| 1. |
- Kragsterman, Björn, et al.
(författare)
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Editor's Choice - Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit
- 2018
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 56:4, s. 467-474
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Tidskriftsartikel (refereegranskat)abstract
- 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. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.
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| 2. |
- Axelsson, Christer, et al.
(författare)
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A description of the prehospital phase of aortic dissection in terms of early suspicion and treatment.
- 2015
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Ingår i: Prehospital and Disaster Medicine. - 1049-023X .- 1945-1938. ; 30:2
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: Aortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff.BASIC PROCEDURES: All patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age<18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables.MAIN FINDINGS: Of 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not).CONCLUSION: Among patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.
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| 3. |
- Baubeta Fridh, Erik, 1982, et al.
(författare)
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Amputation Rates, Mortality, and Pre-operative Comorbidities in Patients Revascularised for Intermittent Claudication or Critical Limb Ischaemia : A Population Based Study
- 2017
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : W B SAUNDERS CO LTD. - 1078-5884 .- 1532-2165. ; 54:4, s. 480-486
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: The aims of this population based study were to describe mid-to long-term amputation risk, cumulative incidence of death or amputation, and differences in pre-operative comorbidities in patients revascularised for lower limb peripheral artery disease (PAD).Methods: This was an observational cohort study. Data from the Swedish National Quality Registry for Vascular Surgery (Swedvasc) were combined with mandatory national health care registries and patient medical records. All patients who underwent revascularisation in Sweden between May 2008 and May 2013 for intermittent claudication (IC) or critical limb ischaemia (CLI), aged 50 years and older, were identified through the Swedvasc database. The mandatory national health care registries and medical records provided data on comorbidities, mortality, and major amputations.Results: A total of 16,889 patients with PAD (IC, n = 6272; CLI, n = 10,617) were studied. The incidence of amputations in IC patients was 0.4% (range 0.3%-0.5%) per year. Among CLI patients, the amputation rate during the first 6 months following revascularisation was 12.0% (95% CI 11.3-12.6). Thereafter, the incidence declined to approximately 2% per year. The cumulative combined incidence of death or amputation 3 years after revascularisation was 12.9% (95% CI 12.0-13.9) in IC patients and 48.8% (95% CI 47.7-49.8) in CLI patients. Among CLI patients, compared with IC patients, the prevalence of diabetes, ischaemic stroke, heart failure, and atrial fibrillation was approximately doubled and renal failure was nearly tripled, even after age standardisation.Conclusion: The risk of amputation is particularly high during the first 6 months following revascularisation for CLI. IC patients have a benign course in terms of limb loss. Mortality in both IC and CLI patients is substantial. Revascularised CLI patients have different comorbidities from IC patients.
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| 4. |
- Baubeta Fridh, Erik, 1982, et al.
(författare)
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Editor's Choice - Impact of Comorbidity, Medication, and Gender on Amputation Rate Following Revascularisation for Chronic Limb Threatening Ischaemia
- 2018
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 56:5, s. 681-688
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Tidskriftsartikel (refereegranskat)abstract
- 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 0.77-0.881) 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. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.
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| 5. |
- Baubeta Fridh, Erik, 1982, et al.
(författare)
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Impact of Preoperative Symptoms and Revascularized Arterial Segment in Patients With Chronic Limb-Threatening Ischemia
- 2019
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Ingår i: Vascular and Endovascular Surgery. - : SAGE Publications. - 1538-5744 .- 1938-9116. ; 53:5, s. 365-372
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Tidskriftsartikel (refereegranskat)abstract
- Background: Little is known about the relative impact of the preoperative symptoms rest pain and tissue loss, and of the arterial segment revascularized, on amputation rate and mortality in patients with chronic limb-threatening ischemia (CLTI). We wanted to investigate this topic further. Method: This population-based observational cohort study involved 10 419 patients revascularized for CLTI in Sweden, 2008 to 2013. Data were collected from health-care registries and medical records. The effect of preoperative symptoms and revascularized arteries was determined using Cox regression models. A competing risk analysis was used to determine the effect of symptoms on the combined endpoint "amputation or death". Results: The amputation rate during a mean follow-up of 2 years was 7.5% in patients with rest pain, 15.6% in patients with tissue loss only, and 20.1% when both symptoms were present. Mortality was 39% lower in patients with rest pain only than in those with both symptoms. Revascularizations targeted the aortoiliac, femoropopliteal, and infrapopliteal segments in 19.4%, 76.8%, and 30.6%, respectively. Distal revascularizations were associated with a higher amputation rate, but this difference disappeared after adjustment for comorbidities. Aortoiliac revascularizations were associated with high mortality. Competing risk analysis showed that mortality became the major determinant of amputation-free survival outcomes from 1 year after revascularization. Conclusions: Tissue loss implies a clearly worse prognosis compared to rest pain for patients with CLTI. Most revascularizations for CLTI are done in the femoropopliteal segment. Infrapopliteal procedures are associated with a higher amputation rate, whereas aortoiliac revascularizations are associated with higher mortality.
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| 6. |
- Behrendt, C. A., et al.
(författare)
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International Variations in Amputation Practice: A VASCUNET Report
- 2018
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 56:3, s. 391-399
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: To study international differences in incidence and practice patterns as well as time trends in lower limb amputations related to peripheral arterial disease and/or diabetes mellitus. Methods: Data on lower limb amputations during 2010-2014 were collected from population based administrative data from countries in Europe and Australasia participating in the VASCUNET collaboration. Amputation rates, time trends, in hospital or 30 day mortality and reimbursement systems were analysed. Results: Data from 12 countries covering 259 million inhabitants in 2014 were included. Individuals aged >= 65 years ranged from 12.9% (Slovakia) to 20.7% (Germany) and diabetes prevalence among amputees from 25.7% (Finland) to 74.3% (Slovakia). The mean incidence of major amputation varied between 7.2/100,000 (New Zealand) and 41.4/100,000 (Hungary), with an overall declining time trend with the exception of Slovakia, while minor amputations increased over time. The older age group (>= 65 years) was up to 4.9 times more likely to be amputated compared with those younger than 65 years. Reported mortality rates were lowest in Finland (6.3%) and highest in Hungary (20.3%). Countries with a fee for service reimbursement system had a lower incidence of major amputation compared with countries with a population based reimbursement system (14.3/100,000 versus 18.4/100,000, respectively, p < .001). Conclusions: This international audit showed large geographical differences in major amputation rates, by a factor of almost six, and an overall declining time trend during the 4 year observation of this study. Diabetes prevalence, age distribution, and mortality rates were also found to vary between countries. Despite limitations attributable to registry data, these findings are important, and warrant further research on how to improve limb salvage in different demographic settings. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.
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| 7. |
- Bäck, Maria, et al.
(författare)
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Home-based supervised exercise versus hospital-based supervised exercise or unsupervised walk advice as treatment for intermittent claudication : a systematic review.
- 2015
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Ingår i: Journal of Rehabilitation Medicine. - : Medical Journals Sweden AB. - 1650-1977 .- 1651-2081. ; 47:9, s. 801-808
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To evaluate the effects of home-based supervised exercise vs hospital-based supervised exercise, and the effects of home-based supervised exercise vs unsupervised "go home and walk advice" on daily life and corridor-walking capacity, health-related quality of life and patient-reported functional walking capacity in patients with intermittent claudication.DATA SOURCES: Systematic literature searches were conducted in PubMed, EMBASE, ProQuest, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), the Cochrane Library, and a number of Health Technology Assessment (HTA)-databases in October 2014.STUDY SELECTION: Randomized controlled trials and non-randomized controlled trials (> 100 patients) were considered for inclusion.DATA EXTRACTION: Data extraction and risk of bias assessment was performed independently and discussed in meetings.DATA SYNTHESIS: Seven randomized controlled trials and 2 non-randomized controlled studies fulfilled the inclusion criteria. The included studies had some, or major, limitations.CONCLUSION: Based on a low quality of evidence, home-based supervised exercise may lead to less improvement in maximum and pain-free walking distance, and in more improvement in daily life walking capacity, compared with hospital-based supervised exercise. Home-based supervised exercise may improve maximum and pain-free walking distance compared with "go home and walk advice" and result in little or no difference in health-related quality of life and functional walking capacity compared with hospital-based supervised exercise or "go home and walk advice". Further research is needed to establish the optimal exercise modality for these patients.
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| 8. |
- Djerf, Henrik, et al.
(författare)
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Cost-effectiveness of revascularization in patients with intermittent claudication.
- 2018
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Ingår i: The British journal of surgery. - : Oxford University Press (OUP). - 1365-2168 .- 0007-1323. ; 105:13, s. 1742-1748
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Tidskriftsartikel (refereegranskat)abstract
- Revascularization is a treatment option for patients with intermittent claudication. However, there is a lack of evidence to support its long-term benefits and cost-effectiveness. The aim of this study was to compare the cost-effectiveness of revascularization and best medical therapy (BMT) with that of BMT alone.Data were used from the IRONIC (Invasive Revascularization Or Not in Intermittent Claudication) RCT where consecutive patients with mild-to-severe intermittent claudication owing to aortoiliac or femoropopliteal disease were allocated to either BMT alone (including a structured, non-supervised exercise programme) or to revascularization together with BMT. Inpatient and outpatient costs were obtained prospectively over 24 months of follow-up. Mean improvement in quality-adjusted life-years (QALYs) was calculated based on responses to the EuroQol Five Dimensions EQ-5D-3 L™ questionnaire. Cost-effectiveness was assessed as the cost per QALY gained.A total of 158 patients were randomized, 79 to each group. The mean cost per patient in the BMT group was €1901, whereas it was €8280 in the group treated with revascularization in addition to BMT, with a cost difference of €6379 (95 per cent c.i. €4229 to 8728) per patient. Revascularization in addition to BMT resulted in a mean gain in QALYs of 0·16 (95 per cent c.i. 0·06 to 0·24) per patient, giving an incremental cost-effectiveness ratio of €42 881 per QALY.The costs associated with revascularization together with BMT in patients with intermittent claudication were about four times higher than those of BMT alone. The incremental cost-effectiveness ratio of revascularization was within the accepted threshold for public willingness to pay according to the Swedish National Guidelines, but exceeded that of the UK National Institute for Health and Care Excellence guidelines.
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| 9. |
- Hasvold, Pal, et al.
(författare)
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Long-term cardiovascular outcome, use of resources, and healthcare costs in patients with peripheral artery disease : results from a nationwide Swedish study
- 2018
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Ingår i: European Heart Journal - Quality of Care and Clinical Outcomes. - : OXFORD UNIV PRESS. - 2058-5225 .- 2058-1742. ; 4:1, s. 10-17
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Tidskriftsartikel (refereegranskat)abstract
- 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 (sic)) (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 (sic)6,577, of which 26% was CV-related ((sic)1,710), during the year prior to the PAD diagnosis. First year after PAD diagnosis, healthcare costs were (sic)12,549, of which (sic)3,824 (30%) was CV-related and (sic)3,201 (26%) lower limb related. Highrisk CV patients had a higher annual total healthcare and CV related costs compared to low risk CV patients during follow-up ((sic)7,439 and (sic)1,442 versus (sic)4,063 and (sic)838). Annual lower limb procedure costs were (sic)728 in the PAD population, with lower limb revascularisations as key cost driver ((sic)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.
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| 10. |
- Hess, C. N., et al.
(författare)
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A Structured Review of Antithrombotic Therapy in Peripheral Artery Disease With a Focus on Revascularization A TASC (InterSociety Consensus for the Management of Peripheral Artery Disease) Initiative
- 2017
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Ingår i: Circulation. - : Ovid Technologies (Wolters Kluwer Health). - 0009-7322 .- 1524-4539. ; 135:25, s. 2534-2555
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Tidskriftsartikel (refereegranskat)abstract
- Peripheral artery disease affects >200 million people worldwide and is associated with significant limb and cardiovascular morbidity and mortality. Limb revascularization is recommended to improve function and quality of life for symptomatic patients with peripheral artery disease with intermittent claudication who have not responded to medical treatment. For patients with critical limb ischemia, the goals of revascularization are to relieve pain, help wound healing, and prevent limb loss. The baseline risk of cardiovascular and limb-related events demonstrated among patients with stable peripheral artery disease is elevated after revascularization and related to atherothrombosis and restenosis. Both of these processes involve platelet activation and the coagulation cascade, forming the basis for the use of antiplatelet and anticoagulant therapies to optimize procedural success and reduce postprocedural cardiovascular risk. Unfortunately, few high-quality, randomized data to support use of these therapies after peripheral artery disease revascularization exist, and much of the rationale for the use of antiplatelet agents after endovascular peripheral revascularization is extrapolated from percutaneous coronary intervention literature. Consequently, guideline recommendations for antithrombotic therapy after lower limb revascularization are inconsistent and not always evidence-based. In this context, the purpose of this structured review is to assess the available randomized data for antithrombotic therapy after peripheral arterial revascularization, with a focus on clinical trial design issues that may affect interpretation of study results, and highlight areas that require further investigation.
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| 11. |
- Hess, Connie N., et al.
(författare)
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A Structured Review of Antithrombotic Therapy in Peripheral Artery Disease with a Focus on Revascularization : A TASC (InterSociety Consensus for the Management of Peripheral Artery Disease) Initiative
- 2017
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Ingår i: Circulation. - 0009-7322. ; 135:25, s. 2534-2555
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Forskningsöversikt (refereegranskat)abstract
- Peripheral artery disease affects >200 million people worldwide and is associated with significant limb and cardiovascular morbidity and mortality. Limb revascularization is recommended to improve function and quality of life for symptomatic patients with peripheral artery disease with intermittent claudication who have not responded to medical treatment. For patients with critical limb ischemia, the goals of revascularization are to relieve pain, help wound healing, and prevent limb loss. The baseline risk of cardiovascular and limb-related events demonstrated among patients with stable peripheral artery disease is elevated after revascularization and related to atherothrombosis and restenosis. Both of these processes involve platelet activation and the coagulation cascade, forming the basis for the use of antiplatelet and anticoagulant therapies to optimize procedural success and reduce postprocedural cardiovascular risk. Unfortunately, few high-quality, randomized data to support use of these therapies after peripheral artery disease revascularization exist, and much of the rationale for the use of antiplatelet agents after endovascular peripheral revascularization is extrapolated from percutaneous coronary intervention literature. Consequently, guideline recommendations for antithrombotic therapy after lower limb revascularization are inconsistent and not always evidence-based. In this context, the purpose of this structured review is to assess the available randomized data for antithrombotic therapy after peripheral arterial revascularization, with a focus on clinical trial design issues that may affect interpretation of study results, and highlight areas that require further investigation.
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| 12. |
- Holsti, Mari, 1963-
(författare)
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Vascular remodelling and circulating basement membrane fragments in abdominal aortic aneurysm
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- An abdominal aortic aneurysm (AAA) is a degenerative disease, characterized by advanced inflammation and extracellular matrix (ECM) remodelling. Enhanced protease activity mediated by cytokines results in the degradation of ECM proteins, leading to the generation of different bioactive fragments. Some of these generated fragments are released from the vascular basement membrane (VBM), a highly specialized ECM. VBM provides mechanical and structural stability and regulates many important cellular functions of the vascular system. Type IV and XVIII collagens are two structural proteins in VBM, with crucial roles in maintaining of the VBM integrity and vascular architecture. Circulating levels of type IV and XVIII collagen fragments are found physiologically, but have also been associated with many diseases. Remodelling of VBM and expression of its components has not been as well studied in AAA as that of the interstitial ECM.Here we investigate these VBM collagens, their expression and possible association with aortic diameter and expansion rate in individuals with an AAA in comparison with different control groups. Further we study whether there is a link between the circulating VBM collagen fragments and several inflammatory markers, all highly involved in AAA pathogenesis. Lastly, we study the impact of surgical intervention on plasma levels of VBM collagens in patients treated by either open surgical repair (OSR) or endovascular aortic aneurysm repair (EVAR).Methods: Circulating levels of type IV and XVIII collagen fragments were analysed in individuals with an AAA and compared with healthy controls and patients with peripheral artery disease (paper I). A possible association between VBM collagen fragments and the aortic diameter and expansion was studied in a large population-based cohort of 615 men stratified into three aortic diameter groups based on initial maximum aortic diameter (paper II). Furthermore, 159 individuals were followed up over time with repeated measurements of aortic diameter and blood samples. The follow up cohort were divided into two subgroups based on expansion rate of AAA. Moreover, the location of VBM collagens in tissue from aortic wall in individuals with an AAA was characterized and the expression pattern was compared with normal aorta (paper II). In paper III, the association between the plasma levels of VBM collagens and inflammatory markers; IL-1 (IL-1α and IL-1β), IL-6, IL-8, TNF-α INF-γ and hs-CRP were studied in same cohort as paper II. Finally, the effect of surgical intervention on circulating levels of VBM collagen fragments was investigated in AAA patients who had undegone either OSR or EVAR by comparison of plasma levels before and after AAA repair.Ultrasound technique was used for measurements of aortic diameter (paper I, II, III and IV). Analysis of circulating VBM collagens and inflammatory markers were performed by ELISA-assay (Paper I, II, III and IV) and Multiplex-assays, respectively (paper III). Aortic wall tissues were analysed by haematoxylin and eosin (H&E) and immunofluorescence staining (Paper II).Results: There were significantly increased plasma levels of VBM collagen fragments in individuals with an AAA, compared with healthy controls and individulas with a peripheral artery disease (PAD), (Paper I). The levels of type IV collagen in AAA patients did not differ from the group with PAD, and there were no significant differences between the control groups regarding plasma levels of both VBM collagen fragments (Paper I). The increased levels of VBM collagen fragments were significantly associated with aortic diameter with highest levels in the group with an AAA (Paper II). Altered expression of the VBM collagens and fragmentation of elastic fibres were observed in tissue from AAA patients (Paper II). A significant association between the levels of pro-inflammatory cytokines IL-6 and IL-8, and VBM collagens was found. Additionally, there were a significant association between the plasma levels of IL-8, TNF-α and hs-CRP and an AAA (Paper III). Aneurysms with faster expansion rate had significantly higher levels of IL-6, IL-1β, and type XVIII/endostatin collagen. Additionally, IL-6, type XVIII/endostatin collagen and baseline-aortic diameter were significantly associated with expansion rate (Paper III). AAA repair was associated with changes in plasma levels of VBM collagens (Paper IV).Conclusion: Circulating levels of VBM collagens were increased in patients with an AAA, and significantly associated with aortic diameter and expansion rate. The expression of VBM collagens was altered in AAA tissue compared with normal aorta. In addition, plasma levels of several inflammatory markers were associated as with VBM collagens, aortic diameter and expansion rate. The levels of both VBM collagens were altered at short and long time after AAA repair.
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| 13. |
- Kumlien, Christine, et al.
(författare)
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Validity and test retest reliability of the vascular quality of life Questionnaire-6: a short form of a disease-specific health-related quality of life instrument for patients with peripheral arterial disease
- 2017
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Ingår i: Health and Quality of Life Outcomes. - : Springer Science and Business Media LLC. - 1477-7525. ; 15
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Tidskriftsartikel (refereegranskat)abstract
- Background: Many existing patient-reported outcome measures are extensive regarding both patient burden and administration, and in terms of analysing and reporting results. The VascuQoL-6 (VQ6) - a short version of the original Vascular Quality of Life Questionnaire (VascuQoL), a disease-specific instrument for peripheral arterial disease - was recently developed. However, the VQ6 has not yet been empirical tested with regard to content validity, construct validity and test retest reliability. Our aim was, therefore, to explore both the validity and the reliability of the VQ-6 in a target population with established peripheral arterial disease. Methods: Two hundred patients treated at two vascular centres were consecutively recruited for the survey. Administered questionnaires included VQ6 and the Short Form Health Survey-36 (SF-36). Out of the 200 patients, 150 also received a second VQ6 questionnaire for a test-retest assessment. Further, a purposive sample of 22 patients consented to participate in cognitive interviews. All included patients suffer from peripheral arterial disease. The questionnaire data was tested by both Rasch analysis and traditional psychometric methods, while the cognitive interviews were analysed descriptively. Results: The validity and reliability of the VQ6, as tested in a target population without the surrounding 19 items from the original VascuQoL, was high, in general, and a good fit to the Rasch model was observed. Further, an excellent internal consistency and significant correlations between comparable dimensions in SF-36 were demonstrated. In the test-retest analysis, the percentage agreement was somewhat poor (<70%) in the six items. However, no systematic disagreements between the two assessments were seen in any of the six items, and the test-retest assessment for the VQ6 sum score showed an acceptable intraclass correlation coefficient (0.86). Finally, all items in the VQ6 were considered as both understandable and relevant by the interviewed patients. Conclusions: The VQ6 has acceptable to good psychometric properties with regard to data quality, scale assumptions, targeting, validity and reliability. Further, VQ6 seems to be easy to use and comprehend within the target population of patients with PAD.
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| 14. |
- Langenskiöld, Marcus, 1972, et al.
(författare)
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Weak Links in the Early Chain of Care of Acute Lower Limb Ischaemia in Terms of Recognition and Emergency Management
- 2017
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 54:2, s. 235-240
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Acute lower limb ischaemia (ALLI) is a potentially fatal, limb threatening medical emergency. Early treatment is essential for a good outcome. The aim was to describe the early chain of care in ALLI focusing on lead times and emergency management in order to identify weak links for improvement. Methods: This was a retrospective, descriptive case study. This study analysed the medical records of all patients with a main discharge diagnosis of ALLI between January 2009 and December 2014. Predetermined emergency care data on lead times, diagnosis recognition, presenting symptoms, emergency care treatment and outcome were collected for patients who were transported by the Emergency Medical Service (EMS) and those who were not. Results: In total, 552 medical records were audited of which 195 patients fulfilled the inclusion criteria and were analysed. Among them were 117 (60%) transported by the EMS. The median time from symptom onset to revascularisation was 23 (interquartile range [IQR] 10-55; EMS transported) and 93 (IQR 42-152, not EMS transported) hours (p < .01). The time from symptom onset to arrival in hospital was 5 (IQR 2-26; EMS transported) and 48 (IQR 6-108; not EMS transported) hours. After arrival in hospital, the median time to first doctor evaluation was 51 (IQR 28-90; EMS transported) and 80 (IQR 44-169; not EMS transported) minutes, p = .01. Low molecular weight heparin (LMWH) was given to 72% of patients in the emergency department (ED) and a multivariate analysis showed that the use of LMWH was associated with a more favourable outcome. Conclusions: Both the time spent in the ED and the time from the onset of symptoms to revascularisation were considerably longer than optimal. Time delays in the early treatment chain can mainly be attributed to "patient delay" and a considerable time spent in hospital before revascularisation. The use of LMWH as an integral part of ED management was associated with a better outcome. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 15. |
- Nordanstig, Joakim, et al.
(författare)
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Assessment of Minimum Important Difference and Substantial Clinical Benefit with the Vascular Quality of Life Questionnaire-6 when Evaluating Revascularisation Procedures in Peripheral Arterial Disease
- 2017
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 54:3, s. 340-347
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Patient reported outcomes are increasingly used to assess outcomes after peripheral arterial disease (PAD) interventions. VascuQoL-6 (VQ-6) is a PAD specific health-related quality of life (HRQoL) instrument for routine clinical practice and clinical research. This study assessed the minimum important difference for the VQ-6 and determined thresholds for the minimum important difference and substantial clinical benefit following PAD revascularisation. Materials and methods: This was a population-based observational cohort study. VQ-6 data from the Swedvasc Registry (January 2014 to September 2016) was analysed for revascularised PAD patients. The minimum important difference was determined using a combination of a distribution based and an anchor-based method, while receiver operating characteristic curve analysis (ROC) was used to determine optimal thresholds for a substantial clinical benefit following revascularisation. Results: A total of 3194 revascularised PAD patients with complete VQ-6 baseline recordings (intermittent claudication (IC) n ¼ 1622 and critical limb ischaemia (CLI) n ¼ 1572) were studied, of which 2996 had complete VQ-6 recordings 30 days and 1092 a year after the vascular intervention. The minimum important difference 1year after revascularisation for IC patients ranged from 1.7 to 2.2 scale steps, depending on the method of analysis. Among CLI patients, the minimum important difference after 1 year was 1.9 scale steps. ROC analyses demonstrated that the VQ-6 discriminative properties for a substantial clinical benefit was excellent for IC patients (area under curve (AUC) 0.87, sensitivity 0.81, specificity 0.76) and acceptable in CLI (AUC 0.736, sensitivity 0.63, specificity 0.72). An optimal VQ-6 threshold for a substantial clinical benefit was determined at 3.5 scale steps among IC patients and 4.5 in CLI patients. Conclusions: The suggested thresholds for minimum important difference and substantial clinical benefit could be used when evaluating VQ-6 outcomes following different interventions in PAD and in the design of Clinical trials.
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| 16. |
- Nordanstig, Joakim, et al.
(författare)
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Deep Femoral Vein Reconstruction of the Abdominal Aorta and Adaptation of the Neo-Aortoiliac System Bypass Technique in an Endovascular Era.
- 2019
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Ingår i: Vascular and endovascular surgery. - : SAGE Publications. - 1938-9116 .- 1538-5744. ; 53:1, s. 28-34
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Tidskriftsartikel (refereegranskat)abstract
- Primary infection of the abdominal aorta is a rare pathology that may threaten the integrity of the aortic wall, while secondary aortic prosthesis infection represents a devastating complication to open surgical and endovascular aortic surgery. Curative treatment is achievable by removal of all infected prosthetic material followed by a vascular reconstruction.Twelve consecutive patients treated with the neo-aortoiliac system bypass (NAIS) procedure were reviewed. Nine were treated for a secondary aortic prosthesis infection (tube graft n = 3, bifurcated graft n = 4, endovascular aortic repair (EVAR) stent graft n = 1, and fenestrated EVAR [FEVAR] stent graft n = 1), while 3 patients underwent NAIS repair due to an emergent primary mycotic aortoiliac aneurysm. Primary Results: Ten of 12 patients survived 30 days. Three patients were operated on acutely, and 9 patients had elective or subacute NAIS surgery. Two of 3 patients operated acutely died within 30 days, whereas no 30-day or 1-year mortality was observed in patients undergoing elective or subacute surgery. The median time from primary reconstruction to the NAIS procedure was 11 months (range: 0-201 months). Stent grafts (n = 5 of 12) were in 4 cases explanted using endovascular balloon clamping. Of the explanted endografts, 2 patients presented with a secondary graft infection after EVAR/FEVAR, while 3 patients had been emergently treated with endovascular cuffs as a "bridge-to-surgery" procedure due to aortoenteric fistula (AEF). Patients who received a "bridge-to-surgery" regimen were treated with the NAIS procedure within 8 weeks (median 27 days, range: 27-60) after receiving emergency stent grafting.Aortic balloon-clamping during explantation of infected aortic prosthetic endografts is feasible and facilitates complete endograft removal. Endovascular bridging procedures could be beneficiary in the treatment of AEF or anastomotic dehiscence due to graft infection, offering a possibility to convert the acute setting to an elective definitive reconstructive procedure with a higher overall success rate.
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| 17. |
- Nordanstig, Joakim, et al.
(författare)
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Echocardiographic assessment at rest and during stress in patients with intermittent claudication
- 2019
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Ingår i: Scandinavian Cardiovascular Journal. - : Informa UK Limited. - 1401-7431 .- 1651-2006. ; 53:3, s. 153-161
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Tidskriftsartikel (refereegranskat)abstract
- Objective. Skeletal muscle perfusion during walking relies on complex interactions between cardiac activity and vascular control mechanisms, why cardiac dysfunction may contribute to intermittent claudication (IC) symptoms. The study aims were to describe cardiac function at rest and during stress in consecutive IC patients, to explore the relations between cardiac function parameters and treadmill performance, and to test the hypothesis that clinically silent myocardial ischemia during stress may contribute to IC limb symptomatology. Design. Patients with mild to severe IC (n=111, mean age 67 y, 52% females, mean treadmill distance 195 m) underwent standard echocardiography, dobutamine stress echocardiography (SE) and treadmill testing. The patient cohort was separated in two groups based on treadmill performance (HIGH and LOW performance). Results. Ten patients (9%) had regional wall motion abnormalities of which three had left ventricular ejection fraction <50% at standard echocardiography. A majority had lower than expected systolic- and diastolic ventricular volumes. LOW performers had smaller diastolic left ventricular volumes and lower global peak systolic velocity during dobutamine stress. No patient demonstrated significant cardiac dysfunction during dobutamine provocation that was not also evident at standard echocardiography. Conclusions. Most IC patients were without signs of ischemic heart disease or cardiac failure. The majority had small left ventricular volumes. The hypothesis that clinically silent myocardial ischemia impairing left ventricular function during stress may contribute to IC limb symptomatology was not supported.
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| 18. |
- Nordanstig, Joakim
(författare)
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Is There a Claudicating Elephant in the Room?
- 2018
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Ingår i: European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. - : Elsevier BV. - 1532-2165. ; 56:4
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
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| 19. |
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| 20. |
- Nordanstig, Joakim, et al.
(författare)
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Two-year results from a randomized clinical trial of revascularization in patients with intermittent claudication
- 2016
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 103:10, s. 1290-1299
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIntermittent claudication is associated with significant impairment of health-related quality of life. The use of revascularization techniques to improve health-related quality of life remains controversial. MethodsPatients with intermittent claudication due to iliac or femoropopliteal peripheral artery disease were enrolled in the IRONIC trial. They were randomized to either best medical therapy (BMT), including a structured, non-supervised exercise programme, or revascularization with either endovascular or open techniques in addition to BMT. The primary outcome was health-related quality of life at 2years assessed using the Short Form 36 (SF-36((R))) questionnaire. Secondary outcomes included VascuQoL questionnaire results, treadmill walking distances and achievement of patient-specified treatment goals. ResultsBoth randomized groups had improved health-related quality of life and treadmill walking distance at 2-year follow-up. Overall SF-36((R)) physical component summary score, three SF-36((R)) physical domain scores, overall VascuQoL score, and three of five VascuQoL domain scores showed significantly greater improvement in the group that also received invasive treatment. Intermittent claudication distance on a graded treadmill improved more in the revascularization + BMT group (117 versus 55m; P=0003) whereas maximum walking distance and 6-min walk test distance were similar. Some 44 per cent of patients in the revascularization + BMT group reported they had fully achieved their treatment goal versus 10 per cent in the BMT group. ConclusionA revascularization strategy with unsupervised exercise improved health-related quality of life and intermittent claudication distance more than standard BMT and an unsupervised exercise programme in patients with lifestyle-limiting claudication. Registration number: NCT01219842 (http://www.clinicaltrials.gov).
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| 21. |
- Sigvant, Birgitta, et al.
(författare)
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Cardiovascular outcomes in patients with peripheral arterial disease as an initial or subsequent manifestation of atherosclerotic disease : Results from a Swedish nationwide study
- 2017
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Ingår i: Journal of Vascular Surgery. - : MOSBY-ELSEVIER. - 0741-5214 .- 1097-6809. ; 66:2, s. 507-514e1
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 22. |
- Sigvant, Birgitta, et al.
(författare)
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Contemporary cardiovascular risk and secondary preventive drug treatment patterns in peripheral artery disease patients undergoing revascularization.
- 2016
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Ingår i: Journal of vascular surgery. - : Elsevier BV. - 1097-6809 .- 0741-5214. ; 64:4
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Tidskriftsartikel (refereegranskat)abstract
- 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.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.Between May 2008 and December 2013, there were 18,742 revascularized PAD patients identified. Mean age was 70.0years among patients with intermittent claudication (IC; n= 6959) and 76.8years 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 36months 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.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.
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| 23. |
- Smidfelt, Kristian, et al.
(författare)
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Routine open abdomen treatment compared with on-demand open abdomen or direct closure following open repair of ruptured abdominal aortic aneurysms: A propensity score-matched study
- 2019
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Ingår i: Sage Open Medicine. - : SAGE Publications. - 2050-3121. ; 7
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate whether a strategy of treatment with a primarily open abdomen improves outcome in terms of mortality and major complications in patients treated with open repair for a ruptured abdominal aortic aneurysm compared to a strategy of primary closure of the abdomen. Design: Retrospective cohort study. Methods: Patients treated with a primarily open abdomen at a centre where this strategy was routine in most ruptured abdominal aortic aneurysm patients were compared to a propensity score-matched control group of patients who had the abdomen closed at the end of the primary operation in a majority of the cases. Results: In total, 79 patients treated with a primarily open abdomen after open repair for ruptured abdominal aortic aneurysm at Sahlgrenska University Hospital were compared to a propensity score-matched control group of 148 patients. The abdomen was closed at the end of the procedure in 108 (73%) of the control patients. There was no difference in 30-day mortality between patients treated with a primarily open abdomen at Sahlgrenska University Hospital and the controls, 21 (26.6%) versus 49 (33.1%), p = 0.37. The adjusted odds ratio for mortality at 30 days was 0.66 (95% confidence interval: 0.35-1.25) in patients treated with a primarily open abdomen at Sahlgrenska University Hospital compared to the controls. No difference was observed between the groups regarding 90-day mortality, postoperative renal failure requiring renal replacement therapy, postoperative intestinal ischaemia necessitating bowel resection or postoperative bleeding requiring reoperation. Conclusions: The study did not show any survival advantage or difference in major complications between patients treated with a primarily open abdomen after open repair for ruptured abdominal aortic aneurysm and propensity-matched controls where the abdomen was primarily closed in a majority of the cases.
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| 24. |
- Smidfelt, Kristian, et al.
(författare)
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The Impact of Initial Misdiagnosis of Ruptured Abdominal Aortic Aneurysms on Lead Times, Complication Rate, and Survival
- 2017
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 54:1, s. 21-27
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Tidskriftsartikel (refereegranskat)abstract
- Objective/Background: To investigate the frequency of initial misdiagnosis and the clinical consequences of an initial misdiagnosis of ruptured abdominal aortic aneurysms (rAAA). Methods: This was a retrospective cohort study. Data from the Swedish National Registry for Vascular Surgery (Swedvasc) and medical charts were extracted for patients treated for rAAA in the West of Sweden in the period 2008-14. Initially misdiagnosed patients were compared with correctly diagnosed patients. Results: In all, 261 patients were included in the study. Patients with rAAA were initially misdiagnosed in 33% (n = 86) of the cases and this caused a 4.8 hour (median time) additional delay to surgical intervention. There were no differences in 30 day mortality between initially misdiagnosed patients and correctly diagnosed patients (27.9% vs. 28.0%; p = 1.00). The adjusted odds ratio for mortality in initially misdiagnosed patients compared with correctly diagnosed patients was 0.78 (95% confidence interval 0.38-1.60). No difference was observed between the groups regarding 90 day mortality, length of intensive care, need for post-operative ventilator support, need of haemodialysis support, and length of hospital stay. Conclusion: Misdiagnosis is common in patients with rAAA, and treatment is significantly delayed in misdiagnosed patients. The study did not show any survival disadvantage or increased frequency of postoperative complications in misdiagnosed patients despite the delayed treatment. However, only patients who reached surgical intervention were included in the analysis. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 25. |
- Wanhainen, Anders, et al.
(författare)
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Misleading study in The Lancet on the outcome of the Swedish AAA screening program : Stor enighet om att screening för bukaortaaneurysm räddar liv.
- 2018
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Ingår i: Läkartidningen. - 1652-7518. ; 115
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- In a recent publication in The Lancet Johansson and colleagues claim no effect on aneurysm mortality among men participating in the Swedish AAA screening program, and question its justification. The study is, however, limited by a corrupt study design and incorrect data, making the publication misleading. On the contrary, several RCTs and contemporary nationwide data with sufficient follow-up clearly show that AAA screening saves lives and is highly cost-effective. The program has so far identified about 6000 men with an AAA, of whom 1500 have been operated on to prevent rupture. Thus, more than 750 men have experienced a longer life (by a mean of 8 years) as a result of the program. Continuous evaluation of the program is important but requires a scientifically sound methodology.
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| 26. |
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| 27. |
- Wanhainen, Anders
(författare)
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Stor enighet om att screening för bukaortaaneurysm räddar liv : [Misleading study in The Lancet on the outcome of the Swedish AAA screening program]
- 2018
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Ingår i: Läkartidningen. - : Läkartidningen Förlag. - 0023-7205 .- 1652-7518. ; 115
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- In a recent publication in The Lancet Johansson and colleagues claim no effect on aneurysm mortality among men participating in the Swedish AAA screening program, and question its justification. The study is, however, limited by a corrupt study design and incorrect data, making the publication misleading. On the contrary, several RCTs and contemporary nationwide data with sufficient follow-up clearly show that AAA screening saves lives and is highly cost-effective. The program has so far identified about 6000 men with an AAA, of whom 1500 have been operated on to prevent rupture. Thus, more than 750 men have experienced a longer life (by a mean of 8 years) as a result of the program. Continuous evaluation of the program is important but requires a scientifically sound methodology.
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| 28. |
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