Chimney Grafts in Aortic Stent Grafting: Hazardous or Useful Technique? Systematic Review of Current Data.

BACKGROUND: The chimney graft (CG) technique was introduced to rescue accidentally covered aortic branches during aortic endovascular repair. It extends the sealing zone. There is concern about "gutter" type I endoleak (EL-I) and about the durability of CGs. The aim of the present report was to analyze the rapidly increasing existing data. METHODS: A search was performed (PRISMA criteria) for all studies of visceral and thoracic/arch chimney grafts. Technical and clinical details and outcome were assessed. RESULTS: The present review includes 831 patients who underwent EVAR/TEVAR (endovascular aneurysm repair/thoracic endovascular aneurysm repair) with one or more chimney, periscope, or sandwich grafts. For aortic visceral vessels 517 patients received 911 visceral CGs and 314 patients received 364 arch CGs. Most procedures (81% visceral and 69% arch CGs) were elective. Thirty day mortality was 4% for both groups. The rate of early EL-I was 13% (visceral CGs) and 11% (arch CGs). Most EL-I were handled conservatively (observation: 70% for visceral CG and 45% for arch CG). Early CG patency was high (97-99%) and remained high during follow up (median 17 months). Late (after 30 days) EL-I was reported in nine visceral (2%) and 12 arch (4%) CG cases. Few other late complications were reported, but those losing a kidney at the initial repair seemed to have a high risk of requiring permanent hemodialysis. CONCLUSION: Increasing amounts of data support the benefit of visceral and arch chimney graft techniques. In particular, the low early mortality and complication rates and high long-term patency seem advantageous; however, the majority of cases have been treated electively, and there is a high risk of bias in all studies. Mid- to long-term data suggest few late complications, except in cases where one renal artery was sacrificed. The CG technique is valuable for complex urgent patients and needs further documentation for other patient groups.

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.

Triple specificity of ZnT8 autoantibodies in relation to HLA and other islet autoantibodies in childhood and adolescent type 1 diabetes.

OBJECTIVE: To establish the diagnostic sensitivity of and the relationships between autoantibodies to all three Zinc transporter 8 (Zinc transporter 8 autoantibody to either one, two, or all three amino acid variants at position 325, ZnT8A) variants to human leukocyte antigen (HLA)-DQ and to autoantibodies to glutamic acid decarboxylase (GADA), insulinoma-associated protein 2 (IA-2A), and insulin (IAA). METHODS: We analyzed 3165 patients with type 1 diabetes (T1D) in the Better Diabetes Diagnosis study for HLA-DQ genotypes and all six autoantibodies (ZnT8RA, arginine 325 Zinc transporter 8 autoantibody; ZnT8WA, tryptophan 325 Zinc transporter 8 autoantibody; ZnT8QA, glutamine 325 Zinc transporter 8 autoantibody; GADA, IA-2A, and IAA). RESULTS: ZnT8A was found in 65% of the patients and as many as 108 of 3165 (3.4%) had 1-3 ZnT8A alone. None had ZnT8QA alone. Together with GADA (56%), IA-2A (73%), and IAA (33%), 93% of the T1D patients were autoantibody positive. All three ZnT8A were less frequent in children below 2 yr of age (p < 0.0001). All three ZnT8A were associated with DQA1-B1*X-0604 (DQ6.4) and DQA1-B1*03-0302 (DQ8). ZnT8WA and ZnT8QA were negatively associated with DQA1-B1*05-02 (DQ2). CONCLUSIONS: Analysis of ZnT8A increased the diagnostic sensitivity of islet autoantibodies for T1D as only 7% remained islet autoantibody negative. The association between DQ6.4 and all three ZnT8A may be related to ZnT8 antigen presentation by the DQ6.4 heterodimer.

Residual beta cell function at diagnosis of type 1 diabetes in children and adolescents varies with gender and season.

BACKGROUND: There are seasonal variations and gender differences in incidence of type 1 diabetes (T1D), metabolic control and responses to immune interventions at onset of the disease. We hypothesized that there are seasonal and gender differences in residual insulin secretion already at diagnosis of T1D. METHODS: In 2005, a national study, the Better Diabetes Diagnosis, was started to classify all newly diagnosed children and adolescents with diabetes. About 95% (3824/4017) of the patients were classified as T1D, and our analyses are based on the patients with T1D. RESULTS: C-peptide was lower in younger children, 0-10 years of age (0.23 ± 0.20 nmol/L) than in older children, 11-18 years of age (0.34 ± 0.28 nmol/L) (p < 0.000 ). There was a seasonal variation in non-fasting serum C-peptide, significantly correlated to the seasonal variation of diagnosis (p < 0.01). Most children were diagnosed in January, February and March as well as in October when C-peptide was highest, whereas fewer patients were diagnosed in April and May when serum C-peptide was significantly lower (p < 0.01). The seasonal variation of C-peptide was more pronounced in boys than in girls (p < 0.000 and p < 0.01, respectively). Girls had higher C-peptide than boys (p < 0.05), especially in early puberty. CONCLUSIONS: Both seasonal and gender differences in residual beta cell function exist already at diagnosis of T1D. These observations have consequences for treatment and for randomizing patients in immune intervention clinical trials.

Age-dependent variation of genotypes in MHC II transactivator gene (CIITA) in controls and association to type 1 diabetes.

The major histocompatibility complex class II transactivator (CIITA) gene (16p13) has been reported to associate with susceptibility to multiple sclerosis, rheumatoid arthritis and myocardial infarction, recently also to celiac disease at genome-wide level. However, attempts to replicate association have been inconclusive. Previously, we have observed linkage to the CIITA region in Scandinavian type 1 diabetes (T1D) families. Here we analyze five Swedish T1D cohorts and a combined control material from previous studies of CIITA. We investigate how the genotype distribution within the CIITA gene varies depending on age, and the association to T1D. Unexpectedly, we find a significant difference in the genotype distribution for markers in CIITA (rs11074932, P=4 × 10(-5) and rs3087456, P=0.05) with respect to age, in the collected control material. This observation is replicated in an independent cohort material of about 2000 individuals (P=0.006, P=0.007). We also detect association to T1D for both markers, rs11074932 (P=0.004) and rs3087456 (P=0.001), after adjusting for age at sampling. The association remains independent of the adjacent T1D risk gene CLEC16A. Our results indicate an age-dependent variation in CIITA allele frequencies, a finding of relevance for the contrasting outcomes of previously published association studies.

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.

The reliability of the disabled children's quality-of-life questionnaire in Swedish children with diabetes.

AIM: To determine the reliability of the disabled children's quality-of-life measure (DISABKIDS) chronic generic questionnaire and diabetes module in children. The questionnaire is being evaluated for repeated routine health-related quality-of-life (HrQoL) assessment and in association with the Swedish national paediatric diabetes registry (Swediabkids), which is a tool for regular clinical use. METHODS: Children and parents completed the questionnaire during a routine visit to the diabetes clinic. In total, 120 families completed the test and retest. Split-half reliability correlation and intraclass correlation (ICC) coefficients were calculated. Bland & Altman plots were calculated on the generic HRQoL domain. RESULTS: Both child and parent versions showed good internal consistency. Test-retest ICC coefficients for the generic HrQoL module were 0.913 for the children and 0.820 for the parent version. All generic domains independently showed good reliability. The diabetes module had a score of 0.855 for children and 0.823 for parents. Split-half correlation for generic and diabetes modules was 0.930 and 0.848 for children, 0.953 and 0.903 for parents. Bland and Altman plots showed substantial agreement between the two administrations for both children and parents. CONCLUSION: The DISABKIDS questionnaire is a reliable instrument for the repeated measurements of HrQoL in children with diabetes.

Low risk HLA-DQ and increased body mass index in newly diagnosed type 1 diabetes children in the Better Diabetes Diagnosis study in Sweden.

OBJECTIVE: Type 1 diabetes and obesity has increased in childhood. We therefore tested the hypothesis that type 1 diabetes human leukocyte antigen DQ (HLA-DQ) risk genotypes may be associated with increased body mass index (BMI). DESIGN: The type 1 diabetes high-risk HLA-DQ A1*05:01-B1*02:01/A1*03:01-B1*03:02 genotype along with lower risk DQ genotypes were determined at the time of clinical onset by PCR and hybridization with allele-specific probes. BMI was determined after diabetes was stabilized. SUBJECTS: A total of 2403 incident type 1 diabetes children below 18 years of age were ascertained in the Swedish national Better Diabetes Diagnosis (BDD) study between May 2005 to September 2009. All children classified with type 1 diabetes, including positivity for at least one islet autoantibody, were investigated. RESULTS: Overall, type 1 diabetes HLA-DQ risk was negatively associated with BMI (P<0.0008). The proportion of the highest risk A1*05:01-B1*02:01/A1*03:01-B1)03:02 genotype decreased with increasing BMI (P<0.0004). However, lower risk type 1 diabetes DQ genotypes were associated with an increased proportion of patients who were overweight or obese (P<0.0001). Indeed, the proportion of patients with the low-risk A1*05:01-B1*02:01/A1*05:01-B1*02:01 genotype increased with increasing BMI (P<0.003). The magnitude of association on the multiplicative scale between the A1*05:01-B1*02:01/A1*05:01-B1*02:01 genotype and increased BMI was significant (P<0.006). The odds ratio in patients with this genotype of being obese was 1.80 (95% confidence interval 1.21-2.61; P<0.006). The increased proportion of overweight type 1 diabetes children with the A1*05:01-B1*02:01 haplotype was most pronounced in children diagnosed between 5 and 9 years of age. CONCLUSIONS: Susceptibility for childhood type 1 diabetes was unexpectedly found to be associated with the A1*05:01-B1*02:01/A1*05:01-B1*02:01 genotype and an increased BMI. These results support the hypothesis that overweight may contribute to the risk of type 1 diabetes in children positive for HLA-DQ A1*05:01-B1*02:01.

C-peptide in the classification of diabetes in children and adolescents.

AIM: To report C-peptide results in newly diagnosed patients and the relation to clinical diagnosis of diabetes. METHODS: A nation-wide cohort, the Better Diabetes Diagnosis study was used to determine serum C-peptide at diagnosis in 2734 children and adolescents. Clinical data were collected at diagnosis and follow-up. C-peptide was determined in a validated and controlled time-resolved fluoroimmunoassay. RESULTS: The clinical classification of diabetes, before any information on human leukocyte antigen, islet autoantibodies, or C-peptide was received, was type 1 diabetes (T1D) in 93%, type 2 diabetes (T2D) in 1.9%, maturity onset diabetes of the young (MODY) in 0.8%, secondary diabetes (0.6%), while 3.3% could not be classified. In a random, non-fasting serum sample at diagnosis, 56% of the patients had a C-peptide value >0.2 nmol/L. Children classified as T2D had the highest mean C-peptide (1.83 + 1.23 nmol/L) followed by MODY (1.04 ± 0.71 nmol/L) and T1D (0.28 ± 0.25 nmol/L). Only 1/1037 children who had C-peptide <0.2 nmol/L at diagnosis was classified with a type of diabetes other than T1D. Predictive value of C-peptide >1.0 nmol/L for the classification of either T2D or MODY was 0.46 [confidence interval 0.37-0.58]. CONCLUSIONS: More than half of children with newly diagnosed diabetes have clinically important residual beta-cell function. As the clinical diagnosis is not always straightforward, a random C-peptide taken at diagnosis may help to classify diabetes. There is an obvious use for C-peptide determinations to evaluate beta-cell function in children with 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.

Continuous glucose monitoring system during physical exercise in adolescents with type 1 diabetes.

AIM: Continuous glucose monitoring system (CGMS) provides detailed information on glucose fluctuations. The aim was to establish whether CGMS could be used during physical exercise and whether it detects more episodes of hypoglycaemia and hyperglycaemia than frequent blood glucose measurements. METHODS: Adolescents with type 1 diabetes (12 girls and 47 boys) participated in three annual sports camps that lasted for 3-4 days and included different types of exercise: soccer, floorball + cross-country skiing and golf. During the study, blood glucose values, mean 8.7 ± 3.3 per day, were obtained with Hemocue in parallel with the CGMS. RESULTS: Ninety-eight per cent of the participants used the sensor at all times during the camps. Eighty-seven per cent of the sensors gave adequate signals for 24 h and 66% for 48 h. Median durations of hypoglycaemia and hyperglycaemia were 1.7 h per day and 3.8 h per day, respectively. The CGMS identified significantly more episodes of hypoglycaemia (p < 0.005) and hyperglycaemia (p < 0.005) during the day and night than frequent blood glucose tests. CONCLUSION: We demonstrate that, even during days that included episodic strenuous physical exercise, CGMS could provide useful information on glucose fluctuations during day and night, albeit with significant failure rates.

Risk factors for haemorrhage during local intra-arterial thrombolysis for lower limb ischaemia.

Assessment of clinical risk factors for haemorrhagic complications in patients undergoing intra-arterial thrombolysis for lower limb ischaemia. Retrospective reviews of consecutive patients subjected to intra-arterial thrombolysis due to lower limb ischemia at the Vascular Center, Malmö University Hospital, during a 5-year period from 2001 to 2005. Two hundred and twenty intra-arterial thrombolytic procedures were carried out in 195 patients (46% women), median age 73 years. Haemorrhagic complications were recorded in 72 procedures (33%), of which 13 were discontinued. Haemorrhage at the introducer and distant sites occurred in 53 and 32 procedures, respectively. Thrombolysis for occluded synthetic grafts was associated with higher risk of haemorrhage (P = 0.043). The platelet count was lower (P = 0.017) and the dose of alteplas higher (P = 0.041) in bleeders than in non-bleeders. Age was not associated with haemorrhage (P = 0.30). Two patients died during thrombolysis, one of them due to intracerebral haemorrhage. The grade of thrombolysis was an independent predictor of both in-hospital amputation (P < 0.001; OR 3.5 [95% CI 2.1-5.8]) and mortality (P = 0.021; OR 3.0 [95% CI 1.2-7.9]). The in-hospital amputation-free survival rate was 85% (188/220). Haemorrhage associated with thrombolysis is common, but does seldom require discontinuation of treatment. Insertion of introducers for local thrombolysis through synthetic grafts, lower platelet count and higher alteplas dose were found to be risk factors for haemorrhage. An algorithm for clinical management of haemorrhage has been proposed.

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.

Early and intermediate outcome of emergency endovascular aneurysm repair of ruptured infrarenal aortic aneurysm: a single-centre experience of 90 consecutive patients.

OBJECTIVE: To evaluate the early and intermediate outcome of a consecutive series of emergency endovascular aneurysm repairs (eEVAR) of computed tomography (CT)-verified infrarenal ruptured abdominal aortic aneurysm (rAAA) at a single tertiary referral centre. METHODS: Prospectively collected data of patients operated between April 2000 and October 2007 were retrospectively reviewed and all their pre-, intra- and postoperative imaging were re-evaluated. Patient and procedural data were analysed using a Cox multiregression model. RESULTS: Ninety patients (86% men, aged 76 (+/-7) years), were identified and included in the analysis. Symptom duration was <3h in 22% of patients, 3-24h in 39% and >24h in 39%. Mean aneurysmal diameter was 73 (+/-14)mm. All patients were treated with the COOK Zenith stent-graft (56% bi-iliac and 44% uni-iliac). Sixty-one percent were haemodynamically unstable on presentation, and 26% required an intra-operative aortic occlusion balloon to maintain haemodynamic stability. The 30-day and 1-year mortality rates were 27% and 37%, respectively. One-year aneurysm-related mortality was 33%. Twenty-eight percent of patients required re-interventions during the follow-up. The use of an aortic occlusion balloon and the presence of cerebrovascular disease or obstructive lung disorder correlated significantly with 30-day mortality in the multivariate analysis. CONCLUSION: EVAR is a valid treatment option for rAAA when used as a first-line method for all patients.

Assessment of childhood diabetes-related quality-of-life in West Sweden.

AIM: To investigate health-related quality-of-life (HrQoL) in childhood diabetes and the level of agreement between West Sweden and European reference data for the new multi-cultural European questionnaire - DISABKIDS. METHOD: Twenty percent of the Swedish paediatric diabetes population was included in the survey. Child-parent pairs completed the DISABKIDS chronic generic (37 questions) and diabetes modules (10 questions) during their routine clinic visit. A one-page results summary, based on positive domains, was used to provide feedback to clinicians. RESULTS: Three hundred and sixty-one child-parent pairs were included in the analysis. In Sweden, diabetes was perceived by the children as having less impact than the European average. Swedish parents rated the HrQoL of their children lower than did the European parents. Swedish girls had a lower HrQoL than boys and greater difficulty accepting their diabetes; adolescents had greater difficulty accepting the diagnosis than younger children. Parents reported greater impact of diabetes on their children than the children themselves but reported no difference between boys and girls. Parents reported better acceptance of treatment in boys. The child's reported quality-of-life (QoL) is related to age and gender. CONCLUSION: Our results confirm the applicability of DISABKIDS to the Swedish paediatric diabetes population.

Temporal trends of HLA genotype frequencies of type 1 diabetes patients in Sweden from 1986 to 2005 suggest altered risk.

The aim of this study was to compare the frequency of human leukocyte antigen (HLA) genotypes in 1-18-year-old patients with type 1 diabetes newly diagnosed in 1986-1987 (n = 430), 1996-2000 (n = 342) and in 2003-2005 (n = 171). We tested the hypothesis that the HLA DQ genotype distribution changes over time. Swedish type 1 diabetes patients and controls were typed for HLA using polymerase chain reaction amplification and allele specific probes for DQ A1* and B1* alleles. The most common type 1 diabetes HLA DQA1*-B1*genotype 0501-0201/0301-0302 was 36% (153/430) in 1986-1987 and 37% (127/342) in 1996-2000, but decreased to 19% (33/171) in 2003-2005 (P \ 0.0001). The 0501-0201/0501-0201 genotype increased from 1% in 1986-1987 to 7% in 1996-2000 (P = 0.0047) and to 5% in 2003-2005 (P > 0.05). This study in 1-18-year-old Swedish type 1 diabetes patients supports the notion that there is a temporal change in HLA risk.

What to do when evidence is lacking--implications on treatment of aortic ulcers, pseudoaneurysms and aorto-enteric fistulae.

UNLABELLED: Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available. MATERIAL: From our centre we collected 65 patients treated with open (n = 15) or endovascular reconstruction (n= 50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment. RESULTS: Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended. CONCLUSION: Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.