Jørgen J. Jørgensen

Stenting for Chronic Post-thrombotic Vena Cava and Iliofemoral Venous Occlusions: Mid-term Patency and Clinical Outcome

OBJECTIVES The aim of this study was to determine the mid-term patency and the clinical outcome after stenting of chronic occluded caval and iliofemoral venous segments. DESIGN Observational study. MATERIAL/METHODS During the period 2000 and 2009, 2400 patients with chronic venous insufficiency (CVI) were evaluated, and 34 with chronic venous occlusions after deep venous thrombosis (DVT) were selected for endovascular treatment. The median age was 41 (range 15-63) years, and 19 were female. The following investigations were undertaken: colour duplex ultrasound (CDU), ascending venography (AV), venous occlusion plethysmography (VOP), venous pressure gradient (VPG) and CT venography or trans-femoral/popliteal venography. The major symptoms were venous claudication, oedema, pain and ulcer. All patients were treated by stenting occluded segments. Self-expanding stents were deployed in 22 iliofemoral, nine iliac and one caval-iliac-femoral. Twenty-one procedures required stenting across the inguinal ligament. RESULTS Primary recanalisation was accomplished in 32/34 (94%). The median follow-up was 33 months (1-96) with clinical examination, CDU and VOP. Two-year primary patency was 14/21 (67%), primary-assisted patency 16/21(76%), and secondary patency was 19/21 (90%). Venous claudication and oedema resolved in those successfully recanalised. Four of the seven ulcers healed. CONCLUSION Stenting to treat venous claudication, oedema and recurrent venous ulcer caused by post-thrombotic chronic venous occlusions has positive clinical outcome and good mid-term patency.

Cost-effectiveness of screening for abdominal aortic aneurysm in the Netherlands and Norway

The aim of this study was to determine the cost‐effectiveness of ultrasound screening for abdominal aortic aneurysm (AAA) in men aged 65 years, for both the Netherlands and Norway.

Bacteria and bacterial DNA in atherosclerotic plaque and aneurysmal wall biopsies from patients with and without periodontitis

Background Several studies have reported an association between chronic periodontitis (CP) and cardiovascular diseases. Detection of periodontopathogens, including red complex bacteria (RCB), in vascular lesions has suggested these bacteria to be involved in the pathogenesis of atherosclerosis and abdominal aortic aneurysms. Objective In this study, we investigate bacteria and their DNA in vascular biopsies from patients with vascular diseases (VD; i.e. abdominal aortic aneurysms, atherosclerotic carotid, and common femoral arteries), with and without CP. Methods DNA was extracted from vascular biopsies selected from 40 VD patients: 30 with CP and 10 without CP. The V3-V5 region of the 16S rDNA (V3-V5) was polymerase chain reaction (PCR)-amplified, and the amplicons were cloned into Escherichia coli, sequenced, and classified (GenBank and the Human Oral Microbiome database). Species-specific primers were used for the detection of Porphyromonas gingivalis. In addition, 10 randomly selected vascular biopsies from the CP group were subjected to scanning electron microscopy (SEM) for visualization of bacteria. Checkerboard DNA–DNA hybridization was performed to assess the presence of RCB in 10 randomly selected subgingival plaque samples from CP patients. Results A higher load and mean diversity of bacteria were detected in vascular biopsies from VD patients with CP compared to those without CP. Enterobacteriaceae were frequently detected in vascular biopsies together with cultivable, commensal oral, and not-yet-cultured bacterial species. While 70% of the subgingival plaque samples from CP patients showed presence of RCB, only P. gingivalis was detected in one vascular biopsy. Bacterial cells were seen in all 10 vascular biopsies examined by SEM. Conclusions A higher bacterial load and more diverse colonization were detected in VD lesions of CP patients as compared to patients without CP. This indicated that a multitude of bacterial species both from the gut and the oral cavity, rather than exclusively periodontopathogens, may be involved as additional risk factors in the pathogenesis of VD.

Supervised Exercise Training Reduces Plasma Levels of the Endothelial Inflammatory Markers E-Selectin and ICAM-1 in Patients With Peripheral Arterial Disease

Elevated plasma levels of vascular inflammatory markers have been reported in patients with peripheral arterial disease (PAD). We assessed the effect of supervised exercise training (ET) on vascular inflammation, hypothesizing that ET reduces plasma levels of the endothelial adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1). Twenty-nine patients with PAD underwent a supervised ET program for 8 weeks. Before and after ET, walking distances (pain-free, PWD; maximal, MWD) were determined by a standard treadmill test. Plasma levels of E-selectin and ICAM-1 were significantly reduced (E-selectin: 45.5-40.4 ng/mL, P = .013); ICAM-1: 342.0-298.0 ng/mL, P = .016). VCAM-1 levels were unchanged. Walking distances increased significantly (PWD: median 77-150 m, P < .001; MWD: median 306-535 m, P < .001). In conclusion, 8 weeks of ET in patients with PAD reduces plasma levels of the specific endothelium-derived inflammatory markers E-selectin and ICAM-1.

Venous Valve Reconstruction in Patients with Secondary Chronic Venous Insufficiency

OBJECTIVES To evaluate the durability of venous valve reconstruction (VVR) and its benefits in terms of symptom improvement, ulcer healing and symptom/ulcer recurrence among patients with secondary chronic venous insufficiency (SCVI) in whom superficial venous surgery and compression treatment had failed. METHODS During a ten year period (1993-2004) 1800 patients with chronic venous insufficiency (CVI) were evaluated by colour duplex ultrasound (CDU) and ambulatory venous pressure measurement (AVP). Approximately two thirds of patients had SCVI. Initial treatment consisted of compression therapy for a 6 month period. In addition, superficial vein and perforator surgery was performed in those presenting with reflux in these venous systems. 121 patients who did not improve with this treatment were investigated by ascending venography, descending video venography, air plethysmography and measurement of post-ischaemic venous pressure gradient. Thirty two cases having venous reflux without obstruction were selected for VVR. RESULTS The ulcer healing rate within three months was 68% (13/19 patients). VVR resulted in valvular competence and a clinical success rate of 47% and 40% after 3 and 7 years respectively. In 8/13 (54%) of patients with a healed leg ulcer, a median post-operative AVP reduction of 33 mm Hg (range 20-38) was recorded. The durability of clinical success was numerically longer in patients with haemodynamic improvement (n=10) median 24 months (12-108), when compared with that in those without haemodynamic improvement (n=22) median 18 months (6-108). Popliteal vein reconstruction was part of the VVR procedure in all patients with haemodynamic improvement (post-op. AVP reduction >or=20 mm Hg). VVR at the popliteal level alone or combined with inguinal reconstruction seemed to be the one significant factor associated with haemodynamic improvement (P=0.014, Chi squared). CONCLUSION VVR may lead to ulcer healing, but when performed at the popliteal level, haemodynamic improvement can be obtained along with a longer recurrence-free period (durability). VVR should be considered in the treatment of patients with SCVI who do not respond to superficial venous surgery and compression treatment.

Blood pressure response to isometric exercise in patients with peripheral atherosclerotic disease

Background  The purpose of this study was to compare the circulatory responses to isometric exercise in patients with peripheral atherosclerotic disease (PAD) with healthy controls.

Twelve-Months Follow-up of Supervised Exercise after Percutaneous Transluminal Angioplasty for Intermittent Claudication: A Randomised Clinical Trial

The aim of this study was to explore the effects during 12 months follow-up of 12 weeks of supervised exercise therapy (SET) after percutaneous transluminal angioplasty (PTA) compared to PTA alone on physical function, limb hemodynamics and health-related quality of life (HRQoL) in patients with intermittent claudication. Fifty patients were randomised to an intervention or a control group. Both groups received usual post-operative care and follow-up measurements at three, six and 12 months after PTA. The intervention group performed 12 weeks of SET after PTA. The control group did not receive any additional follow-up regarding exercise. During the 12 months’ follow-up, the members of the intervention group had significantly better walking distance than the control group. The intervention group had a significantly higher HRQoL score in the physical component score of the SF-36, and the domains of physical function, bodily pain and vitality. For limb hemodynamics, there was a non-significant trend towards better results in the intervention group compared to the control group. Conclusion: SET after PTA yielded statistically significantly better results for walking distance and HRQoL in the intervention group than the control group during the 12 months of follow-up.

Review of postoperative CT and ultrasound for endovascular aneurysm repair using Talent stent graft: can we simplify the surveillance protocol and reduce the number of CT scans?

Background Simplifying a postoperative surveillance protocol for endovascular aneurysm repair (EVAR) requires quality control comparing computerized tomography (CT) and ultrasound (US) results of abdominal aortic aneurysm (AAA) diameter measurements and endoleaks. Purpose To test if US is comparable to CT, then assess a simplified follow-up with our conventional surveillance to assess patient safety. Material and Methods During 2001-2006, data on 56 patients treated with Talent stent graft were prospectively registered. Median follow-up was 41.5 months (range, 2-94 months), with CT, US, and plain film abdomen X-rays (PFA) at 1, 6, and 12 months, then yearly. Bland-Altman plot was used to assess the agreement between CT and US measuring the AAA diameters and mixed model by the time effect to assess the difference in diameter over time. Sensitivity and specificity for detection of endoleaks by US, with CT as ‘gold standard’ were calculated. A simplified surveillance protocol with US/PFA at 6 and 8 weeks, CT/US/PFA at 1 year, and yearly US/PFA thereafter, was evaluated. CT was carried out when poor visibility, endoleak detected, AAA diameter increase (≥5 mm) on US or migration (≥10 mm) on PFA. This regime was compared with our conventional follow-up protocol. Results Diameter measurements on US appear comparable to CT with 91% specificity and 85% sensitivity for endoleaks detected by US. Using the simplified surveillance protocol no endoleaks, migrations, or endotension requiring treatment were overlooked. The simplified protocol generated 53 selective CT scans, avoiding approximately 144 CT scans. If further simplified by omitting the 1-year CT scan, one type II endoleak would be missed with a 1-year delay, eliminating a further 45 CT scans. Conclusion US appears comparable to CT in the follow-up of Talent stent grafts in our institution. The proposed simplified surveillance protocol seems safe and can lead to a significant reduction in the number of CT scans.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

Effect of High-Dose Ampicillin and Cloxacillin on Bleeding Time and Bleeding in Open-Heart Surgery

To determine if platelet dysfunction caused by high doses of penicillin compounds is of practical importance in patients with additional haemostatic defects perioperatively, a study was made of patients undergoing open-heart surgery. They were randomly assigned to prophylactic treatment with ampicillin 8 g plus cloxacillin 4 g daily for three days, or with cephalothin 8 g daily for three days. Fifty patients in each group were evaluated. The median bleeding time preoperatively and on days 1 and 4 postoperatively did not differ between the groups. The bleeding time was prolonged beyond the normal range in eight patients of the ampicillin/cloxacillin group and in three of the cephalothin group (p less than 0.05). Prolonged bleeding time was not associated with lower platelet count or greater blood loss. The total blood loss and the amounts of transfused blood, platelets and cryoprecipitate were all greater in the ampicillin/cloxacillin group, but the difference was not statistically significant. Combined use of ampicillin and cloxacillin in open-heart surgery is associated with increased bleeding, but the increase is without practical importance.