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Surgical resection of soft tissue sarcoma with a margin of healthy tissue may necessitate resection and reconstruction of major blood vessels together with soft tissues of the proximal thigh to preserve the limb. The long-term functional outcomes of these reconstructions remain unestablished. The aim of this report was to assess the vascular and functional outcomes of soft tissue sarcoma patients with femoral vessel reconstructions.Patients who had undergone oncovascular reconstruction during the treatment of proximal thigh soft tissue sarcoma in 2014-2020 were reviewed for details of the vascular and soft tissue reconstructions, and the oncological and functional outcomes. This included eight patients of a median age 59 (range 19-77) years. All had a reconstruction of at least the superficial femoral artery and vein as well as soft tissue reconstruction with a muscle flap. All vessel reconstructions were done with either autologous vein (six grafts/four patients) or allograft (10 grafts/six patients). A microvascular latissimus dorsi flap, with a skin island, was incorporated to cover the vascular grafts in five patients. A pedicled sartorius or gracilis muscle flap was used to fill the defect in three patients.Graft patency was assessed in seven patients with a median follow-up of 48 (1-76) months. The arterial graft was patent in 6/8 and the vein graft in 2/8 patients. The gait had returned to normal in five of the six patients assessed. The median MTSS was 70 (43-87)% and the TESS 90 (75-100)%. No local recurrence of the sarcoma was detected.Vascular reconstruction combined with soft tissue reconstruction enables limb-sparing surgery in patients with soft tissue sarcoma involving proximal femoral vessels. Although the surgeries are complex with high early morbidity, the achieved long-term functional outcomes are worthwhile.

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.

Vascular calcification exists in different forms that reflect variable clinical and histological implications. Categories of calcification have not been quantified in relation to the clinical presentation of lower extremity arterial disease. The study analyzed 51 femoral plaques collected during femoral endarterectomy, characterized by > 90% stenosis. The plaques were longitudinally sectioned, stained with Hematoxylin and Eosin and digitized for a deep learning platform for quantification of the relative area of nodular calcification to the plaque section area. Vessel measurements and quantity of each calcification category was compared to the clinical risk factors and outcomes. nodular calcification area proportion is associated with reduced risk of severely lowered toe pressure (< 30mmHg) (OR=0.910, 95%CI =0.835-0992, ppp

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. Keywords: Angiosarcoma, Lynch syndrome, Aortic reconstruction, Temporary bypass

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.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.The poorest survival was in patients with ABI1.3 (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 TP50 mm Hg.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.

Objectives Critical limb ischemia (CLI) is a clinical diagnosis, confirmed by objective tests, usually ankle-brachial index (ABI), toe pressure (TP) and TcPO2. Furthermore, the anatomical lesions in patients affected by CLI were visualized by ultrasound, angiography, CTA, or MRA. Indocyanine green fluorescence imaging (ICG-FI) is a diagnostic modality for assessing foot perfusion. We aimed to study the usefulness of ICG-FI in the quality control of revascularization. Materials and methods One hundred and four CLI limbs in 101 patients were studied with ICG-FI using SPY Elite before and after open or endovascular revascularization. ABI and TP were also measured. After ICG-FI, assessment of circulation was done using time-intensity curve derived from the two regions of interest the one being in the plantar side of the foot and the other in the dorsal side of the foot. Three parameters were derived from the curves: maximum intensity (the absolute value of the maximum intensity); intensity rate (the value from the time-intensity curve describing the increase in maximum intensity/s) and SPY10 (the intensity achieved during the first 10 s after the foot starts to gain intensity). Results Sixty-two limbs presented category 3 of Rutherford classification, 12 limbs category 4, and 30 limbs category 5. Ninety-five technically successful procedures were achieved, 63 (66.3%) endovascular and 32 (33.7%) surgical revascularizations. In 9 (9.5%) patients, an in-line flow from the aorta to the foot was not achieved due to a failure to recanalize the occlusion (n = 7) or due to distal embolization (n = 2). ABI was not reliable in 58 patients (57.4%) mostly due to pseudohypertension and TPs in 49 (48.5%) patients mostly due to previous minor amputations. ICG-FI was successful in all patients. The mean intensity values before and after the procedure in patients who underwent successful revascularization were 81 +/- 47 units and 120 +/- 5 units of intensity (p

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.

Objectives Vascular binding of dual antiplatelet and anticoagulant (APAC) was assessed in surgically created femoral arteriovenous fistula (AVF) and iliac and carotid artery injury in porcine models. Methods Three models of collagen exposing injury were used: 1) femoral AVF, 2) in vivo iliac and carotid artery balloon angioplasty injury, and 3) in vitro femoral artery endothelial denudation injury. Biotinylated APAC (0.5 mg/mL) was incubated with the injury site before releasing blood flow. APAC, von Willebrand factor (vWF), laminin, platelet endothelial cell adhesion molecule 1 (PECAM-1), and podocalyxin were detected in histological sections using immunofluorescence and confocal microscopy and Manders' co-localisation coefficient (M1). Results APAC bound to AVF at anastomosis and to both in vivo and in vitro injured arteries. APAC co-localised with matrix vWF (M1 ≥ 0.66) and laminin (M1 ≥ 0.60), but less so if endothelial PECAM-1 or podocalyxin was present (M1 ≤ 0.25). APAC targeted and penetrated the injured vessel wall, especially the AVF vein. Conclusions APAC, compatible with its high negative charge, rapidly targets injured vessels co-localizing with matrix vWF and laminin, but not with endothelial PECAM-1 and podocalyxin. This localising feature may have potential antithrombotic implications for vascular interventions.

Objective Radical excision of retroperitoneal or intra-abdominal soft tissue sarcomas may necessitate vessel resection and reconstruction. The aim of this study was to assess surgical results of retroperitoneal or intra-abdominal sarcomas involving major blood vessels. Methods This was a retrospective single centre cohort study and a comprehensive review of literature. Patients with retroperitoneal or intra-abdominal sarcomas treated by the oncovascular team in Helsinki University Hospital from 2010 to 2018 were reviewed for vascular and oncological outcomes. A comprehensive literature review of vascular reconstructions in patients with retroperitoneal sarcoma was performed. Results Vascular reconstruction was performed in 17 patients, 11 of whom required arterial reconstructions. Sixteen of the operations were sarcoma resections; the post-operative diagnosis for one patient was thrombosis instead of the presumed recurrent leiomyosarcoma. Early graft thrombosis occurred in two venous and one arterial reconstruction. Late thrombosis was detected in three (18%). The median follow up was 27 (range 0–82) months. Of the patients with sarcoma resections 5 (31%) died of sarcoma and further 4 (25%) developed local recurrence or new distant metastases. The comprehensive review of literature identified 37 articles with 110 patients, 89 of whom had inferior vena cava reconstruction only. Eight arterial reconstructions were described. Late graft thrombosis occurred in 14%. The follow up was 0–181 months, during which 57% remained disease free and 7% died of sarcoma. Conclusion Vascular reconstructions enable radical resection of retroperitoneal and intra-abdominal sarcomas in patients with advanced disease. The complex operations are associated with an acceptable rate of serious peri-operative complications and symptomatic thrombosis of the repaired vessel is rare. However, further studies are needed to assess the performance of the vascular reconstructions in the long term.

Objective Very-high resolution US (VHRU; 55 MHz) provides improved resolution and could provide non-invasive diagnostic information in GCA of the temporal artery. The objective of this study was to assess the diagnostic utility of VHRU-derived intima thickness (VHRU-IT) in comparison to high-resolution US halo-to-Doppler ratio (HRU-HDR) in patients referred for temporal artery biopsy. Methods VHRU and HRU of the temporal artery were performed before a biopsy procedure in 78 prospectively recruited consecutive patients who had received glucocorticoid treatment for a median of 8 days (interquartile range 0–13 days) before imaging. Based on the final diagnosis and biopsy findings, the study population was divided into the following four groups: non GCA (n = 40); clinical GCA with no inflammation on biopsy (n = 15); clinical GCA with inflammation limited to adventitia (n = 9); and clinical GCA with transmural inflammation (TMI; n = 11). Results Both VHRU and HRU were useful for identifying subjects with TMI, with VHRU outperforming HRU (area under curve: VHRU-IT 0.99, 95% CI 0.97, 1.00; HRU-HDR 0.74, 95% CI 0.52, 0.96; P=0.026). The diagnostic utility for diagnosing clinical GCA (negative biopsy) or inflammation limited to the adventitia was poor for both VHRU and HRU-HDR. From 5 days after initiation of glucocorticoid treatment, VHRU-IT was increased in eight of nine patients, whereas HRU-HDR was positive in three of seven patients. Both methods showed excellent inter-observer agreement (Cohen’s κ: VHRU-IT 0.873; HRU-HDR 0.811). Conclusion In suspected GCA, VHRU allows non-invasive real-time imaging of TMI manifestations of the temporal artery wall. VHRU-derived intimal thickness measurement seems to be more sensitive than the halo sign and HRU-HDR in detecting TMI in patients with prolonged glucocorticoid treatment.

Preliminary findings suggest that very-high resolution ultrasound (VHRU, 55 MHz) could differentiate arterial intima layer thickness (IT) non-invasively in vivo. We aimed to validate ultrasound-derived IT measurements and describe a four-line pattern consistent with intimal thickening. VHRU was applied to temporal arteries of 37 patients with suspected giant cell arteritis without inflammation on histology. Anatomically matched ultrasound-derived measurements of arterial layer thickness with the leading-edge method was compared to histology. Intimal thickening (IT >0.06 mm on histology) was identified as a four-line pattern in VHRU with a sensitivity of 96.3% and a specificity of 100%. Histologic and VHRU IT measurement agreement was excellent (mean difference 0.007 mm; 95% limits of agreement, -0.043 to 0.057) and intra-class coefficient (ICC) 0.923 (95% confidence interval [CI], 0.833-0.964). Intra- and inter-observer agreements for VHRU IT were high: ICC 0.946 (95% CI, 0.877-0.976) and 0.872 (95% CI, 0.773-0.943). VHRU utilizing the leading-to-leading edge method allows accurate and reliable measurements of arterial IT in patients with IT >0.06 mm. Measurements of IT will provide the opportunity to explore early subclinical structural intimal changes in the arterial wall increasing with age. (C) 2019 World Federation for Ultrasound in Medicine & Biology. All rights reserved.

Objective: The aim of this study was to compare deep body temperature obtained using a novel noninvasive continuous zero-heat-flux temperature measurement system with core temperatures obtained using conventional methods. Design: A prospective, observational study. Setting: Operating room of a university hospital. Participants: The study comprised 15 patients undergoing vascular surgery of the lower extremities and 15 patients undergoing cardiac surgery with cardiopulmonary bypass. Interventions: Zero-heat-flux thermometry on the forehead and standard core temperature measurements. Measurements and Main Results: Body temperature was measured using a new thermometry system (SpotOn; 3M, St. Paul, MN) on the forehead and with conventional methods in the esophagus during vascular surgery (n = 15), and in the nasopharynx and pulmonary artery during cardiac surgery (n = 15). The agreement between SpotOn and the conventional methods was assessed using the Bland-Altman random-effects approach for repeated measures. The mean difference between SpotOn and the was +0.08 degrees C (95% limit of agreement-0.25 to +0.40 degrees C). During cardiac surgery, during off CPB, the mean difference between SpotOn and the pulmonary arterial temperature was-0.05 degrees C (95% limits of agreement-0.56 to +0.47 degrees C). Throughout cardiac surgery (on and off CPB), the mean difference between SpotOn and the nasopharyngeal temperature was-0.12 degrees C (95% limits of agreement-0.94 to +0.71 degrees C). Poor agreement between the SpotOn and nasopharyngeal temperatures was detected in hypothermia below approximately 32 degrees C. Conclusions: According to this preliminary study, the deep body temperature measured using the zero-heat-flux system was in good agreement with standard core temperatures during lower extremity vascular and cardiac surgery. However, agreement was questionable during hypothermia below 32 degrees C. (C) 2016 Elsevier Inc. All rights reserved.

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.

Background A variety of minimally invasive techniques are available for the treatment of varicose great saphenous vein (GSVs). Non-tumescent, non-thermal ablation methods have been developed. This study compared mechanochemical ablation (MOCA), a non-tumescent, non-thermal ablation technique, with two endovenous thermal ablation methods requiring tumescence in an RCT. Methods Patients with GSV reflux were randomized to undergo MOCA, or thermal ablation with endovenous laser (EVLA) or radiofrequency (RFA). The primary outcome measure was the occlusion rate of the GSV at 1 year. Results The study finally included 125 patients, of whom 117 (93·6 per cent) attended 1-year follow-up. At 1 year, the treated part of the GSV was fully occluded in all patients in the EVLA and RFA groups, and in 45 of 55 in the MOCA group (occlusion rates 100, 100 and 82 per cent respectively; P = 0·002). The preoperative GSV diameter was associated with the recanalization rate of the proximal GSV in the MOCA group. At 1 year after treatment, disease-specific life quality was similar in the three groups. Conclusion The GSV occlusion rate 1 year after treatment was significantly higher after EVLA and RFA than after MOCA. Quality of life was similar between interventions. Registration number: NCT03722134 (http://www.clinicaltrials.gov).

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.

Objective/Background Owing to the increased life expectancy of the population the number of very old patients referred to vascular surgical units has increased. Advanced age is a well known risk factor in patients undergoing surgical interventions for lower limb ischemia. However, amputation performed on an elderly person living independently will lead to permanent institutional care. The aim of this study was to evaluate the outcome of patients aged 90 years and older with lower limb ischemia undergoing surgical or endovascular revascularization. Methods Two hundred and thirty-three nonagenarians with either chronic critical limb ischemia (CLI) or acute limb ischemia (ALI) who underwent revascularization at the authors' institution between 2002 and 2013 were included in this retrospective study. Risk factors were evaluated and survival, limb salvage, and amputation free survival (AFS) assessed. Results The median age of the study population was 92 years (range 90–100 years). The majority (81.1%) of the patients were female. One in four (24.5%) patients had diabetes, and the incidence of coronary artery disease was 79.8%. Seventy-three percent of the patients had CLI and 27% of had ALI. Seventy percent of the patients underwent surgical revascularization and 30% were treated endovascularly. The majority (72.5%) of the patients maintained their independent living status; 27.5% ended up in institutional care post-operatively. Similarly, the majority (82.0%) of the patients maintained their walking ability, while 18% were not able to ambulate independently after revascularization. One year survival, limb salvage, and AFS rates were 50.9% versus 48.6% ( p = .505), 85.1% versus 87.0% ( p = .259), and 45.7% versus 44.4% ( p = .309) in the surgical versus endovascular group, respectively. Dementia was an independent risk factor of poor AFS (odds ratio: 1.56; 95% confidence interval: 1.077–2.272; p = .019). Conclusion Good limb salvage can be achieved by both surgical and endovascular revascularization, and independent living can be maintained in the majority of the patients. However, the benefit of revascularization is limited owing to high mortality, especially in patients with dementia.

Background New treatment methods have challenged open surgery as a treatment for great saphenous vein (GSV) insufficiency, the most common being ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA). This study evaluated the long-term results of surgery, EVLA and UGFS in the treatment of GSV reflux. Methods Patients with symptomatic GSV reflux were randomized to undergo either open surgery, EVLA or UGFS. The main outcome measure was the occlusion rate of the GSV at 5 years after operation. Results The study included 196 patients treated during 2008–2010; of these, 166 (84·7 per cent) participated in the 5-year follow-up. At 5 years, the GSV occlusion rate was 96 (95 per cent c.i. 91 to 100) per cent in the open surgery group, 89 (82 to 98) per cent after EVLA and 51 (38 to 64) per cent after UGFS (P < 0·001). For patients who had received no additional treatment during follow-up, the occlusion rates were 96 per cent (46 of 48), 89 per cent (51 of 57) and 41 per cent (16 of 39) respectively. UGFS without further GSV treatment was successful in only 16 of 59 patients (27 per cent) at 5 years. Conclusion UGFS has significantly inferior occlusion rates compared with open surgery or EVLA, and results in additional treatments.

Background and Aims: The objective of this study is to analyze outcomes of the first experiences with drug-eluting balloons in native arteries, vein grafts, and vascular accesses. The study is also a pilot for our future prospective, randomized, and controlled studies regarding the use of drug-eluting balloons in the treatment of the stenosis in bypass vein graft and dialysis access. Materials and Methods: A total of 93 consecutive patients were retrospectively analyzed and in the end 81 were included in the study. Inclusion criteria included at least one previous percutaneous angioplasty to the same lesion. Patients were divided into three groups according to the anatomical site of the lesion: native lower limb artery, vein bypass graft, or vascular access. Time from the previous percutaneous angioplasty to the drug-eluting balloon was compared to the time from the drug-eluting balloon to endpoint in the same patient. Endpoints included any new revascularization of the target lesion, major amputation, or new vascular access. Results: The median time from the drug-eluting balloon to endpoint was significantly longer than the median time from the preceding percutaneous angioplasty to drug-eluting balloon in all three groups. This difference was clearest in native arteries and vein grafts, whereas the difference was smaller from the beginning and disappeared over time in the vascular access group. No significant differences were seen between the groups with regard to smoking, antiplatelet regime, diabetes, Rutherford classification, or sex. Conclusion: Although the setup of this study has several limitations, the results suggest that there could be benefit from drug-eluting balloons in peripheral lesions. Very little data have been published on the use of drug-eluting balloons in vein grafts and vascular accesses, and randomized and controlled prospective studies are needed to further investigate this field.

Background: In the event of rupture of an abdominal aortic aneurysm (AAA), mortality is very high. AAA prevalence and incidence of ruptures have been reported to be decreasing. The treatment of AAA has also undergone a change in recent decades with a shift toward endovascular aneurysm repair (EVAR). Our aim was to evaluate how these changes have affected the elective and emergency treatment of AAA and their results in Finland. Methods: All patients treated for AAA in Finland, a country with a population of 5.5 million, during 2000 to 2014 were searched from the registry of the Finnish Institute for Health and Welfare. Data on all patients who had died of AAA during the same time period were obtained from Statistics Finland. The data were combined and analyzed. Results: The annual incidence of ruptured AAA was 16.4 per 100 000 population over 50 years and decreased significantly during the study period. Over half of the 4949 patients who had a ruptured AAA died outside the hospital. Thirty-day mortality after emergency repair was 39.4%. Intact AAA repairs numbered 4956. The absolute number of annual repairs increased during the study period, and the use of EVAR became the dominant method of elective repair. Thirty-day mortality in elective AAA repair dropped significantly from 6.3% in 2000 to 2004 to 2.7% in 2010 to 2014 mostly because of the increased number of EVAR procedures with lower mortality. Long-term mortality in patients treated with EVAR was higher than in patients treated with open repair. Mortality after elective AAA repair was primarily attributable to cardiovascular causes, but there was a slightly higher proportion of AAA-related late deaths in patients treated with EVAR. Conclusions: Ruptured AAA incidence for men >65 years has declined by nearly 30% in Finland, likely because of the decrease in AAA prevalence. The treatment results have improved as well for both elective and emergency repair. Increased use of EVAR has resulted in a decrease of mortality after elective AAA repair, but results of open repair have improved as well. However, late mortality from elective EVAR is surprisingly high in comparison with open repair, which may have been exaggerated by patient selection.

Objective Despite the popularity of endovascular therapy (EVT) for critical limb ischaemia (CLI), there are few studies investigating the efficacy of duplex ultrasound (DUS) surveillance after endovascular interventions. The aim of this study was to evaluate DUS surveillance after EVT for CLI. Methods 146 endovascular procedures in 134 consecutive patients with CLI between 2011 and 2012 were included. Follow-up visits with ankle-brachial index (ABI), toe pressure, and target vessel DUS were performed at 1, 3, and 6 months after revascularisation. Results The median age of the study population was 79 years, 58% were males, and 55% had diabetes. The target artery was at the iliac, femoro-popliteal, and infrapopliteal level in 2%, 54%, and 44% of cases, respectively. There were 282 follow-up visits. In 15 (5.3%) DUS examinations, the target vessel was not seen properly. In the remaining 267 DUS, the majority of the target arteries were patent with no or mild restenosis (n = 169, 63.3%), but in 98 (36.7%) examinations, the target artery was stenosed or occluded. When DUS was compared with the clinical presentation, there was no correlation in 30% and when DUS and toe pressure were compared, discrepancy was seen in 29%. A re-angiogram was performed for 29 patients, and the DUS finding was verified in each case. During the mean follow-up of 11 months, a new endovascular intervention was performed on 37 (25.3%) limbs, and 4 (2.7%) underwent surgical bypass. Four (3.0%) patients died and 6 (4.5%) underwent major amputation. Conclusion Clinical status or toe pressure alone were adequate markers of endovascular revascularisation failure in the majority of the patients, but would have missed up to one-third of the clinically significant restenoses or occlusions. DUS is therefore a valuable aid in surveillance after EVT for CLI, especially for patients with an ischaemic tissue lesion.

Objective Chronic cerebrospinal venous insufficiency (CCSVI) has been proposed as a major risk factor for multiple sclerosis (MS). The aim of this study was to assess inter-observer agreement between two ultrasound examiners and to compare findings in MS patients and control participants. Methods A prospective, blinded, controlled study of MS patients diagnosed within 2 years (MS ≤ 2, n = 39), patients diagnosed more than 10 years ago (MS > 10, n = 43) and age- and sex-matched control participants (n = 40). Ultrasound examinations were performed by two independent examiners. CCSVI criteria 1, 3, 4 and 5 as proposed by Zamboni were explored: (1) reflux in the internal jugular (IJV) and vertebral veins (VV), (3) IJV cross-sectional area (CSA) ≤0.3 cm2, (4) absence of flow in IJV and VV, and (5) reverted postural control of venous outflow. Results Criteria 1, 4 and 5 were met in less than 10% of the MS patients and control participants as studied by both examiners. The level of inter-observer agreement was poor for all parameters except assessment of the CSA of IJV at the thyroid level. Findings meeting CCSVI criterion 3 (CSA ≤ 0.3 cm2) were observed in 18/40 (45%) of the control participants, in 24/37 (65%) of MS ≤ 2 patients (p = 0.09 vs. control participants) and in 30/43 (70%) of the MS > 10 patients (p = 0.022 vs. control participants). Conclusions The feasibility of the CCSVI criteria for common use is questionable because of low inter-observer agreement. Small-calibre IJVs meeting the CCSVI criterion 3 appear common in both Finnish control participants and MS patients, but the clinical significance of this finding is questionable.

Summary Background and objectives The role of thrombophilia in failing arteriovenous fistula (AVF) among patients with ESRD undergoing hemodialysis is not established. This study aimed to assess whether AVF primary patency is associated with thrombophilia and coagulation abnormalities. Design, setting, participants, & measurements This observational study screened 219 patients between 2002 and 2004 for thrombophilia before AVF surgery. Thrombophilia included factor V Leiden and prothrombin G20210A mutations, protein C and antithrombin activities, and protein S. Coagulation abnormalities included high factor VIII:C, homocysteine, fibrinogen, and d-dimer levels; presence of antiphospholipid antibodies; and short thrombin time. We reviewed patient charts for comorbid conditions, AVF maturation and interventions, kidney transplantation, and patient survival (mean follow-up duration, 3.6 [range, 2.3–5.8] years). Primary patency from the AVF placement and functional primary patency from the first AVF cannulation were analyzed with Kaplan-Meier and Cox proportional hazards models. Results Thrombophilia was present in 9% of the patients, and coagulation abnormalities occurred in 77%. One-year primary patency was 68%; 46% of the AVF failures occurred before the initiation of hemodialysis. Female sex (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.7–4.1) and thrombophilia (HR, 2.2; 95% CI, 1.2–4.2) were independent risk factors for loss of primary patency. Thrombophilia mutations or low antithrombin level (HR, 3.8), female sex (HR, 2.5), and diabetes (HR, 1.9) were associated with shortened functional primary patency of AVF. Conclusions Against the background of frequent coagulation abnormalities, thrombophilia and female sex predispose patients with ESRD to access failure, mostly due to thrombosis or stenosis.

ObjectiveBecause of the prolonged healing time of diabetic foot ulcers, methods for identifying ways to expedite the ulcer healing process are needed. The angiosome concept delineates the body into three-dimensional blocks of tissue fed by specific source arteries. The aim of this study was to evaluate the benefit of infrapopliteal endovascular revascularization guided by an angiosome model of perfusion in the healing process of diabetic foot ulcers.MethodsA total of 250 consecutive legs with diabetic foot ulcers in 226 patients who had undergone infrapopliteal endovascular revascularization in a single center were evaluated. Patient records and periprocedural leg angiograms were reviewed. The legs were divided into two groups depending on whether direct arterial flow to the site of the foot ulcer based on the angiosome concept was achieved (direct group) or not achieved (indirect group). Ulcer healing time was compared between the two groups. A propensity score was used for adjustment of differences in pretreatment covariables in multivariate analysis and for 1:1 matching.ResultsDirect flow to the angiosome feeding the ulcer area was achieved in 121 legs (48%) compared with indirect revascularization in 129 legs. Foot ulcers treated with angiosome-targeted infrapopliteal percutaneous transluminal angioplasty healed better. The ulcer healing rate was mean (standard deviation) 72% (5%) at 12 months for the direct group compared with 45% (6%) for the indirect group (P < .001). When adjusted for propensity score, the direct group still had a significantly better ulcer healing rate than the indirect group (hazard ratio, 1.97; 95% confidence interval, 1.34-2.90; P = .001).ConclusionsAttaining a direct arterial flow based on the angiosome model of perfusion to the foot ulcer appears to be important for ulcer healing in diabetic patients.

Background and Aims: Perioperative myocardial infarction is an underdiagnosed complication causing morbidity, mortality, and considerable costs. However, evidence of preventive and therapeutic options is scarce. We investigated the incidence and outcome of perioperative myocardial infarction in non-cardiac surgery patients in order to define a target population for future interventional trials. Material and Methods: We conducted a prospective single-center study on non-cardiac surgery patients aged 50 years or older. High-sensitivity troponin T and electrocardiograph were obtained five times perioperatively. Perioperative myocardial infarction diagnosis required a significant troponin T release and an ischemic sign or symptom. Perioperative risk calculator was used for risk assessment. Results: Of 385 patients with systematic ischemia screening, 27 patients (7.0%) had perioperative myocardial infarction. The incidence was highest in vascular surgery—19 of 172 patients (11.0%). The 90-day mortality was 29.6% in patients with perioperative myocardial infarction and 5.6% in non–perioperative myocardial infarction patients ( p < 0.001). Perioperative risk calculator predicted perioperative myocardial infarction with an area under curve of 0.73 (95% confidence interval: 0.64–0.81). Conclusion: Perioperative myocardial infarction is a common complication associated with a 90-day mortality of 30%. The ability of the perioperative risk calculator to predict perioperative myocardial infarction was fair supporting its routine use.

Objectives: The number of elderly people is increasing; inevitably, the result will be more patients with critical limb ischaemia (CLI) in the future. Tissue loss in CLI is related to a high risk of major amputation. The aim of this study was to analyze the treatment process from referral to revascularisation, to discover possible delays and reasons behind them, and to distinguish patients benefitting the most from early revascularisation. Methods: A retrospective analysis was performed of 394 consecutive patients with a combined 447 affected limbs, referred to the outpatient clinic during 2010-2011 for tissue loss of suspected ischaemic origin. Results: For 246 limbs revascularisation was scheduled. After changes in the initial treatment strategy, endovascular treatment (ET) was performed on 221 and open surgery (OS) on 45 limbs. Notably there was crossover after ET in 17.0% of the procedures, and re-revascularisations were required in 40.1% after ET and 31.1% after OS. The median time from referral to revascularisation was 43 days (range 1-657 days) with no significant difference between ET and OS. For 29 (11.8%) patients the ischaemic limb required an emergency operation scheduled at the first visit to the outpatient clinic. For 25 (10.2%) patients the situation worsened while waiting for elective revascularisation and an emergency procedure was performed. Diabetic patients formed the majority of the study population; with 159 diabetic feet undergoing revascularisation. In multivariate analysis, diabetes was associated with poor limb salvage. When revascularisation was achieved within 2 weeks, no difference was seen in limb salvage. However, when the delay from first visit to revascularisation exceeded 2 weeks, limb salvage was significantly poorer in diabetic patients. Conclusions: Diabetic ulcers always require vascular evaluation, and when.ischaemia is suspected the diagnostics should be organised rapidly to ensure revascularisation without delay, according to this study within 2 weeks from the first evaluation. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background: The definition of angiosome-targeted revascularization is confusing, especially when a tissue lesion affects several angiosomes. Two different definitions of direct revascularization exist in the literature. The study aim was (1) to compare the 2 definitions of direct revascularization in patients with foot lesions involving more than one angiosome and (2) to evaluate which definition better predicts clinical outcome. Methods: This study cohort comprises 658 patients with Rutherford 5-6 foot lesions who underwent infrapopliteal endovascular or surgical revascularization between January 2010 and July 2013. We compared the 2 angiosome-targeted definitions using multivariate analysis; the impact of each angiosome-targeted definition was adjusted for a propensity score obtained by means of nonparsimonious logistic regression. Results: Direct revascularization according to definition A was performed in 367 cases (55.8%) versus 198 cases (30.1%) with definition B. The propensity-score-adjusted analysis showed that definition A of direct revascularization was associated with significantly better wound healing (P

Objectives: This study was planned to evaluate the prognostic impact of end-stage renal disease (ESRD) in patients with critical leg ischemia (CLI) undergoing infrainguinal revascularization. Materials and Methods: 1425 patients who underwent infrainguinal revascularization for CLI were the subjects of the present analysis. Ninety-five patients had ESRD (eGFR < 15 ml/min/m2), and of them 66 (70%) underwent percutaneous transluminal angioplasty and 29 (30%) underwent bypass surgery. Results: ESRD patients had significantly lower overall survival (at 3-year, 27.1% vs. 59.7%, p < 0.0001), leg salvage (at 3-year, 57.7% vs. 83.0%, pConclusions: Lower limb revascularization in patients with CLI and end-stage renal failure is associated with favourable leg salvage. However, these patients have a very poor survival and this may jeopardize any attempt of revascularization. Further studies are needed to identify ESRD patients with acceptable life expectancy and who may benefit from lower limb revascularization.

Introduction This study aimed to evaluate the impact of angiosome targeted (direct) revascularisation according to revascularisation method in patients with diabetes. Materials and methods This retrospective study cohort comprised 545 diabetic patients with critical limb ischaemia and tissue loss (Rutherford 5, 6). All patients underwent infrapopliteal endovascular (PTA) or open surgical revascularisation between January 2008 and December 2013. Differences in the outcome after direct revascularisation, bypass surgery, and PTA were investigated by means of Cox proportional hazards analysis. The endpoints were wound healing, leg salvage, and amputation free survival. Results Overall, 60.3% of the ischaemic wounds healed during 1 year of follow-up. The highest wound healing rate was achieved after direct bypass (77%) and the worst after indirect PTA (52%). The Cox proportional hazards analysis showed that the number of affected angiosomes p = .001). When Cox proportional hazard analysis was adjusted for the number of affected angiosomes, direct bypass gave the best wound healing (p = 0.003). The overall amputation rate was 25.1% at 1 year of follow-up, and the Cox proportional hazards analysis indicated that haemodialysis compared with patients with no haemodialysis (HR 2.55, 95% CI 1.49–4.38), C-reactive protein ≥10 mg/dL (HR 2.05, 95% CI 1.45–2.90), atrial fibrillation (HR 1.54, 95% CI 1.05–2.26), and number of affected angiosomes >3 (HR 1.75, 95% CI 1.24–2.46) were significantly associated with poor leg salvage. Direct PTA was associated with a lower rate of major amputation compared with indirect PTA (HR 0.57 95% CI 0.37–0.89). Conclusion In diabetics, indirect endovascular revascularisation leads to significantly worse wound healing and leg salvage rates compared with direct revascularisation. Therefore, endovascular procedures should be targeted according to the angiosome concept. In bypass surgery, however, the concept is of less value and the artery with the best runoff should be selected as the outflow artery.

The aim of the study was to stratify the risk of diabetic patients with leg ulcer or gangrene undergoing infrainguinal revascularisation for critical limb ischaemia.The study cohort included 732 revascularisation procedures performed in 597 diabetic patients with ulcer or gangrene. Logistic regression and CART analysis were used for identification of predictors of 1-year outcome.Logistic regression showed that chronic kidney disease (CKD) class (OR 1.38, 95% CI 1.16, 1.65) was an independent predictor of 1-year leg salvage (area under the receiver operating characteristic [ROC] curve 0.60, 95% CI 0.54, 0.65). The terminal nodes of the CART for 1-year leg salvage were CKD classes 4-5, the level (infrapopliteal vs femoropopliteal revascularisation), type of revascularisation (bypass surgery vs percutaneous transluminal angioplasty) and gangrene (area under the ROC curve 0.62, 95% CI 0.57, 0.68). Logistic regression showed that pulmonary disease (OR 1.76, 95% CI 1.11, 2.78), CKD class (OR 1.43, 95% CI 1.24, 1.65), foot gangrene (OR 1.76, 95% CI 1.21, 2.60) and patient age (OR 1.02, 95% CI 1.01, 1.04) were independent predictors of 1-year amputation-free survival (area under the ROC curve 0.65, 95% CI 0.60, 0.69). The terminal nodes of the CART for 1-year amputation-free survival were CKD classes 3-5, patient's age of ≥ 75 years and foot gangrene (area under the ROC curve 0.64, 95% CI 0.60, 0.68).CKD is a formidable risk factor for poor intermediate outcome after infrainguinal revascularisation in diabetic patients with foot ulcer or gangrene. CART analysis indicates that foot gangrene is also a significant risk factor for adverse outcome.

ObjectivesTo compare the outcomes of femoropopliteal percutaneous transluminal angioplasty (PTA) and bypass surgery for critical limb ischaemia (CLI).DesignThe study is retrospective in nature.Materials and methodsThis study included 858 consecutive patients, who underwent femoropopliteal revascularisation for CLI at Helsinki University Central Hospital during 2000–2007. As many as 517 patients (60%) underwent PTA and 341 (40%) bypass surgery. Propensity score analysis was used for risk adjustment in multivariable analysis and for one-to-one matching.ResultsIn the overall series, PTA had poorer long-term results than bypass (5-year leg salvage, 78.2% vs. 91.8%, p

Objective Ulcer healing is a seldom reported outcome in studies of critical leg ischemia (CLI). The aim of this study was to analyze local factors affecting ulcer healing time after infrainguinal bypass surgery (IBS) for CLI Fontaine IV. Methods In this prospective single center cohort study, 110 patients (113 legs) undergoing IBS due to CLI with ischemic tissue defects during year 2006 were followed prospectively for 1 year after the bypass. Ulcer location, duration, presence of gangrene, and the University of Texas wound classification (UTWCS) were determined at presentation. Healing time of the ischemic tissue defects, leg salvage, patency, and survival were calculated. The characteristics of the ischemic tissue lesions and patient comorbidities were analyzed to determine risk factors for adverse outcome. Results Complete ulcer healing (±SE) was achieved in 74% ± 5% of the legs 12 months after IBS. Median ulcer healing time was 186 days (range, 11 to >365 days). Leg salvage, secondary patency, and survival at 12 months were 87% ± 3%, 82% ± 4%, and 76% ± 5%, respectively. Amputation-free survival with healed ulcers was attained in 55% at 12 months. Ischemic tissue lesions located in the mid- and hindfoot had significantly prolonged ulcer healing time (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.1 to 0.9, P = .044). None of the UTWCS classes predicted either ulcer healing time or leg salvage. Median ulcer duration before IBS was 68 days, range, 6 to 1154 days. Ulcer duration did not correlate with ulcer healing time (Spearman r = 0.138, P = .267). Ischemic ulcers with gangrene were not associated with prolonged ulcer healing time ( P = .353). Conclusion The location of the ischemic tissue lesions influences ulcer healing time. According to our study UTWCS can be used as descriptive classification of ischemic ulcers but it does not predict the ulcer healing time or leg salvage after infrainguinal bypass surgery.

Objective To evaluate healing time of ischaemic tissue lesions, limb salvage and survival in patients suffering from critical limb ischaemia (CLI) with tissue loss. Design Prospective single centre cohort study. Material and methods Consecutive patients with CLI and tissue loss (Fontaine IV) (148 patients, 150 limbs) were followed prospectively for 1 year after infrainguinal bypass. Healing time of tissue lesions, graft patency, limb salvage, survival rates and the overall need for any type of surgical and endovascular procedure were analysed. Patient comorbidities were assessed by uni- and multivariate analysis to determine risk factors for adverse outcome. Results Complete tissue healing, including healing of ischaemic tissue lesions and surgical wounds, at 6 and 12 months after the infrainguinal bypass were respectively 40% and 75%. The median time to complete tissue healing was 190 days. Diabetes was the only significant risk factor which delayed tissue healing. Overall patency, limb salvage, survival and amputation-free survival rates were respectively at 12 months 80%, 81%, 73% and 63%. The clinically important endpoint amputation-free survival with completely healed wounds was attained in 50% of patients at 1 year. Conclusion Complete healing of ischemic tissue lesions is slow even after a successful infrainguinal bypass.

ObjectivesRenal insufficiency is a risk factor for poor outcome after infrainguinal bypass in patients with critical limb ischemia (CLI). Estimated glomerular filtration rate (eGFR) takes age, gender and body size into account and therefore represents actual renal function more accurately than serum creatinine level alone. The aim of this study was to determine the impact of different stages of renal insufficiency on outcome and to assess the prognostic significance of eGFR in patients with CLI.Material and methods603 patients with CLI who underwent infrainguinal bypass between January 2002 and December 2005 at our institution were included in this retrospective study. We estimated GFR using the Modification of Diet in Renal Disease (MDRD) Study equation. Survival, leg salvage and amputation-free survival were calculated using Kaplan–Meier method. Cox regression analysis was performed to calculate hazard ratios for different outcome variables.ResultsAdjusted hazard ratio (HR) of mortality, limb loss and limb loss and/or death for eGFR 200μmol/l was 4.0 (95% CI 2.22–7.39) vs 3.5 (95% CI 1.82–6.84), 6.5 (95% CI 2.71–15.59) vs 6.2 (95% CI 2.47–15.56) and 4.0 (95% CI 2.40–6.63) vs 3.6 (95% CI 2.03–6.25), respectively.ConclusionEstimated GFR is better predictor of survival, leg salvage and amputation-free survival than serum creatinine alone. eGFR

Objectives To evaluate long-term durability and clinical success of deep venous reconstruction for severe chronic venous insufficiency as a part of routine workload at a university vascular surgery department. Study design Retrospective analysis of clinical series. Patients Between 1996 and 2000, 43 patients underwent deep venous reconstruction, and 38 were available for follow-up. Of these, 29 had secondary valve disease. Median follow-up time was 4.5 years (range, 2-6.5). Preoperatively, 20 had active or healed ulcers. Methods Severity of the disease was assessed by the CEAP classification, clinical severity and disability scores, and duplex evaluation. Criteria for clinical success were the following: no or mild symptoms and ability to work for eight hours. Surgical reconstructions included 12 internal and seven external valvuloplasties, 14 vein transpositions, and 29 valve transplantations. Of the 38 patients, six needed at least one further reconstruction. Follow-up visits were set at one month, six months, and thereafter annually. Two independent examiners performed the final examination. Results The overall cumulative clinical success rate at four years was 23%, and freedom from ulcer 54%. Valvuloplasties were the most durable techniques with a cumulative 4-year durability rate of 55%. The durability rate for transpositions was 43%, and for transplantations 16%. Of 13 reconstructions for primary insufficiency, nine were durable. Conclusions Overall results were unsatisfactory, although the durability of reconstructions for primary insufficiency were acceptable.

Objectives To assess the extent of discrepancies between different vascular registries, at various levels of validation, and to investigate whether such differences might alter the morbidity and mortality rates obtained from the gold standard dataset for carotid endarterectomy (CEA). Methods All CEA operations in Helsinki University Central Hospital from 2000–2005 were retrieved from the local vascular registry (HUSVASC) and the Hospital Discharge Registry (HILMO). Both registries were validated at different levels to form the final dataset. Total and indication-specific perioperative morbidity and mortality rates were estimated from each level of validation and compared with those from the final dataset and with pooled rates from systematic reviews. Results Initial search provided 675 and 681 CEAs from HUSVASC and HILMO, respectively, decreasing to 636 (94%) and 614 (90%) when using the specific operative codes for thrombendarterectomy and patch angioplasty. Manual verification of initial HUSVASC results proved that 655 (97%) operations were true CEAs. 18 further proven CEAs, registered only in HILMO, were added to form the final CEA dataset ( n = 673). The peri-operative morbidity and combined morbidity and mortality rates were 2.23% and 2.67%, respectively. Comparable rates were obtained from both registries, irrespective the level of verification. Conclusion Registry data do not appear to be biased by random loss of some operations and thus they are reliable for decision-making. However, further research is still needed to estimate the permissible volume of omissions in a registry for the data-base to remain trustworthy.

Background Ankle brachial index (ABI), toe pressures (TP), and transcutaneous oxygen pressure (TcPO 2 ) are traditionally used in the assessment of critical limb ischemia (CLI). Indocyanine green (ICG) fluorescence imaging can be used to evaluate local circulation in the foot and to evaluate the severity of ischemia. This prospective study analyzed the suitability of a fluorescence imaging system (photodynamic eye [PDE]) in CLI. Material and methods Forty-one patients with CLI were included. Of the patients, 66% had diabetes and there was an ischemic tissue lesion in 70% of the limbs. ABI, toe pressures, TcPO 2 and ICG-fluorescence imaging (ICG-FI) were measured in each leg. To study the repeatability of the ICG-FI, each patient underwent the study twice. After the procedure, foot circulation was measured using a time-intensity curve, where T1/2 (the time needed to achieve half of the maximum fluorescence intensity) and PDE10 (increase of the intensity during the first 10 s) were determined. A time-intensity curve was plotted using the same areas as for the TcPO 2 probes ( n =123). Results The mean ABI was 0.43, TP 21 mmHg, TcPO 2 23 mmHg, T1/2 38 s, and PDE10 19 AU. Time-intensity curves were repeatable. In a Bland-Altman scatter plot, the 95% limits of agreement of PDE10 was 9.9 AU and the corresponding value of T1/2 was 14 s. Correlation between ABI and TP was significant ( R =.73, p R =.47, p =.048) compared with non-diabetic patients ( R =.89, p =.002). Correlations between ABI and TcPO 2 and TP and TcPO 2 were weak ( R =.37, p =.05 and R =.43, p =.037, respectively). Correlation between TcPO 2 and PDE10 was strong in diabetic patients ( R =.70, p =.003). Conclusions According to this pilot study, ICG-FI with PDE can be used in the assessment of blood supply in the ischemic foot.