Juha-Pekka Salenius

Apolipoprotein E polymorphism, serum lipids, myocardial infarction and severity of angiographically verified coronary artery disease in men and women.

In several populations, the apolipoprotein E (apo E) allele epsilon 4 is associated with high concentration of plasma total and low density lipoprotein (LDL)-cholesterol and coronary artery disease (CAD). We determined the apo E phenotypes of 309 patients with angiographically verified CAD and 38 patients without CAD by isoelectric focusing and Western blotting. In men with CAD, the plasma total and LDL-cholesterol increased according to apo E phenotype in the following order: E3/2 < E3/3 < E4/3 < E4/4 (P = 0.03 for total cholesterol, P = 0.007 for LDL-cholesterol). In women, there was a similar trend (P = 0.22 for total cholesterol, P = 0.15 for LDL-cholesterol). The relative frequency of men with three vessel CAD increased (P = 0.43) together with LDL-cholesterol levels (P = 0.05) according to apo E phenotype E3/2, E3/3, E4/3, E4/4. Total and LDL-cholesterol levels were higher in patients with three vessel CAD than in patients with less serious types of CAD (P = 0.02 for total cholesterol, P = 0.007 for LDL-cholesterol). The relative frequency of patients with myocardial infarction increased according to apo E phenotype (P = 0.51). Both in men and women, there were no differences between apo E phenotypes in age at occurrence of the first myocardial infarction. The apo E allele frequencies of patients with CAD vs. without CAD were 2.3% vs. 1.3% for epsilon 2, 79.0% vs. 76.3% for epsilon 3 and 18.7% vs. 22.4% for epsilon 4. There were no statistically significant differences in apo E allele or phenotype frequencies between patients with CAD and without CAD or between patients with CAD and the general Finnish population. Our results support previous studies in suggesting that the apo E allele epsilon 4 is a risk factor for atherosclerosis, which affects plasma total and LDL-cholesterol. In addition, our results suggest that the apo E allele determines the severity of CAD.

Risk-scoring Method for Prediction of 30-Day Postoperative Outcome after Infrainguinal Surgical Revascularization for Critical Lower-limb Ischemia: a Finnvasc Registry Study

BackgroundThe aim of the present study was to develop a risk-scoring method for prediction of immediate postoperative outcome after infrainguinal surgical revascularization for critical limb ischemia.MethodsThe Finnvasc registry included data on 3,925 infrainguinal surgical revascularization procedures. This database was randomly divided into a derivation and a validation data set of similar sizes.ResultsIn the overall series, 30-day postoperative mortality and major amputation rates were 3.1% and 6.3%, respectively. The 30-day postoperative mortality and/or limb-loss rate was 9.2%. Diabetes, coronary artery disease, foot gangrene, and urgent operation were independent predictors of 30-day postoperative mortality and/or major lower-limb amputation. A risk score was developed by assigning 1 point each to the latter risk factors. In the derivation data set, the 30-day postoperative mortality/amputation rates in patients with scores of 0, 1, 2, 3, and 4 were 7.7%, 6.4%, 11.1%, 20.4%, and 27.3%, respectively, (P < 0.0001); mortality rates were 1.3%, 2.3%, 4.1%, 7.7%, and 12.1%, respectively, (P < 0.0001); and major amputation rates were 6.4%, 4.3%, 7.1%, 12.7%, and 18.2%, respectively, (P < 0.0001). In the validation data set, the 30-day postoperative mortality/amputation rates in patients with scores of 0, 1, 2, 3, and 4 were 4.8%, 7.5%, 10.1%, 15.9%, and 22.2%, respectively, (P < 0.0001); mortality rates were 0.7%, 2.3%, 4.2%, 5.5%, and 14.8%, respectively, (P < 0.0001); and major amputation rates were 4.6%, 5.3%, 6.4%, 11.0%, and 14.0%, respectively (P = 0.011).ConclusionsThis simple risk-scoring method can be useful to stratify the immediate postoperative outcome of patients undergoing infrainguinal surgical revascularization for critical lower-limb ischemia.

Prevalence and Risk Factors of PAD among Patients with Elevated ABI

OBJECTIVES To assess the prevalence and clinical significance of elevated ankle-brachial index (ABI) in patients referred to vascular consultation. DESIGN Retrospective clinical study. MATERIAL AND METHODS In 1,762 patients referred with a suspicion of peripheral arterial disease (PAD), ABI and toe brachial index (TBI) were measured by photoplethysmography. ABI>/=1.3 was considered falsely elevated and TBI<0.60 was the diagnostic criterion for PAD. RESULTS The prevalence of elevated ABI was 8.4% and that of PAD among these patients 62.2%. PAD was significantly more prevalent among subjects with severe symptoms (rest pain, ulcers or gangrene) than in those with intermittent claudication (83.8% and 45.3%, respectively, p<0.001). The risk of PAD diagnosis was ten-fold (OR 10.31, 95% CI 2.07-51.30) among those with chronic renal failure, five-fold among patients with a history of smoking (OR 5.63, 95% CI 1.22-26.00) and over three-fold (OR 3.44, 95% CI 1.46-8.12) among those with coronary heart disease. The specificities of elevated ABI threshold levels (1.3, 1.4 and 1.5) in identifying PAD were 86%, 94% and 96%, respectively, the sensitivities being 44%, 38% and 36%, respectively. CONCLUSIONS The prevalence of elevated ABI in patients referred to vascular consultation is 8.4% and that of PAD among these 62.2%. PAD is significantly more probable among those with chronic renal failure, a history of smoking and coronary heart disease. Furthermore, the specificity of elevated ABI (>/=1.3) in recognizing PAD is good, whereas the sensitivity is only satisfactory.

Mortality in Abdominal Aortic Aneurysm Surgery - The Effect of Hospital Volume, Patient Mix and Surgeon's Case Load

OBJECTIVE Assessment of mortality in abdominal aortic aneurysm surgery. DESIGN A 4-year cross sectional study based on a nationwide vascular registry: Finnvasc. MATERIAL AND METHODS A total of 17,465 vascular interventions included 929 elective repairs for abdominal aortic aneurysms (AAA), and 610 emergency cases with 454 ruptures. Fifty-three percent of the operations were done in university hospitals, 44% in central hospitals and 3% in district hospitals. RESULTS The 30-day mortality rate for AAA repair was 5.1% in elective and 46% in ruptured cases. A clear dependence of operative mortality on surgeons experience in AAA surgery was observed, both regarding the surgeons total vascular case load (p < 0.01) and the number of operated elective aneurysms (p < 0.01), but not the number of operated ruptured aneurysms. However, no association was found between hospital volume and mortality in AAA surgery. CONCLUSIONS Vascular surgical experience clearly improves the results of elective aneurysm surgery.

Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm

The aim of the study was to assess the value of the Glasgow Aneurysm Score in predicting postoperative death after repair of a ruptured abdominal aortic aneurysm (AAA).

Drug-eluting biodegradable poly-D/L-lactic acid vascular stents: an experimental pilot study.

Purpose: To evaluate in vivo a new drug-eluting biodegradable vascular stent with respect to biocompatibility, neointimal hyperplasia formation, and reliability. Methods: Self-expanding biodegradable poly-96L/4D-lactic acid (PLA) stents with 2 drugs (PLA + dexamethasone [DEX] and PLA + simvastatin [SIM]) and 2 different coatings (PLA + P(D,L)LA and PLA + polycaprolactone [PCL]) were compared with a self-expanding stainless steel Wallstent. The stents were implanted in both common iliac arteries of 8 pigs. Prior to sacrifice at 1 month, angiography was performed to determine patency. Specimens were harvested for quantitative histomorphometry; vascular injury and inflammation scores were assigned to the stented iliac segments. Results: All stented arteries were angiographically patent. The mean luminal diameter (3.05 mm) and area (30.36 mm2) of DEX-eluting PLA stents were decreased compared to other stents (PLA + P(D,L)LA: 3.66 mm and 43.92 mm2 PLA + SIM: 4.21 mm and 56.48 mm2 PLA + PCL: 4.19 mm and 54.64 mm2 Wallstent: 5.01 mm and 81.19 mm2). Wallstents and DEX-eluting PLA stents induced minimal intimal hyperplasia: PLA + DEX: 0.16 mm, PLA + P(D,L)LA: 0.35 mm, PLA + SIM: 0.33 mm, PLA + PCL: 0.29 mm, and Wallstent: 0.18 mm. The vascular injury scores demonstrated only mild vascular trauma for all stents. Only mild to moderate inflammatory reaction was noted around stent struts with a vascular inflammation score. Conclusions: Biodegradable polymer stents appear to be biocompatible and reliable, causing minimal neointimal hyperplasia. Furthermore, the new biodegradable poly-D/L-lactic acid stent can be used as a local drug delivery vehicle. The DEX-eluting PLA stent reduces neointimal hyperplasia. The findings show a need for further investigation to prove the efficacy and safety of this new biodegradable drug-eluting stent.

ADAM-9, ADAM-15, and ADAM-17 are upregulated in macrophages in advanced human atherosclerotic plaques in aorta and carotid and femoral arteries—Tampere vascular study

Background and aims. The expression of disintegrin and metalloprotease ADAM-9, ADAM-15, and ADAM-17 has been associated with cell-cell, cell-platelet, and cell-matrix interactions and inflammation. They are possibly implicated in the pathophysiology of atherosclerosis. Methods and results. Whole-genome expression array and quantitative real-time polymerase chain reaction (PCR) analysis confirmed that ADAM-9, ADAM-15, and ADAM-17 are upregulated in advanced human atherosclerotic lesions in samples from carotid, aortic, and femoral territories compared to samples from internal thoracic artery (ITA) free of atherosclerotic plaques. Western analysis indicated that the majority of these ADAMs were in the catalytically active form. ADAM-9, ADAM-15, and ADAM-17-expressing cells were shown to co-localize with CD68-positive cells of monocytic origin in the atherosclerotic plaques using immunohistochemistry and double-staining immunofluorescence analysis. Co-localization was demonstrated in all vascular territories. In the carotid territory, cells expressing the ADAMs co-distributed also with smooth muscle cells and, in femoral territory, with CD31-positive endothelial cells, indicating that the ADAM expression pattern depends on vascular bed territory. Conclusions. Present findings provide strong evidence for the involvement of catalytically active ADAM-9, ADAM-15, and ADAM-17 in advanced atherosclerosis, most notably associated with cells of monocytic origin.

Factors affecting the results of surgery for chronic critical leg ischemia—a nationwide survey

PURPOSE To assess the factors affecting immediate outcome of surgery for chronic critical leg ischemia, especially the influence of surgeons caseload and hospital volume. METHODS The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical leg ischemia during 1991 to 1994. RESULTS The 30-day postoperative leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeons annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical leg ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure. CONCLUSIONS A surgeons caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical leg ischemia.

Influence of surgical experience on the results of carotid surgery

OBJECTIVE To assess the 30-day mortality and morbidity rates related to carotid endarterectomy on a nation-wide basis. DESIGN Retrospective cross-sectional study based on vascular registry Finnvasc. MATERIALS AND METHODS A total of 17,465 recorded vascular and endovascular procedures included exactly 1600 carotid endarterectomies performed by 104 surgeons in 23 hospitals. Fourteen per cent of the patients were operated on for asymptomatic carotid stenosis. RESULTS The combined mortality and permanent stroke rate was 3.3%, without any difference between operations done on symptomatic or asymptomatic patients. There was a clear inverse association between surgeons carotid case load and poor outcomes in carotid surgery (p < 0.005), the critical patient mass per surgeon and year being 10 operations. There was no association between outcome after carotid surgery and hospital volume of carotid operations. CONCLUSIONS Surgeons experience in carotid surgery clearly improves the results of carotid surgery.

PAD as a Risk Factor for Mortality Among Patients with Elevated ABI – A Clinical Study

OBJECTIVE This study aims to evaluate mortality across ankle-brachial index (ABI) values and to assess the association between elevated ABI, peripheral arterial disease (PAD) and mortality. DESIGN This is a retrospective clinical study. MATERIAL AND METHODS A total of 2159 patients referred with a suspicion of PAD had their ABI and toe brachial index (TBI) measured by photoplethysmography. ABI > or =1.3 was considered falsely elevated while TBI <0.60 was the diagnostic criterion for PAD among the subjects. The cohort was followed up for total and cardiovascular mortality until 30 June 2008, by record linkage with the National Causes-of-Death Register. RESULTS The average follow-up time was 39 months. A total of 576 (26.7%) patients died during the follow-up. Mortality was highest in the elevated ABI group (35.7% for elevated ABI; 30.1% for low ABI and 16.0% for normal ABI, p < 0.001). There was a greater than twofold risk of total, and an increased but statistically non-significant risk of, cardiovascular mortality among patients with elevated ABI. Similar risk ratios were noted for the low ABI (< or =0.9) group. More pronounced associations were observed at both ends of the scale when ABI was divided into sub-categories. The overall survival was significantly worse for the elevated ABI group than for both the normal and the low-ABI group (p < 0.01 and p = 0.013, respectively). PAD was found to be independently associated with both total and cardiovascular mortality among those with elevated ABI (odds ratio (OR): 2.21; 95% confidence interval (CI): 1.01-4.85 and OR: 4.90; 95% CI: 1.50-16.04, respectively). CONCLUSIONS The association between elevated ABI and poor survival is similar to that of low ABI. PAD appears to be an independent risk factor for mortality among patients with elevated ABI.