| 1. |
- Sundström, Johan, Professor, 1971-, et al.
(författare)
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Risk factors for subarachnoid haemorrhage : a nationwide cohort of 950 000 adults
- 2019
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Ingår i: International Journal of Epidemiology. - : Oxford University Press. - 0300-5771 .- 1464-3685. ; 48:6, s. 2018-2025
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Subarachnoid haemorrhage (SAH) is a devastating disease, with high mortality rate and substantial disability among survivors. Its causes are poorly understood. We aimed to investigate risk factors for SAH using a novel nationwide cohort consortium.METHODS: We obtained individual participant data of 949 683 persons (330 334 women) between 25 and 90 years old, with no history of SAH at baseline, from 21 population-based cohorts. Outcomes were obtained from the Swedish Patient and Causes of Death Registries.RESULTS: During 13 704 959 person-years of follow-up, 2659 cases of first-ever fatal or non-fatal SAH occurred, with an age-standardized incidence rate of 9.0 [95% confidence interval (CI) (7.4-10.6)/100 000 person-years] in men and 13.8 [(11.4-16.2)/100 000 person-years] in women. The incidence rate increased exponentially with higher age. In multivariable-adjusted Poisson models, marked sex interactions for current smoking and body mass index (BMI) were observed. Current smoking conferred a rate ratio (RR) of 2.24 (95% CI 1.95-2.57) in women and 1.62 (1.47-1.79) in men. One standard deviation higher BMI was associated with an RR of 0.86 (0.81-0.92) in women and 1.02 (0.96-1.08) in men. Higher blood pressure and lower education level were also associated with higher risk of SAH.CONCLUSIONS: The risk of SAH is 45% higher in women than in men, with substantial sex differences in risk factor strengths. In particular, a markedly stronger adverse effect of smoking in women may motivate targeted public health initiatives.
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| 2. |
- Janko, Matthew, et al.
(författare)
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Contemporary Outcomes After Partial Resection of Infected Aortic Grafts
- 2021
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Ingår i: Annals of Vascular Surgery. - : Elsevier. - 0890-5096 .- 1615-5947. ; 76, s. 202-210
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection.METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed.RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01)CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.
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| 3. |
- Bengts, Sophy, et al.
(författare)
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Altered IL-32 Signaling in Abdominal Aortic Aneurysm
- 2020
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Ingår i: Journal of Vascular Research. - : KARGER. - 1018-1172 .- 1423-0135. ; 57:4, s. 236-244
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Tidskriftsartikel (refereegranskat)abstract
- Introduction and Objective:Interleukin (IL)-32 is a pro-inflammatory cytokine not previously studied in relation to abdominal aortic aneurysm (AAA). The aim of this study was to elucidate the expression and localization of IL-32 in AAA.Methods:Expression and localization of IL-32 in human aortic tissue was studied with immunohistochemical analysis and Western blot (AAA:n= 5; controls:n= 4). ELISA was used to measure IL-32 in human plasma samples (AAA:n= 140; controls:n= 37) and in media from cultured peripheral blood mononuclear cells (PBMCs) from 3 healthy donors. IL-32 mRNA in PBMCs, endothelial cells, aortic smooth muscle cells (SMCs), and aortic tissue samples of AAA (n= 16) and control aortas (n= 9) was measured with qPCR.Results:IL-32 was predominantly expressed in SMCs and T-cell-rich areas. Highest mRNA expression was observed in the intima/media layer of the AAA. A weaker protein expression was detected in non-aneurysmal aortas. Expression of IL-32 was confirmed in isolated T cells, macrophages, endothelial cells, and SMCs, where expression was also inducible by cytokines such as interferon-gamma. There was no difference in IL-32 expression in plasma between patients and controls.Conclusion:IL-32 signaling is altered locally in AAA and could potentially play an important role in aneurysm development. Further studies using animal models would be helpful to study its potential role in AAA disease.
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| 4. |
- Bjarnason, Thordur, et al.
(författare)
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One-Year Follow-up After Open Abdomen Therapy With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction
- 2013
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 37:9, s. 2031-2038
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Tidskriftsartikel (refereegranskat)abstract
- Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure. A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006-2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted. The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm(2), respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2-68.8) was the only independent factor associated with an incisional hernia. Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past.
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| 5. |
- Djavani Gidlund, Khatereh
(författare)
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Intra-abdominal Hypertension and Colonic Hypoperfusion after Abdominal Aortic Aneurysm Repair
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Colonic ischaemia (CI), Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are devastating complications after abdominal aortic aneurysm (AAA) surgery. The aims of this thesis were to study the incidence and clinical consequences of IAH/ACS and the association between CI and intra-abdominal pressure (IAP) among patients undergoing OR for ruptured AAA (rAAA), to compare extraluminal pHi monitoring, with standard intra-luminal monitoring among patients operated on for AAA, and to study the frequency and clinical consequences of IAH/ACS after endovascular repair (EVAR) for rAAA. The incidence of ACS was 26% in a retrospective study of 27 patients undergoing OR for rAAA. Consensus definitions on IAH/ACS were appropriate for patients after OR for rAAA: 78% (7/9) of patients with IAH grade III or IV developed organ failure and all patients who developed CI had some degree of IAH. Active fluid resuscitation treating hypovolaemia to avoid CI may partly cause IAH. The association between CI and IAP was investigated in a prospective study on 29 patients operated on for rAAA, 86% (25/29) were treated for hypovolaemia and ten (34%) had both IAH and CI. Since monitoring colonic perfusion is very important and there is no ideal method, a new technique, extraluminal colonic tonometry to detect colonic perfusion was compared with standard intraluminal tonometry. Although, this new method was not able to determine the severity of ischaemia it may serve as a screening test. EVAR of rAAA is feasible and patients may benefit from this less invasive procedure. Of 29 patients treated with this technique, 10% developed ACS, and all patients except one with preoperative shock developed some degree of IAH. In conclusion, IAP/ACS is common after both OR and EVAR for rAAA, and is associated with adverse outcome. Monitoring IAP and colonic perfusion with timely intervention may improve outcome.
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| 6. |
- Janko, Matthew R., et al.
(författare)
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In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas
- 2021
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Ingår i: Journal of Vascular Surgery. - : Elsevier. - 0741-5214 .- 1097-6809. ; 73:1, s. 210-221.e1
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality. Conclusions: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10-months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population. (J Vasc Surg 2021;73:210-21.)
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| 7. |
- Acosta, Stefan, et al.
(författare)
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Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction
- 2011
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 98:5, s. 735-743
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Tidskriftsartikel (refereegranskat)abstract
- Background: Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications. Methods: This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded. Results: Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76.6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8.55, 95 per cent confidence interval 1.47 to 49.72; P = 0.017). The in-hospital mortality rate was 29.7 per cent. Age (OR 1.21, 1.02 to 1.43; P = 0.027) and failure of fascial closure (OR 44.50, 1.13 to 1748.52; P = 0.043) were independently associated with in-hospital mortality. Conclusion: The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia.
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| 8. |
- Acosta, S., et al.
(författare)
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Negative-pressure wound therapy for prevention and treatment of surgical-site infections after vascular surgery
- 2017
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Ingår i: British Journal of Surgery. - : WILEY-BLACKWELL. - 0007-1323 .- 1365-2168. ; 104:2, s. E75-E84
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Forskningsöversikt (refereegranskat)abstract
- BackgroundIndications for negative-pressure wound therapy (NPWT) in vascular surgical patients are expanding. The aim of this review was to outline the evidence for NPWT on open and closed wounds. MethodsA PubMed, EMBASE and Cochrane Library search from 2007 to June 2016 was performed combining the medical subject headings terms wound infection', abdominal aortic aneurysm (AAA)', fasciotomy', vascular surgery' and NPWT' or VAC'. ResultsNPWT of open infected groin wounds was associated with shorter duration of wound healing by 47 days, and was more cost-effective than alginate dressings in one RCT. In one RCT and six observational studies, NPWT-related major bleeding and graft preservation rates were 0-10 and 83-100 per cent respectively. One retrospective comparative study showed greater wound size reduction per day, fewer dressing changes, quicker wound closure and shorter hospital stay with NPWT compared with gauze dressings for lower leg fasciotomy. NPWT and mesh-mediated fascial traction after AAA repair and open abdomen was associated with high primary fascial closure rates (96-100 per cent) and low risk of graft infection (0-7 per cent). One retrospective comparative study showed a significant reduction in surgical-site infection, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT. ConclusionNPWT has a central role in open and infected wounds after vascular surgery; the results of prophylactic care of closed incisions are promising.
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| 9. |
- Acosta, Stefan, et al.
(författare)
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Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair : An International Multicentre Study
- 2017
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 54:6, s. 697-705
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation. Methods: This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate. Results: Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation. Conclusions: VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.
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| 10. |
- Acosta, Stefan, et al.
(författare)
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Temporary Abdominal Closure After Abdominal Aortic Aneurysm Repair : A Systematic Review of Contemporary Observational Studies
- 2016
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 51:3, s. 371-378
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Forskningsöversikt (refereegranskat)abstract
- Objectives: The aim of this paper was to review the literature on temporary abdominal closure (TAC) after abdominal aortic aneurysm (AAA) repair. Methods: This was a systematic review of observational studies. A PubMed, EM BASE and Cochrane search from 2007 to July 2015 was performed combining the Medical Subject Headings "aortic aneurysm" and "temporary abdominal closure", "delayed abdominal closure", "open abdomen", "abdominal compartment syndrome", "negative pressure wound therapy", or "vacuum assisted wound closure". Results: Seven original studies were found. The methods used for TAC were the vacuum pack system with (n = 1) or without (n = 2) mesh bridge, vacuum assisted wound closure (VAWC; n = 1) and the VAWC with mesh mediated fascial traction (VACM; n = 3). The number of patients included varied from four to 30. Three studies were exclusively after open repair, one after endovascular aneurysm repair, and three were mixed series. The frequency of ruptured AAA varied from 60% to 100%. The primary fascia] closure rate varied from 79% to 100%. The median time to closure of the open abdomen was 10.5 and 17 days in two prospective studies with a fascia] closure rate of 100% and 96%, respectively; the inclusion criterion was an anticipated open abdomen therapy time >= 5 days using the VACM method. The graft infection rate was 0% in three studies. No patient with longterm open abdomen therapy with the VACM in the three studies was left with a planned ventral hernia. The in hospital survival rate varied from 46% to 80%. Conclusions: A high fascial closure rate without planned ventral hernia is possible to achieve with VACM, even after long-term open abdomen therapy. There are, however, few publications reporting specific results of open abdomen treatment after AAA repair, and there is a need for randomized controlled trials to determine the most efficient and safe TAC method during open abdomen treatment after AAA repair.
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