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Objective: To report our long-term experience in using the hybrid technique in complex thoracoabdominal aortic aneurysms (TAAAs). Methods: Between March 2005 and September 2013, 10 patients with TAAA underwent hybrid procedures with open renovisceral revascularization and thoracoabdominal aortic endografting. Patients were analyzed retrospectively. Results: Six men and 4 women with a mean age of 66 years (range 54-81 years) were treated electively during the study period. All 4 visceral vessels were revascularized in 8 patients, whereas 1 patient underwent 3-vessel revascularization and another 2-vessel revascularization. The primary technical success rate was 100%. Eight of the procedures were single staged, and the 2 most recent cases were performed in 2 stages. Perioperative and 30-day mortality was 0%. The mean follow-up was 55 months (4-133 months). None of the patients died due to aortic complications. Major complications included paraplegia (10%, n = 1) and bowel ischemia (n = 1). Postoperative cerebrospinal fluid (CSF) pressure and mean arterial pressure measurements were systematically monitored and corrected. The CSF drainage solved another 4 cases of paraparesis. Three patients required postoperative dialysis, but none of them required permanently. Postoperative spinal cord ischemia and renal complications accumulated in extensive TAAA cases. One renal graft was occluded 45 days after the initial procedure but was successfully treated with thrombolysis. One type I and 1 type III endoleak were noted and successfully treated with an additional stent graft. Two cases of type II endoleak were detected—one with a growing aneurysm sac was treated successfully and another showed no growth and further procedures were abandoned after 2 embolization attempts. In long-term follow-up, 90% of the aneurysms showed shrinkage by a mean of 23 mm (range 7-45 mm). Conclusion: The results of hybrid repair on high-risk patients with complex TAAAs are encouraging, and this approach is a valuable alternative when branched and fenestrated endovascular techniques are not considered an option. [ABSTRACT FROM AUTHOR]

Purpose: To report the long-term results of thoracic endovascular aortic repair (TEVAR) in both elective and emergency cases of thoracic aortic aneurysm (TAA) and type B dissection. Material and Methods: A prospective single-center study of 78 TEVAR patients treated between February 1998 and February 2013. Stent-graft implantation was performed in 51 (65%) patients for TAA (43 elective and 8 emergency cases) and in 27 (35%) patients for type B dissection (11 elective and 16 emergency cases). Short- and long-term results were evaluated, and a subgroup of patients with left subclavian artery (LSA) coverage was also analyzed. Results: The patients were followed for a mean of 55 months (1-160 months). The technical success rate was 81% and 30-day mortality 6.4% (n = 5). The stroke rate was 7.7% (n = 6) and permanent paraparesis 2.6% (n = 2). In follow-up, there were 28 (36%) primary (15 type I and 13 type II) and 10 secondary endoleaks (8 type I and 2 type II). Multivariate analysis showed no significant predictive factors for developing a type I endoleak. Secondary interventions were required in 24% of the patients. There was 1 late thoracic aortic rupture and 1 late conversion (1.3%). Patients with LSA coverage had a higher incidence of stroke (12.5% vs 4.3%, P = .18) and paraparesis (3.1% vs 2.2%, P = .79) compared to those without LSA coverage, although this difference was not statistically significant. Stroke rates were significantly higher in patients treated in an emergency setting (P = .048). Conclusion: Thoracic endovascular aortic repair is a relatively safe and effective therapy for different aortic pathologies with good long-term success. The risk of stroke and paraparesis is notable whether the LSA is covered, and strokes clearly accumulate in the emergency setting. A type I endoleak is the most common complication, but there are no predictive factors for its development. [ABSTRACT FROM AUTHOR]

Background and aims: Little is known about the role of peripheral arterial disease (PAD) in the development of balance impairment. The aim of this study was to assess postural balance among people having PAD or PAD combined with diabetes. Methods: As part of the comprehensive health examination of the Health 2000 survey (two-stage stratified cluster sampling), 1323 people aged 65 years or older took part in balance assessments using a force platform system. The presence of PAD was confirmed with data from the National Hospital Discharge Registry. Individuals with hospitalization due to PAD were regarded as having severe disease, whereas those with solely self-reported diagnosis were considered possible cases. Diabetes was ascertained on the basis of self-reported physicians' diagnoses subsequently confirmed in a clinical examination. Results: Forty-five (3.4%) individuals had previously been hospitalized due to PAD, and 32 (2.4%) reported that they had been diagnosed with the disease. 413 (31%) participants had diabetes. Compared with people without PAD, those with confirmed diagnoses exhibited significantly increased movement of the center of pressure while standing, indicating deteriorated balance. Those with possible PAD formed an intermediate group. Diabetes exacerbated the deterioration in balance, but the interaction term between PAD and diabetes did not reach statistical significance. The risk of failing tandem stance tests was over three-fold (OR 3.20, 95% CI 1.09-9.37) among those with confirmed PAD and almost one and a half-fold (OR 1.44, 95% CI 1.07-1.93) among those with diabetes, in comparison to those without these diseases. Conclusions: Individuals over 65 years of age with severe PAD showed increased balance impairment, a known risk factor for falls and disability in aged people. Diabetes affected balance somewhat less than PAD, but there was no formal evidence of the synergetic effect of the two diseases. Additional studies are indicated to reveal the possible effect of proper treatment of PAD and diabetes, combined with suitable training interventions on slowing down the progression of balance impairment. [ABSTRACT FROM AUTHOR]

Background and aims: The purpose of this study was to characterize the prevalence and clinical features of peripheral arterial disease (PAD) among 90-year-old individuals and to assess its relationship to lower extremity functional status and survival over one year. Methods: A prospective, population- based study of all 90-year-old residents of Jyväskylä, Finland. Fifty-eight out of the 79 registered residents were examined for ankle-brachial index (ABI). Lower extremity functional status was assessed as self-reported difficulty in performing specific physical activities of daily living (PADL). In a subgroup of 36 individuals, lower extremity functioning was further assessed by measuring walking endurance and walking velocity. Death dates were collected for one year after the examination from the hospital register. Results: Thirteen persons (22%) had an ABI<0.9. PAD was asymptomatic in 11 of them and the diagnosis of PAD new to 12 of them. Thirty (52%) subjects had a normal ABI (0.9-1.4) and in 15 (26%) cases the ABI was pathologically high (>1.4). A significant accumulation of cardiovascular risk factors was observed among those with an ABI<0.9 compared with those with normal or high ABI (2.0±0.8 vs 1.3±0.8 vs 1.5±0.5, p=0.03). Those with low or high ABI reported more difficulties in the PADL tasks than those with normal ABI, but the results did not reach statistical significance. No difference in maximal walking velocity was observed according to ABI in the subgroup with data available. After one year, nine people had died, of whom only two (7%) with normal ABI and seven with low or high ABI (25%) (p=0.05). Conclusions: PAD was found to be mainly asymptomatic among 90-year-old people. An abnormal ABI was also associated with increased mortality risk over a one-year follow-up. Although our study was small-scale, it does provide novel information about the prevalence of PAD and clinical significance of ABI in very old people. [ABSTRACT FROM AUTHOR]

Mortality remains high after emergency open surgery for a ruptured abdominal aortic aneurysm (RAAA). The aim of the present study was to assess, if intravenous (IV) Interferon (IFN) beta-1a improve survival after surgery by up-regulating Cluster of differentiation (CD73). This is a multi-center phase II double-blind, 2:1 randomized, parallel group comparison of the efficacy and safety of IV IFN beta-1a vs. placebo for the prevention of death after open surgery for an infra-renal RAAA. All study patients presented a confirmed infra-renal RAAA, survived the primary emergency surgery and were treated with IFN beta-1a (10 μg) or matching placebo for 6 days after surgery. Major exclusion criteria included fatal hemorrhagic shock, chronic renal replacement therapy, diagnosed liver cirrhosis, severe congestive heart failure, advanced malignant disease, primary attempt of endovascular aortic repair (EVAR), and per-operative suprarenal clamping over 30 min. Main outcome measure was all-cause mortality at day 30 (D30) from initial emergency aortic reconstruction. The study was pre-maturely stopped due to a reported drug-drug interaction and was left under-powered. Out of 40 randomized patients 38 were included in the outcome analyses (27 IFN beta-1a and 11 placebo). There was no statistically significant difference between treatment groups at baseline except more open-abdomen and intestinal ischemia was present in the IFN beta-1a arm. D30 all-cause mortality was 22.2% (6/27) in the IFN beta-1a arm and 18.2% (2/11) in the placebo arm (OR 1.30; 95% CI 0.21-8.19). The most common adverse event relating to the IFN beta-1a was pyrexia (20.7% in the IFN beta-1a arm vs. 9.1% in the placebo arm). Patients with high level of serum CD73 associated with survival (P = 0.001) whereas the use of glucocorticoids and the presence of IFN beta-1a neutralizing antibodies associated with a poor CD73 response and survival. The initial aim of the trial, if postoperative INF beta-1a treatment results on better RAAA survival, could not be demonstrated. Nonetheless the anticipated target mechanism up-regulation of CD73 was associated with 100% survival. According to present results the INF beta-1a induced up-regulation of serum CD73 was blocked with both use of glucocorticoids and serum IFN beta-1a neutralizing antibodies. The study was pre-maturely stopped due to interim analysis after a study concerning the use if IV IFN beta-1a in ARDS suggested that the concomitant use of glucocorticoids and IFN beta-1a block the CD73 induction. Trial registration: ClinicalTrials.gov NCT03119701. Registered 19/04/2017 (retrospectively registered)., (© 2022. The Author(s).)

Objective: Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism (PE), is an infrequent but consequential and potentially preventable complication after major surgical procedures. The aim of the study was to describe the long-term occurrence of symptomatic VTE in patients undergoing abdominal aortic aneurysm (AAA) repair and to ascertain patient-specific risk factors as well as to compare the rate with that of a reference population., Methods: The study included all patients who had undergone endovascular or open AAA repair, both elective and urgent/acute cases, at the Tampere University Hospital (Finland) between February 2001 and December 2016; 59% of patients had undergone endovascular and 41% open repair, and 23% of all cases had required urgent or emergency treatment. Information about later treatment episodes for symptomatic VTE and survival data were obtained from national registries. The reference population was obtained from national registries with a random sample of inhabitants matched for age, sex, and location of residence with a 4:1 ratio and was analyzed similarly., Results: Altogether, 1021 patients and 4065 controls were included (88% male; median age, 74 years in both groups). The high-risk period for VTE lasted for approximately 3 months, and during that time, its occurrence was highest in patients with coronary disease (2.5%), after open repair (2.4%), and in an urgent or emergency setting (2.6%), whereas the rate was low after endovascular aneurysm repair (1.0%). The cumulative incidence of VTE at 3 months, 1 year, 3 years, and 5 years was 1.1%, 1.6%, 2.7%, and 4.5% in patients and 0.1%, 0.3%, 1.0%, and 1.8% in the reference population, respectively (P < .001 each). Most VTE events were PE in the patient group. The 5-year mortality rates were 37.9% in patients and 23.8% in controls (P < .001)., Conclusions: The incidence of symptomatic VTE, particularly PE, after AAA repair is significant, in both short-term and long-term follow-up. Open surgery, acute setting, and concomitant coronary disease appear to increase the risk., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The problems with first-generation stent grafts for endovascular aneurysm repair are well known, but their long-term outcome remains to be established. The purpose of the study was to characterize the outcome of patients treated for abdominal aortic aneurysm (AAA) with a first-generation stent graft, Vanguard (Boston Scientific, Natick, Mass), in a single academic center with a follow-up of up to 20 years., Methods: There were 48 AAA patients electively treated with a Vanguard stent graft between February 1997 and November 1999. The patients were monitored annually until the end of 2018. The outcomes were overall survival and the number of graft-related complications and reinterventions., Results: The mean age was 70 years (range, 54-85 years), and the mean follow-up was 107 months (range, 6-262 months). All stent grafts were successfully implanted, but 90% of the patients encountered graft-related complications during follow-up. The most common complications were endoleaks (type I, 27%; type II, 29%; type III, 31%), stent fracture (46%), graft thrombosis (31%), and migration (40%). A total of 40 (83%) patients required a secondary procedure during long-term follow-up. The endovascular method for treating the complication was successful in 73 (87%) of 84 cases. There were no primary conversions, but 10 patients (21%) required a late conversion. In five cases, the complications required relining with a newer device. There were four AAA ruptures (8.3%), two of them fatal. The cumulative overall survival rates were 94%, 69%, 33%, 15%, and 13% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively., Conclusions: The use of the Vanguard, a first-generation stent graft, was associated with multiple graft-related complications. However, these complications could mainly be treated by endovascular means. The Vanguard stent graft is a good example of how new technology can cause unpredictable problems that can magnify the workload and endanger the patient's well-being even decades after the initial procedure., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective/background: Although endovascular aneurysm repair (EVAR) has been widely adopted, long-term data remain limited. This study analyses the long-term outcome (16 years) after EVAR with the Zenith stent graft in a single academic centre., Methods: From 2000 to 2010, 282 patients with an abdominal aortic aneurysm (AAA) were treated electively and monitored annually. Primary outcomes were overall and AAA rupture free survival; the secondary outcomes were complication and re-intervention free survival. Kaplan-Meier analysis was used to examine survival., Results: The median patient age was 76 years (range 49-92 years) and mean aneurysm diameter 61 mm (range 40-110 mm). Patients were followed for a median of 76 months (range 0-201 months). Overall survival was 93% (SE 0.02), 61% (SE 0.08), 25% (SE 0.16), and 9% (0.19) at 1, 2, 5, 10, and 16 years, respectively. Ten (3.5%) AAA ruptures occurred, and the cumulative AAA rupture free survival was 100%, 98% (SE 0.01), 96% (SE0.02), and 79% (SE 0.12) at 1, 5, 10, and 16 years, respectively. The mean annual AAA rupture rate was 0.5%. Freedom from any stent graft related complications was 68% (SE 0.03), 58% (SE 0.09), 54% (SE 0.17), and 52% (SE 0.21), respectively; freedom from graft related re-interventions was 95% (SE 0.01), 80% (SE 0.08), 73% (SE 0.11), 70% (SE 0.16), at 1, 5, 10, and 16 years, respectively. Five (1.8%) late conversions were required during follow up. The variables that significantly and independently correlated with ruptured AAA were pre-operative aneurysm size and primary type II endoleak. The latter was the only independent significant factor to increase the risk of re-intervention., Conclusion: The number of graft related complications is high after EVAR, and new complications keep appearing years after the initial procedure. Even though fatal AAA rupture after EVAR is rare, it cannot be totally avoided despite systematic follow up., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The aim of this study is to evaluate the long-term survival and treatment-related outcome in patients treated with intra-arterial thrombolysis for acute lower limb ischemia., Methods: The study was based on a prospective vascular database with retrospectively obtained supplementary information from the patients' files. Additionally, data on the patients' date and cause of death were obtained from Statistics Finland. A total of 155 patients with symptoms or signs of category I-IIa acute lower limb ischemia and angiographic evidence of native artery or bypass graft thromboembolic events were treated with intra-arterial catheter-directed thrombolysis (CDT). Patients with severe ischemic stages at admission or those with contraindications for thrombolysis (n = 185) were treated with conventional surgical modalities and excluded from further analysis., Results: The mean age of the patients at admission was 73 years (95% confidence interval 70.1-74.6). For descriptive purposes, age quartiles were used (≤64, 65-74, 75-82.5, ≥83). The mean follow-up time was 126.3 months. The primary patency rates of native arteries/bypass grafts were 59.8%/31.7%, 35.4%/17.1%, and 18.7%/15.2% at 1, 5, and 10 years, respectively (P = 0.01). Correspondingly, the respective secondary patency rates were 65.2%/55.6%, 46.7%/39.8%, and 22.8%/30.5% (P = 0.88). A total of 190 additional procedures on 122 patients were required to preserve the patency after hospital discharge. At 1 year the cumulative survival was 78%, at 5 years 56%, and at 10 years 29%. The most common cause of death was cardiovascular (68.5%), predominantly presented by an acute coronary syndrome, while 9.6% died of cancer, 6.8% of pulmonary diseases, 8.2% of cerebrovascular causes, and 19.2% owing to trauma and other reasons. Atrial fibrillation (hazards ratio [HR] 2.31) and age over 83 years (HR 5.23 per age category) were significantly and independently associated with poorer cumulative post-procedural survival. Bypass graft thrombosis was associated with an increase in major amputations after CDT (HR 14.77). However, the presence of synthetic bypass grafts had a protective influence on limb salvage (HR 0.086). A total of 39 (25.2%) major amputations were performed during the follow-up period. Age over 75 years was the only significant and independent factor to negatively impact on amputation-free survival (HR 2.01), which was 24% at 10 years., Conclusions: The long-term patency after CDT is unfavorable, and additional procedures are needed to preserve adequate distal perfusion. Approximately 30% of the patients are alive at 10 years after the initial CDT. Increasing age and atrial fibrillation have a negative effect on the patients' survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The results of previous studies reporting the epidemiology of ruptured abdominal aortic aneurysm (RAAA) are highly heterogeneous. Furthermore, although RAAA and the preceding abnormal dilation of the abdominal aorta (AAA) are associated with other cardiovascular comorbidities, the demographic profile of all patients with RAAA has not been thoroughly investigated., Objective: To document accurately the epidemiology, survival, and demographic data (including vascular comorbidities and previous use of health care services) in RAAA-patients., Material and Methods: We conducted a comprehensive retrospective register study of all RAAA patients (operatively treated RAAA patients as well as in- and out-of-hospital nonsurvivors) in a well-defined geographic area during an 11-year period., Results: We found 488 RAAA cases in a catchment area of 689,000. The annual incidence of RAAA was 6.5/100,000. Of these patients 43.2% were underwent surgery. Overall mortality was 79.5%, and 27.5% of the population died out-of-hospital. Age was the only independent risk factor affecting survival (P < .0001). The mean age at the time of RAAA was 73.6 years for men and 82.3 years for women. Off all unexpected RAAA patients, 40% had a previous history of cardiovascular disease (most often coronary artery disease: 32%), and 38% had visited a physician within the previous year., Conclusion: RAAA remains a highly lethal condition with age as the only significant risk factor for mortality. The proportion of women increases strongly with age. A large proportion of patients with unexpected RAAA have history of cardiovascular disease., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Only limited data on the long-term results after endovascular aneurysm repair exist to date., Materials: Data on 282 patients with an abdominal aortic aneurysm treated with a Zenith endoprosthesis between March 2000 and March 2010 were retrospectively analyzed from a prospective database. Operative, total, and aneurysm-related mortality was assessed, as were graft-related complications and reinterventions., Results: All procedures were performed successfully without primary conversions. Median follow-up was 40 months (range: 1-119 months). Thirty-day mortality was 1.4%, and aneurysm-related mortality was 0.7%. Cumulative survival was 62% at 5 years and 52% at 8 years. Graft-related complications occurred in 107 (38%) patients. The most common finding was a type II endoleak (n = 73) that sealed mainly spontaneously (n = 46, 63%). Most endoleaks, and complications in general (87%), appeared during the first 3 years of follow-up, and no events occurred after 6 years. Altogether, 59 additional procedures, mainly embolizations (n = 35), in 38 patients (24%) were required owing to graft-related complications. Of all the reinterventions, 82% were performed during the first 4 years, and no new complications were treated after 6 years., Conclusion: Complications and reinterventions related to endovascular aneurysm repair become practically nonexistent after 5 to 6 years. This finding suggests that a lifelong follow-up may not always be needed after treatment with a Zenith endoprosthesis., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Atherosclerosis is a complex disease with hundreds of genes influencing its progression. In addition, the phenotype of the disease varies significantly depending on the arterial bed., Methodology/principal Findings: We characterized the genes generally involved in human advanced atherosclerotic (AHA type V-VI) plaques in carotid and femoral arteries as well as aortas from 24 subjects of Tampere Vascular study and compared the results to non-atherosclerotic internal thoracic arteries (n=6) using genome-wide expression array and QRT-PCR. In addition we determined genes that were typical for each arterial plaque studied. To gain a comprehensive insight into the pathologic processes in the plaques we also analyzed pathways and gene sets dysregulated in this disease using gene set enrichment analysis (GSEA). According to the selection criteria used (>3.0 fold change and p-value <0.05), 235 genes were up-regulated and 68 genes down-regulated in the carotid plaques, 242 genes up-regulated and 116 down-regulated in the femoral plaques and 256 genes up-regulated and 49 genes down-regulated in the aortic plaques. Nine genes were found to be specifically induced predominantly in aortic plaques, e.g., lactoferrin, and three genes in femoral plaques, e.g., chondroadherin, whereas no gene was found to be specific for carotid plaques. In pathway analysis, a total of 28 pathways or gene sets were found to be significantly dysregulated in atherosclerotic plaques (false discovery rate [FDR] <0.25)., Conclusions: This study describes comprehensively the gene expression changes that generally prevail in human atherosclerotic plaques. In addition, site specific genes induced only in femoral or aortic plaques were found, reflecting that atherosclerotic process has unique features in different vascular beds.

Background: To describe the prevalence and character of complications associated with revascularization procedures as a result of peripheral arterial disease in octogenarians and nonagenarians and to assess their overall survival depending on baseline characteristics, type of treatment modality, and possible procedure-related complications. A retrospective clinical study was carried out., Methods: A total of 383 patients aged >80 years, referred with suspected peripheral arterial disease, were categorized into octogenarians and nonagenarians. Data regarding cardiovascular risk factors, comorbidities, type of treatment, and possible procedure-related complications were collected from patients' files. The cohort was followed up for total mortality until December 31, 2007, by means of record linkage with the National Causes of Death Register., Results: A total of 57 (14.9%) patients were treated surgically, whereas 71 (18.5%) underwent an endovascular procedure. Conservative treatment was chosen significantly more often for nonagenarians (p = 0.032). Postoperative complications (nonfatal, 13.2%; fatal, 3.1%) were equally distributed between the age groups and genders (p = 0.840 and p = 0.820, respectively) but were significantly more common after surgical procedures (p < 0.001 for both fatal and nonfatal complications). As expected, the overall survival was significantly poorer among nonagenarians as compared with octogenarians (33 vs. 45 months, respectively; p < 0.001). Older age, critical limb ischemia (CLI), and males were independently associated with mortality (odds ratio [OR]: 1.89, 95% confidence levels [CI]: 1.18-3.04; OR: 3.72, 95% CI: 2.34-5.91; and OR: 1.77, 95% CI: 1.10-2.80, respectively). The survival for nonagenarian men with CLI was 24 months and for women 28, regardless of the treatment modality., Conclusions: Octo- and nonagenarians seem to tolerate arterial reconstruction relatively well. Endovascular interventions should be favored over surgical procedures as they are associated with fewer complications. At the same time, the life expectancy of nonagenarians with CLI is limited to approximately 2 years, irrespective of the method of treatment. Further studies should be conducted to clarify the actual effect of vascular reconstructions among the elderly population with regard to benefits of both costs and quality of life., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)