Prognostic Risk Factors for the Development of Compartment Syndrome in Acute Lower Limb Ischemia Patients Treated With Catheter-Directed Thrombolysis.

BACKGROUND: To determine predisposing factors that may lead to the development of compartment syndrome (CS) in patients with acute lower limb ischemia (ALLI) managed with intra-arterial catheter-directed thrombolysis (CDT). METHODS: This is a retrospective study of patients admitted between 01/2002 and 12/2015 to three university hospitals in Tampere, Turku, and Oulu, Finland, with acute or acute-on-chronic lower limb ischemia (Rutherford I-IIb). Patients managed with CDT and aspiration thrombectomies (AT) as an adjunct to CDT were included in the study. Multivariable binary logistic regression models were used to detect possible risk factors for the development of CS and its impact on the limb salvage and survival. Amputation-free survival (AFS) rates of CS and non-CS patients were compared using Kaplan-Meier survival analysis. The length of hospitalization was calculated and compared between the CS and non-CS groups. RESULTS: A total of 292 CDTs with or without ATs were performed on patients with a mean age of 71 years (standard deviation 13 years), 151 (51.7%) being male. Altogether, 12/292 (4.1%) treatment-related CS cases were registered. Renal insufficiency (odds ratio [OR] 4.27, P = 0.07) was associated with an increased risk of CS. All CS cases were managed with fasciotomies. Treatment with fasciotomy was associated with a prolonged hospitalization of a median of 7 days versus the 4 days for non-CS patients, P < 0.001. During the median follow-up of 51 months (interquartile range 72 months), 152/292 (52.1%) patients died and 51/292 (17.5%) underwent major amputations. CS was not associated with an increased risk of mortality, but it was associated with a higher risk of major amputation (OR 3.87, P = 0.027). The AFS rates of patients with or without CS did not significantly differ from each other in the long term. CONCLUSIONS: CS after CDT for the treatment of ALLI is uncommon. Renal insufficiency is associated with an increased risk of CS. Fasciotomy prolongs the hospitalization. Patients with CS are exposed to an increased risk of major amputation.

Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins.

BACKGROUND: New treatment methods have challenged open surgery as a treatment for great saphenous vein (GSV) insufficiency, the most common being ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA). This study evaluated the long-term results of surgery, EVLA and UGFS in the treatment of GSV reflux. METHODS: Patients with symptomatic GSV reflux were randomized to undergo either open surgery, EVLA or UGFS. The main outcome measure was the occlusion rate of the GSV at 5 years after operation. RESULTS: The study included 196 patients treated during 2008-2010; of these, 166 (84·7 per cent) participated in the 5-year follow-up. At 5 years, the GSV occlusion rate was 96 (95 per cent c.i. 91 to 100) per cent in the open surgery group, 89 (82 to 98) per cent after EVLA and 51 (38 to 64) per cent after UGFS (P < 0·001). For patients who had received no additional treatment during follow-up, the occlusion rates were 96 per cent (46 of 48), 89 per cent (51 of 57) and 41 per cent (16 of 39) respectively. UGFS without further GSV treatment was successful in only 16 of 59 patients (27 per cent) at 5 years. CONCLUSION: UGFS has significantly inferior occlusion rates compared with open surgery or EVLA, and results in additional treatments.

Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss: Diabetic Patients Require Rapid Revascularisation.

OBJECTIVES: The number of elderly people is increasing; inevitably, the result will be more patients with critical limb ischaemia (CLI) in the future. Tissue loss in CLI is related to a high risk of major amputation. The aim of this study was to analyze the treatment process from referral to revascularisation, to discover possible delays and reasons behind them, and to distinguish patients benefitting the most from early revascularisation. METHODS: A retrospective analysis was performed of 394 consecutive patients with a combined 447 affected limbs, referred to the outpatient clinic during 2010-2011 for tissue loss of suspected ischaemic origin. RESULTS: For 246 limbs revascularisation was scheduled. After changes in the initial treatment strategy, endovascular treatment (ET) was performed on 221 and open surgery (OS) on 45 limbs. Notably there was crossover after ET in 17.0% of the procedures, and re-revascularisations were required in 40.1% after ET and 31.1% after OS. The median time from referral to revascularisation was 43 days (range 1-657 days) with no significant difference between ET and OS. For 29 (11.8%) patients the ischaemic limb required an emergency operation scheduled at the first visit to the outpatient clinic. For 25 (10.2%) patients the situation worsened while waiting for elective revascularisation and an emergency procedure was performed. Diabetic patients formed the majority of the study population, with 159 diabetic feet undergoing revascularisation. In multivariate analysis, diabetes was associated with poor limb salvage. When revascularisation was achieved within 2 weeks, no difference was seen in limb salvage. However, when the delay from first visit to revascularisation exceeded 2 weeks, limb salvage was significantly poorer in diabetic patients. CONCLUSIONS: Diabetic ulcers always require vascular evaluation, and when ischaemia is suspected the diagnostics should be organised rapidly to ensure revascularisation without delay, according to this study within 2 weeks from the first evaluation.

Randomized clinical trial comparing surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy for the treatment of great saphenous varicose veins.

BACKGROUND: Endovenous ablation techniques and ultrasound-guided foam sclerotherapy (UGFS) have largely replaced open surgery for treatment of great saphenous varicose veins. This was a randomized trial to compare the effect of surgery, endovenous laser ablation (EVLA) (with phlebectomies) and UGFS on quality of life and the occlusion rate of the great saphenous vein (GSV) 12 months after surgery. METHODS: Patients with symptomatic, uncomplicated varicose veins (CEAP class C2-C4) were examined at baseline, 1 month and 1 year. Before discharge and at 1 week, patients reported a pain score on a visual analogue scale. Preoperative and 1-year assessments included duplex ultrasound imaging and the Aberdeen Varicose Vein Severity Score (AVVSS). RESULTS: The study included 214 patients: 65 had surgery, 73 had EVLA and 76 had UGFS. At 1 year, the GSV was occluded or absent in 59 (97 per cent) of 61 patients after surgery, 71 (97 per cent) of 73 after EVLA and 37 (51 per cent) of 72 after UGFS (P < 0·001). The AVVSS improved significantly in comparison with preoperative values in all groups, with no significant differences between them. Perioperative pain was significantly reduced and sick leave shorter after UGFS (mean 1 day) than after EVLA (8 days) and surgery (12 days). CONCLUSION: In comparison with open surgery and EVLA, UGFS resulted in equivalent improvement in quality of life but significantly higher residual GSV reflux at 12-month follow-up.

Long-term Results of Inframalleolar Bypass for Critical Limb Ischaemia.

INTRODUCTION: As the population ages and the incidence of diabetes increases, the expected number of patients with critical limb ischaemia (CLI) requiring distal revascularization will remain high or even increase. The aim of this study was to investigate the long-term results of inframalleolar bypass. MATERIAL AND METHODS: A total of 352 inframalleolar bypasses for CLI performed between 2002 and 2013 were included. Risk factors were evaluated and patency (both clinical and imaging based), leg salvage, survival, and amputation free survival (AFS) assessed. RESULTS: The median follow up was 30 months (mean 42 months, range 1-186 months). The median age of the study population was 73 years, and 67% of the patients were male. The incidence of diabetes was 69%. In the majority of cases (82%), the indication for bypass was an ulcer or gangrene, and the remaining 18% of the patients had rest pain. Primary, assisted primary, and secondary clinical patency was 71.2%, 76.5%, 81.0%, and 59.7%, 69.3%, and 70.7%, and 49.0%, 58.6%, and 68.4% at 1, 5, and 10 years, respectively. The last imaging based secondary patency at 1, 5, and 10 years was 79.3%, 68.1%, and 62.8%, respectively. The popliteal artery as the inflow artery (n = 194) was associated with superior primary (p = .013), assisted primary (p = .028), and secondary patency (p = .014) when compared with bypasses originating from the femoral artery (n = 158). The leg salvage rate at 1, 5, and 10 years was 78.6%, 72.0%, and 67.2%, respectively. Leg salvage was equal in patients with and without diabetes (p = .460). The respective survival and AFS rates at 1, 5, and 10 years were 70.3%, 37.4%, and 15.9%, and 58.4%, 29.8%, and 12.8%. CONCLUSION: Bypass to the foot arteries yielded excellent long-term patency, and good limb salvage can be achieved in both non-diabetic and diabetic patients.

The benefit of revascularization in nonagenarians with lower limb ischemia is limited by high mortality.

OBJECTIVE/BACKGROUND: Owing to the increased life expectancy of the population the number of very old patients referred to vascular surgical units has increased. Advanced age is a well known risk factor in patients undergoing surgical interventions for lower limb ischemia. However, amputation performed on an elderly person living independently will lead to permanent institutional care. The aim of this study was to evaluate the outcome of patients aged 90 years and older with lower limb ischemia undergoing surgical or endovascular revascularization. METHODS: Two hundred and thirty-three nonagenarians with either chronic critical limb ischemia (CLI) or acute limb ischemia (ALI) who underwent revascularization at the authors' institution between 2002 and 2013 were included in this retrospective study. Risk factors were evaluated and survival, limb salvage, and amputation free survival (AFS) assessed. RESULTS: The median age of the study population was 92 years (range 90-100 years). The majority (81.1%) of the patients were female. One in four (24.5%) patients had diabetes, and the incidence of coronary artery disease was 79.8%. Seventy-three percent of the patients had CLI and 27% of had ALI. Seventy percent of the patients underwent surgical revascularization and 30% were treated endovascularly. The majority (72.5%) of the patients maintained their independent living status; 27.5% ended up in institutional care post-operatively. Similarly, the majority (82.0%) of the patients maintained their walking ability, while 18% were not able to ambulate independently after revascularization. One year survival, limb salvage, and AFS rates were 50.9% versus 48.6% (p = .505), 85.1% versus 87.0% (p = .259), and 45.7% versus 44.4% (p = .309) in the surgical versus endovascular group, respectively. Dementia was an independent risk factor of poor AFS (odds ratio: 1.56; 95% confidence interval: 1.077-2.272; p = .019). CONCLUSION: Good limb salvage can be achieved by both surgical and endovascular revascularization, and independent living can be maintained in the majority of the patients. However, the benefit of revascularization is limited owing to high mortality, especially in patients with dementia.

Duplex surveillance after endovascular revascularisation for critical limb ischaemia.

OBJECTIVE: Despite the popularity of endovascular therapy (EVT) for critical limb ischaemia (CLI), there are few studies investigating the efficacy of duplex ultrasound (DUS) surveillance after endovascular interventions. The aim of this study was to evaluate DUS surveillance after EVT for CLI. METHODS: 146 endovascular procedures in 134 consecutive patients with CLI between 2011 and 2012 were included. Follow-up visits with ankle-brachial index (ABI), toe pressure, and target vessel DUS were performed at 1, 3, and 6 months after revascularisation. RESULTS: The median age of the study population was 79 years, 58% were males, and 55% had diabetes. The target artery was at the iliac, femoro-popliteal, and infrapopliteal level in 2%, 54%, and 44% of cases, respectively. There were 282 follow-up visits. In 15 (5.3%) DUS examinations, the target vessel was not seen properly. In the remaining 267 DUS, the majority of the target arteries were patent with no or mild restenosis (n = 169, 63.3%), but in 98 (36.7%) examinations, the target artery was stenosed or occluded. When DUS was compared with the clinical presentation, there was no correlation in 30% and when DUS and toe pressure were compared, discrepancy was seen in 29%. A re-angiogram was performed for 29 patients, and the DUS finding was verified in each case. During the mean follow-up of 11 months, a new endovascular intervention was performed on 37 (25.3%) limbs, and 4 (2.7%) underwent surgical bypass. Four (3.0%) patients died and 6 (4.5%) underwent major amputation. CONCLUSION: Clinical status or toe pressure alone were adequate markers of endovascular revascularisation failure in the majority of the patients, but would have missed up to one-third of the clinically significant re-stenoses or occlusions. DUS is therefore a valuable aid in surveillance after EVT for CLI, especially for patients with an ischaemic tissue lesion.

Molecular typing of isolates of Clostridium perfringens from healthy and diseased poultry.

The bacterium Clostridium perfringens can cause both clinical and subclinical disease in poultry. To study the pathogenesis and epidemiology of disease caused by C. perfringens, methods for typing its various strains need to be evaluated. C. perfringens isolates from healthy and diseased poultry from different parts of Sweden were analysed by polymerase chain reaction (PCR) in order to establish the presence of alpha-, beta-, beta2-, epsilon -, iota- and enterotoxin genes. In order to subtype C. perfringens isolates, the two methods amplified fragment length polymorphism (AFLP) and pulsed field gel electrophoresis (PFGE) were compared on 21 C. perfringens isolates from 10 different farms. In a second study, 32 isolates of C. perfringens type A from three broilers from a healthy flock reared without ionophorous anticoccidials were subtyped by PFGE. All 53 isolates analysed with PCR belonged to the toxin type A of C. perfringens, with the gene coding for alpha-toxin production. Two isolates possessed the beta2-gene as well, but none had the other toxin genes. Both AFLP and PFGE differentiated 21 strains into 10 different subtypes. This differentiation correlated closely with the origins of the isolates. Unique subtypes were isolated from seven farms. Only isolates from birds of one farm demonstrated more than one subtype of C. perfringens. The subtyping of the isolates from a healthy flock showed that each bird carried two to three different subtypes and two different subtypes were found in the same kind of tissue sample in four cases. Three of the four different subtypes found in this study were new, compared with the first study. AFLP and PFGE were found to be equally suitable for subtyping of C. perfringens isolates. The wide variation in subtypes in the healthy broilers could be the result of the antibiotic-free rearing of these birds.

Short-term retention of glass-ionomer fissure sealants.

In some studies, rapid loss of glass-ionomer sealants has been reported. The aim of this study was, therefore, to examine the retention rate of 4 month old glass-ionomer sealants (Fuji III). The sealants were applied in 93 newly erupted molars and premolars. After four months, 75% of the sealants were totally present, 22% partially lost and 3% totally lost. No caries was observed. Impressions were taken from occlusal surfaces showing total or partial loss of sealants, and the casts were examined using a stereomicroscope or SEM. Examination revealed that in most of these cases, the material was still left in the bottom of the fissures. This may partly explain why glass-ionomer sealants have prevented caries even after they appear to have been lost. In order to examine the penetration of the sealant into the fissures, 28 teeth were sealed in vitro, bisected and examined using a stereomicroscope. In 19 cases, the sealant had penetrated whole fissure, in 7 cases two thirds of the fissure and in 2 cases one third of the fissure or less.

Effect of different glass ionomers on the acid production and electrolyte metabolism of Streptococcus mutans Ingbritt.

In order to study the effects of different glass ionomers on the metabolism of Streptococcus mutans, test slabs of freshly mixed conventional glass ionomer (Fuji), silver glass ionomer (Ketac-Silver), composite (Silux), and 2-week-old Fuji were fitted into the bottom of a test tube. A plaque-like layer of S. mutans strain Ingbritt was centrifuged onto the test slabs, and the samples were incubated for 20 h in 1.7% (w/v) sucrose solution. For freshly mixed Fuji and Ketac-Silver, the pH fall was significantly smaller than for old Fuji and composite. These materials also released the largest amount of fluoride into the fluid phase. Incubation with glass ionomer materials led to an increase in the cellular concentration of fluoride in bacteria, but intracellular fluoride did not correlate with the fall in pH. The lowest pH was associated with the lowest cellular magnesium content. Ketac-Silver released large amounts of calcium in the fluid phase, and the cellular calcium content was doubled in this group. The results show that freshly mixed glass ionomers affect acid production and electrolyte metabolism of S. mutans in vitro. The effect of conventional glass ionomer, however, seems to disappear after a few weeks. The effects of calcium and silver released by cermet glass ionomer deserve further study.