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The objective of this population-based study was to analyze short- and long-term major adverse cardiovascular events (MACE) after endovascular repair of ruptured or nonruptured thoracic (TAA) and abdominal aortic aneurysms (AAA).Nationwide retrospective registry study including all patients who underwent endovascular repair (thoracic endovascular aortic repair, TEVAR; abdominal endovascular aneurysm repair, EVAR) for nonruptured/intact (iAAA/iTAA) or ruptured (rAAA/rTAA) abdominal or thoracic aneurysms between 2000 and 2018. The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction (MACE).There were 8,641 patients with TAA and AAA; 634 TEVAR procedures [iTAA 488; rTAA 146], and 8007 EVAR procedures [iAAA 7071; rAAA 936] were performed. MACE incidence at 90-day after TEVAR for iTAA was 10.2% and for rTAA 26.7% [HR 3.02, 95% CI 1.99-4.6]; MACE at 90-day after EVAR for iAAA was 3.7% and for rAAA 26.9% [HR 8.5, 95% CI: 7.16-10.11]. There was a higher cumulative incidence of MACE at 90-day after TEVAR for iTAA compared to EVAR for iAAA [HR 2.82, 95% CI 2.09-3.82] but no difference between the procedures after ruptured aneurysm repair. The median follow-up time was 3.28 years [IQR 1.31-5.94]. There was no long-term difference in MACE between EVAR and TEVAR after ruptured [90 days-5 years: HR 1.14, 95% CI 0.76-1.71; 5-10 years: HR 0.78, 95% CI 0.31-1.96] or intact [90 days-5 years: HR 1.19, 95% CI 0.97-1.46; 5-10 years: HR 0.82, 95% CI 0.56-1.21] aneurysm repair. Female gender had higher long-term incidence of MACE after intact [HR 1.14, 95% CI 1.03-1.27] and ruptured [HR 1.36, 95% CI 1.12-1.65] endovascular aortic aneurysm treatment. After intact aneurysms repair; age [HR 1.05, 95% CI 1.04-1.05], history of angina pectoris [HR 1.19, 95% CI 1.08-1.32], heart failure [HR 1.90, 95% CI 1.69-2.13], and stroke [HR 1.33, 95% CI 1.15-1.53] were associated with MACE.This nationwide cohort study still demonstrated a high risk of early and late cardiovascular events after endovascular aortic repair. Comprehensive strategies for postoperative cardiovascular disease prevention may be needed here.

Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions.All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival.A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years.In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.

Supplementary oxygen is administered during anaesthesia to increase oxygen delivery and prevent hypoxia. Recent studies have questioned this routine. In this pilot study, our main aim was to investigate if 21% oxygen compared to ≥50% reduces the risk of postoperative complications and myocardial injury.In this pragmatic, multicentre, single-blind study, patients undergoing vascular surgery were randomised to receive a fraction of inspired oxygen (FThe 191 patients were randomised, and per-protocol principle was used for analyses. At 30-day follow-up, 43 out of 94 patients (46%) had a postoperative complication in group H and 36 out of 90 patients (40%) in group N, p = .46. New myocardial injury was seen in 27% versus 22% in Groups H and N respectively (p = .41). No differences in other outcomes were observed between the groups. Twelve patients (13%) in Group N had SpOIn this pilot study, postoperative complications were similar between the groups in patients randomised to F

Allogenic blood product usage is associated with worse outcomes in open repair of descending and thoracoabdominal aortic aneurysms. This pilot study evaluated the safety and efficacy of a novel modification of the left heart bypass (LHB) circuit to reduce intraoperative blood transfusions.In modified LHB, pump suckers collected shed blood that was directly retransfused through a femoral vein cannula. In standard LHB, cellsavers were used to collect, wash, and retransfuse shed blood. Consecutive patients undergoing elective surgical descending or thoracoabdominal aneurysm repair using modified (N.=12) or standard (N.=21) LHB were compared. Intraoperative blood product use was the primary outcome. Hypotensive episodes, lactate levels, and adverse events (early mortality, spinal cord injury, renal and respiratory insufficiency) were secondary outcomes.Groups were comparable regarding pre- and intraoperative variables. No perfusion-related adverse events occurred. With modified LHB, intraoperative blood product use was significantly reduced: packed red blood cells by 60% from 10 to 4 units (P=0.002), fresh frozen plasma by 70% from 17 to 5 units (P0.001) as well as retransfused cellsaver volume by 75%, from 4500 mL to 1110 mL (P0.001). Hemodynamic instability occurred in 1 (8.3%) vs. 6 (29%), P=0.22 and overall lactate levels were significantly reduced (P=0.045) with modified LHB. Adverse events combined occurred in 1/12 vs. (P=0.022).The novel modified LHB with direct retransfusion was safe and associated with significantly reduced intraoperative blood product use, reduced lactate production and improved clinical outcomes as compared to standard LHB and could represent an important clinical improvement.

Background Gun violence is a global health problem. Population-based research on firearm-related injuries has been relatively limited considering the burden of disease. The aim of this study was to analyze nationwide epidemiological trends of firearm injuries. Methods This is a retrospective nationwide epidemiological study including all patients with firearm injuries from the Swedish Trauma Registry (SweTrau) during the period 2011 and 2019. Registry data were merged with data from the Swedish National Council for Crime Prevention and the Swedish Police Authority. Results There were 1010 patients admitted with firearm injuries, 96.6% men and 3.4% women, median age 26.0 years [IQR 22.0–36.3]. The overall number of firearm injuries increased on a yearly basis (P Conclusions This nationwide study shows an annual increase of firearm-related injuries and fatalities. Firearm injuries affect people of all ages but more frequently young males in major cities. One in six patients succumbed from their injuries within 30 days with most deaths occurring within 24 h of hospital admission. Given the impact of firearm-related injuries on society additional research on a national level is critical.

Background The objective of this clinical study was to investigate the anticoagulant effect of standard fixed dose of heparin during endovascular intervention in the lower extremity arteries. Methods A prospective clinical pilot study was completed with retrospective quality review of patients between 2015 and 2017 (n = 61). Patients undergoing elective endovascular intervention for arterial insufficiency in the lower extremities were enrolled. A standard fixed intra-arterial dose of 5000 IU of unfractionated heparin (UFH) was administered during the procedure without adjustment for weight or monitoring. Activated clotting time (ACT) was measured before and ten minutes after heparin administration and at the end of the procedure. The primary study end point was the level of heparin anticoagulation after standard perioperative administration. Results Mean age was 74 ± 9 years, 48% women. Mean weight was 74 ± 15 kg, and mean BMI, 25.6 ± 4.7 kg/m2. The endovascular interventions were performed at the iliac arteries 19.7% (12/61), at the femoral popliteal segment 50.8 % (31/61), below the knee arteries 6.6% (4/61), and at multiple levels 13% (8/61). The perioperative mean ACT increased from baseline 155 ± 43 s (n = 31) to ten minutes after heparin administration 290 ± 70 s (n = 60) (P 350 (P = 0.0095). The same pattern was seen for heparin dose per BMI and DuBois. In univariate logistic regression analysis, ACT ≥350 s was associated with lower body weight (OR 0.92; 95% CI 0.87–0.98; P = 0.008), lower BMI (OR 0.80; 95% CI 0.67–0.96; P = 0.014), and lower body surface area DuBois (OR 0.53; 95% 0.32–0.85; P = 0.009). In multivariable regression, the ACT association with body weight remained (OR 0.92; 95% 0.87–0.98; P = 0.008). There were no perioperative or immediate postoperative bleeding complications requiring blood transfusion or surgical intervention in this study cohort. Conclusions The standard heparin dosing of 5000 IU during endovascular intervention for arterial insufficiency in the lower extremities helps achieve ACT >200 s in almost all patients, but most patients were outside recommended target interval. To provide a more consistent and predictable heparinization, a weight-based bolus dose of 70 IU heparin/kg is recommended.

Background Severe disease due to the novel coronavirus disease 2019 (COVID-19) has been shown to be associated with hypercoagulation. The aim of this study was to assess the Rotational Thromboelastometry (ROTEM) as a marker of coagulopathy in hospitalized COVID-19 patients. Methods This was a prospective, observational study where patients hospitalized due to a COVID-19 infection were eligible for inclusion. Conventional coagulation tests and ROTEM were taken after hospital admission, and patients were followed for 30 days. A prediction model, including variables ROTEM EXTEM-MCF (Maximum Clot Firmness) which in previous data has been suggested a suitable marker of hypercoagulation, age, and respiratory frequency, was developed using logistic regression to evaluate the probability of death. Results Out of the 141 patients included, 18 (13%) died within 30 days. In the final prediction model, the risk of death within 30 days for a patient hospitalized due to COVID-19 was increased with increased EXTEM-MCF, age, and respiratory frequency. Longitudinal ROTEM data in the severely ill subpopulation showed enhanced hypercoagulation. In an in vitro analysis, no heparin effect on EXTEM–coagulation time (CT) was observed, supporting a severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) effect on prolonged initiation of coagulation. Conclusion Here, we show that hypercoagulation measured with ROTEM predicts 30-day mortality in COVID-19. Longitudinal ROTEM data strengthen the hypothesis of hypercoagulation as a driver of severe disease in COVID-19. Thus, ROTEM may be a useful tool to assess disease severity in COVID-19 and could potentially guide anticoagulation therapy.

Objective The aim was to describe the microbiology of surgically treated infective native (mycotic) aortic aneurysms (INAAs), and associated survival and development of infection-related complications (IRCs). Methods Data were pooled from 2 nationwide studies on surgically treated patients with INAAs in Sweden, between 1994 – 2016. Patients were grouped and analyzed according to culture results: 1) Staphylococcus aureus, 2) Streptococcus species (sp.), 3) Salmonella sp., 4) Enterococcus sp., 5) Gram-negative intestinal bacteria, 6) Other sp. (all other species found in culture), and 7) Negative cultures. Results A sum of 182 patients were included, mean age 71 years (standard deviation; SD: 8.9). The median follow-up was 50.3 months (range 0 – 360). 128 (70.3%) patients had positive blood and/or tissue culture; Staphylococcus aureus n = 38 (20.9%), Streptococcus sp. n = 37 (20.3%), Salmonella sp. n = 19 (10.4%), Enterococcus sp. n = 16 (8.8%), Gram-negative intestinal bacteria n = 6, (3.3%), Other sp. n = 12 (6.6%) and Negative cultures n = 54 (29.7%). The estimated survival for the largest groups at 2-years after surgery was: Staphylococcus aureus 62% (95% Confidence interval 53.9 – 70.1), Streptococcus sp. 74.7% (67.4 – 82.0), Salmonella sp. 73.7% (63.6 – 83.8), Enterococcus sp. 61.9% (49.6 – 74.2), and Negative cultures 89.8% (85.5 – 94.1), P = .051. There were 37 IRCs (20.3%), and 19 (51.4%) were fatal, the frequency was insignificant between the groups. The majority of IRCs, 30/37 (81%), developed during the first postoperative year. Conclusion In this assessment of microbiological findings of INAAs in Sweden, 50% of the pathogens were Staphylococcus aureus, Streptococcus sp., or Salmonella sp.. The overall 20%-frequency of IRCs, and its association with high mortality, motivates long-term antibiotic treatment regardless of microbial findings.

BackgroundSevere disease due to COVID-19 has been shown to be associated with hypercoagulation. Early identification of prothrombotic patients may help guiding anticoagulant treatment and improve survival. The aim of this study was to assess Rotational Thromboelastmetry (ROTEM®) as a marker of coagulopathy in hospitalized COVID-19 patients.MethodsThis was a prospective, observational study. Patients hospitalized due to a COVID-19 infection were eligible for inclusion. Conventional coagulation tests and ROTEM were taken after hospital admission, and patients were followed for 30 days. Patient characteristics and outcome variables were collected, and a prediction model including variables age, respiratory frequency and ROTEM EXTEM-MCF, was developed using logistic regression to evaluate the probability of death.ResultsOut of the 141 patients included, 18 (13%) died within 30 days. D-dimer (p=0.01) and Activated Partial Thromboplastin Time (APTT) (p=0.002) were increased, and ROTEM EXTEM-/INTEM-CT (pConclusionsHere we show that hypercoagulation measured with ROTEM predicts 30-day mortality in COVID-19. Longitudinal ROTEM data strengthen the hypothesis of hypercoagulation as a driver of severe disease in COVID-19. Thus, ROTEM may be a useful tool to assess disease severity in COVID-19, and could potentially guide anticoagulation therapy.

The results of a recent meta-analysis aroused concern about an increased risk of death associated with the use of paclitaxel-coated angioplasty balloons and stents in lower-limb endovascular interventions for symptomatic peripheral artery disease.We conducted an unplanned interim analysis of data from a multicenter, randomized, open-label, registry-based clinical trial. At the time of the analysis, 2289 patients had been randomly assigned to treatment with drug-coated devices (the drug-coated-device group, 1149 patients) or treatment with uncoated devices (the uncoated-device group, 1140 patients). Randomization was stratified according to disease severity on the basis of whether patients had chronic limb-threatening ischemia (1480 patients) or intermittent claudication (809 patients). The single end point for this interim analysis was all-cause mortality.No patients were lost to follow-up. Paclitaxel was used as the coating agent for all the drug-coated devices. During a mean follow-up of 2.49 years, 574 patients died, including 293 patients (25.5%) in the drug-coated-device group and 281 patients (24.6%) in the uncoated-device group (hazard ratio, 1.06; 95% confidence interval, 0.92 to 1.22). At 1 year, all-cause mortality was 10.2% (117 patients) in the drug-coated-device group and 9.9% (113 patients) in the uncoated-device group. During the entire follow-up period, there was no significant difference in the incidence of death between the treatment groups among patients with chronic limb-threatening ischemia (33.4% [249 patients] in the drug-coated-device group and 33.1% [243 patients] in the uncoated-device group) or among those with intermittent claudication (10.9% [44 patients] and 9.4% [38 patients], respectively).In this randomized trial in which patients with peripheral artery disease received treatment with paclitaxel-coated or uncoated endovascular devices, the results of an unplanned interim analysis of all-cause mortality did not show a difference between the groups in the incidence of death during 1 to 4 years of follow-up. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT02051088.).

Objective: Recent randomised controlled trials demonstrated the benefit of intracranial endovascular thrombectomy (EVT) in acute ischaemic stroke. There is no consensus, however, on how to treat concomitant extracranial carotid artery stenosis after EVT. The aim of this study was to evaluate the outcome in patients treated with carotid endarterectomy (CEA) after EVT, comparing complication rates among patients undergoing CEA for stroke without previous EVT. Methods: This was a registry study of all patients (n = 3 780) treated with CEA after stroke in Sweden and the capital Helsinki region, Finland, from January 2011 to September 2020. Sixty three patients (1.7%; 0.5% 2011, 4.3% 2019) underwent EVT prior to CEA. The primary outcome was 30 day stroke and death rate. Results: The EVT+CEA group had major stroke as the qualifying neurological event (QNE) in 79%, but just 5.9% had this in the CEA only group (p < .001). Intravenous thrombolysis was administered before EVT in 54% of patients in the EVT+CEA group, but in just 12% in those receiving CEA only (p < .001). The combined stroke and death rate at 30 days for EVT+CEA was 0.0% (95% confidence interval [CI] 0.0 - 5.7). One patient had a post-operative TIA, none had post-operative intracerebral or surgical site haemorrhage. CEA was performed within a median of seven days (interquartile range 4, 15) after QNE, and 75% had CEA

Background There is a concern that civilian gunshot injuries in Europe are increasing but there is a lack of contemporary studies. The purpose of this study was to investigate the current epidemiology and outcome of firearm injuries. Methods Retrospective cohort study of all patients (n = 235) treated for firearm injuries admitted to a Scandinavian trauma center between 2005 and 2016. Local and national trauma registries were used for data collection. Results Mean age was 31.3 years (SD ± 12.9; range 16–88 years); 93.6% males; mean ISS was 14.3 (SD ± 15.9); 31.9% (75/235) had ISS > 15. There was a significant increase in penetrating trauma (P

BACKGROUND: Patients with peripheral artery disease have an increased risk of cardiovascular morbidity and mortality. Antiplatelet agents are widely used to reduce these complications.METHODS: This was a multicentre, double-blind, randomised placebo-controlled trial for which patients were recruited at 602 hospitals, clinics, or community practices from 33 countries across six continents. Eligible patients had a history of peripheral artery disease of the lower extremities (previous peripheral bypass surgery or angioplasty, limb or foot amputation, intermittent claudication with objective evidence of peripheral artery disease), of the carotid arteries (previous carotid artery revascularisation or asymptomatic carotid artery stenosis of at least 50%), or coronary artery disease with an ankle-brachial index of less than 0·90. After a 30-day run-in period, patients were randomly assigned (1:1:1) to receive oral rivaroxaban (2·5 mg twice a day) plus aspirin (100 mg once a day), rivaroxaban twice a day (5 mg with aspirin placebo once a day), or to aspirin once a day (100 mg and rivaroxaban placebo twice a day). Randomisation was computer generated. Each treatment group was double dummy, and the patient, investigators, and central study staff were masked to treatment allocation. The primary outcome was cardiovascular death, myocardial infarction or stroke; the primary peripheral artery disease outcome was major adverse limb events including major amputation. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, we enrolled 7470 patients with peripheral artery disease from 558 centres. The combination of rivaroxaban plus aspirin compared with aspirin alone reduced the composite endpoint of cardiovascular death, myocardial infarction, or stroke (126 [5%] of 2492 vs 174 [7%] of 2504; hazard ratio [HR] 0·72, 95% CI 0·57-0·90, p=0·0047), and major adverse limb events including major amputation (32 [1%] vs 60 [2%]; HR 0·54 95% CI 0·35-0·82, p=0·0037). Rivaroxaban 5 mg twice a day compared with aspirin alone did not significantly reduce the composite endpoint (149 [6%] of 2474 vs 174 [7%] of 2504; HR 0·86, 95% CI 0·69-1·08, p=0·19), but reduced major adverse limb events including major amputation (40 [2%] vs 60 [2%]; HR 0·67, 95% CI 0·45-1·00, p=0·05). The median duration of treatment was 21 months. The use of the rivaroxaban plus aspirin combination increased major bleeding compared with the aspirin alone group (77 [3%] of 2492 vs 48 [2%] of 2504; HR 1·61, 95% CI 1·12-2·31, p=0·0089), which was mainly gastrointestinal. Similarly, major bleeding occurred in 79 (3%) of 2474 patients with rivaroxaban 5 mg, and in 48 (2%) of 2504 in the aspirin alone group (HR 1·68, 95% CI 1·17-2·40; p=0·0043).INTERPRETATION: Low-dose rivaroxaban taken twice a day plus aspirin once a day reduced major adverse cardiovascular and limb events when compared with aspirin alone. Although major bleeding was increased, fatal or critical organ bleeding was not. This combination therapy represents an important advance in the management of patients with peripheral artery disease. Rivaroxaban alone did not significantly reduce major adverse cardiovascular events compared with asprin alone, but reduced major adverse limb events and increased major bleeding.FUNDING: Bayer AG.

The pathophysiology of acute extremity compartment syndrome involves external compression or internal expansion within the compartment leading to increased tissue pressure, reduced capillary blood flow, tissue hypoxia and necrosis. Acute limb compartment syndrome in vascular surgery is mostly related to ischemia-reperfusion injury associated with acute ischemia or vascular trauma. The upper arm contains two compartments (anterior/posterior), forearm three (volar/lateral/dorsal), thigh three (anterior/medial/posterior), and lower leg four compartments (anterior/lateral/deep posterior/superficial posterior). The time from insult to the development of compartment syndrome may vary from minutes to hours. Any suspicion of acute limb compartment syndrome must lead to either prompt treatment or immediate further diagnostics which may include pressure measurement. Acute limb compartment syndrome should be treated with fasciotomy of all affected compartments. The lower limb is decompressed with anterolateral and posteromedial incisions. Incisions in skin and fascia need to be long enough to make tissues loose and allow for postoperative swelling. When fasciotomy is performed within 6 h of onset, the majority of extremities return to normal function but later fasciotomy is associated with significant complications including neuromuscular dysfunction and amputation.

Objectives The aim was to study blood transfusions and blood product ratios in massively transfused patients treated for ruptured abdominal aortic aneurysms (rAAAs). Methods This was a registry based cohort study of rAAA patients repaired at three major vascular centres between 2008 and 2013. Data were collected from the Swedish Vascular Registry, hospitals medical records, and local transfusion registries. The transfusion data were analysed for the first 24 h of treatment. Massive transfusion (MT) was defined as 4 or more units of red blood cell (RBC) transfused within 1 h, or 10 or more RBC units within 24 h. Logistic regression was used to calculate the odds ratio of 30 day mortality associated with the ratios of blood products and timing of first units of platelets (PLTs) and fresh frozen plasma (FFP) transfused. Results Three hundred sixty nine rAAA patients were included: 80% men; 173 endovascular aneurysm repairs (EVARs) and 196 open repairs (ORs) with median RBC transfusion 8 units (Q1–Q3, 4–14) and 14 units (Q1–Q3, 8–28), respectively. A total of 261 (71%) patients required MT. EVAR patients with MT (n = 96) required less transfusion than OR patients (n = 165): median RBC 10 units (Q1–Q3, 6–16.5) vs. 15 units (Q1–Q3, 9–26) (p = .002), FFP 6 units (Q1–Q3, 2–14.5) vs. 13 units (Q1–Q3, 7–24) (p < .001), and PLT 0 units (Q1–Q3, 0–2) vs. 2 units (Q1–Q3, 0–4) (p = .01). Median blood product ratios in MT patients were FFP/RBC (EVAR group 0.59 [0.33–0.86], OR group 0.84 [0.67–1.2]; p < .001], and PLT/RBC (EVAR 0 [0–0.17], OR 0.12 (0–0.18); p < .001]. In patients repaired by OR a FFP/RBC ratio close to 1 was associated with reduced 30 day mortality (p = .003). The median PLT/RBC ratio was higher during the later part of the study period (p < .001, median test), whereas there was no significant difference in median FFP/RBC ratio (p = .101, median test). Conclusion The majority of rAAA patients undergoing EVAR required MT. EVAR patients treated with MT had lower FFP/RBC and PLT/RBC ratios than OR patients with MT. The mortality risk was lower with FFP/RBC ratio close to 1:1 in open repaired patients requiring MT. The 24 h PLT/RBC ratio increased over the study period. (Less)

Purpose Hemorrhage is the most common cause of preventable death after trauma. Coagulopathy plays a central role in uncontrolled bleeding and is caused by multiple factors. Extracorporeal Membrane Oxygenation (ECMO) is an established treatment for patients with respiratory failure and has in recent years also been used in severely injured trauma patients with cardiopulmonary failure and coexisting bleeding shock. The aim of this study was to evaluate the effect of ECMO on hypothermia, acidosis, and coagulopathy in a traumatic hemorrhagic rabbit model. Methods After anesthesia and tracheostomy, ten New Zealand White rabbits sustained laparotomy, bilateral femur fractures and were hemorrhaged 45% of their estimated blood volume. After 90 min of hemorrhagic shock they were resuscitated with a standard transfusion protocol together with venoarterial ECMO (n = 5) or with a standard transfusion protocol only (n = 5) for 60 min. No systemic heparin was administered. Results ECMO during 60 min of resuscitation significantly increased heart rate (p = 0.01), mean arterial pressure (p = 0.01), body temperature (p = 0.01) and improved the metabolic acidosis, pH (p = 0.01), and lactate (p = 0.01). ECMO also improved the coagulation capacity measured in vitro by Rotational Thromboelastometry with a significant decrease in clot formation time (p

Objectives The aim was to assess whether the level of care influenced the safety related outcomes of catheter directed thrombolysis (CDT) for patients presenting with limb ischaemia and dialysis access thrombosis. Methods This was a retrospective cohort study. All consecutive patients at two tertiary referral centres for vascular surgery undergoing CDT for limb ischaemia and dialysis access thrombosis ( N = 252) between 2012 and 2014 were included. Patients at Centre 1 were cared for on a general vascular ward and patients at Centre 2 were kept on a post-operative recovery unit with an increased level of care including invasive haemodynamic monitoring. Patient medical records were retrospectively scrutinised and data collected on comorbidities, anti-thrombotic medication, indications for CDT, technical success of CDT, bleeding and non-bleeding related complications, and transfer to a higher level of care. Results There were no differences in the frequency of non-bleeding related complications between Centre 1 and Centre 2. Patients on the vascular ward had a higher frequency of minor bleeding ( p = .002) but there was no difference in major bleeding ( p = .12). Eleven patients on the ward required an increased level of care for medical reasons and six were moved for a lack of resources. The presence of cardiac disease was an independent risk factor for patient transfer (OR 3.2; 95% CI 1.04–9.8, p = .04). Conclusions CDT may be undertaken outside of a high dependency setting without a significantly increased risk of complications. Pre-existing cardiac disease was an independent risk factor for transfer to a higher level of care. These findings could have an implication for the clinical cost-effectiveness of CDT.

In a recent publication in The Lancet Johansson and colleagues claim no effect on aneurysm mortality among men participating in the Swedish AAA screening program, and question its justification. The study is, however, limited by a corrupt study design and incorrect data, making the publication misleading. On the contrary, several RCTs and contemporary nationwide data with sufficient follow-up clearly show that AAA screening saves lives and is highly cost-effective. The program has so far identified about 6000 men with an AAA, of whom 1500 have been operated on to prevent rupture. Thus, more than 750 men have experienced a longer life (by a mean of 8 years) as a result of the program. Continuous evaluation of the program is important but requires a scientifically sound methodology.

Mycotic aortic aneurysms are rare, life threatening, and complex. This nationwide study aimed to assess outcome after repair of mycotic thoracic aortic aneurysms (MTAAs).Patients treated in Sweden for MTAAs between 2000 and 2016 were identified in the Swedish vascular registry (2010-16) and local patient registries (2000-09). Primary outcome was survival, and secondary outcomes included surgical strategy, rate of infection related complications (IRC), and re-operations.Fifty-two patients (median age 71 ± 8.1 years; 28 [54%] men, 13 [25%] ruptured) were identified (3.6% of all thoracic aortic aneurysm repairs in Sweden). Aneurysm location was aortic arch (n = 6; 11%), descending aorta (n = 42; 81%), and multiple locations (n = 4; 8%). Twenty-nine (56%) patients had positive cultures; the most prevalent agent was Staphylococcus aureus (n = 16; 31%). Operative techniques included thoracic endovascular aortic repair (TEVAR; n = 35 [67%]), fenestrated/branched TEVAR (n = 8; 15%), hybrid repair (n = 7; 14%), and open patch repair (n = 2; 4%). Survival was 92% (95% confidence interval [CI] 88-96) at 30 days, 88% (95% CI 84-93) at three months, 78% (73-84) at one year, and 71% (64-77) at five years. The mean follow up among survivors (90 days) was 45 months (range 4-216 months). Antibiotics were administered for a median of 15 weeks (range 0-220 weeks). IRCs occurred in nine patients (17%): sepsis (n = 3), graft infection (n = 3), recurrent mycotic aneurysm (n = 1), aorto-oesophageal/bronchial fistula (n = 2). Six (67%) IRCs were fatal; 80% occurred within the first year. Re-operations were performed in nine patients (17%).TEVAR was often used as treatment for MTAAs, with acceptable short- and long-term survival when compared with open cohorts in the literature. IRCs are of concern and warrant follow up and long-term antibiotic treatment.

Introduction: Acute compartment syndrome (ACS) is a challenging and recognized complication to vascular surgery revascularization. The aim of this study was to investigate the current epidemiology, management, and early outcomes of fasciotomy in vascular surgery. Methods: Retrospective cohort study of all patients undergoing lower extremity fasciotomy at a single university center between January 2008 and December 2014. Patient demographics, operative techniques, and outcomes were analyzed. Results: The cohort (n = 113 limbs; 107 patients; 48% women; mean age was 74 (12) years [range, 50-97 years]) included 81 (72%) limbs undergoing revascularization for acute limb ischemia, 7 (6.2%) limbs related to acute aortic disease, and 23 (20%) limbs undergoing elective vascular surgery. Five patients underwent bilateral lower extremity fasciotomy. In all, 64 (57%) limbs had signs of ACS and underwent a therapeutic fasciotomy, while 49 (43%) fasciotomies were prophylactic. There were 20 (18%) fasciotomies performed after endovascular interventions. A 4-compartment fasciotomy was performed in 82% (n = 93) of limbs with a double incision technique. Split thickness skin graft was required in 11% (12/112) and vacuum-assisted closure treatment in 11% (12/111). The mean length of stay in hospital was 11 (9) days. Most common complication was lower extremity nerve deficit 32% (33/104) followed by wound infection 30% (32/108). At 30-day follow-up, amputation rate was 13% (14/107 limbs) and mortality 23% (25/107 patients). In the multivariate logistic regression analysis, prophylactic fasciotomy was associated with amputation (odds ratio: 28.9; 95% confidence interval: 1.96-425; P = .014). Conclusion: Acute compartment syndrome is primarily related to acute ischemic conditions but occurs after both aortic or elective vascular procedures and endovascular treatments. There are significant complications related to lower extremity fasciotomy in vascular surgery.

Objective The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). Methods This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan–Meier estimator and multivariable Cox regression. Results There were 140 patients (age [mean ± SD] 74.1 ± 8.8 years; 56% men; aneurysm size 64.8 ± 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0–132 months). The Kaplan–Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00–1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.19–4.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15–3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20–8.81; p = .001), stroke (HR 2.63; 95% CI 1.37–5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69–25.35; p = .001) were all associated with mortality. Conclusions This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality worldwide, and is a consequence of acute thrombotic events involving activation of platelets and coagulation proteins. Factor Xa inhibitors and aspirin each reduce thrombotic events but have not yet been tested in combination or against each other in patients with stable coronary artery disease.METHODS: In this multicentre, double-blind, randomised, placebo-controlled, outpatient trial, patients with stable coronary artery disease or peripheral artery disease were recruited at 602 hospitals, clinics, or community centres in 33 countries. This paper reports on patients with coronary artery disease. Eligible patients with coronary artery disease had to have had a myocardial infarction in the past 20 years, multi-vessel coronary artery disease, history of stable or unstable angina, previous multi-vessel percutaneous coronary intervention, or previous multi-vessel coronary artery bypass graft surgery. After a 30-day run in period, patients were randomly assigned (1:1:1) to receive rivaroxaban (2·5 mg orally twice a day) plus aspirin (100 mg once a day), rivaroxaban alone (5 mg orally twice a day), or aspirin alone (100 mg orally once a day). Randomisation was computer generated. Each treatment group was double dummy, and the patients, investigators, and central study staff were masked to treatment allocation. The primary outcome of the COMPASS trial was the occurrence of myocardial infarction, stroke, or cardiovascular death. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, 27 395 patients were enrolled to the COMPASS trial, of whom 24 824 patients had stable coronary artery disease from 558 centres. The combination of rivaroxaban plus aspirin reduced the primary outcome more than aspirin alone (347 [4%] of 8313 vs 460 [6%] of 8261; hazard ratio [HR] 0·74, 95% CI 0·65-0·86, pINTERPRETATION: In patients with stable coronary artery disease, addition of rivaroxaban to aspirin lowered major vascular events, but increased major bleeding. There was no significant increase in intracranial bleeding or other critical organ bleeding. There was also a significant net benefit in favour of rivaroxaban plus aspirin and deaths were reduced by 23%. Thus, addition of rivaroxaban to aspirin has the potential to substantially reduce morbidity and mortality from coronary artery disease worldwide.FUNDING: Bayer AG.

Purpose: To evaluate the safety and performance of the Treovance stent-graft. Methods: The global, multicenter RATIONALE registry ( ClinicalTrials.gov; identifier NCT03449875) prospectively enrolled 202 patients (mean age 73.0±7.8 years; 187 men) with abdominal aortic aneurysms (AAA) suitable for endovascular aneurysm repair (EVAR) using the Treovance. The composite primary safety endpoint was site-reported all-cause mortality and major morbidity. The primary efficacy outcome was clinical success. Further outcomes evaluated included technical success; stent-graft migration, patency, and integrity; endoleak; and aneurysm size changes. Results: Technical success was 96% (194/202); 8 patients had unresolved type I endoleaks at the end of the procedure. There was no 30-day mortality and 1% major morbidity (1 myocardial infarction and 1 bowel ischemia). Clinical success at 1 year was confirmed in 194 (96%) patients; 6 of 8 patients had new/persistent endoleaks and 2 had aneurysm expansion without identified endoleak. A total of 8 (4%) reinterventions were required during the mean 13.7±3.1 months of follow-up (median 12.8). At 1 year, the Kaplan-Meier estimate for freedom from reintervention was 95.6% (95% CI 91.4% to 97.8%). Other estimates were 95.5% (95% CI 91.7% to 97.6%) for freedom from endoleak type I/III and 97.4% (95% CI 94.2% to 98.9%) for freedom from aneurysm expansion. Thirteen (6.4%) patients died; no death was aneurysm related. Conclusion: The RATIONALE registry showed favorable safety and clinical performance of the Treovance stent-graft for the treatment of infrarenal AAAs in a real-world setting.

Objectives To compare early (30 day mortality and major complications) and midterm (survival) outcomes in elective open surgical descending and thoraco-abdominal aortic repair using left heart bypass (LHB) versus hypothermic circulatory arrest (HCA) for organ protection, hypothesising non-inferiority of HCA management. Method This was a retrospective clinical cohort study with cross sectional follow-up. All elective ( n = 90) descending or thoraco-abdominal aortic repairs performed between 2004 and 2015 using either LHB ( n = 57) or HCA ( n = 33) were included. Pre- and intra-operative variables were evaluated by univariate statistical analysis. Thirty day and follow-up mortality were primary endpoints; major complications were secondary endpoints. Propensity score matching was employed to adjust for selection bias. Kaplan–Meier methods were used to estimate midterm survival. Results Overall 30 day mortality was 8/90 (8.9%): 6/57 (10.5%) using LHB vs. 2/33 (6.1%) using HCA, p = .47. Five patients (5.6%) suffered paraplegia: 3/57 (5.3%) using LHB vs. 2/33 (6.1%) using HCA, p = .87. Stroke occurred in 6/57 (11%) vs. 2/33 (6.1%), p = .76; renal failure in 27/57 (47%) vs. 19/33 (58%), p = .90; and respiratory failure in 17/57 (30%) vs. 11/33 (33%), p = .68. In 26 propensity score matched pairs, findings remained unaltered. Total follow-up was 443 patient years (median 4.9 years). Estimated survival was 78% at 1 year and 77% at 5 years in LHB vs. 72% and 67%, respectively, with HCA; there were no significant inter-group differences, before or after propensity score matching. Conclusions In elective descending or thoraco-abdominal aortic repair, no statistically significant differences in 30 day mortality, major complications, or follow-up survival were found when LHB and HCA were compared. These findings remained after propensity score matching.

Background: No reliable comparative data exist between open repair (OR) and endovascular aneurysm repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes after OR and EVAR for MAAA in a population-based cohort. Methods: All patients treated for MAAAs in Sweden between 1994 and 2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank tests. A propensity score–weighted correction for risk factor differences in the 2 groups was performed, including the operation year to account for differences in treatment and outcomes over time. Results: We identified 132 patients (0.6% of all operated abdominal aortic aneurysms in Sweden). Mean age was 70 years (standard deviation, 9.2), and 50 presented with rupture. Survival at 3 months was 86% (95% confidence interval, 80%–92%), at 1 year 79% (72%–86%), and at 5 years 59% (50%–68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994–2000 0%, 2001–2007 58%, 2008–2014 60%). Open repair was performed in 62 patients (47%): aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 patients died intraoperatively. EVAR was performed in 70 patients (53%): standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3 months was lower for OR than for EVAR (74% versus 96%, P P =0.054). A propensity score–weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5 years 60% versus 58%, P =0.771), infection-related complications (18% versus 24%, P =0.439), or reoperation (21% versus 24%, P =0.650). Conclusion: This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival in comparison with OR, without higher associated incidence of serious infection-related complications or reoperations.

The purpose of this study was to analyse the effect of dual antiplatelet therapy (DAPT) compared to aspirin on outcome after endovascular interventions in patients with CLI.This was a population based retrospective nationwide cohort analysis. Several linked national databases in Sweden: Swedish National Vascular Registry, Prescribed Drug Registry and National Discharge Registry. A total of 1941 patients (median age 79; range 43-103 years; women 58%) were identified with CLI who had undergone primary femoropopliteal endovascular intervention between 2006 and 2012. Of these, 599 (31%) patients were treated after the intervention with DAPT (aspirin and clopidogrel) and 1342 (69%) patients were treated with aspirin only. Percutaneous transluminal angioplasty (PTA) was performed in 1131 patients (58%), stenting in 633 patients (33%), and subintimal angioplasty (SAP) in 177 patients (9%).DAPT was given after PTA, stenting, and SAP to 17% (n = 188), 53% (n = 334), and 44% (n = 77) of the patients, respectively. During the study period, 77 patients (13%) with DAPT and 228 patients (17%) with aspirin underwent a major amputation. Patients receiving DAPT after stenting had a lower rate of amputation (HR 0.56; 95% CI 0.36-0.86) than patients receiving aspirin alone. In the subgroup analysis, the protective effect of DAPT on amputation seemed to be confined to patients with diabetes mellitus receiving a stent (HR 0.26; 95% CI 0.13-0.52; p .001). DAPT after PTA or SAP did not influence limb salvage, and there was no overall difference in mortality. There was no significant difference in bleeding complications between DAPT and aspirin.DAPT with aspirin and clopidogrel compared to aspirin alone was associated with a lower amputation rate but not a higher bleeding rate in patients with diabetes and CLI after endovascular femoropopliteal stenting.

Purpose: To describe a heretofore unreported complication involving the Zenith Low Profile (LP) stent-graft. Case Report: Two men, aged 75 and 67 years, respectively, underwent abdominal aortic aneurysm repair with a Zenith LP device. At 4 and 3 years, respectively, computed tomography angiography revealed separation of the proximal fixation stent from the stent-graft. In the first patient, there was stent-graft migration but no evidence of an endoleak; however, the aneurysm had grown. A fenestrated cuff was placed, sealing distally in the previous LP graft. The second patient had a type I endoleak. Open surgery was performed, and the main body of the graft was explanted. Postoperative examination of the device revealed that the fixation sutures on the suprarenal stent were still attached to the stent and had eroded through the graft material. Conclusion: Physicians should be aware of the potential for top stent separation from the Zenith LP stent-graft as a cause of endoleak and migration.

This register based study aimed to investigate the rate and pattern of healthcare associated infections (HCAI) in patients treated for lower extremity arterial disease, using antibiotic prescription as a surrogate for post-operative HCAI.A retrospective analysis of prospectively registered data on all patients treated with primary elective, open or endovascular, surgery for lower extremity arterial disease in Sweden between 2005 and 2010, was carried out. Antibiotic prescriptions were determined for three time periods (6 months pre-operative; 30 day post-operative, and 5 months extended post-operative).The cohort (n = 9894) included patients with claudication (27%, n = 2659), critical limb ischemia (rest pain without ulceration; 17%, n = 1681), and ulceration/gangrene (56%, n = 5552). Fifty-nine percent (n = 5865) of the procedures were endovascular interventions. The incidence of 30 day post-operative antibiotic prescriptions was 33% (n = 3294). These were comprised of antibiotics for skin and soft tissue infections (67%, n = 2199); urinary tract infections (UTIs; 21%, n = 703); and respiratory tract infections (12%, n = 383). There was a 92% increase in the antibiotic prescription incidence rate for the 1 month post-operative period compared with the pre-operative period (p .001). In the endovascular group, UTI antibiotics dominated the 30 day post-operative period for patients with claudication (p .001).Antibiotic treatment can be a useful marker for post-discharge surveillance of HCAI in patients with lower extremity arterial disease. The incidence of post-operative HCAI after lower extremity revascularization may have previously been underestimated.

Objectives: Composite sequential arterial bypass is a useful option for treatment of peripheral vascular disease when autologous vein is limited. We have described a modified technique for composite sequential bypass using an extended polytetrafluoroethylene (ePTFE) synthetic graft and the long saphenous vein. These are linked via a common intermediate section anastomosed to the native vessel arteriotomy in a diamond configuration (diamond anastomosis). Methods: The diamond composite sequential bypass procedure was performed on six patients to treat critical limb ischemia (gangrene, ischemic ulceration, severe rest pain). The proximal bypass grafts consist of ePTFE, to