Pär Olofsson

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)

Diagnosis of prosthetic aortic graft infection by magnetic resonance imaging

The accuracy of magnetic resonance imaging (MRI) in the diagnosis of prosthetic aortic graft infection was evaluated in 18 patients with history and findings suggestive of this complication. The prospective interpretation of MRI was compared with surgical findings. Sixteen patients had a graft infection verified at operation. Fourteen patients had infection of the retroperitoneal portion of the graft; two patients had an infection limited to one of the groins; no graft infection was found at surgical exploration in the remaining two patients. Perigraft infection was correctly diagnosed on the basis of MRI findings in 14 of 16 cases; findings were false negative in one case, questionable in another case, and correctly excluded graft infection in two of two cases. MRI also defined the extent of infection in 14 of 16 cases. MRI findings that supported the clinical suspicion of graft infection were perigraft fluid collections remaining more than 3 months after surgery. Furthermore, local inflammation was suggested by an increased signal intensity of adjacent muscle on T2-weighted images in some cases. CT scans were performed in 12 patients; these enabled a correct diagnosis in five and provided indeterminate or false information in seven. These results indicate that MRI is helpful in the diagnosis of aortic graft infection. Furthermore, MRI provides information about the extent of infection crucial for planning therapy.

Endovascular Treatment in Postthrombotic Syndrome

Background: The postthrombotic syndrome is a chronic complication of deep venous thrombosis that leads to considerable pain and suffering to patients. We evaluated our experience of endovascular treatment for patients with chronic postthrombotic femoroiliocaval venous disease. Materials and Methods: From January 2003 through December 2007, 50 patients (51 limbs; 60% women; mean age 45 years; range: 24-74 years) with chronic postthrombotic venous disease were referred to our institution for interventional assessment. All patients underwent duplex ultrasonography as well as ascending and descending venography. The CEAP (clinical, etiologic, anatomic, and pathophysiologic classification) clinical scores were class 0 (no signs) in 2% of limbs, class 3 (edema) in 63%, class 4a (pigmentation or eczema) in 18%, class 5 (healed venous ulcer) in 14%, and class 6 (active venous ulcer) in 4%. The etiology was secondary (postthrombotic) in all patients. The anatomical distribution of reflux and obstruction were deep veins in 63% and a combination of deep and superficial veins in 37%. The underlying pathophysiology due to obstruction of the deep venous outflow with no reflux was found in 25% of limbs, only reflux was found in 14%, and a combination of obstruction and reflux was found in 61%. Results: There were 21 limbs in 20 (38%) patients that underwent endovascular and/or surgical treatment. One limb underwent femoral endovenectomy and 1 limb superficial femoral vein to deep femoral vein transposition. In all, 19 limbs were scheduled for endovascular treatment. The technical success rate was 84%, 3 limbs with iliac vein occlusions could not be recanalized. A total of 11 patients (11 limbs) underwent solely endovascular intervention and 4 patients (5 limbs) underwent endovascular intervention combined with femoral endovenectomy. The endovascular and surgical procedures were performed with no perioperative or postoperative mortality as well as no major bleeding or cardiac, pulmonary, or renal 30-day complications. Early thrombosis (<30 days) of the stented iliac veins occurred in 3 limbs which were lysed and restented successfully. The mean follow-up time was 23 months (range: 1-69 months). Primary and assisted-primary/secondary patency rates at 12 months were 61% and 81%, respectively. The Venous Clinical Severity score was 9.1 (range: 5-15) before endovascular treatment and 6.0 (range: 3-13) after the treatment (P < .0001). There were 30 patients (62%) with symptoms attributable to venous dysfunction or with deep venous pathology that did not undergo interventional treatment after workup. These patients continued with appropriate thromboprophylaxis and elastic compression stockings. Conclusion: Endovascular treatment of chronic postthrombotic femoroiliocaval venous disease is a safe technique that can be performed with acceptable patency rates in this challenging patient population.

MR imaging of complications of aortic surgery

Sixteen patients with a variety of complications of aortic surgery were evaluated with magnetic resonance (MR) imaging. More than one complication occurred in seven patients, resulting in the following types of abnormalities: graft occlusions, two; graft infections; five; pseudoaneurysms or aneurysmal dilatation of graft anastomoses, 10; perigraft hemorrhages, four; and aortoenteric fistulas, two. The MR findings were verified by surgery in 10, by CT in four, and by angiography in 11 patients. The size and extent of pseudoaneurysm or anastomotic dilatation, the presence of thrombus and vessel occlusion, the extent of abscesses, and the effect of pseudoaneurysms and abscesses on adjacent structures were readily demonstrated by MR. The size of the residual lumen in the case of thrombosis could be assessed. Abscesses were identified by their characteristic signal increase with long repetition rates and long echo delays. Magnetic resonance was also able to exclude suspected complications such as perigraft infection, hemorrhage, and graft occlusion in four patients.

Histopathological characteristics of explanted human prosthetic arterial grafts: Implications for the prevention and management of graft infection

OBJECTIVE to study the histopathological characteristics of prosthetic vascular graft infection. DESIGN prospective clinical study over 2 years. SETTING University Hospital. MATERIALS 36 infected and 29 uninfected (control) chronically implanted vascular prostheses (half aortic) were removed and 352 sections prepared. CHIEF OUTCOME MEASURES light microscopy (multiple stains), scanning electron microscopy (SEM), and multiple culture techniques to identify characteristics of healing, infection, and microorganisms. MAIN RESULTS Acute inflammation (AI) (neurophils, granulocytes and necrosis) were seen in 75% of infected grafts, were most prominent in the perigraft tissue and rarely seen on the luminal surface. These were usually well localised, leaving the remainder of a graft well incorporated with no signs of infection. In 25% of clinically infected, culture-positive grafts there was no significant acute inflammation. Chronic inflammation (CI) (macrophages, lymphocytes, monocytes, giant cells) was seen in 70% of both control and infected grafts. In 50% of both groups a significant lymphocytic population was composed exclusively of T-lymphocytes suggesting a true host vs graft response. Unincorporated chronically implanted grafts (> 1 yr) were seen with equal frequency in the two groups although more diffusely unincorporated grafts were infected. Microorganisms were cultured from 23 infected grafts (64%) and were, at microscopy, mostly found outside the graft and nerves on the luminal side. CONCLUSIONS This data cast doubt on criteria commonly used to distinguish graft infections and host vs. graft reactions from normal graft healing. Acute and chronic inflammation are not predictive of infection.

Changes in Postocclusive Reactive Hyperaemic Values as Measured with Laser Doppler Fluxmetry after Infrainguinal Arterial Reconstructions

OBJECTIVES The aim of the present study was to evaluate microcirculartory changes of the postocclusive reactive hyperaemia test measured with Laser Doppler fluxmetry to detect results of arterial reconstructions. DESIGN Prospective open study. SETTING Vascular laboratory of a University Hospital. MATERIAL Sixty patients with peripheral arterial occlusive disease who underwent infrainguinal reconstruction were examined the day before and 1-2 days after surgery. CHIEF OUTCOME MEASURES The values were obtained during postocclusive reactive hyperaemia induced by release of a 3 min arterial occlusion with a cuff at ankle level with the laser Doppler probe placed dorsally on the first toe. The alterations after surgery in these hyperaemia parameters were compared to changes in ankle/brachial index and clinical improvement at 30 days postoperatively. MAIN RESULTS Patients improved by surgery according to ankle/brachial index had significantly reduced time to peak (p < 0.001) and significantly increased resting flux value (p < 0.05) and peak flux value (p < 0.05). There was a significant correlation between the change after surgery in time to peak flux and increment of ankle/brachial index (r = 0.63, p < 0.001). CONCLUSIONS Changes in reactive hyperaemia values as measured with laser Doppler fluxmetry, especially the time to peak flux, seem to detect circulatory changes caused by arterial reconstructions.

Aortorenal arterial autografts: the last two decades.

Arterial autografts were introduced nearly a quarter century ago at the University of California, San Francisco and have proven their value for replacement in many demanding arterial problems. Renal artery fibrodysplasia is one of the more common lesions treated with arterial autograft. Arterial autografts that ideally match the renal artery and its branches are procured from the patients own internal iliac artery. Either straight or branched configuration are available depending on the replacement requirements. In-situ aortorenal autografts are employed for lesions of the main renal artery or primary branches. Ex vivo repair involves temporary nephrectomy, pulsatile hypothermic perfusion and precise micro-vascular repair with unrestricted exposure, illumination, and an unhurried pace with no threat of renal ischemic insult. Autografts are attached proximally to the side of the aorta and distally to the disease-free end of the renal artery or a branch. The technique of arterial substitution for ex vivo repairs are identical except for the additional reanastomosis or reattachment of the renal vein. The arterial autograft exhibits the compliance characteristics which resemble a normal artery, maturation when used in the growing child, and durability essential for the long life span of this treated population. When the objective of a renal artery reconstruction is a normal renal arterial system, then the internal iliac artery autograft is the only choice.

Level of arterial obstruction in patients with peripheral arterial occlusive disease (PAOD) determined by laser Doppler fluxmetry

AIM To evaluate the laser Doppler fluxmeter as a non-invasive screening method to determine the level of peripheral arterial occlusive disease (PAOD) in the lower limb. DESIGN Open study of the veno-arterial reflex (VAR) during a shift in body position using a laser Doppler fluxmeter at five probe positions distal to the knee, compared with the occlusion level determined by arteriography and segmental plethysmography. MATERIALS 50 legs comprising 10 normal controls, 20 legs with suprainguinal obstructions (10 claudication and 10 critical ischaemia) and 20 legs with infrainguinal obstructions (10 claudication and 10 critical ischaemia). RESULTS Controls had normal VAR (mean flux reductions of 38% during dependency) at all probe positions. Legs with infrainguinal disease had normal reflexes proximally but significantly disturbed reflexes distally, whereas suprainguinal disease showed alterations at all sites. Claudicants had diminished flux reduction (mean 12%) whilst those with critical ischaemia increased the flux (mean 32%). CONCLUSION This simple, non-invasive technique may be of use in determining the level of obstruction in PAOD.

Correlation between peripheral vascular resistance and time to peak flow during reactive hyperaemia

Earlier studies have proposed that the time to reach peak hyperaemic flux recorded with laser Doppler (tp) is a simple and accurate method of evaluating ischaemic limbs and possibly a method of estimating the peripheral vascular resistance (PR). The aim of this study was to investigate the relationship between the tp and changes in limb vascular resistance caused by arterial stenosis. Forty postocclusive hyperaemia tests with arterial stenoses of different pressure gradients were performed in four pigs. A laser Doppler fluxmeter was used to record postocclusive hyperaemia in the skin of one hind limb. A specially designed tourniquet was used for the arterial occlusion. Proximal and distal to the occlusion level a snare was used to form different grades of stenosis. The PR (mmHg.ml-1.min-1) was either estimated by infusion of a known blood volume into the tested limb over a given time period with simultaneous measurement of pressure or calculated on the basis of measurements of limb blood flow and blood pressure gradients. The tp was closely related to total limb vascular resistance assessed by the blood infusion method (r = 0.83, p < 0.0003) and to the resistance calculated from volume blood flow and intraarterial pressures (r = 0.86, p < 0.0001). This study suggests that the tp accurately reflects limb vascular resistance in an experimental model. Thus tp may be used as a quantitative indicator of overall blood flow impairment, and should be evaluated in patients with lower-limb atherosclerosis.

Reproductive History in Women with Lower Limb Ischemia

The purpose of this study was to identify reproductive factors that may contribute to the development of arteriosclerosis in the leg arteries by comparing the reproductive history of women with lower limb ischemia to a reference group of women. All 173 female patients treated for chronic lower limb ischemia with surgical or endovascular procedures performed from 1994 to 1996 at a university clinic received a validated questionnaire to which 116 (67%) responded. The reference group, 348 women, 197 (57%) of whom responded, was recruited randomly from the hospital catchment area. The 2 groups were similar regarding age at menopause and menarche, pregnancies, salpingo-oophorectomies, and hormone replacement therapy. There was a higher number of women who had used oral contraceptives in the reference group than in the patient group (53% vs 16%, p<0.001). The same results were found when comparing the subgroup of patients younger than 55 years to the references. No association between reproductive history and development of lower limb ischemia could be found. Our results support that use of oral contraceptives early in life is not associated with an increased risk for lower limb ischemia.