Editor's Choice - Treatment of Aortic Prosthesis Infections by Graft Removal and In Situ Replacement with Autologous Femoral Veins and Fascial Strengthening

Introduction: Aortic prosthetic graft infection (AGI) is a major challenge in vascular surgery. Eradicating the. infection requires prosthetic material removal, debridement, and lower limb revascularization. For the past 15 years, we have used femoral veins for aorto-iliac reconstruction and tensor fascia lata to strengthen the upper anastomosis. Objective: The purpose of this single institution retrospective study is to present results regarding in situ replacement of infected aortic grafts with autologous femoral veins (FVs). Methods: From October 2000 to March 2013, patients treated for AGI with graft removal and autologous FV reconstruction at Helsinki University Hospital were included. Primary outcome measures were 30 day mortality, long-term treatment related mortality, and re-infection rate. Secondary outcome measures were long-term all cause mortality and event free survival (graft rupture, re-intervention, major amputation). Results: During a 13 year period 55 patients (42 male, 13 female) were operated on using a venous neo-aorto-iliac system for AGI. The mean follow up was 32 months (1-157 months). The 30 day mortality rate was 9% (5) and overall treatment related mortality 18% (10). All cause mortality during follow up was 22 (40%) and overall Kaplan-Meier survival was 90.7% at 30 days, 81.5% at 1 year, and 59.3% at 5 years. Graft rupture occurred in three (5%) cases, two of which were caused by graft re-infection. (4%). Four patients required major amputation, one of them on arrival and three (5%) during the post-operative period. Nine (16%) patients needed interventions for the vein graft, and two graft limbs occluded during follow up. Conclusion: In situ reconstruction for aortic graft infection with autologous FV presents acceptable rates of morbidity and mortality, and remains the treatment of choice for AGI at Helsinki University Hospital. (C) 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.Peer reviewe

APOE epsilon 4 associates with increased risk of severe COVID-19, cerebral microhaemorrhages and post-COVID mental fatigue : a Finnish biobank, autopsy and clinical study

Apolipoprotein E epsilon 4 allele (APOE4) has been shown to associate with increased susceptibility to SARS-CoV-2 infection and COVID-19 mortality in some previous genetic studies, but information on the role of APOE4 on the underlying pathology and parallel clinical manifestations is scarce. Here we studied the genetic association between APOE and COVID-19 in Finnish biobank, autopsy and prospective clinical cohort datasets. In line with previous work, our data on 2611 cases showed that APOE4 carriership associates with severe COVID-19 in intensive care patients compared with non-infected population controls after matching for age, sex and cardiovascular disease status. Histopathological examination of brain autopsy material of 21 COVID-19 cases provided evidence that perivascular microhaemorrhages are more prevalent in APOE4 carriers. Finally, our analysis of post-COVID fatigue in a prospective clinical cohort of 156 subjects revealed that APOE4 carriership independently associates with higher mental fatigue compared to non-carriers at six months after initial illness. In conclusion, the present data on Finns suggests that APOE4 is a risk factor for severe COVID-19 and post-COVID mental fatigue and provides the first indication that some of this effect could be mediated via increased cerebrovascular damage. Further studies in larger cohorts and animal models are warranted.Peer reviewe

Does a Completely Accomplished Duplex-based Surveillance Prevent Vein-graft Failure?

AbstractObjectives: to assess the benefits of duplex-based vein-graft surveillance over clinical surveillance with distal pressure measurements. Design: prospective randomised comparative trial. Material and methods: three hundred and forty-four patients with 362 consecutive infrainguinal vein bypasses were prospectively randomised to a follow-up regime with or without duplex scanning (ABI group and DD group) at 1, 3, 6, 9, and 12 months postoperatively.Results: one hundred and eighty-three grafts were enrolled to the ABI group and 179 to the DD group. The primary assisted patency, secondary patency and limb salvage rates were 67%, 74%, 85% for the ABI group and 67%, 73%, 81% for the DD group. Ninety grafts in the ABI group and 57 in the DD group had surveillance that completely adhered to the protocol. The outcome was also similar for these groups at one year (77%, 87%, 94% and 77%, 83%, 93% respectively), although grafts were revised more frequently in the DD group.Conclusions: intensive surveillance with duplex scanning did not improve the results of any outcome criteria examined. To demonstrate any potential benefit of duplex scanning for vein-graft surveillance a multicentre study with a large number of patients to ensure sufficient power is needed

Rupture of Abdominal Aortic Aneurysms in Patients Under Screening Age and Elective Repair Threshold

Peer reviewe

Angiographic Runoff Score as a Predictor of Outcome Following Femorocrural Bypass Surgery

AbstractObjective:to evaluate the efficacy of the revised ad hoc scoring system in predicting the outcome of femorocrural bypass surgery.Design:retrospective study.Materials and methods:seventy-seven infrainguinal bypass procedures to the crural arteries were performed in 69 patients with critical leg ischaemia. Preoperative angiographic findings were graded according to the revised ad hoc scoring system and other preoperative angiographic measures.Results:the revised ad hoc scores were valuable in predicting the outcome of these grafts. The status of the outflow artery throughout its length had a great impact on the long-term outcome in terms of secondary patency, leg salvage, patients alive with legs, and survival rates. In situ autogenous saphenous grafts achieved the best immediate and long-term results.Conclusions:the revised ad hoc angiographic scoring method is useful in predicting the outcome of patients undergoing femorocrural arterial reconstruction. Patients with an outflow artery completely open throughout its length had excellent long-term results

Internal Arteriovenous Fistula Within a Radial Forearm Flap – A Novel Technique to Increase Femorodistal Bypass Graft Flow to the Diabetic Foot and Flap Covering Ischaemic Tissue Loss

AbstractBackgroundThe fascio-cutaneous radial forearm flap is especially suitable to rebuild the contour of the foot, but because of low natural low flow this flap lacks the beneficial effect of large muscle flaps on bypass graft flow. The aim of this study was to introduce a novel technique of flap coverage combined to vascular bypass: an internal av-fistula was created within a radial forearm flap.MethodsNine critically ischaemic limbs were treated with a modified radial forearm flap in the Department of Plastic and Vascular Surgery, Helsinki University Central Hospital 1998–2003. All the patients were candidates for a major amputation unless this combined operation was attempted. A two-team approach was used: the vascular surgeon performed the distal bypass and the radial forearm flap was raised by the plastic surgeon. In eight cases a femorodistal bypass was performed and in the ninth the vein graft supplied the flap directly. The internal fistula within the flap was created between the distal end of the radial artery and either the cephalic vein or the concomitant vein of the radial artery. Flow was measured during surgery.ResultsVein graft flow increased significantly after the radial forearm flap anastomosis (76 vs 44ml/min, p=0.016). The flow of both the bypass graft and the flap artery were higher with the av-fistula patent (p=0.016 and p=0.004). Graft patency was 89% at 2 years. Infection was a major cause of amputation, 1- and 2-year limb salvages being 67 and 53%.ConclusionIn a group of diabetic patients increased flow in a vascular bypass graft was achieved by an internal av-fistula within a radial forearm flap. This method is useful in selected cases with poor run off and large ischaemic lesions