RSAD2 is abundant in atherosclerotic plaques and promotes interferon-induced CXCR3-chemokines in human smooth muscle cells.

In atherosclerotic lesions, monocyte-derived macrophages are major source of interferon gamma (IFN-γ), a pleotropic cytokine known to regulate the expression of numerous genes, including the antiviral gene RSAD2. While RSAD2 was reported to be expressed in endothelial cells of human carotid lesions, its significance for the development of atherosclerosis remains utterly unknown. Here, we harnessed publicly available human carotid atherosclerotic data to explore RSAD2 in lesions and employed siRNA-mediated gene-knockdown to investigate its function in IFN-γ-stimulated human aortic smooth muscle cells (hAoSMCs). Silencing RSAD2 in IFN-γ-stimulated hAoSMCs resulted in reduced expression and secretion of key CXCR3-chemokines, CXCL9, CXCL10, and CXCL11. Conditioned medium from RSAD2-deficient hAoSMCs exhibited diminished monocyte attraction in vitro compared to conditioned medium from control cells. Furthermore, RSAD2 transcript was elevated in carotid lesions where it was expressed by several different cell types, including endothelial cells, macrophages and smooth muscle cells. Interestingly, RSAD2 displayed significant correlations with CXCL10 (r = 0.45, p = 0.010) and CXCL11 (r = 0.53, p = 0.002) in human carotid lesions. Combining our findings, we uncover a novel role for RSAD2 in hAoSMCs, which could potentially contribute to monocyte recruitment in the context of atherosclerosis.

Semi-Conservative Treatment Versus Radical Surgery in Abdominal Aortic Graft and Endograft Infections.

OBJECTIVE: Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort. METHODS: Patients with abdominal AGI related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for the definition of AGI. Multivariable regression was performed to identify factors associated with mortality. RESULTS: One hundred and sixty-nine patients with surgically treated abdominal AGI were identified, comprising 43 SC (14 endografts; 53% with a graft enteric fistula [GEF] in total) and 126 RS (26 endografts; 50% with a GEF in total). The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated five year survival for SC vs. RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated five year survival for SC patients with a GEF vs. without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC with RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in five year survival comparing SC vs. RS (HR 1.0, 95% CI 0.6 - 1.5). CONCLUSION: In this national AGI cohort, there was no mortality difference comparing SC and RS for AGI when adjusting for comorbidities. Presence of GEF probably negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC treated patients.

Editor's Choice - Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra-anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study.

OBJECTIVE: Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study. METHODS: The Swedish Vascular Registry (Swedvasc) was used to identify surgically treated abdominal AGIs in Sweden between January 1995 and May 2017. The primary aim was to compare short and long term survival, as well as complications for EAB and ISR. RESULTS: Some 126 radically surgically treated AGI patients were identified - 102 graft infections and 24 endograft infections - treated by EAB: 71 and ISR: 55 (23 neo-aorto-iliac systems, NAISs). No differences in early 30 day (EAB 81.7% vs. ISR 76.4%, p = .46), or long term five year survival (48.2% vs. 49.9%, p = .87) were identified. There was no survival difference comparing NAIS to other ISR strategies. The frequency of recurrent graft infection during follow up was similar: EAB 20.3% vs. ISR 17.0% (p = .56). Survival and re-infection rates of the new conduit did not differ between NAIS and other ISR strategies. Age ≥ 75 years (odds ratio [OR] 4.0, confidence interval [CI] 1.1 - 14.8), coronary artery disease (OR 4.2, CI 1.2 - 15.1) and post-operative circulatory complications (OR 5.2, CI 1.2 - 22.5) were associated with early death. Prolonged antimicrobial therapy (> 3 months) was associated with reduced long term mortality (HR 0.3, CI 0.1 - 0.9). CONCLUSION: In this nationwide multicentre study comparing outcomes of radically treated AGI, no differences in survival or re-infection rate could be identified comparing EAB and ISR.

Mortality with Paclitaxel-Coated Devices in Peripheral Artery Disease.

BACKGROUND: The results of a recent meta-analysis aroused concern about an increased risk of death associated with the use of paclitaxel-coated angioplasty balloons and stents in lower-limb endovascular interventions for symptomatic peripheral artery disease. METHODS: We conducted an unplanned interim analysis of data from a multicenter, randomized, open-label, registry-based clinical trial. At the time of the analysis, 2289 patients had been randomly assigned to treatment with drug-coated devices (the drug-coated-device group, 1149 patients) or treatment with uncoated devices (the uncoated-device group, 1140 patients). Randomization was stratified according to disease severity on the basis of whether patients had chronic limb-threatening ischemia (1480 patients) or intermittent claudication (809 patients). The single end point for this interim analysis was all-cause mortality. RESULTS: No patients were lost to follow-up. Paclitaxel was used as the coating agent for all the drug-coated devices. During a mean follow-up of 2.49 years, 574 patients died, including 293 patients (25.5%) in the drug-coated-device group and 281 patients (24.6%) in the uncoated-device group (hazard ratio, 1.06; 95% confidence interval, 0.92 to 1.22). At 1 year, all-cause mortality was 10.2% (117 patients) in the drug-coated-device group and 9.9% (113 patients) in the uncoated-device group. During the entire follow-up period, there was no significant difference in the incidence of death between the treatment groups among patients with chronic limb-threatening ischemia (33.4% [249 patients] in the drug-coated-device group and 33.1% [243 patients] in the uncoated-device group) or among those with intermittent claudication (10.9% [44 patients] and 9.4% [38 patients], respectively). CONCLUSIONS: In this randomized trial in which patients with peripheral artery disease received treatment with paclitaxel-coated or uncoated endovascular devices, the results of an unplanned interim analysis of all-cause mortality did not show a difference between the groups in the incidence of death during 1 to 4 years of follow-up. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT02051088.).

Risk factors in 50-year-old men predicting development of abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a potentially lethal condition associated with several well-known risk factors including age, smoking, and male sex. The aim of this study was to identify risk factors predicting future development of AAA, which could influence future prevention strategies. METHODS: This study collected the data sets of the Westmannia Cardiovascular Risk Factors Study (WICTORY) from 1990 to 1999 and combined them with cases of individuals who have undergone ultrasound examination of the infrarenal aortic diameter as part of the Västmanland County's ongoing AAA screening program that commenced in 2007 or for other purposes. The study analyzed 5817 men aged 50 years at the time they participated in WICTORY and who underwent an ultrasound examination of the infrarenal aorta on average 15 years later. RESULTS: The prevalence of AAA in our study was 2.6%. Age, smoking status, angina pectoris treatment, prior myocardial infarction, blood pressure treatment, body mass index, waist circumference, systolic blood pressure, heart rate, and total cholesterol level were found to be associated with the development of AAA later in life in the univariate analysis. In the multivariate analysis, current smokers at age 50 years had 11 times higher risk for later development of AAA (hazard ratio [HR], 11.178; confidence interval [CI], 6.277-19.908; P < .001). Former smokers did not suffer a similar risk of AAA development. Elevated total cholesterol concentration at baseline was associated with later AAA development (HR, 1.275; CI, 1.119-1.451; P < .001), as were increasing age (HR, 1.702; CI, 1.153-2.512; P = .007) and waist circumference (HR, 1.019; CI, 1.002-1.037; P = .031). CONCLUSIONS: Both the well-known and the somewhat less established possible predictors for future development of AAA identified in this study can support improvement of strategic preventive measures toward specific risk groups and thereby possibly reduce the risk for development of AAA later in life or at least increase the possibility of an early diagnosis in patients with intact AAA.

Low Walking Impairment Questionnaire score after a recent myocardial infarction identifies patients with polyvascular disease.

OBJECTIVES: To evaluate whether the Walking Impairment Questionnaire score could identify patients with polyvascular disease in a population with recent myocardial infarction and their association with cardiovascular events during two-year follow-up. DESIGN: A prospective observational study. SETTING: Patients admitted to the acute coronary care unit, the Department of Cardiology, Uppsala University Hospital. PARTICIPANTS: Patients admitted with acute Non-STEMI- or STEMI-elevation myocardial infarction. MAIN OUTCOME MEASURES: The Walking Impairment Questionnaire, developed as a self-administered instrument to assess walking distance, speed, and stair climbing in patients with peripheral artery disease, predicts future cardiovascular events and mortality. Two hundred and sixty-three patients with recent myocardial infarction answered Walking Impairment Questionnaire. Polyvascular disease was defined as abnormal findings in the coronary- and carotid arteries and an abnormal ankle-brachial index. The calculated score for each of all three categories were divided into quartiles with the lowest score in first quartile. RESULTS: The lowest (worst) quartile in all three Walking Impairment Questionnaire categories was associated with polyvascular disease, fully adjusted; distance, odds ratio (OR) 5.4 (95% confidence interval (CI) 1.8-16.1); speed, OR 7.4 (95% CI 1.5-36.5); stair climbing, OR 8.4 (95% CI 1.0-73.6). In stair climbing score, patients with the lowest (worst) score had a higher risk for the composite cardiovascular endpoint compared to the highest (best) score; hazard ratio 5.3 (95% CI 1.5-19.0). The adherence to medical treatment was high (between 81.7% and 99.2%). CONCLUSIONS: The Walking Impairment Questionnaire is a simple tool to identify myocardial infarction patients with more widespread atherosclerotic disease and although well treated medically, stair climbing predicts cardiovascular events.

Editor's Choice - Impact of Comorbidity, Medication, and Gender on Amputation Rate Following Revascularisation for Chronic Limb Threatening Ischaemia.

OBJECTIVE/BACKGROUND: Chronic limb threatening ischaemia (CLTI) has a high risk of amputation and mortality. Increased knowledge on how sex, comorbidities, and medication influence these outcomes after revascularisation may help optimise results and patient selection. METHODS: This population based observational cohort study included all individuals revascularised for CLTI in Sweden during a five year period (10,617 patients in total). Data were retrieved and merged from mandatory national healthcare registries, and specifics on amputations were validated with individual medical records. RESULTS: Mean age at revascularisation was 76.8 years. Median follow up was 2.7 years (range 0-6.6 years). Male sex (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.09-1.33), renal insufficiency (HR 1.57, 95% CI 1.32-1.87), diabetes (HR 1.45, 95% CI 1.32-1.60), and heart failure (HR 1.17, 95% CI 1.05-1.31) were independently associated with an increased amputation rate, whereas the use of statins (HR 0.71, 95% CI 0.64-0.78) and low dose acetylsalicylic acid (HR 0.77, 95% CI 0.70-0.86) were associated with a reduced amputation rate. For the combined end point of amputation or death, an association with increased rates was found for male sex (HR 1.25, 95% CI 1.18-1.32), renal insufficiency (HR 1.94, 95% CI 1.75-2.14), heart failure (HR 1.50, 95% CI 1.40-1.60), and diabetes (HR 1.31, 95% CI 1.23-1.38). The use of statins (HR 0.74, 95% CI 0.67-0.82) and low dose acetylsalicylic acid (HR 0.82, 95% CI 0.77-0.88]) were related to a reduced risk of amputation or death. CONCLUSIONS: Renal insufficiency is the strongest independent risk factor for both amputation and amputation/death in revascularised CLTI patients, followed by diabetes and heart failure. Men with CLTI have worse outcomes than women. These results may help govern patient selection for revascularisation procedures. Statin and low dose acetylsalicylic acid are associated with an improved limb outcome. This underlines the importance of preventive medication to reduce general cardiovascular risk and increase limb salvage.

Editor's Choice - Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit.

BACKGROUND: The benefit of carotid endarterectomy (CEA) or stenting (CAS) for symptomatic stenosis depends on the timing in relation to the presenting event. As the risk of recurrent events is highest in the early phase, guidelines recommend a short delay. The purpose of this national audit was to study the effects of more expedient carotid intervention on the risk of recurrent ischaemic events. METHODS: Data on all CEA and CAS for symptomatic stenosis, including both recurrent ischaemic events during the waiting time to carotid intervention and peri-operative 30 day complication rates, were obtained from the Swedish Vascular Registry between May 2008 and December 2015. The National Prescribed Drug Registry provided data on preventive medication prior to hospitalisation with the presenting event. The primary endpoint was a recurrent cerebral ischaemic event occurring after the presenting event up to 30 days of post-operative follow up. RESULTS: A total of 6814 procedures for symptomatic carotid stenosis were studied. The proportion of recurrent ischaemic events, meaning all secondary events occurring after the presenting event up to 30 days follow up with inclusion of all pre- and post-intervention recurrences was recorded. These recurrent events decreased over time, from 31% in 2008-2009 to 21% in 2014-2015 (p < .01, chi-square test). In parallel, the median waiting time for carotid intervention decreased from 13 (IQR 6-27) to 7 days (IQR 4-12). Baseline demographic variables and comorbidities were similar during the study period. The proportion of pre-operative recurrences were reduced from 25% to 18% (p < .01, chi-square test) while the peri-operative stroke and/or death rate was 3.6%, and improved slightly during the study. CONCLUSIONS: A substantial reduction in the secondary ischaemic event rate was observed when the median waiting time for CEA/CAS was reduced, and this was not counterbalanced by any increase in the peri-operative complication rate.

Long-term cardiovascular outcome, use of resources, and healthcare costs in patients with peripheral artery disease: results from a nationwide Swedish study.

Aims: Data on long-term healthcare costs of patients with peripheral artery disease (PAD) is limited, and the aim of this study was to investigate healthcare costs for PAD patients at a nationwide level. Methods and results: A cohort study including all incident patients diagnosed with PAD in the Swedish National Patient Register between 2006-2014, and linked to cause of death- and prescribed drug registers. Mean per-patient annual healthcare costs (2015 Euros [€]) (hospitalisations and out-patient visits) were divided into cardiovascular (CV), lower limb and non-CV related cost. Results were stratified by high and low CV risk. The study included 66,189 patients, with 221,953 observation-years. Mean total healthcare costs were €6,577, of which 26% was CV-related (€1,710), during the year prior to the PAD diagnosis. First year after PAD diagnosis, healthcare costs were €12,549, of which €3,824 (30%) was CV-related and €3,201 (26%) lower limb related. High-risk CV patients had a higher annual total healthcare and CV related costs compared to low risk CV patients during follow-up (€7,439 and €1,442 versus €4,063 and €838). Annual lower limb procedure costs were €728 in the PAD population, with lower limb revascularisations as key cost driver (€474). Conclusion: Non-CV related hospitalizations and outpatient visits were the largest cost contributors for PAD patients. There is a substantial increase in healthcare costs in the first year after being diagnosed with PAD, driven by PAD follow-up and lower limb related procedures. Among the CV-related costs, hospitalisations and outpatient visits related to PAD represented the largest costs.

Carotid Endarterectomy Induces the Release of Inflammatory Markers and the Activation of Coagulation as Measured in the Jugular Bulb.

BACKGROUND AND PURPOSE: Transient cerebral hypoxia may induce neuronal injury through an ischemia-reperfusion (I/R) response, with a subsequent activation of inflammation and coagulation-fibrinolysis. During carotid endarterectomy (CEA), the artery is clamped, which might impair the regional cerebral perfusion and initiate a local I/R response. Data suggest that the CD40-CD40 ligand dyad acts as a modulator in the induced activation. The aim of this study was to locally measure soluble CD40 ligand (sCD40L), in conjunction with inflammation and coagulation activation markers, during CEA. SUBJECTS AND METHODS: This is a prospective study of 18 patients undergoing CEA. Blood samples from the venous jugular bulb (JB) and the radial artery (RA) were drawn at baseline and during the procedure. Measurements of sCD40L, interleukin-6 (IL-6), fragment 1 + 2 (F1 + 2), plasminogen activator inhibitor-1 (PAI-1), and d-dimer were analyzed. Comparisons during CEA were made between levels: baselines versus JB, JB versus RA, and sequential JB measurements. Fifty cardiovascular healthy patients were the reference group for the sCD40L baseline comparison. RESULTS: Increased cerebral IL-6 levels were demonstrated throughout the procedure, as well as the temporal influence in F1 + 2, PAI-1, and d-dimer values. sCD40L remained unchanged throughout the procedure . This indicates a local cerebral inflammatory reaction together with an activation of coagulation-fibrinolysis, but it does not appear to primarily involve the CD40-CD40 ligand dyad. CONCLUSIONS: Signs of a local inflammatory reaction and activation of coagulation were observed during CEA, but levels of sCD40L remained stable, unaffected by carotid artery clamping and reperfusion.

Cardiovascular outcomes in patients with peripheral arterial disease as an initial or subsequent manifestation of atherosclerotic disease: Results from a Swedish nationwide study.

OBJECTIVE: Long-term progression of peripheral arterial disease (PAD) as initial manifestation of atherosclerotic arterial disease is not well described. Cardiovascular (CV) risk was examined in different PAD populations diagnosed in a hospital setting in Sweden. METHODS: Data for this retrospective cohort study were retrieved by linking data on morbidity, medication use, and mortality from Swedish national registries. Primary CV outcome was a composite of myocardial infarction, ischemic stroke (IS), and CV death. Kaplan-Meier analysis and Cox proportional hazards modeling was used for describing risk and relative risk. RESULTS: Of 66,189 patients with an incident PAD diagnosis (2006-2013), 40,136 had primary PAD, 16,786 had PAD + coronary heart disease (CHD), 5803 had PAD + IS, and 3464 had PAD + IS + CHD. One-year cumulative incidence rates of major CV events for the groups were 12%, 21%, 29%, and 34%, respectively. Corresponding numbers for 1-year all-cause death were 16%, 22%, 33%, and 35%. Compared with the primary PAD population, the relative risk increase for CV events was highest in patients with PAD + IS + CHD (hazard ratio [HR], 2.01), followed by PAD + IS (HR, 1.87) and PAD + CHD (HR, 1.42). Despite being younger, the primary PAD population was less intensively treated with secondary preventive drug therapy. CONCLUSIONS: PAD as initial manifestation of atherosclerotic disease diagnosed in a hospital-based setting conferred a high risk: one in eight patients experienced a major CV event and one in six patients died within 1 year. Despite younger age and substantial risk of future major CV events, patients with primary PAD received less intensive secondary preventive drug therapy.

Simplified ultrasound protocol for the exclusion of clinically significant carotid artery stenosis.

OBJECTIVES: To evaluate a simplified ultrasound protocol for the exclusion of clinically significant carotid artery stenosis for screening purposes. MATERIAL AND METHODS: A total of 9,493 carotid arteries in 4,748 persons underwent carotid ultrasound examination. Most subjects were 65-year-old men attending screening for abdominal aortic aneurysm. The presence of a stenosis on B-mode and/or a mosaic pattern in post-stenotic areas on colour Doppler and maximum peak systolic velocity (PSV) in the internal carotid artery (ICA) were recorded. A carotid stenosis was defined as The North American Symptomatic Carotid Endarterectomy Trial (NASCET) >20% and a significant stenosis as NASCET >50%. The kappa (κ) statistic was used to assess agreement between methods. Sensitivity, specificity, positive predictive (PPV), and negative predictive (NPV) values were calculated for the greyscale/mosaic method compared to conventional assessment by means of PSV measurement. RESULTS: An ICA stenosis was found in 121 (1.3%) arteries; 82 (0.9%) were graded 20%-49%, 16 (0.2%) were 50%-69%, and 23 (0.2%) were 70%-99%. Eighteen (0.2%) arteries were occluded. Overall, the greyscale/mosaic protocol showed a moderate agreement with ICA PSV measurements for the detection of carotid artery stenosis, κ = 0.455. The sensitivity, specificity, PPV, and NPV for detection of >20% ICA stenosis were 91% (95% CI 0.84-0.95), 97% (0.97-0.98), 31% (0.26-0.36), and 97% (0.97-0.97), respectively. The corresponding figures for >50% stenosis were 90% (0.83-0.95), 97% (0.97-0.98), 11% (0.08-0.15), and 100% (0.99-1.00). CONCLUSION: Compared with PSV measurements, the simplified greyscale/mosaic protocol had a high negative predictive value for detection of >50% carotid stenosis, suggesting that it may be suitable as a screening method to exclude significant disease.

Contemporary cardiovascular risk and secondary preventive drug treatment patterns in peripheral artery disease patients undergoing revascularization.

OBJECTIVE: Peripheral artery disease (PAD) is common worldwide, and PAD patients are increasingly offered lower limb revascularization procedures. The aim of this population-based study was to describe the current risk for cardiovascular (CV) events and mortality and also to elucidate the current pharmacologic treatment patterns in revascularized lower limb PAD patients. METHODS: This observational, retrospective cohort study analyzed prospectively collected linked data retrieved from mandatory Swedish national health care registries. The Swedish National Registry for Vascular Surgery database was used to identify revascularized PAD patients. Current risk for CV events and death was analyzed, as were prescribed drugs aimed for secondary prevention. A Cox proportional hazard regression model was used to explore risk factors for suffering a CV event. RESULTS: Between May 2008 and December 2013, there were 18,742 revascularized PAD patients identified. Mean age was 70.0 years among patients with intermittent claudication (IC; n = 6959) and 76.8 years among patients with critical limb ischemia (CLI; n = 11,783). Antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and beta-blockers were used by 73%, 60%, 57%, and 49% at admission for revascularization. CV event rate (a composite of myocardial infarction, ischemic stroke, or CV death) at 12, 24, and 36 months was 5.1% (95% confidence interval [CI], 4.5-5.6), 9.5% (95% CI, 8.7-10.3), and 13.8% (95% CI, 12.8-14.8) in patients with IC and 16.8% (95% CI, 16.1-17.6), 25.9% (95% CI, 25.0-26.8), and 34.3% (95% CI, 33.2-35.4) in patients with CLI. Best medical treatment, defined as any antiplatelet or anticoagulant therapy along with statin treatment, was offered to 65% of IC patients and 45% of CLI patients with little change during the study period. Statin therapy was associated with reduced CV events (hazard ratio, 0.76; 95% CI, 0.71-0.81; P < .001), whereas treatment with low-dose aspirin was not. CONCLUSIONS: Revascularized PAD patients are still at a high risk for CV events without a declining time trend. A large proportion of both IC and CLI patients were not offered best medical treatment. The most commonly used agent was aspirin, which was not associated with CV event reduction. This study calls for improved medical management and highlights an important and partly unmet medical need among revascularized PAD patients.

Ankle brachial index most important to identify polyvascular disease in patients with non-ST elevation or ST-elevation myocardial infarction.

BACKGROUND: Atherosclerosis is a systemic disease. In patients with acute myocardial infarction (MI) the extent of polyvascular disease (PvD) is largely unknown. In this study we investigate the prevalence and clinical characteristics predictive of PvD in patients with non-ST-elevation (NSTEMI) and ST-elevation (STEMI) MI. METHOD: 375 patients with acute MI included in the REBUS (Relevance of Biomarkers for Future Risk of Thromboembolic Events in Unselected Post-myocardial Infarction Patients) study were examined. Atherosclerotic changes were assessed in three arterial beds by coronary angiography, carotid ultrasound and ankle brachial index (ABI). Results compared findings of atherosclerosis in three arterial beds to fewer than 3 beds. PvD was defined as atherosclerosis in all three arterial beds. RESULTS: A medical history of MI, peripheral artery disease (PAD) or stroke was reported at admission in 17.9%, 2.1% and 3.7% of the patients, respectively. After evaluation, abnormal ABI was found in 20.3% and carotid artery atherosclerosis in 54.9% of the patients. In the total population, PvD was found in 13.8% of patients with no significant differences observed between NSTEMI and STEMI patients. Age (p<0.001), diabetes (p=0.039), previous PAD (p=0.009) and female gender (p=0.016) were associated with PvD. ABI was the most important predictor of PvD with a positive predictive value of 68.4% (95% CI 57.7-79.2%) and specificity of 92.4% (95% CI 89.5-95.4%). CONCLUSIONS: PvD is underdiagnosed in patients suffering from MI, both NSTEMI and STEMI. ABI is a useful and simple measurement that appears predictive of widespread atherosclerosis in these patients.

Management and outcome of pediatric vascular injuries.

BACKGROUND: Vascular injuries in children are relatively uncommon. The objective of this population-based study was to investigate the epidemiology, management, and early outcomes of pediatric vascular injuries. METHODS: A nationwide survey of prospectively collected data on pediatric vascular injuries in children 15 years or younger between 1987 and 2013 was conducted. Data were retrieved from the National Vascular Surgery registry (Swedvasc) and cross-matched with the National Population Register for mortality data. Demographics, operative techniques, and outcomes were analyzed. RESULTS: There were 222 children (boys, n = 148; girls, n = 74) included in this study, with a mean (SD) age of 9.6 (4.1) years (range, 0.5-15 years; <6 years, 18 %; 6-10 years, 39%; >10 years, 42%). Blunt trauma mechanism (n = 146, 66%) was dominant, followed by penetrating (n = 51, 23%) and iatrogenic trauma (n = 21, 9%). Anatomic locations of vascular injuries were primarily upper extremities (n = 134, 60%) and lower extremities (n = 65, 29%), followed by the abdomen (n = 16, 7.2%). Upper extremity injuries were most common in the age group of 10 years or younger (78%, 100 of 128), and lower extremity injuries were most common in the age group of 11 years to 15 years (48%, 45 of 94). Major repair techniques included interposition graft (n = 54, 24%), patch (n = 43, 19%), primary repair (lateral suture/direct anastomosis) (n = 27, 12%), bypass (n = 21, 9.5%), and endovascular techniques (n = 8, 3.7%). Exploration or release of artery was performed in 51 cases (23%). Vein (n = 110) was the dominant graft material, and synthetic grafts (polytetrafluoroethylene/dacron) were only used in four open cases. The most common postoperative complication was arterial occlusion/thrombosis (n = 12). At 30-day follow-up, there was one above-knee and two below-knee amputations as well as one death. No more deaths at 1-year follow-up did occur. CONCLUSION: This nationwide population-based study shows that traumatic vascular injuries in children are associated with high limb salvage rates and low mortality. Blunt trauma mechanism is dominant, and injuries are primarily located to the upper and lower extremities. The preferred repair techniques are venous patch angioplasty and interposition graft, and the frequency of endovascular repair is still low. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Urgent carotid surgery and stenting may be safe after systemic thrombolysis for stroke.

BACKGROUND AND PURPOSE: Early carotid surgery or stenting after thrombolytic treatment for stroke has become more common during recent years. It is unclear whether this carries an increased risk of postoperative complications and death. The aim of this nationwide population-based study was, therefore, to investigate the safety of urgently performed carotid procedures in patients treated with thrombolysis for stroke. METHODS: Using the national Vascular and Stroke registries, we identified 3998 patients who had undergone carotid endarterectomy or carotid artery stenting for symptomatic carotid stenosis between May 2008 and December 2012. Among these, 2% (79 of 3998) had undergone previous thrombolysis for stroke. We conducted a retrospective review of registry data and individual case records with regard to postoperative complications, including surgical-site bleeding, stroke, and death. The outcome was compared with the results for the remaining patient cohort (3919 of 3998) undergoing carotid surgery and stenting during the study period. RESULTS: The median time between thrombolysis and the carotid procedure was 10 days. Seventy-one patients underwent carotid endarterectomy, and 6 patients underwent carotid artery stenting. The 30-day death and stroke rate for the thrombolysis cohort was 2.5% (2 of 79), and for the whole cohort, it was 3.8% (139 of 3626; P=0.55). The postoperative bleeding rates requiring reoperation were not significantly different between the groups (3.8% [3 of 79] in the thrombolysis group versus 3.3% [119 of 3626] in the whole cohort; P=0.79). There was no correlation between time from lysis to surgery or stenting and complications at 30 days postoperatively. CONCLUSIONS: Urgent carotid endarterectomy or carotid artery stenting after thrombolysis for stroke may be safe without increased risk of serious complications.

EndoVAC, a novel hybrid technique to treat infected vascular reconstructions with an endograft and vacuum-assisted wound closure.

PURPOSE: To report an initial experience and midterm results of a novel hybrid technique (EndoVAC) combining stent-grafts, surgical revision, and vacuum-assisted wound closure (VAC). METHODS: All 10 patients (5 men; mean age 62 years) treated with the EndoVAC technique for infected vascular reconstructions (5 carotid, 4 femoral) or access sites (1 femoral and 1 brachial artery) between November 2007 and June 2010 were retrospectively reviewed. Follow-up included laboratory investigations, duplex ultrasonography, and imaging. RESULTS: VAC therapy was applied for a median 15 days (range 9-54). Three complications occurred: a watershed infarction (dysphasia), a transient hypoglossal nerve palsy, and a late stent-graft thrombosis. Two patients died during treatment but with local infection under control. Over a median follow-up of 11 months (range 1-33), no recurrent infection was noted after healing of the skin in any of the 8 survivors. CONCLUSION: The EndoVAC technique seems to be a promising option for treatment of infected vascular reconstructions in selected cases.

Long-term survival after carotid endarterectomy for asymptomatic stenosis.

BACKGROUND AND PURPOSE: Large randomized trials have demonstrated a net benefit of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis compared with best medical treatment. However, it takes years to overcome the perioperative risk and gain the reduction in stroke or death risk. Long-term survival after CEA for asymptomatic stenosis may be an important consideration in deciding on this prophylactic procedure, but is not well documented. The aim was to analyze long-term survival after CEA for asymptomatic stenosis and the impact of risk factors in a population-based study. METHODS: The Swedish vascular registry (Swedvasc) covers all centers performing CEA. Data on all registered CEAs during 1994 to 2003 were retrieved. All patients were cross-matched with the Population-Registry for accurate data on mortality (date of death). Analyses with Kaplan-Meier curves for survival and relative odds ratio (OR) for predictors of survival were performed. RESULTS: A total of 6169 CEAs in 5808 patients were registered, with a median time at risk of 5.1 (range, 0.1 to 11.8) years. The indication for CEA was asymptomatic stenosis in 10.8% of the patients. Survival after CEA for asymptomatic stenosis was 78.2% after 5 and 45.5% after 10 years. Previous vascular surgery (OR, 1.8; 1.1 to 3.0), cardiac disease (OR, 1.7; 1.0 to 2.8), diabetes mellitus (OR, 2.3; 1.3 to 4.1), and age (OR, 1.5; 1.1 to 2.1 per 10 years) were predictors of decreased 5-year survival. CONCLUSIONS: In this population-based study of patients operated on for asymptomatic stenosis, a substantial reduction in long-term survival was observed. Predictors of decreased longevity were age at operation, diabetes, cardiac disease, and previous vascular surgery.

Outcomes of carotid endarterectomy for asymptomatic stenosis in Sweden are improving: Results from a population-based registry.

OBJECTIVE: In large randomized trials, carotid endarterectomy (CEA) for asymptomatic stenosis has shown a net benefit compared with best medical treatment. To justify an increased number of procedures for this indication, the perioperative risk of stroke or death must not exceed that of the trials. The aim of this study was to evaluate the outcome in routine clinical practice in Sweden in a population-based study. METHODS: The Swedish Vascular Registry (Swedvasc) covers all centers performing CEA. Data on all registered CEAs during 1994 to 2003 were analyzed both for the whole time period and for two 5-year periods to study alterations over time. Four validation procedures of the registry were performed. Medical records were reviewed for both a random sample and a target sample (a total of 12% of the CEAs for asymptomatic stenosis). Swedvasc data were cross-matched with the In-Patient-Registry (used for reimbursement) and the Population-registry (death). RESULTS: A total of 6182 CEAs were registered, 671 being for asymptomatic stenosis. In the validation process, no missed registration of major stroke or death was found. Patients with asymptomatic stenosis had, when the whole time-period was analyzed, a perioperative combined stroke or death rate of 2.1%. Outcome improved over time; the combined stroke or death rate decreased from 3.3% (11/330) from 1994 to 1998 to 0.9% (3/341) from 1999 to 2003 (P = .026). During the second time period, no patient with a perioperative major stroke or death was reported. CONCLUSIONS: This extensively validated national audit of CEA for patients with asymptomatic carotid artery stenosis showed results well comparable with those of the randomized trials. The results improved over time.