ET-1 and uric acid.

Predictors of long-term beneficial effects on blood pressure after percutaneous transluminal renal angioplasty in atherosclerotic renal artery stenosis.

AIM: This retrospective study evaluated long-term effects of percutaneous transluminal renal angioplasty (PTRA) in atherosclerotic renal artery stenosis (ARAS), and predictors of benefit on blood pressure (BP). METHODS: During 1997-2003, 234 patients (age 69+/-11 years, 138 [59%] males) underwent PTRA for ARAS at Malmö Vascular Centre. Cure was defined as diastolic (D)BP<90 mmHg and systolic (S)BP <140 mmHg off antihypertensive medication. Improvement was defined as DBP <90 mmHg and/or SBP <140 mmHg on the same or reduced number of medications, or reduction in DBP of >or=15 mmHg with the same or reduced number of medications. Benefit was defined as cure or improvement. RESULTS: After PTRA, SBP and DBP decreased (P<0.001), and remained lower (P<0.001) until last follow-up after 4.1+/-3.3 years. Antihypertensive medication decreased (P<0.001), and remained lower at one month (P<0.001), one year (P<0.01), and last follow-up (P<0.05). Renal function was unchanged until last follow-up, when it deteriorated (P<0.001). Patients showing benefit of PTRA on BP at last follow-up (N.=150 [64%]) used more antihypertensive drugs before PTRA (P=0.012), especially angiotensin converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) (P=0.010), and diuretics (P=0.015). In logistic regression, use of ACEi or ARBs failed to reach significancy (P=0.054). Patients dying during follow up (N.=100 [43%]) showed higher age (P<0.0001) and s-creatinine (P<0.0001), lower glomerular filtration rate (P<0.0001), and higher frequency of diabetes mellitus (P<0.005). In logistic regression only age (P=0.009) and diabetes mellitus (P=0.014) predicted mortality. CONCLUSIONS: We confirmed beneficial effects on BP with PTRA in ARAS. ACEi, ARB and diuretic treatment before PTRA predict favourable long-term BP-response in univariate analysis.

Epidemiology and long-term prognostic factors in acute type B aortic dissection.

The epidemiological data and reports on long-term predictors of mortality after medically or endovascularly and medically treated patients with acute type B aortic dissection (AD) are scarce. Patients with type B AD between 2000 and 2004 were identified through the inpatient endovascular or autopsy registry at Malmö-Lund University Hospital, Sweden. Seventy-two patients had acute type B AD, of whom eight were found at autopsy. Shock due to ruptured type B AD was associated with in-hospital mortality (P = 0.006) in the 64 eligible patients. Renal insufficiency (odds ratio [OR] = 4.7, 95% confidence interval [CI] 1.1-19.4) and coexistent aortic disease (OR = 4.1, 95% CI 1.0-16.9) remained as independent predictors for long-term mortality after multivariate logistic regression analysis. Endovascular intervention (n = 32) was associated with neither short- nor long-term mortality. The estimated overall incidence of acute type B AD was 2.1/100,000 person-years, and the highest incidence rates were found in men aged 65-74 years (14.6/100,000 person-years) and women aged 75-84 years (19.0/100,000 person-years). Survival in patients with complicated acute type B AD managed with the endovascular technique was the same as in uncomplicated medically treated patients. Renal insufficiency and coexistent aortic disease were strong predictors for long-term mortality.