Bo Almgren

Abdominal aortic aneurysm with perianeurysmal fibrosis: Experience from 11 Swedish vascular centers ☆ ☆☆

Case records of 2026 patients operated on because of abdominal aortic aneurysms from 11 Swedish Vascular Centers were reviewed and revealed 98 cases (4.8%) of inflammatory abdominal aortic aneurysm. Also included in this case-control study was an analysis of a randomized group of 82 patients from the same centers who had noninflammatory abdominal aortic aneurysms. Four inflammatory aneurysms were ruptured, compared with 16 in the noninflammatory group (p less than 0.01). A higher proportion of patients with inflammatory abdominal aortic aneurysms had symptoms that led to radiographic investigations. The median erythrocyte sedimentation rate was 39 mm versus 19 mm (26% of patients with inflammatory abdominal aortic aneurysms had erythrocyte sedimentation rates greater than 50 mm; p less than 0.001), and the serum creatinine level was increased in 27 and 8 patients (p less than 0.01) in the inflammatory and noninflammatory groups, respectively. Preoperative investigations revealed ureteral obstruction in 19 patients with inflammatory abdominal aortic aneurysms, of whom 12 had preoperative nephrostomy or ureteral catheter placement. At operation, 20 additional patients exhibited fibrosis around one or both ureters. Although ureterolysis was performed in 19 patients, preoperative and postoperative creatinine levels did not differ between these patients and the conservatively treated ones. Duration of surgery (215 vs 218 minutes), intraoperative blood loss (2085 vs 2400 ml) and complications did not differ significantly between the groups. Overall operative (30-day) mortality was equal (11% vs 12%) but was increased for patients undergoing elective surgery for inflammatory abdominal aortic aneurysms (9% vs 0%; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of below-knee percutaneous transluminal angioplasty in arterial occlusive disease causing chronic critical limb ischemia.

PurposeTo determine the efficacy, safety and long-term results of crural artery percutaneous transluminal angioplasty (PTA) in limbs with chronic critical limb ischemia (CLI).MethodsPatients undergoing crural artery PTA due to CLI were followed at regular clinic visits with ankle brachial pressure index (ABPI) measurements. PTA of the crural arteries was attempted either alone (n=39) or in combination with PTA of the superficial and/or popliteal artery (n=55) in 86 limbs (82 patients and 94 procedures) presenting with CLI. The ages of patients ranged from 37 to 94 years (mean 72 years). The indications for PTA were rest pain in 10 and ulcer/gangrene in 84 limbs.ResultsA technically successful PTA with at least one crural level was achieved in 88% of cases (n=83). Cumulative primary clinical success rates at 6, 12, 24, and 36 months were 55%, 51%, 36%, and 36%, respectively. Cumulative secondary clinical success and limb salvage rates at 36 months were 44% and 72%, respectively.ConclusionPTA of the crural arteries might be considered the primary choice of treatment in patients with CLI and distal lesions with localized stenosis or segmental short occlusions.

Influence of the profunda femoris vein on venous hemodynamics of the limb: Experience from thirty-one deep vein valve reconstructions

Venous valve reconstruction in 31 limbs (28 patients) with chronic deep venous insufficiency is analyzed. The indications for operation were primary or secondary deep valvular incompetence with severe reflux and venous hypertension. Valvuloplasty was performed on a proximal valve of the superficial femoral vein (SFV) in 17 limbs and on a common femoral vein valve in two limbs; transplantation of a valve-bearing segment of the axillary vein was made to the common femoral vein in two limbs, to the SFV in seven limbs, and to the popliteal vein in three limbs. The results of valvuloplasty were satisfactory, with six failures observed during a follow-up period extending to 84 months (mean, 44 months). Eight of 12 valve transplant reconstructions failed within 2 years. Patency and competence of the reconstruction were obtained in 27 limbs at the 6-month postoperative control period. The effects on venous pressure were analyzed regarding the presence or absence of reflux into the profunda femoral vein (PFV) with preoperative retrograde phlebography. The results showed significant reduction of the ambulatory venous pressure (p less than 0.05) and increase in venous recovery time (p less than 0.01) in limbs with PFV competence. In limbs in which the PFV was incompetent the pressure values remained unchanged. These findings suggest that the functional state of the PFV is of great importance to the venous hemodynamics of the limb. This study also indicates that the principle of one-level repair in the SFV seems appropriate in limbs with a competent PFV.

Reduction of Requirement for Leg Vascular Surgery During Long-term Treatment of Claudicant Patients with Ticlopidine: Results from the Swedish Ticlopidine Multicentre Study (STIMS)

OBJECTIVE To study the effect of long-term treatment of the platelet inhibitor ticlopidine as secondary prevention against the need of vascular surgery in patients with intermittent claudication. DESIGN The Swedish Ticlopidine Multicentre Study (STIMS), was conducted in six medical and surgical clinics of university hospitals in Sweden. METHODS 687 claudicants were randomised to ticlopidine 250 mg bd or placebo and vascular surgery events were recorded prospectively over a 7-year period. Cox proportional hazards models of risk for leg vascular surgery were constructed using drug treatment and 11 putative risk factors for vascular disease as covariates. Surgical event-free survivals were compared by Kaplan-Meier analysis. RESULTS The overall rate of first operations was 2.4% per annum. More than half of these operations were in the aortoiliac region. One-quarter of patients operated during the period required further operations but amputation was rare. Ticlopidine treatment reduced the need for vascular reconstructive surgery by about half, both in intention-to-treat and on-treatment analyses (unadjusted relative risks 0.486, 95% CI 0.317-0.745; p < 0.001; 0.493, 95% CI 0.290-0.841: p < 0.01, respectively). In Cox model analysis only male sex was confirmed as a risk factor for surgery. Previous peripheral arterial surgery was the strongest predictor of the need for surgery. None of the risk factors examined interacted statistically with the effect of treatment with ticlopidine. CONCLUSION In patients with intermittent claudication it seems possible to prevent the need for future vascular surgery by the use of platelet inhibition with ticlopidine.

Comparative analysis of patency, limb salvage and survival in diabetic and non-diabetic patients undergoing infrainguinal bypass surgery

In 92 diabetic and 175 non‐diabetic patients undergoing 336 femoropopliteal or femorodistal bypass procedures, 1‐ and 3‐year cumulative life‐table patency, limb salvage, and survival rates were comparatively analysed. The peroperative mortality rate was significantly higher in diabetic patients (5% compared to 1.4%, p < 0.001). The cumulative graft patency rates were 61% at 12 months and 46% at 36 months in diabetic patients compared to 64 and 52% in non‐diabetic patients. Significantly better patency rates were observed in limbs with good runoff compared to limbs with poor runoff in both groups. The limb salvage rates at 3 years were 70% in diabetic patients and 62% in non‐diabetic patients. The survival rate at 3 years was significantly lower in diabetic patients, 62% compared to 86% in non‐diabetic patients. Diabetic patients with poor runoff demonstrated a significantly lower survival rate after 36 months compared to diabetic patients with good runoff (48% and 74%, respectively). The results of this study demonstrate that the early and intermediate patency and limb salvage rates are similar in diabetic and non‐diabetic patients. On the other hand the survival rate in diabetic patients, especially in those with poor distal runoff, is significantly lower than non‐diabetic patients.

Postoperative predictive value of a new method of intraoperative angiographic assessment of runoff in femoropopliteal bypass grafting

In 96 consecutive patients undergoing primary femoropopliteal bypass grafting, the runoff was evaluated with a new grading system, based on findings at intraoperative postreconstruction serial angiography. This concept, which takes foot vessel involvement into account in patients with only one patent crural artery, is a modification of the traditional method of runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot or one patent, vessel continuous with intact anterior or posterior foot arch. In limbs with no patent vessel or one patent vessel with deficient or occluded foot arches, the runoff was classified as poor. The cumulative primary patency rates at 12 months in groups with good and poor runoff were 81% and 37%, respectively. The predictive value of the new method was superior to that of other comparable methods (traditional method, Society for Vascular Surgery and International Society for Cardiovascular Surgery criteria, and modified Society for Vascular Surgery and International Society for Cardiovascular Surgery criteria). This improved prediction can be ascribed to the optimal angiographic technique for visualizing distal vessels, selective evaluation of foot vessel runoff with a new concept, and the criteria used to define good and poor runoff.

Surgical Reconstruction of Incompetent Deep Vein Valves

Conventional treatment of deep venous insufficiency results in a rather high failure rate. The introduction of methods for surgical repair of incompetent deep vein valves has implied new possibilities for active treatment and has added increased knowledge to venous pathophysiology. This study summarizes our clinical experience with surgical reconstruction of deep vein valves during a nine-year period.

Phlebographic evaluation of nonthrombotic deep venous incompetence: New anatomic and functional aspects

The anatomy, valvular function, and reflux patterns in the deep veins of the lower extremities were studied by ascending and descending phlebography in 126 limbs with nonthrombotic deep venous incompetence. The most common patterns were isolated reflux in the superficial femoral vein (51%), and combined reflux in the superficial femoral and the deep femoral veins (44%). Isolated deep femoral vein reflux occurred in 5%. As the degree of reflux in this vein varied considerably, a grading system for classification of deep femoral vein reflux was proposed. Depending on variations in the deep femoral vein anatomy, four different patterns could be distinguished. This study demonstrated that contrast filling of the deep femoral vein during ascending phlebography may indicate the presence of reflux in this vein. Complete visualization of the deep femoral vein is a new diagnostic sign that strongly correlates (p less than 0.001) with reflux in the deep femoral vein. The mean number of valves in the superficial femoral vein was reduced with increasing degree of reflux compared with a reference group consisting of 41 extremities without reflux. The diameter of the popliteal vein was significantly increased in the presence of pathologic reflux, which may indicate that vein wall dilation is a major cause of primary nonthrombotic deep venous incompetence.

Bypass grafting to the popliteal artery in limbs with occluded crural arteries

Intraoperative completion angiograms of 47 femoropopliteal bypasses in limbs with occluded crural arteries were reviewed to identify the angiographic determinants of early outcome. Of 28 limbs in which the foot vessels were available for analysis, only 2 (7%) had an intact pedal circulation, and 18 limbs demonstrated no crural arteries suitable for distal reconstruction. The overall cumulative patency rate was 51% with a 76% limb salvage rate at 12 months. All seven grafts performed onto a popliteal artery segment of less than 8 cm occluded in the early period. The status of crural and foot arteries and the number of collaterals did not correlate well with early patency. Limbs with no patent crural artery that were analyzed in the poor angiographic runoff group, according to our previously reported classification, demonstrated relatively higher patency rates than the other subgroups with poor runoff. In cases where angiography demonstrates a poor runoff for distal revascularization, popliteal bypass with occluded crural arteries might achieve acceptable patency rates.

Angiographic criteria for prediction of early graft failure of secondary infrainguinal bypass surgery.

Complete intraoperative postreconstruction angiograms were obtained during 93 reoperations after failed femoropopliteal and femorodistal bypass grafts to evaluate the predictive value of a new method of angiographic runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot, or one patent vessel continuous with an intact anterior or posterior foot arch in femoropopliteal and proximal femorodistal bypasses, and integrity of both arches in low femorodistal bypasses. All other outflow patterns were considered poor. The cumulative 1-year patency rate was 61% with a 79% limb salvage rate after reoperations performed in limbs with good runoff. In reoperations with poor runoff, the patency rate was only 5% with a 22% limb salvage rate. In reoperations with good runoff, and 85% patency rate of vein grafts compared to 43% of prosthetic grafts clearly demonstrated the importance of graft material on early outcome. The improved prediction of early outcome with this new method of angiographic runoff evaluation might allow more rational management of patients with failed infrainguinal grafts.