Verisuonikirurgian haaste : alaraajan iskeeminen haava

There is a widespread reporting habit of combining the outcomes for patients with rest pain (Fontaine III) and tissue loss (Fontaine IV) under the single category of critical leg ischaemia (CLI). This study focused on patients with ischaemic tissue loss treated with infrainguinal bypass surgery (IBS). All patients included in the study were treated at Helsinki University Central Hospital in 2000-2007. First, ulcer healing time after IBS and factors influencing healing time were prospectively assessed in 2 studies including 148 and 110 patients, respectively. Second,the results of redo IBS were retrospectively evaluated in 593 patients undergoing primary IBS for CLI with tissue loss . Third,long-term outcome were retrospectively analysed in 636 patients who underwent IBS for CLI with tissue loss . Fourth, the outcome of IBS was retrospectively compared with endovascular treatment (PTA) of the infrapopliteal arteries in 1023 CLI patients. Fifth, the influence multidrug resistant Pseudomans aeruginosa (MDR Pa) bacteria contamination in CLI patients treated with IBS was retropectively assessed. Sixty-four patients with positive MDR Pa -culture were matched with 64 MDR Pa - negative controls. Complete ulcer healing rate, including the ischemic ulcers and incisional wounds, was 40% at 6 months after IBS and 75% at one year. Diabetes was a risk factor for prolonged complete ulcer healing time. Ischaemic tissue lesions located in mid-and hindfoot healed poorly. At one year after IBS 50% of the patients were alive with salvaged leg and completely healed ulcers. The absence of gap between tertiary graft patency and leg salvage rates indicates the importance of a patent infrainguinal graft to save a leg with ischaemic tissue loss. Long-term survival for patients with ischaemic tissue loss was poor, 38% at 5 years. Only 30% of the patients were alive without amputation at 5 years. Several of the patient comorbidities increased independently the mortality risk; coronary artery disease, renal insufficiency, chronic obstructive lung disease and high age. When both PTA and bypass is feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized. MDR Pa in a patient with CLI should be considered as a serious event with increased risk of early major amputation or death. Conclusion: Despite a successful infrainguinal bypass healing of the ischaemic ulcers and incisional wounds ulcer healing is a slow process especially in diabetics. Bypass surgery and PTA improve the outcome of the ischaemic leg but the mortality rate of the patients is high due to their severe comorbidities.Kriittisessä alaraajaiskemiassa verenkierto on siinä määrin huonontunut että kudoksen elinkelpoisuus on uhattuna. Krooninen kriittinen iskemia ilmenee usein ensin leposärkynä (luokitus Fontaine III), myöhemmin haavaumana (Fontaine IV). Alaraajan valtimo-ohitusleikkaus on tärkein hoitomenetelmä raajan pelastamiseksi laaja-alaisessa tukkivassa valtimokovettumataudissa. Leposärky- ja haavapotilaat ovat perinteisesti tutkimuksissa käsitelty yhtenä ryhmänä. Tämän tutkimuksen tarkoituksena oli selvittää alaraajan valtimo-ohitusleikkauksen tuloksia potilailla joilla oli kriittisestä alaraaja-iskemiasta johtuva haava (Fontaine IV). Tutkimuksen aineistona oli 1265 potilasta joille tehtiin iskeemisen alaraajahaavan (1038 potilasta) tai leposärkyn takia (227) Helsingin Yliopstollisessta Keskussairaalassa vuosina 2000-2007 alaraajavaltimon ohitusleikkaus (1003) tai -pallolaajennus (262). Tutkimuksessa todettiin että ohitusleikkauksen jälkeen 60 %:lla potilaista leikkaushaavojen ja iskeemisten haavojen paranemiseen kului yli puoli vuotta. Vuoden kohdalla 25%:lla oli vielä haava auki. Diabetes hidasti haavojen paranemista. Myös iskeemisten haavojen sijainti jalassa vaikutti paranemisaikaan, kantapään alueen haavat paranivat huonosti. Tutkimus osoitti että toimiva alaraaja ohite on tärkeä raajan säilyttämiseksi mikäli potilaalla on iskeeminen haava. Ohitteen tukkeutuminen johti 52%:lla vuoden sisällä amputaatioon ellei uusitaleikkausta tehty. Uusintaleikatuilla potilailla vastaava luku oli 14%. Pitkäaikaistulokset osoittivat että ohitusleikkauksella pystytään valtaosa, 5 vuoden kohdalla 76%, alaraajoista säilyttämään. Sen sijaan potilaiden kuolleisuus oli suuri. Viiden vuoden kohdalla 38% oli elossa ja 30% elossa ilman amputaatiota. Suurentunutta kuolleisuutta ennustivat korkea ikä, sepelvaltimotauti, munuaisten vajaatoiminta ja keuhkoahtaumatauti. Lisäksi todettiin että mikrobilääkkeille vastaustuskykyinen Pseudomonas aeruginosa- tartunta lisäsi riskiä menettää alaraaja tai kuolla. Mikäli suonensisäinen pallolajennus on mahdollinen polven alapuolisiin valtimoihin sillä voidaan saavuttaa samanlaiset tulokset kuin ohitusleikkauksella mutta pallolaajennushoito johtaa useamiin uusintatoimenpiteisiin ohitusleikkaukseen verrattuna. Yhteenveto: Tutkimus osoittaa että iskeemisten haavojen paraneminen on hidas tapahtuma, etenkin diabeetikoilla. Onnistunut alaraajan ohitusleikkaus tai pallolaajennus parantaa alaraaajan ennustetta, mutta potilaiden pitkä-aikaisennuste on heikko perussairauksista johtuen

Bovine pericardial patch : A good alternative in femoral angioplasty

Objective: Bovine pericardial patch (BPP) is currently used in femoral angioplasty as an alternative for autologous vein patch (AVP), but studies comparing the results of the two methods are scarce. In this retrospective study, we aimed to discover the differences between BPP and AVP closure in long-term durability.Methods: This study consisted of all femoral endarterectomies with BPP closure performed in Helsinki University Hospital from January 1, 2014, to December 31, 2017. For comparison, the same number of consecutive patients who underwent femoral endarterectomy with AVP closure from January 1, 2014, to October 16, 2016, were reviewed. Follow-up ended December 31, 2020. The mean follow-up was 19 months (range, 0-74 months) in the BPP group and 22 months (range, 079 months) in the AVP group. The primary endpoint was primary patency. Secondary endpoints were restenosis at patch site detected by imaging or perioperatively, patch rupture, and deep surgical wound infection. Propensity score analysis was performed for adjustment of differences between the AVP and BPP groups.Results: Overall primary patency was superior in the AVP group compared with the BPP group: at 1 year, 96.5% vs 85.0% and at 5 years, 83.0% vs 72.3% (P =.04). In propensity score-matched pairs (n = 92), no difference was found between the groups in primary patency: 95.7% and 95.7% at 1 year and 92.5% and 78.6% at 5 years (P =.861) or in freedom from restenosis: 100% and 100% at 1 year and 89.1% and 84.0% at 5 years (P =.057). Deep wound infections occurred slightly more often after BPP closure (8%) than after AVP closure (4%), but the difference was not statistically significant (P =.144). There were no patch ruptures in the BPP group, but in the AVP group, there were five ruptures (3.5%) (P =.024).Conclusions: BPP is compatible to AVP in femoral endarterectomy in patency and can be regarded as the safer choice considering the risk of patch rupture.Peer reviewe

The Feasibility of Angiosome-Targeted Endovascular Treatment in Patients with Critical Limb Ischaemia and Foot Ulcer

Peer reviewe

Long-term Results of Inframalleolar Bypass for Critical Limb Ischaemia

Peer reviewe

Potential for soil organic carbon sequestration in grasslands in East African countries: A review

Grasslands occupy almost half of the world's land area. Soil organic carbon (SOC) is a key indicator of soil fertility and grassland productivity. Increasing SOC stocks (so‐called SOC sequestration) improves soil fertility and contributes to climate change mitigation by binding atmospheric carbon dioxide (CO2). Grasslands constitute about 70% of all agricultural land, but their potential for SOC sequestration is largely unknown. This review paper quantitatively summarizes observation‐based studies on the SOC sequestration potential of grasslands in six East African countries (Burundi, Ethiopia, Kenya, Rwanda, Tanzania and Uganda) and seeks to identify knowledge gaps related to SOC sequestration potential in the region. In the studies reviewed, SOC stocks in grasslands range from 3 to 93 Mg C/ha in the upper 0.3 m of the soil profile, while SOC sequestration rate ranges from 0.1 to 3.1 Mg C ha‐1 year‐1 under different management strategies. Grazing management is reported to have a considerable impact on SOC sequestration rates, and grassland regeneration and protection are recommended as options to stimulate SOC sequestration. However, a very limited number of relevant studies are available (n = 23) and there is a need for fundamental information on SOC sequestration potential in the region. The effectiveness of potential incentive mechanisms, such as payments for environmental services, to foster uptake of SOC‐enhancing practices should also be assessed

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

Introduction In the context of chronic limb threatening ischemia (CLTI), the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated. Materials and method This series includes 580 patients who underwent endovascular (n=407) and surgical revascularization (n=173) of the infrapopliteal arteries for CLTI 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 revascualrization. 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 to complete pedal arch were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (SHR 2.131, 95%CI 1.282-3.543) and no visualized pedal arch (SHR 3.022, 95%CI 1.553-5.883) compared to complete pedal arch. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of complete pedal arch had a lower risk of major amputation (adjusted SHR 0.463, 95%CI 0.240-0.894) compared to angiosome-directed revascularization without complete pedal arch. In the subanalysis, among patients who underwent endovascular revascularization, complete pedal arch (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.Peer reviewe

Mediterranean Diet Adherence and Health-Related Quality of Life during Pregnancy: Is the Mediterranean Diet Beneficial in Non-Mediterranean Countries?

This study aimed to examine the association of Mediterranean diet (MD) adherence and MD components with health-related quality of life (HRQoL) in pregnant women from Spain and Sweden. A total of 138 pregnant women from Spain (age: 32.9 ± 4.6 years old) and 302 pregnant women from Sweden (age: 31.3 ± 4.1 years old) were included. MD adherence was assessed with the Mediterranean food pattern (i.e., a MD index) at the 14–16th gestational weeks. HRQoL was assessed with the Spanish and Swedish versions of the 36-item Short-Form Health Survey (SF-36 and RAND-36, respectively) at the 14–16th and 34–37th gestational weeks. A greater MD adherence was associated with better physical functioning, bodily pain, vitality, emotional role, and mental health in cross-sectional associations (2nd trimester) in the Spanish sample (all p < 0.05). Furthermore, a greater MD adherence was associated with lower bodily pain in both Spanish and Swedish samples (both p < 0.05) in the 3rd trimester. The associations of MD adherence with pain seem to be explained by a greater intake of fiber, fish, fruits, nuts, and legumes (all p < 0.05). A greater MD adherence, driven by a higher intake of fiber, fish, fruits, nuts, and legumes, was associated with lower pain throughout pregnancy in both Mediterranean and non-Mediterranean populations.Regional Ministry of Health of the Junta de Andalucía (PI-0395-2016)University of Granada, Excellence actions: Units of Excellence, Unit of Excellence on Exercise and Health (UCEES)Junta de Andalucía, Consejería de Conocimiento, Investigación y Universidades, and the European Regional Development Fund (ERDF), REF. SOMM17/6107/UGRSpanish Ministry of Education, Culture, and Sports (Grant number FPU17/03715)Swedish Research Council (2016-01147

Effects of dipeptidyl peptidase 4 inhibition on inflammation in atherosclerosis: A 18F-fluorodeoxyglucose study of a mouse model of atherosclerosis and type 2 diabetes

Background and aims: Dipeptidyl peptidase 4 (DPP-4) inhibitors have anti-inflammatory and atheroprotective effects. We evaluated the effects of the DPP-4 inhibitor linagliptin on atherosclerotic plaque and hepatic inflammation using histology and 2-deoxy-2-[18F]-fluoro-d-glucose (18F-FDG), a positron emission tomography tracer of inflammation, in a mouse model of hypercholesterolemia and type 2 diabetes.Methods: Igf2/Ldlr-/-Apob100/100 mice were fed a high-fat diet (HFD) for 8 weeks and then randomly allocated to receive HFD (n = 14), or HFD with added linagliptin (n = 15) for additional 12 weeks. Five mice fed a chow diet were studied as an additional control. At the end of the study, glucose tolerance, aortic and liver uptake of 18F-FDG, and histology were studied.Results: Mice in linagliptin and HFD groups had similar fasting glucose concentrations, but linagliptin improved glucose tolerance. Aortas of linagliptin and HFD groups showed advanced atherosclerotic plaques with no difference in the mean intima-to-media ratio or number of macrophages in the plaques. Autoradiography showed similar 18F-FDG uptake by atherosclerotic plaques in linagliptin and HFD groups (plaque-to-wall ratio: 1.7 ± 0.25 vs. 1.6 ± 0.21; p = 0.24). In the liver, linagliptin reduced the histologic inflammation score but had no effect on 18F-FDG uptake. Compared with chow diet, uptake of 18F-FDG was similar in the aorta, but higher in the liver after HFD.Conclusions: Linagliptin therapy improved glucose tolerance and reduced hepatic inflammation but had no effect on plaque burden or atherosclerotic inflammation, as determined by histology and 18F-FDG uptake, in atherosclerotic mice with type 2 diabetes.   </p