Publications by authors named "Maarit Venermo"

96 Publications

Osteoid Metaplasia in Femoral Artery Plaques Is Associated With the Clinical Severity of Lower Extremity Artery Disease in Men.

Front Cardiovasc Med 2020 10;7:594192. Epub 2020 Dec 10.

Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

Lamellar metaplastic bone, osteoid metaplasia (OM), is found in atherosclerotic plaques, especially in the femoral arteries. In the carotid arteries, OM has been documented to be associated with plaque stability. This study investigated the clinical impact of OM load in femoral artery plaques of patients with lower extremity artery disease (LEAD) by using a deep learning-based image analysis algorithm. Plaques from 90 patients undergoing endarterectomy of the common femoral artery were collected and analyzed. After decalcification and fixation, 4-μm-thick longitudinal sections were stained with hematoxylin and eosin, digitized, and uploaded as whole-slide images on a cloud-based platform. A deep learning-based image analysis algorithm was trained to analyze the area percentage of OM in whole-slide images. Clinical data were extracted from electronic patient records, and the association with OM was analyzed. Fifty-one (56.7%) sections had OM. Females with diabetes had a higher area percentage of OM than females without diabetes. In male patients, the area percentage of OM inversely correlated with toe pressure and was significantly associated with severe symptoms of LEAD including rest pain, ulcer, or gangrene. According to our results, OM is a typical feature of femoral artery plaques and can be quantified using a deep learning-based image analysis method. The association of OM load with clinical features of LEAD appears to differ between male and female patients, highlighting the need for a gender-specific approach in the study of the mechanisms of atherosclerotic disease. In addition, the role of plaque characteristics in the treatment of atherosclerotic lesions warrants further consideration in the future.
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http://dx.doi.org/10.3389/fcvm.2020.594192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758249PMC
December 2020

Thoracic endovascular aortic repair practice in 13 countries: A report from VASCUNET and the International Consortium of Vascular Registries.

Ann Surg 2020 Nov 17. Epub 2020 Nov 17.

Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.

Objective: To assess practice patterns and short-term outcome after TEVAR, based on an international vascular registry collaboration.

Summary Background Data: Thoracic endovascular aortic repair (TEVAR) has become the primary surgical treatment modality for descending aortic pathologies, and has expanded to new patient cohorts, including the elderly.

Methods: Data on thoracic aortic aneurysms (TAA), type B aortic dissections (TBAD), and traumatic aortic injuries (TAI) treated with TEVAR from 2012 to 2016 were retrieved from registries and centers in 13 countries.

Results: 9518 TEVAR for TAA (n = 4436), TBAD (n = 3976) and TAI (n = 1106) were included. The distribution of TEVAR procedures per pathology varied, with TAA repair constituting from 40% of TEVARs in the US to 72% in the UK (p < 0.001).Mean intact TAA (iTAA) diameter varied from 59 (US) to 69 mm (Nancy, France) (p < 0.001), 25.3% of patients having a diameter of < 60 mm. Perioperative mortality after iTAA repair was 4.9%; combined mortality, stroke, paraplegia and RRT outcome was 12.8%. 18.6% of iTAA patients were ≥80 years old. Mortality was higher in this group (7.2%) than in patients < 80 (3.8%) (p < 0.001). After rTAA repair, perioperative mortality was 26.8%.Mortality was 9.7% after acute (within 14 days from onset of dissection) and 3.0% after chronic TBAD repair (p < 0.001). Mortality after TAI was 7.8%, and depended on injury severity (grade IV (free rupture) 20.9%).

Conclusions:: This registry collaboration provides a unique platform to evaluate cross-border patterns of use and outcomes of TEVAR. A common core dataset is proposed, to achieve harmonization of registry-based quality outcome measures for TEVAR.
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http://dx.doi.org/10.1097/SLA.0000000000004561DOI Listing
November 2020

No difference in mid- to long-term mortality after vascular paclitaxel exposure.

Ann Vasc Surg 2020 Sep 23. Epub 2020 Sep 23.

Helsinki University Hospital, Abdominal Center, Dept. of Vascular Surgery.

Objectives: Concern has been raised over potential paclitaxel-related increase in mortality following treatment with drug-coated balloons. We report mid- to long-term patient-level mortality in three trials from our institution.

Methods: Patient data from the DRECOREST I and II trials as well as the FINNPTX-trial were included for analysis. The DRECOREST I involved patients with stenosis in a bypass vein graft, and the DRECOREST II included patients with stenosis in a dialysis fistula. The FINNPTX -trial randomized patients to either a prosthetic bypass or drug-eluting stent for long femoropopliteal lesions. Since the present retrospective study addressed mortality related to intravascular paclitaxel exposure, and population data in Finland are comprehensive, we were able to include all patients exposed to paclitaxel in the three trials. Mortality data were extracted from the population registry as well as patient records. Survival rates were analyzed for all trials pooled and separately. Late mortality was retrospectively analyzed and cross-referenced with national registry data.

Results: A total of 142 patients were included, 76 treated with paclitaxel eluting device and 66 without. Mean follow-up time for survivors was 3.9 years. Overall all-cause mortality was 31.7% during follow-up. In the DRECOREST I -trial 35.5% patients died in the paclitaxel group and 37.9% in the control group (p=.84). In the DRECOREST II, overall mortality was 55.6% in paclitaxel group and 44.4% in the control group (p=.51). In the FINNPTX-trial 22.2% died in the paclitaxel group and 10.5% in the control group during follow-up (p=.30). No single cause of death was overrepresented. The most common causes of death in both groups were cardiovascular death, 59.3% in the paclitaxel group and 52.4% in the control group (p=.733) followed by malignancy (14.8% vs. 14.3% in the groups respectively).

Conclusions: No significant difference was seen in the overall analysis between paclitaxel and control group. A statistically non-significant elevated late mortality in the FINNPTX-trial after paclitaxel exposure was observed. However, the numbers in the individual trials are small, and should be interpreted in the context of future patient-level meta-analysis.
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http://dx.doi.org/10.1016/j.avsg.2020.08.147DOI Listing
September 2020

The VASCUNET Manifesto on Data Privacy Compliant Real World Evidence.

Eur J Vasc Endovasc Surg 2020 Dec 18;60(6):942-943. Epub 2020 Sep 18.

Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.

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http://dx.doi.org/10.1016/j.ejvs.2020.08.036DOI Listing
December 2020

Late Outcome after Surgery for Type-A Aortic Dissection.

J Clin Med 2020 Aug 24;9(9). Epub 2020 Aug 24.

Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland.

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316-12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193-10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067-9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.
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http://dx.doi.org/10.3390/jcm9092731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563246PMC
August 2020

Contemporary Treatment of Popliteal Artery Aneurysms in 14 Countries: A Vascunet Report.

Eur J Vasc Endovasc Surg 2020 Nov 15;60(5):721-729. Epub 2020 Aug 15.

Department of Surgical Sciences, Section of Vascular Surgery, Uppsala, Sweden.

Objective: Popliteal artery aneurysm (PAA) is the second most common arterial aneurysm. Vascunet is an international collaboration of vascular registries. The aim was to study treatment and outcomes.

Methods: This was a retrospective analysis of prospectively registered population based data. Fourteen countries contributed data (Australia, Denmark, Finland, France, Hungary, Iceland, Italy, Malta, New Zealand, Norway, Portugal, Serbia, Sweden, and Switzerland).

Results: During 2012-2018, data from 10 764 PAA repairs were included. Mean values with between countries ranges in parenthesis are given. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3 years (66.8-75.3). Most patients, 93.3%, were men and 40.0% were active smokers. The operations were elective in 73.2% (60.0%-85.7%). The mean pre-operative PAA diameter was 32.1 mm (27.3-38.3 mm). Open surgery dominated in both elective (79.5%) and acute (83.2%) cases. A medial surgical approach was used in 77.7%, and posterior in 22.3%. Vein grafts were used in 63.8%. Of the emergency procedures, 91% (n = 2 169, 20.2% of all) were for acute thrombosis and 9% for rupture (n = 236, 2.2% of all). Thrombosis patients had larger aneurysms, mean diameter 35.5 mm, and 46.3% were active smokers. Early amputation and death were higher after acute presentation than after elective surgery (5.0% vs. 0.7%; 1.9% vs. 0.5%). This pattern remained one year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective open compared with endovascular surgery had similar one year amputation rates (1.2% vs. 0.2%; p = .095) but superior patency (84.0% vs. 78.4%; p = .005). Veins had higher patency and lower amputation rates, at one year compared with synthetic grafts (86.8% vs. 72.3%; 1.8% vs. 5.2%; both p < .001). The posterior open approach had a lower amputation rate (0.0% vs. 1.6%, p = .009) than the medial approach.

Conclusion: Patients presenting with acute ischaemia had high risk of amputation. The frequent use of endovascular repair and prosthetic grafts should be reconsidered based on these results.
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http://dx.doi.org/10.1016/j.ejvs.2020.07.005DOI Listing
November 2020

Three-year results of a randomized controlled trial comparing mechanochemical and thermal ablation in the treatment of insufficient great saphenous veins.

J Vasc Surg Venous Lymphat Disord 2020 Aug 12. Epub 2020 Aug 12.

Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland.

Objective: Mechanochemical ablation (MOCA) is a nonthermal nontumescent method of treating saphenous vein insufficiency. The feasibility and short-term results of MOCA are good, but its long-term results are unknown. A randomized study was performed to compare MOCA with endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in the setting of unilateral great saphenous vein (GSV) insufficiency.

Methods: Venous outpatient clinic patients with varicose veins (CEAP class C2-C4) caused by GSV insufficiency were invited to participate in the study; in total, 132 patients met the inclusion criteria and were willing to participate. Patients were randomized to treatment (2:1:1 for MOCA, EVLA, and RFA, respectively). The state of the GSV with duplex Doppler ultrasound examination and the disease-specific quality of life were assessed at 1 month, 1 year, and 3 years after the treatment.

Results: Some patients declined to continue in the study after randomization; in total, 117 patients underwent treatment. At 3 years, the occlusion rate was significantly lower with MOCA than with either EVLA or RFA (82% vs 100%; P = .005). Quality of life was similar between the groups. In the MOCA group, GSVs that were larger than 7 mm in diameter preoperatively were more likely to recanalize during the follow-up period. The partial recanalizations of proximal GSV observed at 1 year progressed during the follow-up.

Conclusions: MOCA is a feasible treatment option in an outpatient setting, but its technical success rates are inferior compared with endovenous thermal ablation. Its use in large-caliber veins should be considered carefully.
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http://dx.doi.org/10.1016/j.jvsv.2020.08.007DOI Listing
August 2020

Toe pressure should be part of a vascular surgeon's first-line investigation in the assessment of lower extremity artery disease and cardiovascular risk of a patient.

J Vasc Surg 2021 Feb 23;73(2):641-649.e3. Epub 2020 Jul 23.

Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. Electronic address:

Objective: Toe pressure (TP) is an accurate indicator of the peripheral vascular status of a patient and thus cardiovascular risk, with less susceptibility to errors than ankle-brachial index (ABI). This study aimed to analyze how ABI and TP measurements associate with overall survival and cardiovascular death and to analyze the TP of patients with ABI of 0.9 to 1.3.

Methods: The first ABI and TP measurements of a consecutive 6784 patients treated at the Helsinki University Hospital vascular surgery clinic between 1990 and 2009 were analyzed. Helsinki University Vascular Registry and the national Cause of Death Registry provided the data.

Results: The poorest survival was in patients with ABI >1.3 (10-year survival, 15.3%; hazard ratio, 2.2; 95% confidence interval, 1.9-2.6; P < .0001; reference group, ABI 0.9-1.3), followed by the patients with TP <30 mm Hg (10-year survival, 19.6%; hazard ratio, 2.0; 95% confidence interval, 1.7-2.2; P < .0001; reference group, TP ≥80 mm Hg). The best 10-year survival was in patients with TP ≥80 mm Hg (43.9%). Of the 642 patients with normal ABI (0.9-1.3), 18.7% had a TP <50 mm Hg. The highest cardiovascular death rate (64.6%) was in the patients with TP <30 mm Hg, and it was significantly lower than for the patients with TP >50 mm Hg.

Conclusions: Low TP is associated significantly with survival and cardiovascular mortality. Patients with a normal ABI may have lower extremity artery disease (LEAD) and a considerable risk for a cardiovascular event. If only the ABI is measured in addition to clinical examination, a substantial proportion of patients may be left without LEAD diagnosis or adequate treatment of cardiovascular risk factors. Thus, especially if ABI is normal, LEAD is excluded only if TPs are also measured and are normal.
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http://dx.doi.org/10.1016/j.jvs.2020.06.104DOI Listing
February 2021

In Oncovascular Surgery Well Planned is Half Done: A Field That Still Requires Major Open Vascular Surgery.

Eur J Vasc Endovasc Surg 2020 08 4;60(2):300. Epub 2020 Jun 4.

University of Helsinki and Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.

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http://dx.doi.org/10.1016/j.ejvs.2020.04.036DOI Listing
August 2020

Competing Risk Analysis of the Impact of Pedal Arch Status and Angiosome-Targeted Revascularization in Chronic Limb-Threatening Ischemia.

Ann Vasc Surg 2020 Oct 9;68:384-390. Epub 2020 Apr 9.

Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. Electronic address:

Background: In the context of chronic limb-threatening ischemia, the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated.

Methods: This series includes 580 patients who underwent endovascular (n = 407) and surgical revascularization (n = 173) of the infrapopliteal arteries for chronic limb-threatening ischemia associated with foot ulcer or gangrene. The risk of major amputation after infrapopliteal revascularization was assessed by a competing risk approach. A subanalysis was made separately for patients who underwent endovascular or open surgical revascularization.

Results: At 2 years, survival was 65.1% and leg salvage was 76.1%. Multivariable competing risk analysis showed that C-reactive protein ≥10 mg/dL, diabetes, rheumatoid arthritis, increased number of affected angiosomes, and the incomplete or total absence of pedal arch compared with complete pedal arch (CPA) were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (subdistribution hazard ratio [SHR], 2.131; 95% confidence interval [95% CI], 1.282-3.543) and no visualized pedal arch (SHR, 3.022; 95% CI, 1.553-5.883) compared with CPA. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of CPA had a lower risk of major amputation (adjusted SHR, 0.463; 95% CI, 0.240-0.894) compared with angiosome-directed revascularization without CPA. In the subanalysis, among patients who underwent endovascular revascularization, CPA (SHR, 0.509; 95% CI, 0.286-0.905) and angiosome-targeted revascularization (SHR, 0.613; 95% CI, 0.394-0.956) were associated with a lower risk of major amputation.

Conclusions: Competing risk analysis showed that a patent pedal arch had significant impact on leg salvage and that the subset of patients undergoing endovascular procedure may most benefit of an angiosome-targeted revascularization.
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http://dx.doi.org/10.1016/j.avsg.2020.03.042DOI Listing
October 2020

Editor's Choice - Assessment of Correlation Between Mean Size of Infrarenal Abdominal Aortic Aneurysm at Time of Intact Repair Against Repair and Rupture Rate in Nine Countries.

Eur J Vasc Endovasc Surg 2020 Jun 23;59(6):890-897. Epub 2020 Mar 23.

Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.

Objective: This study aimed to analyse the mean abdominal aortic aneurysm (AAA) diameter for repair in nine countries, and to determine variation in mean AAA diameter for elective AAA repair and its relationship to rupture AAA repair rates and aneurysm related mortality in corresponding populations.

Methods: Data on intact (iAAA) and ruptured infrarenal AAA (rAAA) repair for the years 2010-2012 were collected from Denmark, England, Finland, Germany, Hungary, New Zealand, Norway, Sweden, and the USA. The rate of iAAA repair and rAAA per 100 000 inhabitants above 59 years old, mean AAA diameter for iAAA repair and rAAA repair, and the national rates of rAAA were assessed. National cause of death statistics were used to estimate aneurysm related mortality. Direct standardisation methods were applied to the national mortality data. Logistic regression and analysis of variance model adjustments were made for age groups, sex, and year.

Results: There was a variation in the mean diameter of iAAA repair (n = 34 566; range Germany = 57 mm, Denmark = 68 mm). The standardised iAAA repair rate per 100000 inhabitants varied from 10.4 (Hungary) to 66.5 (Norway), p<.01, and the standardised rAAA repair rate per 100 000 from 5.8 (USA) to 16.9 (England), p<.01. Overall, there was no significant correlation between mean diameter of iAAA repair and standardised iAAA rate (r = 0.04, p = .3). There was no significant correlation between rAAA repair rate (n = 12 628) with mean diameter of iAAA repair (r = 0.2, p = .1).

Conclusion: Despite recommendations from learned society guidelines, data indicate variations in mean diameter for AAA repair. There was no significant correlation between mean diameter of AAA repair and rates of iAAA repair and rAAA repair. These analyses are subject to differences in disease prevalence, uncertainties in rupture rates, validations of vascular registries, causes of death and registrations.
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http://dx.doi.org/10.1016/j.ejvs.2020.01.024DOI Listing
June 2020

Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review.

Diabetes Metab Res Rev 2020 03;36 Suppl 1:e3277

Bristol Centre for Surgical Research, University of Bristol, Bristol, UK.

The accurate identification of peripheral artery disease (PAD) in patients with diabetes and foot ulceration is important, in order to inform timely management and to plan intervention including revascularisation. A variety of non-invasive tests are available to diagnose PAD at the bedside, but there is no consensus as to the most useful test, or the accuracy of these bedside investigations when compared to reference imaging tests such as magnetic resonance angiography, computed tomography angiography, digital subtraction angiography or colour duplex ultrasound. Members of the International Working Group of the Diabetic Foot updated our previous systematic review, to include all eligible studies published between 1980 and 2018. Some 15 380 titles were screened, resulting in 15 eligible studies (comprising 1563 patients, of which >80% in each study had diabetes) that evaluated an index bedside test for PAD against a reference imaging test. The primary endpoints were positive likelihood ratio (PLR) and negative likelihood ratio (NLR). We found that the most commonly evaluated test parameter was ankle brachial index (ABI) <0.9, which may be useful to suggest the presence of PAD (PLR 6.5) but an ABI value between 0.9 and 1.3 does not rule out PAD (NLR 0.31). A toe brachial index >0.75 makes the diagnosis of PAD less likely (NLR 0.14-0.24), whereas pulse oximetry may be used to suggest the presence of PAD (if toe saturation < 2% lower than finger saturation; PLR 17.23-30) or render PAD less likely (NLR 0.2-0.27). We found that the presence of triphasic tibial waveforms has the best performance value for excluding a diagnosis of PAD (NLR 0.09-0.28), but was evaluated in only two studies. In addition, we found that beside clinical examination (including palpation of foot pulses) cannot reliably exclude PAD (NLR 0.75), as evaluated in one study. Overall, the quality of data is generally poor and there is insufficient evidence to recommend one bedside test over another. While there have been six additional publications in the last 4 years that met our inclusion criteria, more robust evidence is required to achieve consensus on the most useful non-invasive bedside test to diagnose PAD.
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http://dx.doi.org/10.1002/dmrr.3277DOI Listing
March 2020

Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: A systematic review.

Diabetes Metab Res Rev 2020 03;36 Suppl 1:e3278

Bristol Centre for Surgical Research, University of Bristol, Bristol, UK.

Clinical outcomes of patients with diabetes, foot ulceration, and peripheral artery disease (PAD) are difficult to predict. The prediction of important clinical outcomes, such as wound healing and major amputation, would be a valuable tool to help guide management and target interventions for limb salvage. Despite the existence of a number of classification tools, no consensus exists as to the most useful bedside tests with which to predict outcome. We here present an updated systematic review from the International Working Group of the Diabetic Foot, comprising 15 studies published between 1980 and 2018 describing almost 6800 patients with diabetes and foot ulceration. Clinical examination findings as well as six non-invasive bedside tests were evaluated for their ability to predict wound healing and amputation. The most useful tests to inform on the probability of healing were skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg, or TcPO  ≥ 25 mmHg. With these thresholds, all of these tests increased the probability of healing by greater than 25% in at least one study. To predict major amputation, the most useful tests were ankle pressure < 50 mmHg, ABI < 0.5, toe pressure < 30 mmHg, and TcPO  < 25 mmHg, which increased the probability of major amputation by greater than 25%. These indicative values may be used as a guide when deciding which patients are at highest risk for poor outcomes and should therefore be evaluated for revascularization at an early stage. However, this should always be considered within the wider context of important co-existing factors such as infection, wound characteristics, and other comorbidities.
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http://dx.doi.org/10.1002/dmrr.3278DOI Listing
March 2020

Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review.

Diabetes Metab Res Rev 2020 03;36 Suppl 1:e3279

Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands.

In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non-healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13 000 patients. Amongst 60 case series and 4 non-randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78-82%) and 78% (IQR 75-83%), whereas open therapy was associated with rates of 85% (IQR 80-90%) at 1 year and 87% (IQR 85-88%) at 2 years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50-69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30 days, 10% vs 9% at 1 year and 13% vs 9% at 2 years. For both strategies, overall mortality was found to be high, with 2% (1-6%) perioperative (or 30 day) mortality, rising sharply to 13% (9-23%) at 1 year, 29% (19-48%) at 2 years and 47% (39-71%) at 5 years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.
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http://dx.doi.org/10.1002/dmrr.3279DOI Listing
March 2020

Radiation Doses to Staff in a Hybrid Operating Room: An Anthropomorphic Phantom Study with Active Electronic Dosimeters.

Eur J Vasc Endovasc Surg 2020 04 12;59(4):654-660. Epub 2020 Feb 12.

Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Objective: To quantify the effects of different imaging settings on radiation exposure to the operator and surgical team in a hybrid operating room (OR).

Methods: Measurements to determine scatter radiation in different imaging and geometry settings using an anthropomorphic phantom were performed in a hybrid OR equipped with a robotic C arm interventional angiography system (Artis Zeego; Siemens Healthcare, Erlangen, Germany). The radiation dose (RD) was measured with seven calibrated Philips DoseAware active electronic dosimeters and a Raysafe Xi survey detector, which were placed at different locations in the hybrid OR. The evaluated set ups included low dose, medium dose, and high dose fluoroscopy for abdomen; fluoroscopy fade; roadmap; and digital subtraction angiography (DSA), all using 20 s exposures. The effect of magnification, tube angulation, field size, source to skin distance, and RADPAD protection shields were assessed. Finally RD during cone beam computed tomography (CBCT) was obtained.

Results: In the operator position the initial settings with low dose fluoroscopy caused a RD of 1.03 μGy. The use of fluorofade did not increase the radiation dose (1.02 μGy), whereas the roadmap increased it threefold (2.84 μGy). The RD with "normal fluoro" was 4.13 μGy and increased to 6.44 μGy when high dose fluoroscopy mode was used. Magnification or field size varying from 42 cm to 11 cm led the RD to change from 0.86 μGy to 2.10 μGy. Decreasing the field of view to 25% of the initial size halved the RD (0.48 μGy). The RDs for the left anterior oblique 30° and right anterior oblique 30° were 3.26 μGy and 1.63 μGy, respectively. DSA increased the cumulative dose 33 fold but the RADPAD shield decreased the DSA RD to 4.92 μGy. The RD for CBCT was 47.2 μGy.

Conclusion: Radiation exposure to operator and personnel can be significantly reduced during hybrid procedures with proper radiation protection and dose optimisation. A set of six behavioural rules were established.
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http://dx.doi.org/10.1016/j.ejvs.2020.01.018DOI Listing
April 2020

Invasive Treatment of Claudication is Safe, but There Are Situations in which Caution Should be Exercised.

Authors:
Maarit Venermo

Eur J Vasc Endovasc Surg 2020 05 12;59(5):823. Epub 2020 Feb 12.

Helsinki University Hospital, University of Helsinki, Helsinki, Finland. Electronic address:

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http://dx.doi.org/10.1016/j.ejvs.2020.01.020DOI Listing
May 2020

Morphology and Computational Fluid Dynamics Support a Novel Classification of Common Iliac Aneurysms.

Eur J Vasc Endovasc Surg 2020 May 22;59(5):786-793. Epub 2020 Jan 22.

Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia; Australian Research Council Centre for Personalised Therapeutics Technologies, Australia; BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK. Electronic address:

Objective: Isolated common iliac artery aneurysms (CIAAs) are uncommon, and evidence concerning their development, progression, and management is weak. The objective was to describe the morphology and haemodynamics of isolated CIAAs in a retrospective study.

Methods: Initially, a series of 25 isolated CIAAs (15 intact, 10 ruptured) in 23 patients were gathered from multiple centres, reconstructed from computed tomography, and then morphologically classified and analysed with computational fluid dynamics. The morphological classification was applied in a separate, consecutive cohort of 162 patients assessed for elective aorto-iliac intervention, in which 55 patients had intact CIAAs.

Results: In the isolated CIAA cohort, three distinct morphologies were identified: complex (involving a bifurcation); fusiform; and kinked (distal to a sharp bend in the CIA), with mean diameters of 90.3, 48.3, and 31.7 mm, and mean time averaged wall shear stresses of 0.16, 0.31, and 0.71 Pa, respectively (both analysis of variance p values < .001). Kinked cases vs. fusiform cases had less thrombus and favourable haemodynamics similar to the non-aneurysmal contralateral common iliac artery (CIA). Ruptured isolated CIAAs were large (mean diameter 87.5 mm, range 55.5-138.0 mm) and predominantly complex. The mean CIA length for aneurysmal arteries was greatest in kinked cases followed by complex and fusiform (100.8 mm, 91.1 mm, and 80.6 mm, respectively). The morphological classification was readily applicable to a separate elective patient cohort.

Conclusion: A new morphological categorisation of CIAAs is proposed. Potentially this is associated with both haemodynamics and clinical course. Further research is required to determine whether the kinked CIAA is protected haemodynamically from aneurysm progression and to establish the wider applicability of the categorisation presented.
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http://dx.doi.org/10.1016/j.ejvs.2019.11.035DOI Listing
May 2020

Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update).

Diabetes Metab Res Rev 2020 03 20;36 Suppl 1:e3276. Epub 2020 Jan 20.

Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands.

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.
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http://dx.doi.org/10.1002/dmrr.3276DOI Listing
March 2020

En bloc resection of visceral aorta and right kidney due to aortic sarcoma using temporary extracorporeal bypass grafting.

J Vasc Surg Cases Innov Tech 2019 Dec 26;5(4):589-592. Epub 2019 Nov 26.

Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland.

Aortic sarcomas have not been linked to Lynch syndrome in humans, although other soft tissue malignancies have been. We report the case of a 31-year-old man with Lynch syndrome, who presented with abdominal pain and severe claudication. The clinical and diagnostic workup revealed near occlusion of the infrarenal aorta due to aortic angiosarcoma. En bloc resection of the visceral and infrarenal aorta with right nephrectomy was performed, facilitated by temporary extracorporeal bypass to the visceral arteries. The aorta was reconstructed with a bifurcated Dacron graft. At the 24-month follow-up examination, the patient was free of disease but was experiencing chronic diarrhea.
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http://dx.doi.org/10.1016/j.jvscit.2019.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6881628PMC
December 2019

Editor's Choice - Follow-up of Patients After Revascularisation for Peripheral Arterial Diseases: A Consensus Document From the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery.

Eur J Vasc Endovasc Surg 2019 Nov;58(5):641-653

Department of Cardiology, Dupuytren University Hospital and Inserm 1098, France.

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.
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http://dx.doi.org/10.1016/j.ejvs.2019.06.017DOI Listing
November 2019

Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery.

Eur J Prev Cardiol 2019 12 1;26(18):1971-1984. Epub 2019 Nov 1.

Department of Cardiology, Dupuytren University Hospital and Inserm 1098, France.

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.
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http://dx.doi.org/10.1177/2047487319846999DOI Listing
December 2019

Cryopreserved Venous Allografts in Supra-inguinal Reconstructions: A Single Centre Experience.

Eur J Vasc Endovasc Surg 2019 Dec 17;58(6):912-919. Epub 2019 Oct 17.

Department of Vascular Surgery, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland.

Objective: This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis.

Methods: Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate.

Results: Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n = 12 [52%]), mycotic aneurysms (n = 5 [22%]), femorofemoral prosthetic infections (n = 3 [13%]), anastomotic pseudo-aneurysms (n = 2 [9%]), and aortic thrombosis with intestinal spillage (n = 1 [4%]). In hospital and 90 day mortality were 9% (n = 2); overall treatment related mortality during the median follow up of 15 months was 13% (n = 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n = 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan-Meier estimation for survival was 76% (95% confidence interval [CI] 57%-95%) at one year and 70% (95% CI 49%-91%) at two years.

Conclusion: Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material.
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http://dx.doi.org/10.1016/j.ejvs.2019.06.024DOI Listing
December 2019

Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms.

Ann Surg 2019 Oct 7. Epub 2019 Oct 7.

Imperial College London, London, United Kingdom.

Background: EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked.

Methods: Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored.

Results: Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions.

Conclusions: All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.
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http://dx.doi.org/10.1097/SLA.0000000000003625DOI Listing
October 2019

VASCUNET, VQI, and the International Consortium of Vascular Registries - Unique Collaborations for Quality Improvement in Vascular Surgery.

Eur J Vasc Endovasc Surg 2019 Dec 14;58(6):792-793. Epub 2019 Aug 14.

Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.

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http://dx.doi.org/10.1016/j.ejvs.2019.07.023DOI Listing
December 2019

The association of endothelial injury and systemic inflammation with perioperative myocardial infarction.

Ann Clin Biochem 2019 11 4;56(6):674-683. Epub 2019 Sep 4.

Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

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http://dx.doi.org/10.1177/0004563219873357DOI Listing
November 2019

Predictors of Wound Healing Following Revascularization for Chronic Limb-Threatening Ischemia.

Vasc Endovascular Surg 2019 Nov 12;53(8):649-657. Epub 2019 Aug 12.

Department of Vascular Surgery, "Attikon" University Hospital, Athens, Greece.

Objectives: After surgical or endovascular revascularization, some ischemic lesions will not heal, while some others will heal at a variable period of time from the intervention, indicating a multifactorial interaction between local and systematic "wound healing-promoting" factors. Our objective was to identify predictors of wound healing following revascularization for chronic limb-threatening ischemia (CLTI).

Methods: A literature review was performed to identify published research concerning clinical, biochemical, and noninvasive methods as predictors of wound healing time and wound-free period after surgical and endovascular revascularization for CLTI.

Results: Our review indicated that potential predictors included local wound factors, wound depth, patient's comorbidities, medications, smoking and alcohol abuse, poor vessel runoff, and direct versus indirect revascularization. Among the clinical biomarkers, platelet-derived growth factor, transforming growth factor β, basic fibroblast growth factor, tumor necrosis factor α, interleukin (IL) 1, and IL-6 have been proposed as potential predictors. Furthermore, the potential of noninvasive microcirculation assessment to predict proper wound healing has been the topic of extensive investigation. Among the novel methods, transcutaneous measurement of oxygen partial pressure, skin perfusion pressure, oxygen-to-see method, indocyanine green fluorescence imaging, and multispectral optoacoustic tomography have shown promising results.

Conclusions: The risk factor profile of an ischemic lesion in the lower extremities with a delayed/failed healing response, following a successful revascularization, is not fully clarified. Although many predictors have been assessed so far, further research needs to be done to identify the optimal clinical and biochemical indices and the noninvasive technique assessing the microcirculation that is associated with complete wound healing.
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http://dx.doi.org/10.1177/1538574419868863DOI Listing
November 2019

Bilateral low systolic toe pressure and toe-brachial index are associated with long-term mortality in patients with peripheral artery disease.

J Vasc Surg 2019 12 7;70(6):1994-2004. Epub 2019 Aug 7.

Department of Vascular Surgery, Turku University Hospital and University of Turku, Turku, Finland. Electronic address:

Objective: Based on our previous reports, ipsilateral systolic toe pressure (STP) and toe-brachial index (TBI) have a strong association with midterm cardiovascular and overall mortality as well as with amputation-free survival in patients with symptomatic lower extremity peripheral artery disease (PAD). The effect of the often overlooked contralateral lower limb on patient outcome remains unknown. This study aimed to resolve the significance of contralateral STP (CL_STP) and contralateral TBI for long-term overall and cardiovascular mortality.

Methods: This is a retrospective cohort study of 727 consecutive patients with symptomatic lower extremity PAD. All patients admitted to the Department of Vascular Surgery at Turku University Hospital for digital subtraction angiography between January 2009 and August 2011 and for whom STP measurements were available were recruited and observed for up to 7 years. Dates and causes of death were collected from the national cause of death registry of Statistics Finland.

Results: In the study cohort, STP was <30 mm Hg in 67 contralateral limbs and 227 ipsilateral limbs. CL_STP <30 mm Hg resulted in a 60-month estimated freedom from cardiovascular death and overall survival of 39% (standard deviation [SD], 0.57) and 25% (SD, 0.41), respectively, and contralateral TBI <0.25, of 45% (SD, 0.54) and 36% (SD, 0.54), respectively. Cumulative freedom from cardiovascular death and overall survival at 60 months for patients with ipsilateral STP <30 mm Hg varied by CL_STP as follows: CL_STP <30 mm Hg: 41% (SD, 0.58) and 25% (SD, 0.43); CL_STP of 30 to 49 mm Hg: 56% (SD, 0.49) and 44% (SD, 0.49); STP ≥50 mm Hg: 62% (SD, 0.52) and 47% (SD, 0.52), respectively. In Cox regression analysis, low STP or TBI of either extremity was associated with significant (P < .001) risk of death for cardiovascular or any reason.

Conclusions: Low STP and TBI of both contralateral and ipsilateral lower extremities are associated with high cardiovascular and overall mortality in symptomatic PAD patients. Bilaterally low STP and TBI are associated with a particularly poor prognosis.
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http://dx.doi.org/10.1016/j.jvs.2019.03.073DOI Listing
December 2019